The vendors were from low-income groups with a mean family income of 3,600 pesos a month. More than half of them had not finished high school and 20 percent were unemployed. Almost all of them said that they gave up their kidneys primarily for money (seven said that their motive was to help the patient). They were paid about one hundred thousand pesos to give up one of their kidneys.

The survey showed that most of the kidney vendors (71 percent) would not have sold their kidneys knowing now that their economic status has not improved and their physical health is probably compromised. All of them said that, if asked by others, they would not recommend their friends or relatives undergo the operation.

This study reveals a number of the reasons why the removal of a kidney from an otherwise healthy human being for the purpose transplanting the organ to a patient in kidney failure who has no relation to the donor is almost always unethical and should not be allowed legally. Exposure to surgical risk per se and the high probability of future health impairment certainly violates the first principle of medical ethics – "first, do no harm".

Contemporary ethicists would allow possible harm to a human being if there is a commensurate benefit to be derived from the procedure. In the case of the Quezon kidney vendors, the only benefit was the small sum of money which in fact did not alleviate their financial and social conditions. Although the removal may have benefited the recipients, without any kinship links, such benefits were far removed from the vendors.

Then there is the issue of free and informed consent. The study showed that the Quezon vendors did not realize the risk they took when they underwent the surgeries. Additionally, the offer of a hundred thousand pesos to a person whose family income is only three thousand a month is tantamount to coercion. On this score, the procedures performed on the Quezon vendors are also ethically flawed.

But on the issue of allowing the transplantation of kidneys from living non-related donors (LNRD), individual ethical considerations pale in comparison to the grave public health and social implications of a government policy that not only allows but actually encourages this procedure to be carried out in public and private hospitals. This is in fact what the Department of Health’s A.O. 2008 s. 004 does in effect.

With its provision that allows "non-directed" donors to give up their kidneys, the Order opens a loophole that kidney brokers can exploit to entice surgeons to harvest kidneys from LNRD individuals. This will create a cohort of members of society whose health is at greater risk than others. If and when, universal health care becomes a reality, this pool of at-risk individuals will potentially be a burden to whatever health system is in place at that time. But even if the present system is maintained, the social welfare community will have to bear the burden of taking care of them when they do get ill. This is a fatal policy flaw since policies, especially in health, should be forward looking and anticipate the future.

As pointed out in last week in this space, the worst implication of the recent issuance on LNRD is that on equity and justice within the health system. As pointed out during last week’s press conference called by the Philippine Society of Nephrologists, any policy is immoral that allows wealthy Filipinos and foreigners access to the kidneys of economically deprived Filipinos who themselves do not have access to any of the interventions needed for diseases such as end stage renal disease.

There is an interesting sidelight in the simmering controversy over LNRD. This is the difference of opinion between kidney transplant surgeons on one hand and nephrologists on the other. Obviously, there is a minority on the fringe of either side of the controversy whose motivation is financial (i.e., when a patient in end stage renal disease is transplanted, the surgeon gains (from his substantial fee) at the expense of the nephrologists (who loses a patient who would otherwise be on dialysis). Nevertheless, the vast majority of the doctors involved are ethically upright and act on their perception of what is best for the patient.

For this majority, many of the issues are technical – covering questions such as when is the optimal to do a transplant, or whether an available kidney is truly suitable for the matched recipient. In order to avoid distraction from the major considerations of equity, justice and appropriateness of interventions, it behooves this majority group of concerned doctors to resolve these differences in a collegial manner and to agree on set guidelines and protocols for transplantation itself.

Only when this happens, can the whole health community led by DOH mobilize a major effective effort to promote living related donor and cadaver donations on a scale massive enough to meet the needs of all Filipino patients in need. Should the effort result a surplus, then and only then can the country open its kidney transplant program to foreigners.