1 Introduction

The prospect of buying and selling human organs raises important ethical issues. The arguments offered by opponents of a market for human organs are mostly founded on contingent factors, such as the conditions under which it takes place, the motives for participating in such transactions and the possible (undesirable) outcomes of this practice. These claims are mostly driven by generally accepted principles of biomedical ethics such as autonomy, beneficence, justice, nonmaleficence, and also from plausible moral concerns such as the protection of the vulnerable (Radcliffe-Richards 2013; Biller-Andorno and Alpinar 2014). More specifically, the usual objections to organ markets focus on concerns about harm, exploitation, coercion and social values.Footnote 1 In response to these concerns, some claim that none of the objections would necessarily apply in a fairly regulated organ market.Footnote 2 If the contingent factors were adjusted, all these arguments against organ selling could be defeated or reformulated.

Although it can be argued that such a fair organ market might never be possible in practice, the question remains whether we have reasons to think that there is something intrinsically wrong with buying and selling human organs for transplantation. Many intuitively believe that there is. A prominent argument in this regard is that selling organs violates human dignity.

However, it must be noted that there is not only one, but many different approaches to human dignity in bioethical debates. On the one hand, there are autonomy-enhancing arguments stating that having dignity means having claims of self-determination. On the other hand, there are arguments in which dignity is regarded as a constraint on our autonomous choices. This paper investigates these different approaches and critically evaluates both the negative and positive features of each of them. Such a critical evaluation leads us to propose a social account of dignity. It is argued that this approach presents the most plausible understanding of the concept of dignity in the debate by showing that (a) it can capture the moral difference between donating and selling an organ, (b) it accounts for the importance of including the relations between people and their attitudes towards each other, and (c) it sheds an interesting light on the question of why many people think that offering a transplantable organ for sale is morally impermissible.

The central claim of this paper is that treating persons in a way which is in conformity with their dignity is crucially linked to the symbolic meaning that specific actions as well as policies have. With regard to the organ selling debate in particular, it is argued that the practice of organ selling inherently runs the risk of promoting the idea that some persons have less worth than others, or even that their worth is comparable to a price. This paper claims that human dignity is violated by the fact that persons are symbolically perceived and treated in certain ways that are incompatible with their worth as persons. This approach is defended against possible objections, and it is shown that it can capture the idea that autonomy is linked to human dignity in important ways, while at the same time dignity can constrain the autonomous choices of persons under certain circumstances on the level of policy-making.

2 Is dignity just a rhetorical concept?

References to (human) dignity appear quite frequently in European Charters and International Conventions and Declarations (United Nations 1948; UNESCO 2005; Council of Europe/United Nations 2009) as well as in national laws and constitutions. Despite its widespread usage, the content of dignity is often vague, and is used to support opposing positions (e.g. in the debate about assisted suicide; cf. Beyleveld and Brownsword 1998; Andorno 2011). This vagueness has raised suspicions about its meaning and its possible role in moral debates: Does the notion of human dignity have any specific content? Or is it a redundant or merely rhetorical concept which is used as an argument-stopper?

There is an ongoing debate in the current philosophical literature about these questions. In very general terms it is argued, on the one hand, that dignity is a useless concept since the principles of ‘respect for autonomy’ (Macklin 2003) and ‘respect for the person’ (Pinker 2008) can be used instead of dignity without any loss of content. On the other hand, dignity is acknowledged as an absolute, intrinsic, metaphysical property possessed by all human beings regardless of any contingent properties (Nordenfelt 2004; Sulmasy 2009), as systematically developed by Kant (MMFootnote 36, pp. 434–436: 435; GFootnote 44, pp. 434–4: 436). From this latter perspective, human dignity is regarded as the basis of human rights (Schachter 1983; Gewirth 1992) and morality (Kass 2002). Some authors present also another understanding of dignity in addition to intrinsic dignity, which is not absolute and can be lost or gained. These variations of dignity depend on the subjects’ deeds and their consequences, on the subjects’ virtues, skills and talents, on their acting in accordance with society’s expectations; or on their positions or social ranks (Nordenfelt 2004; Schroeder 2008; Sulmasy 2009).

