ALTRUISM AND OWNERSHIP: JUSTIFYING PAYMENT FOR ORGAN DONATION A thesis ...

239 Pages·2014·2 MB·English

ALTRUISM AND OWNERSHIP:
JUSTIFYING PAYMENT FOR ORGAN DONATION

A thesis submitted to the University of Manchester for the degree of
PhD in Bioethics and Medical Jurisprudence

In the Faculty of Humanities

2014

Voo Teck Chuan

School of Law
For Jacqueline,
Ellie & Charles

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TABLE OF CONTENTS

Page
Abstract 7
Declaration & Copyright Statement 8
Acknowledgements 9
The Author 10
Table of Cases 12
Table of Statutes 13

PART I: INTRODUCTION

Chapter

1 PROBLEM, AIMS AND APPROACH 14
1.1 Introduction 14
1.2 Consequences of an Organ Shortage 13
1.3 Altruistic Gifting 17
1.4 Reconciling Altruistic Gifting with Financial Reward 19
1.5 Rewarding Deceased Donor Registration 21
1.6 Criticisms of Motivation-Focused Justification 22
1.7 Thesis Aims and Approach 24

2 PHILOSOPHICAL APPROACH 28
2.1 Introduction 28
2.2 The Gift of Titmuss? 28
2.3 Gift and Commodity: Compatible Forms? 30
2.4 Funeral Expense Reimbursement as a Rewarded
Gift Form 35
2.5 Altruism: From Pure to Primary Motive 37
2.6 The Moral Insignificance of Altruism? 43
2.7 Conclusion 46

3 LEGAL APPROACH 48
3.1 Introduction 48
3.2 ‘No Property in a Dead Body’ Principle 51
3.3 Work/Skill/Alteration Principle 52
3.4 Property, Public Interest and Abandonment 54
3.5 Property Interest and Intent 55
3.6 What can be Drawn from the Cases 57
3.7 Organ Donation in England: Statutory Framework 60
3.8 Organ Donation in the US: Statutory Framework 62
3.9 Reward as a Legislative Imperative? 64
3.10 Organs as Descendible Valuables 68
3.11 Issues with Reasoning from Descendibility 71
3.12 Conclusion 74

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4 SUMMARY OF ARTICLES 75
4.1 Article 1 75
4.2 Article 2 76
4.3 Article 3 78
4.4 Article 4 79

PART II: THE SUBMITTED ARTICLES

5 Article 1: The Social Rationale of the Gift Relationship 80
5.1 Abstract 80
5.2 Introduction 81
5.3 Social Justice and Social Policy 83
5.4 Community as Emotional Integration 86
5.5 Community, Altruism and Value Pluralism 87
5.6 Motivating BMD in TGR 92

6 Article 2: The Moral Insignificance of Altruism to Deceased Organ Donation?
A Response 97
6.1 Introduction 97
6.2 Overvaluing Altruism 101
6.3 Solidarity, not Altruism 103
6.4 Wilkinson and Saunders: Similarity and Differences 104
6.5 No Support from Nagelian Altruism 105
6.6 Altruism and Self-Sacrifice: Concept and Valuation 109
6.7 The Irrationality of Devotion to Self-Sacrifice 111
6.8 Creative Altruism 112
6.9 Impartiality as a Constraint on Altruism 112
6.9.1 The Demand of Moral Impartiality 113
6.9.2 First- and Second-Order Impartiality 115
6.10 NHS Blood and Transplant Allocation 116
6.11 Donation: Altruistic and Solidaristic 118
6.12 Lack of Sacrifice? 120
6.13 High Praise and True laudability 123
6.14 Altruism Verification: A Non-Problem 126
6.15 Conclusion 129

7 Article 3: Altruism and Reward: Motivational Compatibility in Deceased
Organ Donation 132
7.1 Abstract 132
7.2 Introduction 133
7.3 Why Maintain Altruism? 134
7.4 Ethical Acceptability of Financial Rewards 137
7.5 Motivationally Mixed yet Altruistic 139
7.6 Intervention Ladder 141
7.7 Motivationally Mixed but Not Altruistic 142
7.7.1 Altruistic intent 147
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7.8 The Perspective of Altruism 151
7.9 Reward and Social Responsibility 156
7.10 Conclusion 158

8 Article 4: Organs as Inheritable Property? 160
8.1 Abstract 160
8.2 Introduction 161
8.3 Body Ownership and Property Ownership 162
8.3.1 Assimilating Body Ownership to Ownership of Property 162
8.3.2 Thinghood and Alienation 164
8.4 Organs as Tradable Property, Organs as
Inheritable Property? 166
8.5 Anti-waste 170
8.6 Reasons against Inheritability 172
8.7 Conclusion 176

