Remember that scene in Fellini's "Satyricon," where the guy gets his hand chopped off? I heard that it was real: The man was some poor Italian farmer, or baker, who really needed the money. Fellini gave him maybe $1,000. Good deal for both of them.
Apocryphal stories like this one, which circulated on my college campus after the movie was released in 1969, abound in American popular culture. Rod Serling worked a similar theme in his pilot for "Night Gallery" in the same year: Joan Crawford played a rich, blind art collector who saves a gambler's life by paying off his debts to the Mob, in return for his agreeing to submit to a radical operation that would give her his eyes.
We find these stories disturbing because there is a deep, if somewhat vague, presumption in our culture that the body and its parts are sacred and shouldn't be subject to the standard economic laws of supply and demand. To the extent that body parts find themselves in the marketplace at all, there is usually a message--overt or covert--that altruism ought to be at the heart of the transaction. We donate rather than sell our blood, bone marrow and kidneys because we believe it's wrong to engage in cold-blooded commerce in corporeal components.
Yet the buying, selling and even renting of body parts does happen outside the bounds of television and the movies. Many people routinely sell their plasma to companies that extract from the straw-colored fluid therapeutic proteins worth far more than their weight in gold. Young women can, and increasingly do, sell clutches of their ripened eggs for $5,000 or more. And in many states, women rent their wombs for nine months at a time, charging whatever fee the market will bear.
In fact, the more you look into the issue of what is allowed and not allowed in the trafficking of body parts and bodily fluids in this country, the more inconsistencies you find. Buying and selling organs such as kidneys and livers is illegal under the National Organ Transplant Act of 1984. But sperm can be sold (though on a per capita basis, they have a tiny fraction of the value of human eggs). And you can sell your hair to the neighborhood wig maker. It's illegal, however, to sell a lobe of your liver to someone in liver failure, even though your body would regenerate the missing lobe at least as quickly as your hair would grow back.
Moreover, restrictions on the sale of body parts, where they exist, generally don't apply to third-party profiteers. In the most famous legal case to deal with the question, the California Supreme Court ruled in 1990 that a patient did not hold property rights to his cells and tissues removed during surgery. But the court said the surgeon and biotechnology company that sought to make those cells into a blockbuster drug were entitled to keep the billions of dollars in profits they projected would come from the uncompensated man's tissues.
That economic system, which some critics have likened to legalized biological pillaging, is about to become federal policy in the emerging arena of human embryo research. Federal guidelines now being devised by the National Institutes of Health would preclude women undergoing fertility treatments from selling their leftover embryos to federally funded scientists wishing to do research on those embryos. Only donation would be allowed--a reflection of the discomfort many people feel about the prospect of parents selling their offspring. (It's already illegal, of course, to sell a child, but in another example of our inconsistencies, price controls on private adoptions in some states are so loose that the result is virtually indistinguishable from child selling.) Yet the scientists who gain access to these freebie embryos would explicitly be allowed to patent and profit from cell lines or other biological products they might derive from them.
Because we're so confused and conflicted about the market valuation of our bodies and their parts, and in particular our reproductive tissues, wouldn't it make sense to come up with a consistent approach to regulating commerce in body parts? Especially given that today, as never before, the body is valued not simply as the vessel within which we each enjoy the brief privilege of personal existence but also as a biological resource that can be cultivated, propagated, farmed, mined, extracted and transformed into value-added commodities.
Placentas are being whisked from delivery rooms for sale to companies that make shampoos. Foreskins are passed from the circumcision table to the ice bucket for shipment to scientists who want to experiment with the easily cultured cells. Even cancerous lumps once destined for the surgical ashcan are now coddled and preserved for stock-optioned researchers who hope to turn the tissue into a cancer vaccine.
With improved immune system-suppressing drugs and better surgical techniques, pancreases, hearts, lungs and other internal organs are becoming more transplantable--and therefore more valuable.
And most recently, as scientists have learned to master the tools of biotechnology, the market for individual genes and even fragments of genes has begun to expand. A brain cancer gene might, if tamed a bit, hold the secret to regenerating ailing neurons in patients with Alzheimer's or other neurodegenerative diseases. A gene that makes the clotting protein that hemophiliacs lack is no longer a mere product of nature but a potentially curative molecular therapy.