These discussions often stay at a very general and theoretical level. Although it might be difficult to find a unique definition of dignity, its violations are quite recognizable. In our view, one way to explore whether dignity has a distinct content and role is to probe it in specific practical contexts. A satisfactory notion of dignity would be able to reveal violations of dignity with regards to certain acts, and thus should be associated with occurrences in social life (Kaufmann et al. 2011, pp. 1–2). Furthermore, it would show that concerns about dignity are different from other concerns about, e.g., autonomy or harm. The practice of organ selling provides us with such a context, in which violations of human dignity are (supposedly) revealed. This issue is discussed in the following section.

3 Dignity-based arguments

3.1 Dignity as empowerment

Beyleveld and Brownsword (2004) distinguish two different views on human dignity: human dignity as empowerment and human dignity as a constraint. At the core of the discussion is the relationship between dignity and autonomy (Beyleveld and Brownsword 1998). This sub-section will keep the focus on the first view.

If dignity is considered as empowerment, then human dignity plays an important role in the founding of human rights (Beyleveld and Brownsword 2004, p. 11). Humans have intrinsic dignity, and it is this inherent dignity that serves as a foundation of human rights (Schachter 1983). Only by virtue of their dignity are people entitled to be recognized as a class of beings having worth, to be respected by others and to have the conditions under which they can experience their own dignity (Beyleveld and Brownsword 2004, p. 27).

According to this approach, ‘respect for human dignity involves treating agents as autonomous ends; it is, thus, complementary to the fundamental right of agents that their freedom and well-being should not be interfered with against their own will’ (Beyleveld and Brownsword 1998, p. 680). Hence, it might be argued that if dignity has a function, then it is not to restrict autonomous choices, but rather to reinforce the claims of self-determination.

Understanding dignity as reinforcing the claims of self-determination is a prominent position in the debate. It could be argued that any idea of dignity should be able to explain the link to respect for people’s autonomy. From this, it seems to follow that referring to the respect for autonomy principle is sufficient to authorize organ sales (unless this poses a threat or harms third parties), and hence there is no need to refer to dignity specifically.Footnote 5 From this understanding, dignity seems to be a redundant concept in the organ selling debate. This approach falls short of explaining the worry, raised in the introduction, regarding the practice of organ selling, and the concerns about dignity’s possible role in this specific debate. There could be a distinct role of dignity in this debate if it had a constraining role. The arguments that define dignity as a non-redundant value refer to dignity either as a social value that shall be protected or as an intrinsic value that human beings have by virtue of being human. In the following, the focus will be kept on these interpretations of dignity.

3.2 Dignity as a constraint

3.2.1 Dignity and the integrity of the body: the argument from the principle of totality

The first of these approaches to dignity states the importance of bodily integrity. This approach emphasizes the importance of the body as a whole and its inviolability. The idea of the human being as being ‘essentially embodied with all its parts’ (Stempsey 2000, p. 196) supports the view that although having autonomous claims over our bodies might enhance our autonomy, it misses ‘the dignity of our embodied human nature’ (ibid., p. 199).

This emphasis on the significance of the body as a whole is founded on Aquinas’ argument from the principle of totality. This principle requires an anatomical wholeness; hence any attempt to destroy this wholeness is morally impermissible—except for the removal of a diseased part that threatens the person’s life (Cherry 2005, pp. 118–121). Since the removal of any healthy organ ‘violates the natural good of the wholeness of the body’, it is ‘morally impermissible’ (ibid., p. 118).

Due to the emergence of transplantation techniques and the good outcomes that donation might be able to promote, this principle was then reinterpreted by contemporary Thomists with an emphasis on the wholeness of the body to preserve human biological functioning rather than anatomical wholeness (ibid.). On the basis of this interpretation, the removal of redundant organs or regenerative tissues, while maintaining the adequate biological functioning of the human body, does not violate the principle of totality (ibid., pp. 124–126; Wilkinson and Garrard 1996, p. 338).

According to Cherry, the removal of a healthy organ could sufficiently be justified by the principle of charity, which would counteract the moral inappropriateness of such removal according to the principle of totality. Although a violation of bodily integrity occurs by donating an organ, the good of being charitable—the ultimate end and the purity of the motive—has more weight and is more valuable than the good of preserving one’s own body as a whole (Cherry 2005, p. 123; Smith 1999, p. 105; Wilkinson and Garrard 1996, p. 338).