PART III: CONCLUDING SECTION

9 CONCLUSION 177
9.1 Introduction 177
9.2 Altruism-Payment Incompatibility 180
9.3 Altruism-Reward Compatibility 180
9.4 Moral Insignificance 181
9.5 Devotion to Humanity 182
9.6 Altruism and Other-regarding Motives 186
9.7 Community and Compatibility 189
9.8 Social Responsibility without Altruism? 192
9.9 Gift, Altruism and Body Exceptionalism 193
9.10 Future Research 195
9.11 Conclusion 197

Bibliography 199
Appendix: Published Papers 215

Word Count of main text including footnotes: 63,198

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ABSTRACT

The University of Manchester
Doctoral Programme in Bioethics and Medical Jurisprudence

Voo Teck Chuan
31st March 2014

ALTRUISM AND OWNERSHIP: JUSTIFYING PAYMENT FOR ORGAN DONATION
Organ donation is traditionally based on the notion of making a gift based on altruism. An
important aspect of ‘altruistic gifting’ is commitment to a solidaristic approach to meeting
transplant needs. In line with this, people are encouraged to donate their organs at death to a
common pool for collective provision, or donate a live organ to another freely. Given a
chronic organ shortage, proposals have been made to change this system to increase donation.
Proposals include introducing some organ market or payment in the form of a reward to
incentivise live or deceased donation. However, these proposals have been opposed because
of the grip of ‘altruistic gift’ as the only ethically acceptable way to procure and distribute
organs.
To support the ethical acceptability of other systems, ‘altruistic gift’ has been subject to
various criticisms. One criticism is the moral relevance of altruism: people may donate on
other motives other than altruism; or, altruism is not the motive that underpins most deceased
organ donations. Another criticism is the moral value of altruism: even if deceased organ
donations are in general altruistic, altruism does not express communal virtues like generosity
that support solidarity.
A third criticism is the value of the concept of altruism when understood in the pure sense:
‘pure altruism’ fashions an unnecessary or false dichotomy – gift versus sale – in the way
people can ethically relate and help each other. Consistent with or following this criticism, it
has been argued that use of a financial reward to incentivise donation can be compatible with
preserving donation as altruistic albeit in a ‘non-pure’ sense. ‘Altruism’ and reward can co-
exist as motives for donation.
This thesis concerns itself centrally with the third criticism. It argues that the concept of
altruism delineates a distinctive moral ‘perspective’ of a common humanity that engenders a
devotion to others’ interests. Accordingly, as I argue, ‘non-pure’ definitions of altruism are
misleading as to how a financial reward can be compatible with altruism. From this, the
thesis argues that introduction of a financial reward for organ donation would not preserve
donation as altruistic. Based on an understanding of altruism as also a motive for ‘creative’
relationships, the thesis counters criticisms of its relevance and value to deceased organ
donation under a gift model.
As part of its legal analysis, the thesis considers the antithesis of ‘altruistic gift’: the idea of
organs as property which places individual control on their disposition at its moral centre. It
has been argued that organs should be owned as property so that individuals can sell them, or
transmit them to relatives so that relatives can claim payment from donation. To provoke
thought on whether organs should be owned as private property like any other, the thesis
proposes an inheritance regime for organs with family as default successor.
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DECLARATION
No portion of the work referred to in the thesis has been submitted in support of an
application for another degree or qualification of this or any other university or other institute
of learning.

COPYRIGHT STATEMENT
i. The author of this thesis (including any appendices and/or schedules to this thesis)
owns any copyright in it (the “Copyright”) and s/he has given The University of
Manchester the right to use such Copyright for any administrative, promotional,
educational and/or teaching purposes.

ii. Copies of this thesis, either in full or in extracts, may be made only in accordance
with the regulations of the John Rylands University Library of Manchester. Details of
these regulations may be obtained from the Librarian. This page must form part of
any such copies made.

iii. The ownership of any patents, designs, trade marks and any and all other intellectual
property rights except for the Copyright (the “Intellectual Property Rights”) and any
Reproductions of copyright works, for example graphs and tables (“Reproductions”),
which may be described in this thesis, may not be owned by the author and may be
owned by third parties. Such Intellectual Property Rights and Reproductions cannot
and must not be made available for use without the prior written permission of the
owner(s) of the relevant Intellectual Property Rights and/or Reproductions.

iv. Further information on the conditions under which disclosure, publication and
exploitation of this thesis, the Copyright and any Intellectual Property Rights and/or
Reproductions described in it may take place is available from the Head of School of
Law (or the Vice-President) and the Dean of the Faculty of Life Sciences, for Faculty
of Life Sciences’ candidates.

