Black Markets: The Supply and Demand of Body Parts

  • Michelle Goodwin
Cambridge Univ. Press, 2006 288 pp., hardcover, $30 ISBN 0521852803 | ISBN: 0-521-85280-3

If you want to attract attention to the problems of health disparities along racial and ethnic lines, take a page from Michelle Goodwin. In fact take her title page: Goodwin's provocatively labeled Black Markets makes good on the implicit promise of any book bearing such a label: it shocks the reader with well-researched accounts of the abuse of black patients who are candidates for organ transplantation, then argues that the systematic inequality in organ transplantation is the result of racism inherent to the transplantation system. The book is a blistering critique of the supposed altruism that is at the core of transplantation ethics: Goodwin takes on the heavy burden of showing not only that the system operates in a racist way, but that racism and ethnocentrism arise almost necessarily, and indeed almost by design, from the way in which that altruism is framed.

There is no doubt that the current organ donation (or to use the more apt term for Goodwin, procurement) process in the United States is flawed in its design and efficacy. More than 82,000 listed patients await transplants. Seventeen of these patients die each day. Such is the reality of a system that is built around three incoherent parts. First, the patient must be medically evaluated, which can be a significant economic and/or social barrier. Second, the evaluation, in ideal circumstances, is made primarily in terms of how well the patient would fare with transplantation: that is, whether the patient would survive the transplant, comply with and thrive in the face of immunosuppression and other post-transplant regimes, and generally be unlikely to 'fail' transplantation. Third, patients wait until their number comes up—which happens in most cases when they are the sickest on the list of those selected as appropriate candidates for transplantation. Being wealthy helps in step one. Being healthy helps in step two. Being the least likely to live helps in step three. Does this make sense?

Unsurprisingly, this system does not help blacks in America. They wait longer than all other ethnic groups for organs. They have the highest death rate of all populations while on the transplantation list. Blacks, says Goodwin, citing a Case Western Reserve study, are more likely to be donors of organs used in cadaveric organ transplantation than whites. For all of these types of organs, whites are more likely to be recipients.

What makes this book most interesting are two claims: that race has significantly shaped our organ procurement system in the United States and that the most promising solution to both a lack of organs and racial problems in this system might be a market-based one.

Relying heavily on interviews with 40 people, Goodwin argues that, in the transplantation system, the medical establishment hurts blacks in ways that almost cannot be avoided. Through these stories, she offers a telling look at the unfortunate history of minorities' interactions with the healthcare system, intentional and incidental, that contributes to minorities' social mistrust of the medical system and how that mistrust manifests itself in the particular case of organ donation. In this sense, this book builds on the growing literature on black perspectives in bioethics by providing another case study of a context in which race has an important influence on the structure, function and outcome of healthcare.

Although it is clear that there is a disparity between blacks (and other minorities) and whites in the receipt of organs, the key ethical question is whether this difference amounts to injustice for the purposes of refining or gutting the organ procurement system. To answer this question, one would need to delve into the complex socioeconomic, cultural and institutional factors that may help to explain these disparities. Goodwin doesn't. It is highly likely that at least some of the causes of these disparities are rooted in racism and social injustice, but Goodwin could have made a much clearer and more defensible case by accounting for other social and cultural factors that could help to explain them, before asserting her claims. Instead she returns again and again to the system's lack of transparency and to possibilities of reform based on the directed donation to particular recipients of organs in a transparent system, without providing the economic analysis to make her claims strong enough to sustain the title.

Oddly, despite concerns that organ markets might be analogous to slavery or promote commodification of the body, Goodwin embraces the notion of cadaveric organ markets for organ donation and notes that fear of what an open market might bring—homicide for money, using people as a means to an end, and a possible return to slavery—are insufficient reasons to dismiss markets as a policy alternative. Goodwin concludes that the pressures that would exist with financial compensation/market systems for cadaveric organs already exist within the altruistic model of organ donation, and that a cadaveric market system would reduce reliance on altruism and give greater incentives to donors to participate. This is not a new idea, having been espoused by economists and discussed in the popular press. In a system so inadequately meeting demand, Goodwin seems to believe that alternative approaches demand consideration. But where is the analysis? Neither her interviews nor any of her arguments address the thousands upon thousands of peer-reviewed studies of market failure in transplantation.

However, the book more than makes up for what it lacks in rigorous analysis of the organ markets literature and in its discussion of the international organ trade by providing a rich description of the social and cultural contexts of African American experience with the healthcare system in the United States and detailed case studies of how this reality plays out in the organ procurement system. Goodwin has made a significant contribution to the American bioethics literature—the reader just has to make it past the provocation of the title.