However, the principle of totality does not say anything about the sale of organs. Hence, following the reinterpretation of the principle, if one is able to donate or give away a healthy organ, one may also have a sufficient reason to sell an organ (Cherry 2005, pp. 125–126; Bole 1999, p. 333; Boyle 1999, pp. 135–136). Therefore, it might be argued that a market for organs is not inconsistent with the principle of totality as long as only regenerative tissue and redundant organs are removed and biological human functioning is maintained (Cherry 2005, p. 126).

Cherry (ibid., p. 125) argues that the differentiation between donating and selling an organ is only justified if it can be shown that selling organs is intrinsically wrong. William E. Stempsey argues against a market for human organs on the grounds that commodification of organs destroys ‘the integrity of the embodied persons that we are’ (2000, p. 201). Though not clearly expressed, it is stated that dignity is established by the integrity of one’s own body. ‘Paying living people to give up their organs violates the dignity of embodied human persons by encouraging them to fragment their very persons for economic benefit’ (ibid., p. 202).

An important point about Stempsey’s argument is his distinction between transplantable organs and other parts that are different from organs, such as hair. He argues that, since organs are ‘integral parts of us because they sustain life’, and hair is not, ‘[t]o commodify organs is to destroy the integrity of the embodied persons that we are’ (ibid., p. 201). He supports his argument about persons as embodied human beings by referring to Kant’s passages on the difference between persons and things (ibid., pp. 199–200). However, although he is right when he states that when a person sells one of her organs, the person is treated as if she was a thing, he cannot clarify the difference between donating an organ and selling it. This is, in our view, an important shortcoming of his position and presents a crucial step for the following sub-section.

3.2.2 Dignity as an intrinsic value

Immanuel Kant does not provide any specific arguments relevant to a market for human organs. However, the passages emphasizing his concern about the moral relationship between our bodies and our selves are referred to in order to argue in favor of the impermissibility of the practice of organ selling.

According to Kant, human beings have an intrinsic worth, which is dignity. This significance of the person is derived from the nature of the human being as a rational being, who is the ‘subject of a morally practical reason’ (MM 6, pp. 434–436: 435). Dignity is ‘an absolute inner worth’ inherent in possessing the faculty of reason (ibid.), hence rational beings, i.e. human beings, cannot be devoid of it.

Regarding the organ trade debate, Kant’s most important distinction is between price and dignity. Dignity is an incomparable and unconditional worth, which is above all price (G 4, pp. 434–4: 436). It should be noted that ‘Kant’s meaning of price does not only pertain to the market’, but also refers to human inclinations, needs and people’s interests (Gerrand 1999, p. 64; G 4, pp. 434–4: 435). Thus, if something can be replaced by anything equivalent, then this thing can be valued by means of a price, whereas if a being has dignity, there cannot be any value equal to that being.

According to Kant, there are restrictions on what a person is morally allowed to do with her body and its parts. The significance of the body and its parts is derived from the significance of the person because the person constitutes every part of the body together with the self (LEFootnote 627, p. 387). Persons should be treated with respect, as ends in themselves (MM 6, pp. 434–436: 435), as is commanded by the second categorical imperative (G 4, pp. 428–4: 429). From this it follows that treating a body part as if it was a thing, by self-maiming (MM 6, p. 423), would mean transforming one’s body into a thing, which in turn would mean transforming one’s self into a thing (LE 27, p. 387). To treat one’s body as if it was separate, as if it was a thing, would end in degrading the person’s humanity. Because, humanity does not only include rational aspects of persons, but also the body together with those aspects. All the specific features that characterize humans as rational beings, such as rationality, autonomy and freedom are included in the concept of humanity. These features distinguish humans from all other beings and are the source of mutual respect which leads to acknowledgment as a rational being (MM 6, pp. 434–435).

It might be argued from this line of reasoning that Kant’s concern when applied to giving away body parts is about treating the person as a thing, and not as a subject, an end in herself, which leads to a contradiction in the nature of the human being. Thus, when persons give away their organs or body parts, either by selling or donating them, they treat these organs or body parts as things, and hence they treat themselves as if they were things.Footnote 7 Hence not only would selling an organ be impermissible, but donating it would be too. For that reason, it is unclear whether we can morally differentiate between donating an organ and selling it.

