The Interdisciplinarian

HPHR Fellow Sofia Weiss Goitiandia

By Sofia Weiss Goitiandia


Is it ethical to allow people to sell a kidney to overcome poverty?

From my vantage point as a master’s student paying to live in Stockholm in part to study ethics, this is an interesting dilemma to consider. Of course, I only have to consider it: that’s the privilege of looking down from the Ivory Tower built not by my own virtues, but by the money into which I happened to be born. Others are not so lucky. For over twenty years, it has been reported that people across the world sell a kidney, as their ticket out of poverty1-4.


Like any other business, the kidney trade is based on the market principle of ‘supply and demand’; the present disease burden of kidney failure has reached a point where demand outstrips supply4-6. The economic logic – and I dare to add, the ethics – holds: some people need kidneys and others need money, so why not play the world’s most morbid game of ‘blind date’, where one meets their match and both players get to live? “Because it’s wrong!” comes the reply. But, is it? People have two kidneys, and the autonomy to choose to sell one for the chance of a better life. I suspect that few would contend that it is ethically justifiable to deprive some of the world’s poorest people of such a chance.


However logical or even ethical the conclusion is, it leaves a bitter taste. Something doesn’t feel right about it. There lurks a deeper question here. One that asks not ‘is it ethical to do this?’, but ‘what kind of society puts people into this dilemma in the first place?’ If we spar only with the ethics, we miss the point: the ethics adapt to whatever society is willing to tolerate7,8. Across much of the world, societies tolerate an economic system where it is each person for themselves, and individual profit is the prize. Capitalism is the name of that game9. And the issue is that there are very few winners, and they tend to win all the time; the rich get richer and the poor ever poorer9. When we accept this, we accept that the answer to our titular question will be yes.


Medicine is not immune: it is driven by the same economic incentives that run the rest of society. Access to healthcare is for many limited by their ability to pay9-12, and medical care is often prioritised for those who show a greater potential for economic contribution down the line13-15. In 2010, healthcare spending caused financial catastrophe for about 10% of the world’s population16. Calls to ensure that all people have access to the quality healthcare services they need without suffering financial hardship – known as ‘universal health coverage’17 – are growing17, but is this possible within capitalism as we currently do it? Are the same societies that allow their people to ethically sell a kidney in order to survive likely to start providing them with affordable healthcare? The chances seem slim.  


Acknowledgments: this work is written solely by me, but my worldview has been influenced by the philosopher Miran Epstein.




1WHO | The state of the international organ trade: a provisional picture based on integration of available information [Internet]. WHO. World Health Organization; [cited 2020 Sep 12]. Available from: https://www.who.int/bulletin/volumes/85/12/06-039370/en/


2Iraqi families sell organs to overcome poverty. BBC News [Internet]. 2016 Apr 19 [cited 2020 Sep 12]; Available from: https://www.bbc.com/news/world-middle-east-36083800


3The Bangladesh poor selling organs to pay debts. BBC News [Internet]. 2013 Oct 28 [cited 2020 Sep 12]; Available from: https://www.bbc.com/news/world-asia-24128096


4The illegal kidney trade: who benefits? | SGOC [Internet]. [cited 2020 Sep 12]. Available from: https://standinggroups.ecpr.eu/sgoc/the-illegal-kidney-trade-who-benefits/


5McCormick F, Held PJ, Chertow GM. The Terrible Toll of the Kidney Shortage. JASN. 2018 Dec 1;29(12):2775–6.


6Astier H. Should kidney donors be paid? BBC News [Internet]. 2020 Feb 18 [cited 2020 Sep 12]; Available from: https://www.bbc.com/news/world-us-canada-51266959


7Epstein M. For a truly humanistic ethic, we need truly humanistic medicine. BMJ [Internet]. 2014 Jan 29 [cited 2020 Sep 12];348. Available from: https://www.bmj.com/content/348/bmj.g1133


8Epstein M. Re: Evidence based medicine is broken. 2020 Sep 12 [cited 2020 Sep 12]; Available from: https://www.bmj.com/content/348/bmj.g22/rr/680463


9Sell SK. 21st-century capitalism: structural challenges for universal health care. Globalization and Health. 2019 Nov 28;15(1):76.


10Thomson S, Cylus J, Evetovits T, Srakar A. Can people afford to pay for health care? new evidence on financial protection in Europe: [regional report [Internet]. Copenhagen: World Health Organization, Regional Office for Europe; 2019 [cited 2020 Sep 12]. Available from: https://apps.who.int/iris/bitstream/handle/10665/311654/9789289054058-eng.pdf?sequence=1&isAllowed=y


11Krohmal BJ, Emanuel EJ. Access and Ability to Pay: The Ethics of a Tiered Health Care System. Arch Intern Med. 2007 Mar 12;167(5):433–7.


12European Commission | Inequalities in access to healthcare – A study of national policies. Publications catalogue – Employment, Social Affairs & Inclusion – European Commission [Internet]. [cited 2020 Sep 12]. Available from: https://ec.europa.eu/social/main.jsp?catId=738&langId=en&pubId=8152&furtherPubs=yes


13Shaw AB. In defence of ageism. Journal of Medical Ethics. 1994 Sep 1;20(3):188–94.


14Archard D, Caplan A. Is it wrong to prioritise younger patients with covid-19? BMJ [Internet]. 2020 Apr 22 [cited 2020 Sep 12];369. Available from: https://www.bmj.com/content/369/bmj.m1509


15Jessop J. The UK lockdown and the economic value of human life. Economic Affairs. 2020 Jun;40(2):138–47.


16Wagstaff A, Flores G, Hsu J, Smitz M-F, Chepynoga K, Buisman LR, et al. Progress on catastrophic health spending in 133 countries: a retrospective observational study. The Lancet Global Health. 2018 Feb 1;6(2):e169–79.


17WHO | Universal Health Coverage [Internet]. WHO. World Health Organization; [cited 2020 Sep 12]. Available from: http://www.who.int/healthsystems/universal_health_coverage/en/

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