How the best intentions of the medical community accidentally created an international organ-trafficking underground.
It was a revolutionary idea at the time, and it succeeded wildly, helping create one of the most robust and safe blood supplies in the world. Today, Americans donate so much blood in excess of the country's needs that the United States is the number one blood exporter on the planet. We send almost 1.5 million gallons of blood plasma abroad every year, enough to fill two and a half Olympic swimming pools.
Titmuss's model also applied to acquiring and selling body parts -- which has since become the gold standard throughout medicine. In 1984, the U.S. Congress passed the National Organ Transplant Act, forbidding the sale of body parts and effectively requiring an altruism-based system for acquiring them. Anonymity, too has become the rule. In the 1960s, it was still possible for organ recipients to learn who donated the organ that saved their life. Now we take it as a given that such knowledge should be protected by the strictest standards of medical privacy. The prevailing logic has been that making it possible to connect the dots between donor and recipient could compromise the entire system, maybe even stopping people from donating their tissue in the first place.
Unfortunately, the anonymous-altruistic system has produced unintended consequences. Even Congress couldn't get rid of the market for body parts entirely: Individuals can't directly buy and sell bodies, but doctors, nurses, ambulance drivers, lawyers, and hospital administrators can all bill for their services. (You may not pay for a heart, but you definitely pay for a heart transplant.) And the flipside of anonymity is opacity: Although confidentiality provisions are meant to protect the interests of the donor, they also obscure the supply chain.
The result is a system whose best intentions create ample opportunities for criminally minded entrepreneurs. There are huge profits to be made by middlemen dealing in everything from kidneys to human eggs to sight-unseensurrogate pregnancies. In the age of globalization the brokers are adept at exploiting the knowledge and legal gaps between national jurisdictions to arrange just about any sort of organ acquisition, and advances in anti-rejection drugs allow people with widely diverse genetic backgrounds to swap organs. In Romania, Moldovia, Turkey, and Egypt brokers can easily acquire kidneys for $3000 and sell them for $50,000 or more. In 2008, an Indian broker was arrested for kidnapping people from the New Delhi slums and literally stealing their kidneys to sell to foreign transplant patients. In China, selling the organs of executed prisoners continues to be an official state policy.
Law and economics recognize three types of markets with varying degrees of legality: white, gray, and black. The trade in human flesh has evolved into its own category of commercial activity, what you might call the "red market" -- a market whose economic characteristics are complicated by the fact that customers owe their lives and family relationships to the supply chain, yet know perilously little about it. I spent the past six years tracking the red market across South Asia, Europe, and the United States, exploring the business practices of kidney traders, skeleton thieves, blood pirates, and child kidnappers. In every case, I was astonished to find that most people who bought a piece of a human being had no idea what series of events had had to occur to make that body part available.
Obscuring the source of raw materials for any market is almost always a bad idea. We would never allow an oil company to hide the locations of their oilrigs, or not disclose their environmental policies. And when an oilrig fails and leaks millions of barrels of petroleum into the ocean we demand accountability. Transparency is capitalism's most basic safety feature.
Solutions to the problem are hard to come by, however, and will likely require a wholesale revamp of the tissue donations system. Economists have argued that a commercial system similar to the one that exists in Iran for kidneys -- in which the state pays donors a modest sum for the organ -- could allow the market to regulate the human tissue supply. Others argue that it is possible to increase actual altruistic donation rates -- and cadaver donations for internal organs -- to the point at which supply and demand will be balanced, reducing the need for a red market.
In my view, neither is likely to work until we answer a simple question: At what point is one person entitled to use the flesh of another? The central problem with the human supply chain is that it has been dehumanized -- its very opacity allows us to elide the fact that we aren't just buying tissue, but a piece of a person, and one that comes with a history. Perhaps then we can accept that people are not commodities and our own lives are often predicated on the sacrifices of others.