Some authors appeal to Kant to argue in favor of organ donation and against organ selling. First, some state that the individual motivation is crucial in this regard and argue that Kant’s arguments do not prohibit donating organs but only selling them (Morelli 1999; Heubel and Biller-Andorno 2005). For instance, Morelli argues that only giving away an organ for monetary interests would turn the organ into a commodity. Organ donation might be an imperfect duty of beneficence (Morelli 1999) or love (Heubel and Biller-Andorno 2005) and not lead to any contradiction, hence making it morally permissible in Kant’s ethical framework. Second, some argue for the moral impermissibility of selling by making a distinction between body parts that are integral to our functioning and those that are not (Cohen 1999, 2002).

However, in Kant’s ethical framework, it is not plausible to argue against selling whilst promoting live donation. First, although motivations are relevant in Kant’s moral philosophy, the only exception for the removal of an organ or body part is for the sake of self-preservation, as Kant’s amputation example implies (MM 6, p. 423). This is because self-preservation is the only condition under which people treat their body parts as things without treating themselves as if they were things, and self-preservation is not a discretionary end (MM 6, pp. 422–426: 423). Thus, the removal of diseased organs is allowed; however, such diseased organs cannot be used for donation. Second, the organ would turn into a commodity not only by putting a market price on it, but also by giving it away (even for beneficiary reasons), since it would be treated as if it was a thing. Third, since every part of the body, whether integral to the functioning or not, constitutes the person together with the self (LE 27, p. 387), it is not very plausible to claim that Kant distinguishes between body parts that are essential to functioning and those that are not. Some argue that a distinction might be made for giving away an organ or part based on their effect on one’s rationality. However, this position would imply supporting organ selling as no distinction is made between selling and donating an organ (Gill and Sade 2002; Cherry 2005).

Compared to the position which is grounded on the functional wholeness of the body, Kantian arguments, with an emphasis on the distinction between price and dignity, sound more promising. However, they are still problematic since no clear and reasonable moral distinction can be made between donating and selling an organ.

3.2.3 Dignity as a social value

If someone autonomously decided to sell one of her kidneys, why would she not be allowed to do so? According to Cohen (1999, 2002), the dignity of human beings functions as a constraint on individual preferences and choices. These constraints are based on social convictions that Cohen explains by referring to what John Rawls describes as ‘public reason’, i.e. the reasons that all citizens should rationally and reasonably agree upon (Cohen 2002, pp. 59–60). Since the people are living together in a society, some values, agreed upon by public reason, ought to be respected and protected by the government. These values include respect for the dignity of all human beings, which would be violated by turning one’s own body into a commodity. Thus, Cohen’s concern is not about the autonomy of the person who offers one of her kidneys for sale, but rather about whether such an act would violate human dignity. Cohen’s main thesis is that we should not permit organ selling, since such a practice would diminish human dignity (that of everyone), as well as solidarity among (all) people (ibid., p. 59), whereas we should promote organ donation, since it promotes respect for persons and humanity.

Thinking of dignity as a constitutive social value, and of its function as restricting autonomous free choices, raises a social concern: a highly promoted social value (i.e. dignity) would be jeopardized by organ selling, which in turn would shake the pillars of mutual respect. The social element of this aspect is important if we think of how the relations and attitudes of individuals towards each other might be shaped concerning some practices. However, in Cohen’s argument we cannot find a deeper analysis of what dignity means, why it is important and what it encompasses. Hence, she just refers to this concept without any content, but simply as a value to be protected, no matter what.

4 What have we ascertained so far? A brief analysis

The aim of this section is to give an overview of dignity up to this point to see both the positive and negative aspects of each interpretation of dignity. This analysis, we think, will help us to find out which aspects should be adopted and further developed in order to build up a successful understanding of dignity.

First, we considered dignity as reinforcing the claims of self-determination, and thus enhancing the autonomy of the person. This approach somehow equalizes respecting persons’ autonomous choices with respecting their dignity. Hence, dignity seems to have no specific function except to emphasize respect for people’s autonomous choices. Also, this approach does not provide us with any answers regarding why there is a moral difference between offering a kidney for sale and donating it, and whether social relations and attitudes towards others are at all significant when we consider such practices. Underlying this approach is a view of persons as isolated individuals responsible for their own decisions and actions. If we think that some actions, such as offering organs for sale, or even tossing dwarfs for fun,Footnote 8 raise concerns and are widely believed to pose a threat to human dignity, then a merely autonomy-based position seems insufficient as it fails to take the social relations between persons seriously.

