Session 2: Procuring Organs for Transplantation: Ethical Considerations

Council Discussion

CHAIRMAN KASS: Council Members, could we get started, please?

Council Members will find at their seats a blue sheet with information on where we're gathering this evening for dinner and there are three additional handouts here that are pertinent to tomorrow. Let me just mention them while we're looking at this. Professor Merrill who has sent in an advance paper, sent along the notes which are the outline for his talk and suggested that Members might want to have it in advance. And then there are the latest issue of the Archives of Pediatrics and Adolescent Medicine has an essay on the "Psychotropic Practice Patterns for Youth: The 10-Year Review." And then an editorial from the same journal on this question of prescribing psychotropic medicine to children. I'd like to ask Council Members to just glance over these things in relation to the discussion we're to have amongst ourselves in the last session tomorrow morning. This is not for careful reading, but at least to help us get started in thinking about how we want to proceed in the area of neuropsychopharmacology with special attention to children.

In this session, we will be discussing the ethical considerations in relation to procuring organs for transplantation. The Council has neither determined, nor has it been asked to study organ transplantation, yet the topic is going to be of increasing interest. The Secretary of Health and Human Services has indicated his own grave concern regarding organ supply and I'm pleased to see that we have with us Jack Kress, who is the Executive Director of the Secretary's Advisory Committee on Organ Transplantation. They have their first report soon, I think, to be issued.

The AMA and Congress have variously considered plans and legislation to increase the supply. Legislation was introduced into the last Congress and is likely to be introduced again. And therefore the Council might be invited into these discussions, but in any case I thought it would be worthwhile if we would engage ourselves in the preliminary consideration of some of these proposals that are floating out there to increase the supply.

We are not altogether new to this topic. Already in Gil Meilaender's survey paper, "Toward a Richer Bioethics," in the very first meeting, the meeting of embodiment, the relation of parts and wholes and integrity were questions that were raised. We had that short story which at least some of us liked in the donation of the heart, "Whither Thou Goest," to at least address this question of part and whole. We had some discussions on commerce and the body, more in connection with patenting, but that was an issue of concern here.

And it does seem to me that in keeping with the search for a richer bioethics, the full human and moral significance of innovations and practices growing out of the relation to advances in biomedical technology belong to our domain.

A background paper that was prepared was intended to bring to the Council's attention the range of practical suggestions that are now under discussion to increase the organ supply, but to do so in the context of questions that deserve further attention and in the background paper, at least these were mentioned and raised for view, the value of saving life, the desirability of preserving bodily integrity and respect for mortal remains, and the importance of individual autonomy of the potential donor, as well as the rights and responsibilities, needs and wishes of surviving family members.

But I would at least like to add to the questions for consideration two points. One, the need to appreciate the heterogeneity when we come to talk about organs and supply. There are different organs for different diseases with differing success rates and differing age and ethnic populations, of donors and recipients who have also not only different medical conditions, but also differing cultural attitudes that affect this problem.

You cannot, it seems to me, talk about supply neutrally without paying some attention to why it is that some people do and other people do not donate. In some cases, expressed fear of decreased care, if one is known to be a potential donor, inhibits some people. There are other people who might express concern for bodily wholeness in death when they go to meet their maker. It seems to me terribly important that we not homogenize this subject and treat in the abstract.

And then a more philosophical question, not necessarily for discussion, but something to keep in mind is the human body really like a car with completely fungible and replaceable parts, not just morally, but even medically. Medically, of course, we have the immune rejection problem which no automobile has, suggesting that there is some kind of difference between us and simply a heap of spare parts.

To talk about the person that somehow survives the replacement of these parts invites the kind of person, machine or person-body dualism and one of the questions I think that we want to keep in mind is what kind of a view of ourselves are we tacitly promoting, not only in organ transplantation to begin with, but how might that view be affected by the varying proposals to increase the supply. The culture is not homogeneous on this one. We don't have a single answer, but it does seem to me that those larger questions of self-understanding are at issue here, in addition to the questions of just saving lives, of respecting the wishes of the deceased.

With that in mind, I think I can summarize the present situation as follows. The present policy seems to be that organ transplantation is a great good. The practice is donation with individuals and also families free to decide to donate, but only to give and not to sell. Allocation being separated from supply. We have an allocation system with triage based on need and the probability of success.

In view of the tremendous, the growing shortage of organs, the list of people on the list of waiting for donors increases faster than the increase of the supply with large numbers of deaths now off the list. I'm thinking now especially of kidney donation. A number of proposals have been made and they are summarized in the background paper, between the system we now have, a system of giving and receiving, of organ donation and a system that they have in certain European countries which is called either routine retrieval or in this country it has the euphemism of presumed consent in which the organs are taken unless there is objection. A number of proposals in-between from public recognition and community pressure, honoring donors, shaming those who don't, to some kind of system of public compensation, the most widely discussed example would be either some kind of credit on tax return or donation, public donation toward funeral expenses, to more vigorous promotion of outright markets of buying and selling, have been in the discussion over the last several years, increasingly so.

And whereas earlier proposals of required requests were trying to put pressures on physicians to make sure they asked, the new proposals are designed to provide increased incentives for people to donate whether those incentives would be honor, some kind of public compensation or actually cash in terms of the free market. And it seems to me that it's, I think, worth our while to have at least this preliminary discussion as to what we think about these various proposals that are out there and without any prejudice as to which way this conversation goes, I think we should get started. I will say that I've asked at least three people to be prepared to offer some comment; Dan Foster, to make sure that we didn't misunderstand and forget the medical perspective; Rebecca Dresser, to give us some insight from the legal side; and Bill May, who has written very movingly on the newly dead body and honor embodiment, to make sure we don't forget that aspect.

So if I might, Dan, if you wouldn't mind starting us off. If that's unfair, I'll go elsewhere.

DR. FOSTER: No, I'll be happy to make a comment or two, not that they're very profound or that I know a whole lot about that. Certainly with Bill May sitting in the wings, I wouldn't want to say too much, but I think that in the background we have to think about the fact that one certainty of life is that we're going to die.

I jotted down Bertrand Russell's famous statement from "A Free Man's Worship" where he says "one by one, as they march, our comrades vanish from our sight, seized by the silent orders of omnipotent death."