----------------------------------------------------------------------------------- 31st March 2014

Voo Teck Chuan

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ACKNOWLEDGEMENTS

I thank my supervisors, Professor Søren Holm and Professor Margaret Brazier, for all their
help in the completion of this thesis. They were encouraging, patient and kind throughout the
process, for which I will always be grateful. I was given incredible support during the last lap
of writing. Dr. Anne-Maree Farrell, who was involved in my supervision earlier, gave me
lasting advice on academic writing.

The learning environment at the School was warm, inviting and stimulating. For this, I would
like to thank Professor Rebecca Bennett, the course director; Dr. Sarah Chan; Dr. John
Coggon; Dr. Iain Brassington; Dr. Sarah Devaney; Dr Catherine Rhodes; Dr. Charles Erin;
and Professor John Harris. I greatly enjoyed and learned a good deal at the seminars
organised by the Institute for Science, Ethics and Innovation. My course mates also gave me
useful suggestions on the direction and substance of my thesis during our scheduled meetings
to share our work-in-progress. Paul Mũtuanyingĩ Mũrĩithi gave me much needed moral
support and friendship. Jackie Boardman, Stephen Wadsworth, Mary Platt, and Catherine
Spanswick were always welcoming and prompt with their administrative support.

I was funded by a Wellcome Trust Studentship in the undertaking of this PhD. I would to
acknowledge the Trust for the support, and Professor John Harris for awarding me the
studentship.

Lastly, I believe my wife would like to thank me for finishing. I would like to think we had
some good times. In the cold winter of Manchester, we warmed ourselves in an igloo, and
played some ping pong. She has waited long enough.

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THE AUTHOR
I am Lecturer at the National University of Singapore (NUS), Yong Loo Lin School of
Medicine, Centre for Biomedical Ethics (CBmE). Prior to joining the structured PhD
programme in Bioethics and Medical Jurisprudence at The University of Manchester, School
of Law, I was Research Fellow at CBmE.
I obtained a Master of Arts at NUS, Department of Philosophy in 2005. I did my Bachelor of
Arts (First Class Hon.) at the same place.
Publications for the purpose of the thesis
Altruism and Reward: Motivational Compatibility in Deceased Organ Donation.2014.
Bioethics. 2014. DOI: 10.1111/bioe.12078.
Organs as Inheritable Property? Journal of Medical Ethics2014;40:57-61. First author, with
Søren Holm; incorporated into the journal’s special issue on “The Human Body as Property:
Possession, Control and Commodification” for its contribution to the debate on control and
commercialisation of human biological materials
The Social Rationale of the Gift Relationship. Journal of Medical Ethics 2011;37:663-7.
Other publications (selected) during the period of the thesis
Trade in Human Body Parts. Forthcoming in November 2014. In: The Routledge Handbook
of Global Ethics. D. Moellendorf and H. Widdows, eds. Routledge. First author, with
Alastair V. Campbell.
Brain-machine Interfaces and Personal Responsibility for Action—Maybe Not as
Complicated After All. Studies in Ethics, Law, and Technology 2010.Published online. DOI:
10.2202/1941-6008.1153. Joint author with Søren Holm.

Poster
Considering the Reification Argument for Organ Trading. Sept 2011. Poster presentation for
Faculty of Life Sciences Annual Symposium.
Presentations

The Moral Dimensions of Rewarded Organ Donation: Permissibility and Meaning. Dec
2012.NUS CBmE Journal Club.

Organs as Tradable Property, Organs as Inheritable Property? Oct 2012. PhD Bioethics and
Medical Jurisprudence (BMJ) student meeting.
Understanding Exploitation as Justification for Prohibiting Organ Trading. Oct 2012.The
University of Manchester School of Law Postgraduate Research Conference 2012.
On Why Some Offers of Directed Donation Should Be Rejected. Aug 2012. NUS CBmE
Journal Club.
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The Morality of Rewarding Deceased Organ Donation. Apr 2012. PhD BMJ student meeting.
The Property Relationship: From Human Organs to Economic/Political Policy. May 2011.
PhD BMJ student meeting.
Imperium and Dominium: Kidneys as Properties. Jan 2011. NUS CBmE Journal Club.
Four Legs Good, Two Legs Bad! Regulating Kidney Donation. Nov 2010. Institute of
Science and Ethics (iSEI) seminars series.
The Political Rationale of the Gift Relationship. May 2010. iSEI seminar series.

Service

Assistance with event organisation. Nov 2011. ‘Human Bodies: Animal Bodies’. Public panel
event organised by iSEI and The Academy of Medical Sciences.
Note-taker. Apr 2010. Session on ‘Bodies and Boundaries’ as part of the conference ‘Beyond
the Body? Perspectives on Enhancement’ organised by iSEI.

Essay Marker. Apr 2010. BIOL30152 Bioethics, Module for The University of Manchester,
Faculty of Life Sciences.

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