Second, we went through the approaches that consider dignity as having a constraining function on one’s choices. We began with an approach that explains dignity in terms of the integrity of the body. The significance of the body as a (functional) whole leaves us with a quite limited perspective on how one should treat one’s own body. According to this approach, if people’s bodily integrity were violated, their dignity would also be violated. As argued, a violation of bodily integrity occurs through donating an organ. Thus, although the body’s functional wholeness would not be that much affected, the integrity of embodied human beings would inevitably be violated. Although the defenders of this view want to draw a distinction between donating and selling an organ, they fail. We did not come across any argument showing how donating an organ would not violate bodily integrity, but selling an organ would.

Considering dignity as an intrinsic value—as developed by Kant—seems to be the understanding mostly referred to in the debate when arguing against organ trade. Although it is very attractive, this Kantian view also has some controversial implications with regard to giving away an organ, either by donating or selling it. As argued, this view does not allow to make a moral distinction between donating and selling an organ.

The account of dignity that regards it as a social value offers a promising approach to understanding dignity and explaining why organ selling is regarded as a violation of dignity. Its emphasis on the social relevance of dignity strikes us as quite important (see above). However, Cohen does not explain the content of the concept of dignity satisfactorily.

Thinking of dignity as a socially relevant value, which manifests itself through the relations or attitudes of people towards each other in a society, would help us to see whether violations of dignity occur with regards to certain acts. In the following section, we will develop an account that can deal with the challenges that have been formulated in the last sections: A successful account of dignity should (a) show what the moral difference is between donating an organ and selling it, (b) explore whether a moral impermissibility exists with regard to offering an organ for sale, and (c) include relations between people and their attitudes towards each other.

5 A social understanding of dignity

Some actions, independently of whether the person has chosen to act autonomously, are considered to pose threats to the dignity of the person in question by symbolizing the view that some people might lack the worth, which is believed to be possessed by every human being equally from birth (United Nations 1948, Art. 1). The practice of organ selling is believed to be such an action (Council of Europe/United Nations 2009; WHO 2010). The account of dignity developed and defended here addresses exactly this point.

The distinction between having a price and having dignity is worth considering. Putting a price on an organ makes ‘calculable the value of the organ and the whole human being to which it is integral’ (de Castro 2003, p. 144), which is an argument used to demonstrate the moral inappropriateness of organ selling (Cohen 1999; Morelli 1999). One can object to this claim that the money offered for the loss of an organ is ‘a symbolic token of the worth of the organ’, which also means that it symbolizes compensation only for the loss of the organ and not for the so-to-say immeasurable price of the organ itself (Joseph 2006, p. 18). It might also be stated that it is wrong to equate one’s organs with one’s entire body, and hence selling a kidney is not actually selling one’s self (Gill and Sade 2002). However, these considerations miss the important point that price should not be understood as being limited to a market price, but should rather be interpreted in a social way.

The main idea regarding this account is this: Some practices are supposed to have symbolic meanings, to which dignity is crucially linked. Such practices inherently run the risk of others being perceived as if they had a lesser worth or as if their worth was comparable to a price and that is incompatible with dignity, which is also raised by WHO Guiding Principles (2010, Commentary on Guiding Principle 5). This approach explains why it is intuitively held by many that the purchase of organs involves something wrong, violating human dignity even when the person (i.e. the vendor) is argued to have participated in the practice willingly. Dignity’s social elementFootnote 9 appears when dignity constitutes an idea about how people would like to be perceived and treated by others. This account clarifies such an intuitive notion of dignity with an emphasis in the social relations about people’s changing attitudes, perceptions and conceptions towards others who participate in such transactions.

It is important to note that in this account, the worth of persons is unconditional (each person has this worth equally) and incomparable (no one person can be traded for the sake of another). This ‘incomparableness’ feature, in particular, emphasizes the worth of humans that should be acknowledged in our attitudes and actions (Hill and Zweig 2002, p. 80), and it puts emphasis on social relations as stated above.Footnote 10 Being different from social dignity,Footnote 11 this understanding of dignity has moral relevance. A person cannot herself can violate her own dignity; only the attitudes and perceptions of people towards her might pose threats to her dignity. In this sense, relations actually play a role for dignity. Though violated, a person’s dignity cannot be lost or gained.