It can come early or late, but against the scale of historical time, it always comes quickly. I was involved with the – in the death of a colleague at another medical school at the ceremony, who died early from asbestos exposure at his own university. But the speaker said something that I thought was very moving to me. He said, "Life is but an instant. It is the quickest thing. It is over before we turn around. In this brief instant, there's only time for love."

It's always very short against historical time. Now death comes from disease or from entropy. You'll remember that the Second Law of Thermodynamics says that entropy is always increasing in a closed system. I always liked Heinz Pagel's explanation of entropy for nonphysicists. He says if you take a salt shaker and you put pepper on the bottom and salt on the top and you have a top screwed on that has no holes in it, and you turn it up and down, then randomness becomes complete, the black granules and the white granules are completely mixed. Now one can reverse that if the system is opened. If I pour it out and put it on a sheet of paper, I may laboriously with work separate out the salt and the pepper and reconstitute order, but in a closed system, it's always running down.

We have an open system that keeps us alive. We have oxygen, water and a few vitamins and fuels and that keeps us alive for a while, but it doesn't stop entropy. In fact, a classic example in the transplantation business is that the kidney which is where we have the most experience with a perfect match, runs down in about 30 years. Those are Tom Starzl's numbers. He's talked to me about that. And when you biopsy the kidneys as the creatinine tends to go up, they're not being rejected, it's not a late rejection or autoimmune defect, they're just running out and we have to retransplant them if you're going to do that. I have a close friend who has three of his four children have renal failure and they've all had transplants and the first one is now at 32 years and his creatinine is starting to go up.

But we are concerned mainly here with the issue of premature death, in some sense, even though life is very short. And what medicine tends to try to do is to prevent premature death and it doesn't necessarily have an interest in preventing entropic death, that is the simply running down with time. We talk about that all the time. The mother of a prominent person in Dallas has a glioblastoma. She's 80 years old and the people that she went to see operated on her and gave her a very, in my view, outlandish optimistic prognosis and so she was planning to take a trip to Europe in 2004. She's going to be dead in six months. And the question is whether she should be radiated at 80 years of age with the side effects and taking away that time. And so in the conversations with the chair of Neurology and the chair of Neurosurgery, we all say this is silly. Let's let her live her life and not try to fight these, this late disease.

So transplantation is to prevent premature death and as Leon said, there's a great shortage of organs. I certainly agree with the view that we have to be specific. I mean kidneys are one thing. Hearts and lungs are another. I mean you live a long time with kidneys and it's so much better to have a transplantation than to be on dialysis that it's something that is just not arguable.

What you may not recognize is that this long list of waiting for kidneys, and I'm going to focus on them for just a second. It means you may die because dialysis is not real good. You certainly don't have a good lifestyle on dialysis, but what we don't – what most people don't recognize is that the longer you wait when you need a transplantation, the less it works. In other words, if you transplant – the data now are very strong that if you transplant early with kidneys you do much better, so the shortage of organs is a serious one.

Now what do we do? I want to say gently that some of the solutions really strike me as foolish in the real world. Goya once said that "the sleep of reason brings forth monsters." I think that saying we're going to give a medal to somebody to donate or $300 for a funeral that cost $5,000 to $10,000 or to appeal for altruism, to think that those will solve the problems are foolish.

In my state we are required to ask at every death, the attending physician for organs and we do that. I've done it a lot of times and we do pretty well at Parkland Hospital, particularly with minorities where it's harder. We at one point, I don't know whether that's still true, had more donations from African Americans for transplantation than any other hospital in the country. We worked hard on it.

But there are many forces, for example, funeral home directors actively tell families not to do that because it's harder to embalm when you've taken out these things. I mean there's an active lobby at death not to allow transplantation because it's going to make it harder on the funeral director. So the question that we come to is money and money usually talks. I mean our whole society is based on that.

I spoke with three transplant surgeons this week in preparation and they say that I am extraordinarily naive because even in this country for living donors, the payments are going on, right under our eyes, despite the federal laws and everything else. And nobody talks about it.

My own view in thinking about this is that incentives are never going to work. You may decide you don't want to increase this, but incentives are never going to work. I think money talks. And this is big business.

If you get seven organs from a body and it goes to an organ bank, let's say you get two kidneys, a heart, lungs, maybe a pancreas, corneas, not to talk about bones, the amount of money that's charged the hospital is very great. I didn't have a chance to get the exact amount where I work, but they oftentimes will charge thousands of dollars, even though they're nonprofit to the hospital to do it. A transplant surgeon, I think is paid by Medicare $1800 to do the procedure and they won't allow any work up until three months before you have to do it. But privately, the surgeon may make $30,000. So all the transplant surgeons said you all are naive. Everybody – it's in the papers and in The New England Journal, too – is making money out of this except the people who are most involved.

And so I don't think these incentive plans that I've read about are going to do anything at all.

Now I worry, very much about the coercive effect of money on the poor for living donors. I mean I really do for things like livers. As you probably read, we've already had a number of deaths from donors, even of kidneys, 56 or something like that. I don't know. So it's dangerous.

As an aside, I think that everybody who gives, who is a living donor, should be supplied, particularly if they're poor, with catastrophic life insurance and with life insurance – I mean catastrophic health insurance and life insurance. I think that should be – that's a payment.

My own view after thinking about this is that we ought to concentrate on increasing the organ supply on cadaveric organs and not living donors. And I think that I would be very willing to pay substantial amounts to families for the donation of cadaveric organs which puts no one at risk for the donation itself, and in good transplant centers, cadaveric organs do very well.

So if I were going to be making a policy, I would say I'm willing to pay, I'm going to increase the cost for the health system. It will all be passed back ultimately to us for taxes or increased insurance rates and so. It's going to cost. You may decide it's not worth trying to add a license on there, but I'd pay for it, so I would make absolutely clear to a family there are still issues there, that if they donated they could make some money out of it along with everybody else. That's the only way that I can see that this, that a system like this, that this would work. I don't know, how much should it be? I don't know. In talking to the transplant surgeons I've talked to, I thought $5,000 for – you know, you could put it for one organ less or something, but I'd pay for cadaveric organs and I'm pretty sure that there would be a significant increase in organ availability if we did that.

