The sale of human organs is one of the greatest of all medical taboos. It provokes instinctive revulsion. We can sell our labour and our skills, but the idea of cutting out bits of ourselves and offering them to the highest bidder seems grotesque. So when the British Medical Association (BMA) held a debate last week on whether a market in human organs should be established, it provoked outrage. Critics argued that even by holding the debate, the BMA was lowering the ethical barrier against a grossly exploitative practice: the selling of organs by the poor to the rich.
The association quickly rushed out a statement reaffirming its opposition to such a market. Rosie Winterton, the health minister, declared that the Government had no plans to change the law under which it is illegal to trade in organs. And on Thursday it emerged that officials from the Department of Health are looking at ways of using the Human Tissue Bill, announced in the Queen's Speech, to clamp down on "transplant tourists" who go abroad to buy organs in deals that would be prohibited here.
But before rushing to judgement on the matter, it is worth examining a few facts. For people who suffer kidney failure, even modern health systems have little to offer. There is no shortage of skill or knowledge, but there is a shortage of the raw material - the kidneys - that can save lives.
In western Europe 40,000 people are waiting for a transplant of kidneys or other organs; between 15 per cent and 30 per cent will die on the waiting list. That is between 6,000 and 12,000 unnecessary, avoidable deaths. The average wait for a transplant is three years and by 2010 it is expected to have increased to 10 years, according to a report published by the parliamentary assembly of the Council of Europe.
So what is someone with a failing kidney to do, apart from getting on a waiting list as soon as possible? Dialysis will keep you going for a while but availability is limited. It is burdensome and the average patient survives just four years. The only cure for kidney failure is a transplant. If you cannot get a kidney by legal means and it is your only hope, then what next?
In matters of life and death the law counts for little. A person confronting their own mortality, or that of a loved one, will acknowledge few constraints on their behaviour. That is why the market in human organs is booming.
The going price paid to young people in eastern Europe for one of their kidneys is $2,500-$3,000 (£1,500-£1,800), according to the Council of Europe report. It is perfectly possible to lead a normal, healthy life after donating a kidney, provided the operation is carried out by a skilled surgeon and the aftercare is good. That unfortunately, is often not the case. The absence of medical follow-up combined with the harsh conditions in which many of the eastern European donors live frequently results in worsening health.
In Britain, where there are about 7,000 patients waiting for a kidney transplant with about 3,000 operations a year, patients are known to have travelled abroad to buy replacement organs. A survey by Queen Elizabeth Hospital, Birmingham, last year revealed that 29 NHS patients had bought kidneys which were transplanted abroad - mostly in India. But the risks of undergoing the operation in clandestine conditions are stark. In more than half the cases the kidney failed, and a third of the patients died.
The Council of Europe report said wealthy patients paid between $100,000 and $200,000 for an illegal transplant. Attracted by these large sums, international crime syndicates are said to have established trafficking networks targeting poor European countries such as Moldova, a prime source of kidney donors for the West.
What is to be done about the trade? It is futile to try to stop it. Desperate people, with nothing to lose, will not be deterred by the law. As with the trade in hard drugs, if we accept that some people are going to avail themselves of the market - whatever efforts are made to prevent them - then is it not sensible to try to reduce the harm associated with the trade rather than try to stop it altogether? Support for the harm reduction approach is growing in Britain and around the world among transplant surgeons who witness at first-hand the consequences of the shortage of donors, and the terrible risks that patients are driven to take.
The proposal, which is finding increasing favour, is that an ethical market in organs should be established, as a rival to the illegal, unethical and dangerous trade. Under this proposal the ban on individuals buying and selling organs would remain. Instead, governments - in Britain the NHS - could invite living donors to offer kidneys in return for payment. The organs would be donated to a pool and allocated to the most suitable recipient. Donor safety would be assured by screening and comprehensive after-care.
This would prevent the rich exploiting the poor and using their wealth to jump the queue for a transplant. Governments could have an economic interest in such a scheme because of the huge costs of dialysis, which are £20,000 to £30,000 a year - double the cost of maintaining a transplant for a worse quality of life.
The idea has attracted growing support from transplant surgeons such as Andrew Ready, clinical director of the renal transplant unit at Queen Elizabeth Hospital, Birmingham; Professor Nadey Hakim of St Mary's Hospital, London and president of the Royal Society of Medicine's transplant committee; and John Dark, transplant surgeon at the Freeman Hospital, Newcastle.
Sir Graeme Catto, a kidney specialist and president of the General Medical Council, which sets ethical standards for the profession, has called for a debate on the issue on the grounds that the trade in organs is happening and cannot be ignored. Surgeons were looking to make the best of a bad job, but people preferred not to think about it because it was uncomfortable. They preferred to "hide from the grim reality", he said.
There are problems with the proposed "ethical" market. One is that it could promote "donor tourism" if governments in different countries offered different rates of payment. But to prevent rich nations preying on poor nations, donors could be restricted to a country or region, such as the European Union. This would not satisfy critics such as Professor Alastair Campbell, emeritus professor of ethics and medicine at Bristol University, who argued at the BMA's debate that even in a developed country only the most needy would subject themselves to the risks of surgery for cash.
This is to ignore those who trade their health for financial gain. The man trying to support his family by selling a kidney is not so very different from one who puts in shifts down a mine or risks his life as a deep-sea fisherman. The ethical market is aimed at reducing harm, not eliminating it. The question is not whether it would be good but whether it would be less bad than the existing illicit, unregulated trade.
Organs can be taken safely from living donors and given to dying patients to save lives. Boosting the supply of organs through a form of ethical market would not only bring hope to the thousands awaiting a transplant; it would also reduce the exploitation of the vulnerable poor exposed to a rapidly growing illicit market. It is time to confront that grim reality.
Jeremy Laurance is health editor of 'The Independent on Sunday'Reuse content