This understanding offers, in our view, a promising way of explaining why some actions are considered to violate human dignity. The occurrences of violation are generated by actions that are regarded as humiliating and degrading,Footnote 12 which might be influenced by the attitudes of people towards each other. Violations of dignity in the organ trade debate symbolize a tendency to see ‘each other as repositories of organs and other bodily bits and pieces’ (Cohen 1999, p. 294), to perceive people as if they had a price (Kerstein 2009)Footnote 13 or to see them as objects to be used at will.

This concern becomes relevant when people’s attitudes towards others start to change; such as seeing other people as an inferior species, which in turn establishes a threshold determining which actions are legitimate and which not. Hence, a social understanding of dignity takes notice of the relationships of people to each other, how they see each other and how they are regarded. This perspective has also been adopted by some international policy. According to the WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation (2010), all commercial removal of transplantable parts should be forbidden due to the concern that ‘[s]uch payment conveys the idea that some persons lack dignity, that they are mere objects to be used by others’ (Commentary on Guiding Principle 5). There are some qualitative studies which indicate that people who offer their kidneys for sale are seen as worthless and seemingly inferior to others, in addition to their experience of social harm and isolation from society (Zargooshi 2001; Scheper-Hughes 2003; Budiani-Saberi and Delmonico 2008). They are stigmatized by their families, as well as by society, and are labeled as weak and useless (Zargooshi 2001).

A general public opposition might justify the prohibition of organ trade. However, that is not enough to show the crucial moral difference between donating an organ and selling it if we pay attention to the external factors already mentioned in the introduction. Besides, if one argues that the varying motivations of each person taking part in such a transaction, might probably affect people’s notion of the acceptability or unacceptability of the action as being dignified or humiliating (de Castro 2003), then to claim there is a general public opposition might be quite misleading. Why are commercial transactions of human organs generally thought to be unacceptable whereas donating organs is appreciated, praiseworthy and encouraged? We do not come across the notion that when someone donates a kidney, her dignity is violated. On the one hand, it is usually claimed that when a person donates an organ, she is acting autonomously. On the other hand, it is often argued that the seller’s dignity is violated even though she has acted autonomously. The reason for this might be that donating an organ as a kind of gift does not usually lead other people to see the donor as an inferior kind of person or as a person to be used at will, and hence the donor is not subject to any violations of dignity.

A social understanding of dignity draws on the idea of symbolic violations of dignity. The affected persons do not have a lesser worth, but they might be perceived as if they had a lesser worth than others. If a specific kind of social practice encourages or induces to perceive the persons involved in that practice as if they had a price or a lesser worth, then this claim is an empirical one. Although we cannot measure how such a violation of dignity occurs (i.e. how strong an idea about seeing people in a specifically inferior way is induced), the empirical studies mentioned in this section seem to indicate that there actually is a tendency to see others as lacking dignity whenever they perform unfavorable acts. This is more about an intuition that certain ways of treating people conflict with how we ought to view people.

It should be noted here that although this social account of dignity is inspired by Samuel J. Kerstein’s approach, it differs from it. Kerstein’s approach (2009) cannot avoid including a contingency in his account when he lays emphasis on perceiving certain classes of people as lacking value. For him, whether a practice violates dignity depends on a cultural and social context in which some more affluent people tend to see others as available to use at will or as purchasable. Whereas, in our account, a more stringent and coherent idea of dignity, which encompasses every individual regardless of the contingent situations that people are in, is used to determine the moral permissibility of a practice. It is understood as a social value regardless of how materially well-off the people are.

Is the argument proposed a strong one? Can we say that it is principally wrong to offer a kidney for sale on this account? Instead of starting out with an identification of the action as an act of a certain sort, we critically assessed the dignity-based arguments and arrived at the implication that a social understanding of dignity is better suited to explain why organ selling is usually considered to violate dignity. This explanation applies regardless of whether people involved in practice are materially well-off or economically vulnerable. In this regard, organ selling is not contingently wrong, but is necessarily wrong. It might be claimed that it is not principally wrong, since the argument is founded on a certain kind of contingency in that it takes into account human relations. However, even if the circumstances under which the action takes place were improved, the readiness to see others as having a lesser worth or as having a price would probably remain.Footnote 14

The social approach to dignity thus gives us a basis for understanding why violations of dignity occur with regard to some specific social practices. Although this approach might not seem convincing enough for the man in the street, or the poor vendor with limited options offering her kidney for sale as a last resort, it does address the practice of organ selling in general; that is, on the level of policy-making, rather than on the individual level.

