Lucille Hubbard is a tiny woman. Lucille, not her real name, is poor, black, and dependent on Medicaid and public assistance. After leaving the West Indies for New York as a young adult, Lucille made her living caring for people in need. Before turning 25, however, she learned that she suffered from untreated hypertension and kidney disease. Her physician at a large public hospital told her that her end-stage renal disease was dire. She would need dialysis while waiting for a transplant, or she would die. “I went through so much in my life,” Lucille said. “This seemed like the last straw.”

After a long struggle over her resident status, Lucille obtained her green card and was put on dialysis while waiting for a donor kidney. After several frustrating years waiting for the United Network of Organs Sharing (UNOS) to offer Lucille what she needed—a dead man or woman’s kidney—she finally received a transplant from a brain-dead donor. But the transplant failed after a few years when she rejected the kidney. A serious heart condition and severe anemia made it impossible for Lucille to endure regular dialysis treatments. She tried to find a living donor among friends and relatives, but those who agreed were bad matches.

Her health rapidly deteriorating, Lucille considered an illegal transplant abroad from a paid living kidney donor. Lucille was put in touch with an Israeli-led syndicate of organ brokers, part of a worldwide network of transplant traffickers. The brokers suggested a “transplant tour” to Turkey or Romania, but the price of the prearranged package deal to Turkey was an astronomical US$180,000, and the cheaper option of rural Transylvania was frightening. Lucille feared that she might reject a kidney from a Romanian or Turkish peasant. She needed a cheaper alternative and an organ from a person who was, she felt, biogenetically “closer” to herself, preferably a kidney from a black person. “I am not a racist,” she told me. “But I was afraid of going all that distance and facing another organ rejection.”

Then Lucille got the call she was hoping for. A broker arranged a bargain transplant tour package: US$65,000, including the US$6,000 fee to pay a poor donor to forfeit a spare part. A kidney seller had been found in a slum of Recife, Brazil: a strong, healthy, Afro-Brazilian man with an O (universal donor) blood type. But Lucille and her donor would have to travel halfway around the world to a private transplant clinic in a prestigious hospital in Durban, South Africa.

The New Medical Ethics

The neo-liberal adjustments of societies to meet the demands of economic globalization have been accompanied by depletion of traditional modernist, humanist, and pastoral ideologies, values, and practices. New relations between capital and labor, bodies and the state, inclusion and exclusion, belonging and extraterritoriality, have taken shape. Some of these realignments have resulted in surprising new outcomes: for example, the demands for “medical” and “sexual” citizenship in countries such as Brazil and India, which have challenged international patent laws and trade restrictions to make lifesaving drugs available. Others—for example, the spread of paid surrogacy in assisted reproduction—have reproduced existing inequalities.

These trends are starkly crystallized in the global markets in bodies, organs, and tissues, which supply the needs of transplant patients willing to travel great distances to procure them. But rather than lament the decline of humanistic social values, I recognize that the material grounds on which they were based have been altered almost beyond recognition.

The entry of market incentives into organs procurement has thrown into question the transplant rhetoric on “organs scarcity.” There is obviously no shortage of desperate individuals willing to sell a kidney, a portion of their liver, a lung, or a cornea for a pittance. While erasing one vexing scarcity, the organs trade has produced a new one—a scarcity of transplant patients of sufficient means and willingness to break, bend, or bypass laws and longstanding codes of medical ethical conduct. The organ trade depends on four populations: desperate buyers, equally desperate sellers, renegade surgeons, and well-organized organs brokers.

Organs markets require a radical breach or highly selective use of classical medical ethics, based on a blend of Aristotelian virtues and the Hippocratic ethic of purity, loyalty, compassion, and respect for the dignity of the patient. In the Hippocratic tradition of medical ethics, the physician owes his loyalties to the patient alone, as if society, let alone the rest of the world, did not exist. This tradition has allowed many esteemed transplant surgeons to turn a blind eye to private arrangements that violate existing laws.

In response to the privatization and commercialization of transplant medicine, many surgeons espouse a post-humanist utilitarian ethic. The late transplant nephrologist Michael Friedlander explained his own acceptance of kidney trading to advance a greater good: “Recently I was told that I am a utilitarian. I had always considered myself a humanitarian, but I have since developed some doubts about my beliefs.” He was convinced by the favorable outcomes of his post-transplant kidney patients, both Jews and Arabs, who had traveled abroad for a transplant from a living donor. “I would do it myself,” he told me on many occasions.

Indeed, the kidney trade evokes Primo Levi’s timeless moral and ethical gray area. One will go to great lengths to save or prolong one’s own life, but at what cost to another person’s life, and to such cherished social values as social solidarity, justice, and equity that had previously informed organ donation practices?

The Buyer

Before leaving for Durban, Lucille had her blood drawn at a New York City hospital. Meanwhile, blood was drawn for cross-matching in Recife, Brazil. After a strong, healthy man was identified as a compatible donor, contracts were signed, false affidavits witnessed, and Lucille briefed on her arrival in South Africa. She would have to pretend that the impoverished stranger, dressed in a blue polyester running suit, and with whom she could not communicate a single word, was her first cousin. “I am a poor, God-fearing woman,” Lucille said. “I didn’t want to lie and I never wanted to hurt anyone. I just wanted a few more years to live.” The South African doctors and surgeons seemed too busy to ask questions. The operation took only a few days.