In short, as biomedical science has progressed during the past few years, the market value of our bodies has pretty much tracked the Dow. Which means that, to the extent that we are willing to put our bodies on the block, each of us is probably a bit richer than we think.
So why shouldn't we be allowed to freely dispose of ourselves--or at least the more fungible parts of ourselves--and trade our natural endowments for cash or some other form of spendable wealth? If everyone is really so proud these days that capitalism has proven so globally victorious, why not let it strut its stuff and let folks profit from the one thing we each most definitively own--our bodies?
Consider the rules for participating in medical research. The government allows perfectly healthy people to participate in risky medical research--and be financially compensated--even when the research has no promise of benefiting them personally, as long as they have willingly consented. The same rules could apply to giving up a kidney--or the hand in Fellini's movie. Just five months ago, surgeons in Kentucky did this country's first hand transplant. Other transplants are planned. Donors will be needed!
A few brave souls have seriously suggested that market forces should reign in the arena of organ transplants. An article in the Fall 1997 Cato Journal, known for its free-market orientation, argued that the U.S. ban on buying and selling organs is causing today's massive shortages, which leave thousands waiting for a transplant.
The need for organs grows every year, but donation rates have long remained almost flat. Let's face it, the Cato authors say, lots of people are not crazy about giving up their organs, even after they die. A little cash incentive may well grease the gears. What's more, they argue, a payment system could lessen the waiting time disparity that exists between blacks and whites, since payments would probably encourage people of lower income, including blacks, to donate more organs.
But that potential for attracting donations from the neediest members of society is one of the big problems. A policy that allows the wealthy as well as the desperate to sell themselves piecemeal brings to mind Anatole France's famous 1894 observation that "The law, in its majestic equality, forbids the rich as well as the poor to sleep under bridges, to beg in the streets, and to steal bread."
Rather than reducing disparities between the rich and the poor, compensation for organs might exacerbate the differences, turning the poor into surgical ward slaves or feudal donors for the rich.
Some also warn that by encouraging organ donations from the poor, a payment system might inadvertently boost donations of the least healthy organs. That was certainly one of the reasons the nation's blood banks switched to an all-volunteer system for blood donors in the early 1970s. Donors who gave their blood for cash were often poor alcoholics and intravenous drug users, many infected with the hepatitis virus. By switching to volunteers, the blood supply got an instant cleanup.
And, at the risk of sounding old-fashioned, there is still the argument that our bodies and their components are not simply economic units of trade: That even though they are worth more, monetarily, than ever before, they also have special personal and cultural meaning, and by putting too much emphasis on the money side we actually cheapen ourselves. "The problem," as Jane Larson, a law professor at the University of Wisconsin, says, "is how to value these things without destroying or diminishing their value."
Surely there is room for a Third Way of dealing with this special segment of the global economy. Something between the harsh and potentially enslaving laws of pure capitalism and the current system of not compensating people at all for "donations" of raw materials that in many cases promise to reap enormous profits for others.
To find such a way would require some legal and ethical trailblazing. "We are constrained by existing legal categories," says Lori Knowles, an associate at the Hastings Center, a bioethics think tank in Garrison, N.Y. "In law, all is either person or property. There are very few things that are not one or the other. But embryos outside the body, embryonic stem cells, organs removed from a person before they're transplanted--they have connections with both. They are inanimate but also are derived from human beings, and we're not sure where to draw the line."
Pennsylvania is about to try one novel approach: An experimental program that will allow payments of $300 to aid families of deceased organ donors. The money would be available not as a direct payment for the organs, but to offset funeral expenses.
Another plan, floated by Cato authors Charles Carlstrom and Christy Rollow, would create, in effect, a barter system for patients who are in need of a kidney but whose willing relatives turn out to be a bad match for transplantation. A relative could donate a kidney to someone who is a good match, in return for someone else donating a kidney to their family member.
