Exchanging One Hardship for Another

In this issue, Moazam and colleagues offer a complex and nuanced study of the postsurgical consequences of kidney vending in Pakistan’s Punjab region, providing a comprehensive response to highly polarized debates over the commercialization of “fresh” body parts. Proponents consider organ sales a legitimate solution to organ scarcity, defending vendors’ rights to make autonomous decisions in a national or global marketplace. Opponents condemn commercialization as unjust and immoral because it preys upon poor, disenfranchised, and desperate people denied access to basic human needs. This study impressively disentangles vending’s clinical, psychological, and social consequences, marking an important paradigmatic shift in biomedical, bioethical, and ethnographic understandings of body commercialization.

The study is methodologically sophisticated and interdisciplinary in scope, enriching existing knowledge. As physicians, the team members possess the skill to assess clinical and psychiatric dangers; their ethnographic rigor is also exemplary. Although several important ethnographies expose the detrimental social consequences of kidney vending, a paucity of clinical data remains, especially for impoverished populations. In North American clinical circles, only one post–World War II study (that predates organ transplantation) informs discussions of the benign effects of living with one kidney. Contemporary data on postsurgical morbidity among kidney donors is also scant and often anecdotal. Generally, studies are based in transplant wards most concerned with recipients’ needs, fail to track donors’ postsurgical health beyond a few months, and only involve patients with access to quality health care. This project challenges the relevance of North American assumptions by expanding the field to include impoverished communities in Pakistan. Vendors’ already shaky socioeconomic status and health are dangerously compromised by selling a supposed “redundant” organ.

By journeying beyond the hospital and into vendors’ communities, the research generates troubling findings. All vendors endure strenuous manual labor (and certainly suffer from poor nutrition, too); simple nephrological tests reveal evidence of kidney disease or failure. Such clinical dangers are compounded by anxiety, depression, self-loathing, diminished self-worth, and suicidal tendencies. Vendors are marginalized socially, too—considered “half a person” once they’ve lost a kidney. Pronounced fatigue is common, rooted simultaneously in sickness and depression. Vendors and their kin can ill afford such outcomes when their ability to labor is a matter of life and death. Economic survival is often worsened, generating a vicious cycle of inclusion as others are pressured to sell their kidneys, too.

Market principles hold that vending alleviates shortages and generates a safe supply of organs, yet scrutiny of the data reveal shocking sociomedical dangers affecting a surprisingly wide range of parties. Several vendors recount tales of recipients’ deaths, from which one might assume that vending attracts middlemen and surgeons who privilege profit over safety and willingly endanger both rural vendors and foreign “medical tourists.” At its worst, vending does not merely shift the burden of ill health from buyers to impoverished vendors; it may devastate a range of households and communities at either end of the buyer/vendor spectrum. Even zamindars, who profit from vending through debt repayments, now fear kidney failure. Vending clearly endangers an extraordinary range of parties.

The justifications of commercialization thus rely on faulty premises. Rather than helping to expand the pool of available organs, vendors replace altruistic donors—a finding relevant to both South Asia and North America. Kidney sales also fail to improve vendors’ lives, often driving them deeper into debt because their labor power is diminished. Instead, the sale replaces one kind of hardship with another. Punjabi vendors are locked in a lifetime of debt controlled by zamindars and facilitated by national policies. A contemporary form of enslavement is at work, where more privileged parties can own another’s labor power or purchase their body parts.

The frightening truth revealed here is that laboring vendors’ lives are expendable. This in turn drives the slippery slope of embodied “redundancy” wherever organ markets thrive: some vendors now sell sections of their livers, one of their two corneas, sometimes even their lungs or other body parts hoping to acquire just a bit more cash to free themselves temporarily from their insurmountable debt and suffering.