Where I am now, what's probably going to happen like everything else, I would be against paying for living donor organs because of the danger to the person and because of the possibility of coercion to people who don't have resources or strengths to do it.

So those are just a few of the thoughts that I had in terms of how we would go. They probably don't mean very much and I'll just toss it out there, and as I say, it's one of these 10 minute things that you can toss into the garbage if it doesn't mean anything, but that's what I would do. I would concentrate, as I've said twice already, on the cadaveric source which is very large and wasted to a large extent and many of these will be the kind of organs that you want, traumatic deaths from car wrecks and so forth.

And I say in passing that at least middle class families that I'm aware of and people, those particularly who have been able to – particularly people who have been in religious faith, really do feel a sense of partial grief relief when their loved one's organs are used for the maintenance of life. I don't think that's a fake. I've seen that. Now why it is, I don't know.

CHAIRMAN KASS: Thank you. In the interest, actually of having some coherent conversation, let me invite some responses to Dan Foster's comment before asking the others to add their comments to be raised here.

Charles?

DR. KRAUTHAMMER: I just wanted to ask a question. You talked about selling already is going on, could you tell us about how that works? I'm just curious.

DR. FOSTER: I have no hard data for this at all. This is anecdotal from talking to people who are transplanting organs and what they – and these are people who are – these are not the sort of surgeons that I don't respect. I mean they see a lot of things. And what tends to happen is that there is a surreptitious, I mean it's mentioned in some of these papers. There are surreptitious promises of financial reward in response to advertisements or personal talking about people who – some who work for an employer or something of that sort and nobody talks about it. I mean there is a presumption that nobody will talk. Well, sooner or later, somebody is going to talk anyway. I couldn't find out what the usual, you know, what all three of these people had experienced what the price was. And they don't have hard data about that, but what they think is, what they tell me is that they think that this goes on – they know about it happening because a few people have told them.

DR. KRAUTHAMMER: This is from living donors?

DR. FOSTER: Yes, living donors, all living donors. I'm not talking about cadaveric. I don't know of any payment for cadaveric things. It's the living donor payment that I'm talking about. It's very soft. I want to make it clear that this is just a statement, but three people told me that they thought that this was much more prevalent than what we had thought was going on.

CHAIRMAN KASS: Janet?

DR. ROWLEY: Well, first, if I can just follow on this line of conversation before I ask my own question. I understand from you that there is somebody here representing transplant surgeons and since this is a question of fact, would it be possible to see if the person representing the transplant surgeons might give us factual information, if that's available?

CHAIRMAN KASS: I misspoke. I mentioned the presence of Jack Kress, who is the Executive Director of the Secretary's Advisory Committee on Organ Transplantation, if you have some comment on this.

MR. KRESS: It's purely anecdotal.

DR. ROWLEY: I think we need information, whatever – recognizing from your comment that it's not the – not scientifically obtained or things of that sort of thing.

MR. KRESS: No, I really don't have any data at all. I'm sorry for coming up here with all of this and then telling you I have nothing to offer – it seems like a real waste of time – on this issue. It's purely anecdotal.

DR. ROWLEY: Which is?

MR. KRESS: Which is that some people weigh that particularly, as you know, in the living donation area, one of the things my committee has spent a good time on recently is ensuring that there's – trying to ensure there's no coercion of the living donor, that it be freely given, as much as possible. And in the conversation surrounding that, there's often the speculation that there is familial coercion, quite frequently, because the vast majority of living donations are with family members. So siblings, for example, feel coerced by the family and on those where there are employment relationships, there's often the suspicion that money played a role or something of that nature.

I actually have not heard that part of it. I've actually heard much more about the familial coercion rather than the money, I must say, just in response to what you said. But again, I have no hard data to offer.

DR. HURLBUT: May I add?

CHAIRMAN KASS: Please.

DR. HURLBUT: To both of you, is there a better outcome with an organ from a live donor?

MR. KRESS: My understanding is that the data at the moment indicate that it is slightly better.

DR. FOSTER: I think the key word is slightly, slightly better. I think most – you know this is relatively knew, particularly giving parts of livers and things like that, you know, so I think that it's slightly. You would expect it to be because of the ischemia time. I mean by the time you collect an organ and fly it someplace and so forth, there's going to be some anoxic damage to that thing and so I wouldn't have any argument at all that if you could get a living kidney from a living donor or something that it would be better.

MR. KRESS: And they are also much more able to check whether or not the matching is more perfect, etcetera, but just because of the time factor involved in death as opposed to someone who is living.

DR. FOSTER: I do think one of the things that has shifted because the advance in immunosuppression has really become, is really remarkable, that there's less concern about matches now then there used to be and besides what we usually test for, there are many other antigens now and alleles that appear to be involved with both graft-versus-host reaction and so forth that are not part of the major histocompatibility complex, the HLA molecules which are the main things that we usually match for. So that's developing. But there are also many more, well, I don't want to get too technical, but I saw a fascinating experiment in our own institution that changes the rejection of cells or organs. This happened to be with islet cells that replace insulin production in diabetes. I mean it's so early, I'm not even going to tell you what it was, but it's one of the most dramatic experiments I've ever seen. I might be false, because it's only a few animals. But I mean there's going to be changes so that it will be much easier, even if things are not matching, you don't have to have all this immunosuppression that's so hard to deal with.

CHAIRMAN KASS: Thank you. Janet, did you want to ask a question?

DR. ROWLEY: Yes, because in the material that you sent us, you indicated that in Europe, with the exception of Britain, that taking organs from cadavers was a relatively common practice, so I was wondering what the experience is in countries, advanced countries where this is a more common practice. Do they have the same long waiting lists that we do? What's the outcome of using these? What tissues or organs are actually included in cadaveric transplants?

MR. KRESS: Unfortunately, the waiting list problem exists overseas as well. So I don't think that necessarily is the solution. People are discussing it, of course. That gets into the whole presumed consent and all of that where Belgium and some other nations have that system. And internationally – Spain is often spoken of because of the Spanish model in terms of their version of it. They have a higher rate than we do in the United States, but how translatable all of those are to the American system is always an open question.