Neither of these approaches deals directly, however, with the fastest-growing class of trade in body parts: the burgeoning quasi-marketplace in genes, cells, tissues and, yes, embryos and fetuses. Here, more than with organs for transplantion, some legal heavy lifting is going to be needed.
Specific models are still wanting, but many experts believe that it's time to consider allowing for some modest, non-coercive and properly regulated payments for people who give up their personal cache of biological resources to for-profit entities. A properly drawn system would protect people in the same way labor agreements protect people from slavery.
"We say you cannot sell all of yourself unconditionally, 24 hours of the day, but you can sell yourself eight hours a day at a fair wage with a set of controls that gives you some autonomy and that allows you, for example, to quit," Larson says. "Under those conditions, you are allowed to sell an important aspect of yourself: the best that you have in mind and body. So I think there is also the possibility of selling parts of yourself with similar controls over the transaction."
Alternatively, says E. Richard Gold, a professor of law at the University of Western Ontario and author of "Body Parts" (Georgetown University Press), perhaps companies should have access to volunteers' tissues for free but should be granted only limited patent rights over products they make from those materials. The remaining rights could be passed to a nonprofit foundation whose mandate would be to ensure that any medical benefits derived from those human tissues eventually are made available to everyone equally.
No doubt there are other ways to compensate people willing to share their biological resources. But we'll have to be sure the pendulum does not swing too far: There's always the risk that in the effort to protect ourselves from plundering biotech buccaneers, we will grow greedy ourselves and forget that, in the long run, even we don't necessarily own our own biological wealth.
Rod Serling, for one, recognized the universe's perverse propensity to punish those who forget such humility. The blind dowager in his story, desperate for even a fleeting tryst with vision, saves the gambler's life and arranges for the surgery, knowing that she'll get just a few hours of sight before the transplanted eyes will fail.
The episode ends with the removal of her bandages one night--just as New York City experiences the great blackout of 1965.
Rick Weiss is a science writer for The Washington Post.
The Sum of Our Parts
Over the past 30 years, organ transplantation has changed from a rare experimental procedure conducted in a handful of highly sophisticated medical centers to a treatment that's widely available in hospitals and clinics around the world.
No other country can compete with the United States' centralized system for identifying donors and matching them with recipients. (Information about the private, nonprofit United Network for Organ Sharing, which acts under contract with the U.S. Department of Health and Human Services, is available on the Internet at www.unos.org.) Even so, the gap between supply and demand here is widening. Despite numerous well-funded publicity campaigns, 4,857 people died last year while waiting for organ transplants in the United States. Only a very few countries have sufficient organs to satisfy all their citizens' needs, according to a 1997 report by an international task force of doctors, ethicists and scientists.
Trafficking in human organs has long been discouraged by Western governments and is now illegal in most nations. The World Health Organization declared that the sale of organs violates the Universal Declaration of Human Rights. Stories abound about kidnappings and murder to remove organs--often supported by arguments that when a commodity is in short supply, an illegal market inevitably develops. But the constraints of the transplantation procedure, from finding a matching donor to the need for specialized surgery, suggest many of these may be mere rumor.
In India, where commercial transactions in kidneys were not officially outlawed until the passage of the Human Organ Transplant Act just five years ago, the controversial underground practice of "paid donation"--donating a kidney for financial reimbursement--probably continues today. Those who can afford it have been prepared to travel anywhere an organ is available. People from Persian Gulf states (including Kuwait, Saudi Arabia, Bahrain, Oman and the United Arab Emirates) as well as from Malaysia and Singapore have traveled to India to buy kidneys. Residents of Taiwan, Hong Kong and Singapore have traveled to China, where organs from executed prisoners have been available.
In some countries, religious or cultural assumptions inhibit organ donation. In Japan, where criteria for brain death were only recently adopted, cultural misgivings about proper treatment of the corpse contribute to concerns about transplantation. And in many parts of the world, taboos about mutilation of the human body also prevent such harvesting. All these factors contribute to the scarcity--and value--of organs.
Sources: Bellagio Task Force Report on Transplantation, Bodily Integrity, and the International Traffic in Organs; www.unos.org; Patricia A. Marshall, associate professor of medicine at Loyola University of Chicago.