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Bioethical arguments conceal the coercion underlying the choice between poverty and selling ones organs
In mid‐May 2006, three Palestinian prisoners detained in Israel applied to the Israeli Prison Service (IPS) for permission to sell their kidneys in order to send money to their children for food. Whether truly sincere or merely propagandistic, the request was made against the background of Israel's decision to suspend the transfer of Palestinian tax moneys to the Hamas‐led Palestinian Authority, and the subsequent increasing poverty and famine in the Gaza Strip.1
An official decision was yet to be made when this paper was written. However, the IPS chief medical officer had already made it clear that the request is likely to be rejected. Aside from emphasising that the cost of the pertinent treatment of the prisoners could not be imposed on the IPS, especially as it would greatly exceed the sum to be obtained by the sellers (ca £3500), he asserted that the IPS “won't lend a hand to endangering the prisoner”. He also reiterated the official IPS policy, according to which the prisoners' consent to such transaction could not be valid, since they might have been threatened by people from inside or outside the prison.1
This is ironic. While the IPS' professed concerns for the welfare and best interests of the prisoners are commendable, they conceal and hence reaffirm the real coercion implicit in the dilemma the prisoners face: to sell their kidney or let their children starve. Interestingly, approval of their request would have equally concealed the coercion, this time behind concerns for either their autonomy, or the welfare of their children, or both.
At present, it is unlikely that Israel will acknowledge the role of national oppression and poverty in producing this dilemma. Rather, the debate will remain focused on orthodox the bioethical arguments concerning the possibility of autonomous choice in such extreme circumstances. Ideas which expose fundamental coercive social relationships of whatever kind are normally marginalised, whereas the ones that conceal them most effectively stand the best chances of being endorsed. Here, the case of the Palestinian prisoners will be used as an opportunity to explore how bioethical arguments conceal the coercion underlying all dilemmas involving the option of selling one's organs. Free, uncoeroed, people do not choose to face such dilemmas. To this degree, bioethical arguments take on an added ideological dimension—covertly supporting political and economic environments which impose tragedy on individuals by forcing them to choose between horrible options—either poverty or selling body parts. This can occur in a variety of ways.
To sum up, many bioethical arguments render the legal status quo sufficiently comfortable for all parties involved (perhaps apart from prisoners) as not to require any formal legalisation of commerce in organs. These arguments have successfully obscured the fact that the choice between starvation and any form of commodification of the body implies coercion. In doing so, they may have concealed the coercive origins of poverty, but they have certainly exposed their own poverty. Political and economic factors may coerce people into making tragic choices. Those engaged in the ethical and legal evaluation of healthcare have so far focused on the conditions that could ensure that such choices are made autonomously. Perhaps bioethicists should focus more on how to ensure that people do not have to make such choices in the first place.
Thanks to Professor Len Doyal for his comments on earlier drafts of this paper.
Competing interests: None.