CHAIRMAN KASS: Why don't we – thanks very much. Unless people want to put more questions to Dan or follow up on his comments, I was going to call on Rebecca.

Alfonso?

CHAIRMAN KASS: Rebecca, you want to –

PROF. DRESSER: These comments are not particularly from a legal perspective, but just from teaching and reading about organ transplantation for quite a few years.

I am – I have a lot of reservations about paying people to provide organs or families to provide organs, but I do think there is a fairness or a hypocrisy problem with prohibiting it and Dan mentioned it. It really struck me, I read Julia Mahoney's 2000 Virginia Law Review article which is cited in the articles we received, and she does really an excellent job of making this case that the debate is really not about commodification of organ transplantation, it's heavily commodified. It's just the initial step that's not commodified, the initial transfer from the person who has the organ to the procurement organization. Everybody else makes a lot of money on this and you can see that whenever they propose changes. I understand there are data showing that transplant centers where this is done a lot have better results, so there have been efforts to try to concentrate transplantation more into these centers and then there's always a lot of opposition to that from other hospitals where they are doing transplantation and most people say it's economics. I mean these hospitals make a lot of money from this, as well as the surgeons and so forth.

So something that is initially a gift, Mahoney argues, is transformed into something that's actually sold to the recipient. Now she says people would say well, the recipient is just paying for services, but without the organ, the services really aren't worth much, so the organ is critical to what the recipient is paying for or the recipient's insurance is paying for.

Now, we might say that all these other people are being paid for services. You could probably say it would be force the services model on at least some organ donation and this is what I think we do in research and in people who provide oocytes, sperm, other tissues, blood sometimes, where the compensation is characterized as for the time and trouble people put into the process as opposed to the thing itself.

Certainly, a living organ donor puts a lot of time and trouble into that process. I'm not sure how much time and trouble – the cadaver doesn't, but perhaps the family does have to put some energy in and a services model could be imposed. I think it would be a stretch. But on the other hand, the idea that well, everybody else in the system who's getting paid, it's purely based on services. I think she makes a good point that the services aren't worth anything without the organ.

Paul Ramsey and others who argue that if you put money, attach money to the initial transfer, this would deprive people of the opportunity to be altruistic. You might flip that around and say well, maybe we should change our whole system, all these other components, we could be saying well, we're depriving all these other people of the opportunity to be altruistic. I mean the doctors could donate their time, the hospitals could donate the services, so maybe we should just change the system so none of it's commodified. I think we all know it wouldn't work.

I remember being struck a few years ago and this may be an example of hard cases make bad law, but a story of a family, of a person whose organs were given and they didn't have enough money to pay for her funeral and so she had to be buried in the Potter's Field and meanwhile the surgeon was making a good salary and so forth, everybody else was financially comfortable and it did strike me that there is some unfairness there.

Now the question then becomes are there persuasive reasons for saying this initial organ transfer should not be commodified, is there something different or distinct or dangerous about coercion or with families? Would they be more likely to say well, stop treatment and those kinds of questions. And I think that's worth discussion.

On the other hand, the question is could you regulate the market in this first step so that you could allow commerce, rather than prohibit it.

Another thing that I've thought about is the step of donating all of us donating, signing our donor card or putting it on our license, it actually seems to me a fairly trivial exercise of altruism because most of us probably won't die in ways that produce brain death, so that our cadavers would not be in the best condition for transplantation. They are working on other – getting organs from so-called nonheart beating cadaver donors and – but really, the chances that somebody who signs a donor card or who exercises his altruism at this earlier stage that their organs will actually be taken because of age and health, they're pretty low. So it seems to me very – it's easy for me. To me, the true altruism is the family and the cadaver donor situation. That is, they're the ones who I think bear the emotional burdens and so I wonder if that affects our analysis of whether altruism or payment is preferable to locate the altruism, at least for me and the next of kin as opposed to the individual whose organs are taken.

If we allow financial or some other benefits, say a family member is put higher on a waiting list, if you agree to be a donor, then I think the system has to take into account the very low probability that the organs will actually be usable, so the nature of the benefit, that goes to others when you agree in advance to donate is not that significant.

I think another point that's important to remember is that the results of transplantation are mixed and the slogans always say it's lifesaving and so forth. It is lifesaving for many, but not everyone and of course, it depends on the kind of organs we're talking about.

And many people have complications and compromised quality of life. Now certainly if you ask most of them would they rather have gotten the organ, they say yes, but it's not – these organs do wear out and sometimes it sounds as though you're giving sort of life forever if you donate an organ and it is a possible life, not necessarily as healthy as an ordinary person has.

I think it's unclear what effect payment would have on satisfying a supply. We know that. The point is though that even if it does, we'll still be having this conversation in 10 years. Anything that increases the supply will not get rid of the waiting list because the waiting list is long and also people don't get on the waiting list now who would be put on the waiting list if the waiting list weren't so long because of their other health problems or so forth, they never get put on.

So I think if we were going to do something on this area, I think we should try to examine what's the nature of the social obligation or the obligation to be a good Samaritan, to provide organs to those in need. This is related to Leon's point about why do people not give organs? There's a complicated set of reasons. Do we want to say that everybody who doesn't give organs is a bad Samaritan? You know, what is the nature of that obligation?

And on the other side, what is the nature of – is it an entitlement to expect that you will get an organ? If not, you know, this whole idea of people dying on the waiting list, what kind of a moral violation is that? How troubled should we be and so forth?

And then finally, what about the obligation to get organs to people who are well qualified in terms of health and so forth, but they don't pass the so-called wallet biopsy? That is, they don't have insurance that will cover this. They're not able to get it covered by Medicare or Medicaid, excuse me, and so what do we owe to them?

If we were to start paying people to give – for providing organs, that money will have to come from somewhere. Is that – so that would raise health care costs. Is that money well spent or given that we have so many people who lack access to basic health care, is the best way to spend limited dollars to channel that money to other forms of care?

So those are my thoughts.

CHAIRMAN KASS: Thank you very much. Why don't we follow on with Bill?