6 Three possible objections and replies

6.1 Constraining autonomy

As we have seen, in our approach dignity functions as a constraint. This might raise some concerns about how a social understanding of dignity can take priority over persons’ autonomy. Is it justifiable to constrain people’s autonomy on the level of policy-making? Although it is not self-evident to claim that the practice of organ selling is among the actions considered to involve violations of dignity, it is generally believed that selling an organ for an amount of money is perceived as humiliating and degrading, even when the parties participate freely and autonomously. Since this claim is founded on an assumption shared by many individuals, it is intuitive, which would make it seem not to be a good justification for such constraints. However, it would be out of place to claim that such restrictions on our autonomous choices could lead to an unacceptable paternalistic state for in our liberal democratic societies we actually do have justified public limits and restrictions. It should be mentioned that respect for one’s dignity involves respect for one’s individual choices. Not respecting people’s choices and autonomy also means not treating them in a respectable way. However, some individual choices, independent of how autonomously they are made, encourage the idea that some persons have a lesser worth or a worth comparable to a price. As has been argued, organ selling encourages this idea.

6.2 Redundancy

It might also be argued that although dignity can have a specific content emphasizing the importance of social relations, we do not need to refer to this concept in order to support the prohibition of organ markets. This criticism hints at a potential redundancy in this concept. Based on the evidence of the circumstances under which organ trade is being practiced, and on the assumption that it not very likely for an economically well-off person to offer one of his kidneys for sale (Rid et al. 2009), organ trade targets economically vulnerable people. Thus, in order to avoid exploitation of the poor, this practice should be forbidden. Although these facts and arguments concerning exploitation, vulnerability and fairness give us reasons to raise global awareness and to forbid the practice, they fall short of demonstrating the significance of the thesis of seeing people as if they had a price. The practice’s social impact is unlikely to be limited to those who are economically vulnerable, but instead is broader. It seems plausible to say that the same attitudes and feelings would probably arise even if the act was performed by a materially well-off person. In addition, besides the exploitation and fairness issues, this understanding presents us with different, even better reasons to support a global prohibition, which demonstrates the distinct function of dignity.

6.3 Taking ‘having a price’ too seriously

Does our approach lead to strong, unintended conclusions? Could the same notion be encouraged with all, so-to-say unfavorable practices? For instance, the jobs that no one wholeheartedly chooses to perform might be considered as among the practices which encourages the notion that some people, especially those who need to work to make a living, have a price or can be used at will for money. If this is so, then violations of dignity occur whenever people perform such jobs. However, this is not so likely to happen. Working at a job is not generally considered to be a humiliating or a degrading act, and therefore no violations of dignity occur by performing such jobs. It is not performing the job itself, but rather the conditions of the job that might be considered as leading to violations of dignity.Footnote 15 The conditions can always be bettered, so performing such jobs might not encourage that notion. However, for organ selling, this might not be the case. As the main thesis of this paper points out, it still poses threats to one’s dignity even under better regulated conditions. For instance, the conditions under which the practice takes place could be improved by having a regulated market. However, even in a legal regulated market system, people’s attitudes and feelings are not subject to such parametric factors with regards to organ selling (Zargooshi 2001).

7 Conclusion

This paper claims that a social account of human dignity offers intelligible reasons for why many think that organ selling violates dignity and is, therefore, morally impermissible. A social understanding of dignity shows the significance of dignity’s role in the debate by emphasizing that this concept is not merely synonymous with respect for autonomy. The position defended in this paper draws our attention to the constraining function that dignity may have. It also presents supportive reasons for why it is generally thought that organ trade, independently of the contingent circumstances in which it takes place, poses threats to one’s dignity. Therefore, it is a promising approach to assess the moral impermissibility of organ trade. Our account of dignity implies that dignity is not just rhetoric—its emphasis on social relations, and how the attitudes and conceptions of people change towards others, draws attention to the content this term has absorbed, making it far more than just an argument-stopper.