DR. ROWLEY: Can I just – I think one of the points in your very last statement that you didn't really take into account is the fact that dialysis is an extraordinarily costly and costly to the public health system or the insurance system. And so that you have to balance that enormous cost, compared with the cost of providing that individual with a functioning kidney and I don't think that you introduced that sense of balance in your last comment.

PROF. DRESSER: Right. I was mainly focusing on if we did decide to pay people for organs, we'd have to get the money somewhere, so if we had extra money to spend on health care, is that the best way to spend it.

CHAIRMAN KASS: Janet's point would be that these people are now on dialysis and therefore, the money used to pay for the transplant might be in that saving, if I understood her.

PROF. DRESSER: Right.

CHAIRMAN KASS: Bill May?

DR. MAY: A word first about the history of the discussion, as I've experienced it across the last 25 years and then some reflections dating back to Leon's reflections on the wisdom of repugnance, the whole question of feeling and the relationship of religious rights to feelings and so forth might be bringing to the attention of the group.

In the early 1970s and again, in the late 1980s, when I and others wrote about organ transplants, the discussion focused chiefly on two alternatives, individual giving which we've talked about here and the other alternative that was chiefly discussed was routine salvaging, individual giving linked with the prevailing system of opting in, in common law countries. The requirement of opting in seemed respectful of the quasi-property rights vested in the family for the purposes of a decent burial, but it, of course, did not supply enough organs and so created other pressures.

The second alternative, routine salvaging, presumes consent, unless and only unless the individual of the family opts out. You talk about European countries, I gather even where that system prevails, the tendency is for doctors to ask anyway. It isn't quite the explicit, routine salvaging that it seemed to be. And some worry that this system dangerously overrode sentiments, rights and symbols.

Culturally, one tended to associate the requirement of "opting in" with the Anglo-Saxon common law tradition and its greater emphasis on individualism and volunteerism and the provision for opting out with the Continental traditions of civil law, where the individual and the family bore the burden of withdrawing the body from the commons, as it were.

The debate, in fact, was more complicated than individualism versus communitarianism, individual rights versus the states' prerogatives. Paul Ramsey, for example, in the chapter we've read, argued that a system of explicit giving would help to shore up consensual community, a shoring up from which community itself in the long run stands to profit. So that it isn't simply isolated individualism versus communitarianism.

Today, the continuing shortfall in the supply of organs has generated pressure, once again, for an alternative to giving, but this time, not routine or near routine salvaging by government authority, but buying and selling in the marketplace. And of course, once one moves in this direction, the wrinkles multiply. In our reading, this was quite obvious, and as the staff paper indicates. For example, futures market where individuals agree before a death to sell their organs, and receive cash payment or lowered health insurance rates while still living, would one have to rewrite the contract constantly over time as the product ages and deteriorates? Kind of interesting problem. Or insurance rates rising with aging and the cash value of the body still inconveniently at hand, declining as a downpayment against premiums.

Now critics worry that the marketplace, left to its own energies tends to respect no boundaries. Neither the body as a whole, nor any of its parts, in this setting tends to be tinged with the sacred. The existentialists used to say that we not only have a body, if that's all it was, then it might be sold as property in some senses, important senses, we also are our bodies, as media, of disclosure of ourselves to others and so forth.

And in the setting of the marketplace and spirit, the thing tends to have whatever worth someone is willing to pay for it and another to sell it for. And of course, to facilitate sales more efficiently, could brokers set up a kind of e-bay auction of pre-used body parts with suitable protection of the purchaser through regulations, guaranteeing transparency and truth in advertising.

To avoid some of the vulgarities of the marketplace, Congressmen have offered bills proposing a tax credit from $10,000 to $25,000 for the provision of an organ. Once again, the ironies abound. Let us suppose a rich man and a poor man both provide kidneys for their daughters. The rich man's kidney is worth $25,000 as a tax credit and the poor man's kidney in the eyes of the bill is somewhat worthless.

One moralist complained about the effort of economists. It's very interesting. It was an economist who talked about the distinction between buying and selling and the gift relationship and that was Titmuss in the book with that title. And one tended to distinguish sharply between the arenas of giving and receiving and selling and guying. He pointed out that a Southeast Asian, this critic pointed out, that a Southeast Asian who is willing to sell a kidney for $2,000 to supply a daughter with a dowry or to educate a child, that's an extraordinary noble act on the part of that person. It isn't simply ruthless selling of something that one has. It's a noble act. But as I see it, the nobility of a particular act of selling does not redeem the tawdriness of a social system that would force a straitened individual to resort to this act of generosity. A health care system ought not solve the health problem of the desperately ill through the desperately poor. And this applies with particular force with respect to living donors.

Now to return to the question that Leon raised earlier, if I may, is you know you wrestle with the problem of our natural revulsion of the prospect of cutting up the body for the sake of extracting organs. It's human sentiment here.

We can be given to the mysticism of the marketplace, but doesn't it reach its territorial limit with regard to commodifying the body, this initial first step that Rebecca talked about.

However, such powerful feelings such as revulsion are morally neither infallible, nor automatically decisive. I think it's interesting that Leon himself, of course, made this point. For practical purposes directed to important ends, we dissect the body in gross anatomy, conduct post-mortems and authorize autopsies and so forth.

Thomas Aquinas emphasized the importance of a rational control of our aversions for the sake of good ends, in his discussion of the virtue of courage. The philosopher Joel Feinberg pled for the rational control of aversive feelings. He argued in favor of the routine salvaging of organs, even though the bereaved might react emotionally to the cutting up of the corpse for the sake of organ transplants. He observed in his presidential address before the American Philosophical Association that our aversion to cutting up a corpse should give way to a "careful, rational superintendency, and education and discipline of the feelings."

We cannot construct a social system entirely on the basis of our raw feelings. We should not sentimentalize the sentiments.

But reason, it seems to me, doesn't provide us with a sole means for disciplining our feelings. Religious symbols and the rites by which we appropriate them can help express, but also contain and discipline our most powerful feelings and I want to explore this whole issue.

Indeed, religious symbols and rites may strengthen much more than appeals to reason our capacity to secure organ donations because religious communities, for better or for worse, not reason, shape most rites surrounding death.

A word about – I'm not an anthropologist, but a word about the whole question of the emergence of funeral rites. Some students of funeral practices have pointed out that flight characterizes the most primitive human response to a corpse. Flight reflects more than an instinctive hygiene or an individual aversion to a dead body. Entire villages have been known to move to another location to avoid any further contact with the corpse.

This powerful human aversion, however, does not escape discipline. Funeral services arose, at least partly, as a way in which the community could contain and appropriate the dread that it experienced before the newly deceased. Analysts today have come to respect the psychological necessity of such rites, the living can pass on to mature life only through death and through their consent to the death of those who were close to them.

The development of funeral rites, therefore, represents a secondary response of containment on the part of the community to force itself to be present to death. It doesn't allow raw feeling alone to drive it. The community must discipline its aversion. It must still its feet, as it were, before death and stay with the deceased. This form of presence, of course, doesn't wholly eliminate the original aversion. The community becomes present, after all, with the intent of removal. It burns or buries the corpse. The community no longer journeys away from the dead, but removes the dead from its presence. The original element of aversion and dread persists, even within the constraining form of funeral practice.

And of course, societies traditionally vested in the family through the notion of quasi-property rights, the responsibility for burial. Such property rights were quasi in the sense that the family could not put up the cadaver for commercial use or sale, but rights they were in the sense that no other party could normally interpose claims upon the corpse that would interfere with the families right and obligation to provide for a fitting disposition of the remains.

In other words, whatever use and abuse, conflicts and tragedies a person has suffered in the course of his public or private life, the society cannot reduce him or her to those events or to a marketplace utility. Jacques Maritain would call this Sophoclean insight, Antigone comes to mind, the principle of the extraterritoriality of the person.

Therefore, are we stuck with a containment of sentiment through burial practices, normally vested in the family only to render the corpse untouchable and the rites of burial and cremation unchangeable. I think not, for funeral rites themselves have already contained in discipline the original raw impulse to avoid and to flee. But now where does that leave us?

It seems to me today, we haven't yet adequately explored organized giving. The power of feeling, as I've tried to articulate it, argues that bland appeals to reason and to the general ideals of altruism and philanthropy will not suffice. We may need to appeal not simply to the superintendency of reason, but to the religious traditions themselves in their shaping symbols to develop sufficiently powerful reasons, religious and moral, securing organ donations.

Indeterminate appeals to the public at large through media appeals and advertisements on buses and subways or a signature when you're getting your driver's license renewed, will not likely generate enough donors. Purely individual appeals lack organizational momentum, even though it's an organization that is organized, these individual appeals.

They also address the isolated individual, one on one, exactly in that condition and circumstance which most resembles death itself, the individual, solitary and removed from community. To secure substantial support for organ and tissue donations, one may have to go beyond a tepid legal permit and general appeals to individuals. We may need to mobilize institutions, chiefly religious institutions, since most funerals, for better or for worse, still occur under religious auspices.

Now a word simply about Christianity, not because I think one should ignore the whole question of the other traditions in a kind of society in which we live and not that Christian tradition could or should be legislatively decisive, laws based on Christian ethics alone would likely be divisive and therefore objectionable on Christian grounds as well.

On the other hand, the Christian Church remains a major Western institution with significance for better or for worse, for millions, especially in the area of funeral practices. Its attitude on organ transplants could have considerable impact on the success or failure of programs for blood donation, organ and tissue retrieval.

Now I won't bother discussing the negative obstacle within Christianity itself which was, of course, the whole notion of the resurrection of the body which led to the replacement of ancient practice of cremation with burial. And the whole issue emerged for Augustine as to whether therefore burial was a precondition of the resurrection and Augustine said not on your life, it's a miracle enough involved in all this. It's an office of humanity burial. There was nothing essential about maintaining the practice of burial as a kind of precondition of the Christian affirmation of resurrection.

Well, that only deals with the whole question of negative obstacle on all this, on the question of positive warrants. Are there positive moral and liturgical reasons for the act of giving? I think there are. Moral reason, self-expending love defines the life of the one who is the focus of the faith. He lays down his life for the brother and the sister, the neighbor, the enemy and the stranger. This love calls for concrete service to the bodily needs of others, their hunger, their thirst, their illness.

There are, of course, two limitations to this service. One, some chance of success and two, the sacrifice or must ordinarily not neglect those duties to himself or herself that will sustain a capacity to serve. That's real reticence about most forms of live donation.

Second, there is that extraordinarily liturgical warrant for transplants. In its central sacrament, Christians believe that Christ shares, under the form of bread and wine, his body and blood, his self-expending love. Fittingly, believers may participate in the substantive love by their readiness to share a portion of their bodies and blood with others, when their bodies no longer sustains a future capacity to serve.

While Christian ethics and worship, I think, encouraged transplants, Christians, I suspect, would have to draw back from the sentimental and inflationary rhetoric of symbolic immortality through such deeds. My child died in the accident, yet he lives on by supplying others with a heart and a kidney.

We should rather talk simply about the assistance. I think it was Paul Ramsey who put it this way, that one mortal being renders to another who after all one way in his own right or her own right in time, will have to do his or her own dying.

CHAIRMAN KASS: Anyone dare to speak?

(Laughter.)

CHAIRMAN KASS: Gil Meilaender will speak.

PROF. MEILAENDER: I did have some notes to myself whether – and some of them follow up on what Bill had to say, in fact. I have three comments, I guess, comments, questions. I'm not quite sure what they are.

One, as someone who is – I don't know what the right word is, just tentative or hesitant or skeptical about the whole undertaking, and I think actually, although I understand that none of us ever knows until we're in the position almost more hesitant about the receiving, being a receiver, a recipient, than a giver. I sometimes wonder in my pessimistic moments whether acceptance of organ transplantation is really not the crucial step, in fact. And I think in a way it's a useful way to think about. In other words, if you once have given your imprimatur to that are we sure that there are really sort of determinative reasons for saying but it may only be done by say a method of giving and receiving donation.

There may be arguments that tilt us in one direction or another, but I just – I think it's worth thinking about and perhaps talking about, whether the crucial step is learning to think of the body and its parts in a certain way and after that it's just refinement under the ineluctable force of claims about shortages and so forth. I'm not so sure about that.

Certainly, and this actually – two things to take up what Bill said, even if we're going to stop, even if we wanted to press for some kind of system of giving, altruistic donation, all – I, myself, find it unattractive and unappealing to think we're beginning – your word, Bill – mobilize institutions to encourage this. I'd find myself another congregation, if mine started to mobilize itself to do this, I think.

One of the other things that Paul Ramsey said was that when Christians began to wax eloquent about self-giving love and the way it can give, even the body, that physicians would have to remain the only Hebrews who reminded us of the body's integrity, I'm not clear that we can rely on physicians to fill that role any longer. I'm not sure who will, but a spirit of self-giving does not in itself necessarily constitute what Christians call love. I mean Bill would disagree with that, I'm sure, but it needs more thought. So that's my first point that it's really the fundamental question that in some sense needs thinking about.

Second thing, it's true, as Rebecca said that there may be something paradoxical about denying the possibility of commodification at the first level and having everybody else get rich off the process. And actually, I'd be quite happy to think of a system whereby the transplant surgeons could not get rich, but I suppose she's right, that that would be hard to do. But nevertheless, I think there is a certain kind of difference here. I mean for instance, when they wheeled me into the operating room, I want my surgeon to think in a rather detached way about my body and even think of it as sort of a collection of parts that fit together. It would be very bad if that surgeon spent his whole life thinking of his wife and his children and so forth in the same way. There are different moments in life when we have to think in different ways. And it's commodifying at the very first step is to some degree inviting us to treat ourself or those whom we most love in that way. And so there may be a difference to be thought about still there. It seems to me at least again, I'd want to think about that.

And then the third question that came up, about whether there might even be an entitlement to such thing or you'd have a civic duty to do such a thing, language that I find very unappealing. It seems that if ever it is clear that we do not belong to the whole of our being, to the community that we inhabit, death is the moment when that's clear. And that office of humanity that burial requires is kind of the last – it's not just the reverence and the tribute we pay to that person, but it's the acceptance of the fact that he or she did not belong entirely, wholly and entirely to us. So that whatever else we say, it seems to me we ought to recoil from that notion.

So I guess my point would be one, I really do think the procedure itself raises crucial questions and one has to think about whether once you've approved it, the rest is just a matter for interesting arguments, but nothing very decisive. I think that there is something different about that first step because it involves how we're learning to think about ourselves or those closest to us. And I think we maybe have some reasons to back away from any kind of entitlement language.

CHAIRMAN KASS: If I might, Bill, do you want to respond, Bill May, to Gil directly?

DR. MAY: Well, the way you put it, I tried to incorporate the whole question of the individual does not belong wholly to the state. That was the point made in Antigone. In one sense, one way of interpreting burial is not simply the person doesn't belong to the state, it belongs to the family, I don't think that's quite right. I think why it's located in the family, in a way, the family is the one who has most used up this person. And so there's something fitting about doing this in the setting of the family by way of release of that person. I think that's one unspoken dimension of funeral rites. It's not some, simply an occasion which the aurora borealis of the person extends into the future in mortality by way of memory and into the future, but that's one way of seeing the funeral service is it allows for the extension into the family, the radiance of this life. But it's the occasion in which the family is forced to acknowledge release, put in the ground or whatever, it's done and then you walk away. That's in part, insisting on the power of those rites, the importance of those rites, it seems to me, would interpret the event in that way. But that argues also, it seems to me, for involving the family in the final decision as to whether the person will be released for use in this further form.

I understand the problem of justice that Rebecca raised with regard to first step, but I think ironically what you do in order to make that just is you simply completed the last step in the commodification and increasing pressures upon those who consent to sell. And I think that's going to fall disproportionately on the poor in the setting of our culture. And so yes, there is an irony of this is the only one who doesn't make money, but it still clears out – it doesn't simply complete a closed system of handling this entirely through the newfound – not the newfound, but the old wondrous mechanism of buying and selling. So it's important preserving that first step, it seems to me, as it bears on the significance of human feeling towards the newly dead and the rights that we mount in relationship to that dead person.

CHAIRMAN KASS: Let me join in too, if I might. I also think that one shouldn't – I've heard the argument and I think there's some merit to it, saying everything else is commodified, why shouldn't the person whose organ this is somehow participate, but the transplant surgeons would get the same amount, roughly the same amount of money, perhaps, if they put in a mechanical piece, a mechanical organ in its place. The fact that we have all kinds of – we have a commercial system of medical care doesn't finitely determine whether we should absorb organic parts of either recently deceased or of living people into that system.

And I agree with you, Gil, that in a way the original question about the meaning of our embodiment, the challenge to it that comes from allowing the transplantation of organs is somehow primary, but as I tried to argue and puzzling through this myself, it does seem to me that it is in a way moderated by the gifting of it, so that one is not simply just transmitting body part, but as in any kind of gift there is the sentiment of generosity that accompanies it and if you simply treat the body part as a body part, inalienable, which to some extent it is, you have somehow already done some kind of violence, but I think we can find a theoretical way of overcoming our initial repugnance of this if we somehow stay within the language and the practice of giving.

Whether we don't somehow really radically underscore what might be questionable about this practice once we start the buying and selling of these parts, is one of the reasons why I'm a little hesitant to cross this line.

Just two other things to the side, I really do think there is a major step here and that if we think simply in terms of increasing supply without paying attention to what it actually means to put the body parts themselves in commerce, we will be missing something of the sort that Bill May is talking about.

Two things. First of all, the system of organ allocation, having now been federalized and bureaucratized has in a way moved the relation of donor to potential recipient – you have to think of the universal national community, rather than the communities in which one actually lives out one's religious life at least as it is agreed, so part of this kind of appeal is somehow obviated by the desire for efficiency and in fact, fairness so that you don't simply have certain kinds of unfairnesses in the local place.

Second, I would at least want to raise a caveat about this concern for the poor which I do share, but the economists, and by the way, I should see that people get, these are my colleagues at AEI that are referenced in the staff paper, but they're calling for an outright system of buying and selling, partly on the grounds that it's patronizing. I mean who are we to somehow to say to the poor that you can enter into this, maybe, but only at some kind of fixed rate and whereas we – our concern for them keeps them out of the one system in which they might be able to turn something to advantage? I say that with nervousness, but it seems to me it's part of the – it's part of this discussion.

Gil, do you want to respond?

PROF. MEILAENDER: Yes. I appreciate what you say about the sense in which keeping it as a kind of a process of giving might retain a certain kind of – my key point from thinking of it simply as alienating some part of the self. I understand that. Some days that persuades me and other days it doesn't. But I had two questions for you on it: Are you attracted to language where people might talk about organ donation as in a sense almost kind of conferring a kind of immortality, carrying on the sense, that's one. And, are you attracted to occasions when people want to somehow know and stay in touch with the person in whom some loved one's heart or something lives on? You see, it seems to me that you ought to be, at least I try to think about it, you ought to be attracted to both of those, if you want to make that move with a giving language. And I not personally attracted to either of them, so I just wonder.

CHAIRMAN KASS: Yes. I better retreat on the first and confess on the second, too. I do think that there's something about all acts of generosity, all acts of generosity that carry with them the giver to the recipient. "The giver is alive in the deeds as received." It's a wonderful passage in Aristotle's Ethics, in fact, where he raises the question why does the benefactor love the recipient more than the recipient loves the benefactor? You think it would be the other way around.

There are two answers. A vulgar people say the benefactor loves the recipient because the recipient is in his debt and therefore he somehow wants to make sure that some day he'll get it back. But the more profound answer is the benefactor loves the recipient more than the recipient loves the benefactor because the benefactor lives in the recipient, the way in which the poet lives in the poem. And there is a way in which it seems to me these acts of generosity, I'm not talking about immortality, but there is a way in which one's being extends through acts of love and generosity into the lives of other people and it seems to me there's no reason why the gift of one's body part can't partake of that same kind of generous spirit.

On the other hand, as I perhaps alone in that discussion of "Whither Thou Goest" thought that while it's a creepy story, while it's a creepy story, the heart that now beats in that other man is not altogether and absolutely the other man's heart, not absolutely. And that's part of the funny thing about what it means. I mean a heart is a special case, all of that, but to the extent to which we really are our bodies and rather than hitch a ride to them, then these hands, these gestures are also part of who I am.

So I don't know where that leaves me on the question of policy. I'm somewhat squeamish, I think, about entering into these financial arrangements, and I think if we're going to go into them, I'm with Dan. I think half-hearted measures, if you're really going to say this is what we have to do in order to increase the supply and we're willing to ride roughshod over these other things, then let's do it in a way in which in fact is going to succeed rather than step by step, first with the funeral expenses, then – but I'm very nervous about taking that next step and would like very much to try to find some way get Bill May out on the stump, to make the kind of very deep and profound appeal that he makes.

Michael?

PROF. SANDEL: Well, I'm still trying to recover from Bill's dazzling comments and I haven't fully absorbed them, but I would like to draw upon what I understand of them and some of the other comments to offer a policy proposal that incorporates elements of Dan's suggestions and also of the moral sensibility that Bill just laid out for us.

There are at least two reasons to oppose markets in organs. One of them has to do with coercion and coercing the poor. Dan brought this out. And Bill when he said that we shouldn't solve the problem of the desperately ill by creating a problem for the desperately poor. That's one objection to having markets in organs.

Another objection which is independent of the coercion objection has to do with commodification as such with treating bodies as objections of possession as our own property, reasons that Leon has developed in the article that he wrote.

The second, the commodification objection is independent of the first because whereas it's quite apart from rich and poor, about encouraging us to view our bodies as our own property, rather than as a gift with a certain telos connected with the sustenance of life.

Now there is the hypocrisy problem in rejecting markets that Rebecca raised, but the hypocrisy problem can be solved in two directions. It can be solved by universalizing the practice of commodification or it can be solved in the other direction by decommodifying the practice of organ transplantation altogether. And I think there are reasons and ways to advance the second which is what I would propose.

In the discussion paper, there were five proposals that were laid out and what I would propose would be a combination of numbers 5 and 3. Number 5 is the routine retrieval which – and Dan and Bill have both given us reasons to take that very seriously. The routine retrieval I would say not based on some theory of presumed consent, but to the contrary, as a way – and not only by the way for the sake of increasing the supply, although it would have that desirable effect, but also as a way of giving expression to the moral sensibility that Bill articulated. That's the reason even beyond the reason of increasing the supply to favor routine retrieval, so that there's a presumption built into the practice that the body isn't our property as individuals. Now I would make this routine retrieval subject to religious exemption, so that those who had religious convictions that saw the body as somehow necessary to the afterlife, allow a kind of conscientious objection provision so that those people wouldn't be subject or they could opt out.

But beyond that, there would be a presumption and expectation and then couple that with proposal 3, the public compensation, not compensation in money, but in kind. And what would count as compensation in kind for enacting the presumption that our bodies are now our property, but rather gifts of life that are in our care for a time, not just funeral expenses, certainly not a tax credit for the reasons that Bill explained, and not discounted health insurance either which is subject to the perplexities and anomalies Bill played out very well about when – should the discount be reduced when the kidney diminishes in its value? No, the proper compensation in kind would be universal health insurance and universal health insurance, not just for the familiar public policy reasons that there are people in need who aren't cared for, but as a way of giving expression to the same ethic and Bill elaborated on this, the same ethic that underlies the routine retrieval part, namely, that if our bodies are not our own property as individuals, but a gift of life that is for a time in our care, then it follows that when our bodies fail us, when we fall into ill health or disease, that isn't our responsibility as individuals either, but a shared common responsibility.

So the ethic that underwrites the presumption of routine retrieval is also an ethic that supports compensation in kind, not in a discount, not in funeral costs, but in universal health care. And while we're at it, once we have that we can solve Rebecca's problem of the transplant surgeons making a whole lot of money on this because there will be a single payor who can set fair rates.

CHAIRMAN KASS: Very eloquently done. The hour is late.

DR. KRAUTHAMMER: Can I make a short comment? It's a lovely idea, but it means that we will be postponing the issue of organ shortages for a very long time because the prospects of that kind of proposal succeeding are very small right now and I think there might be less radical and dramatic and universal ways of approaching it.

I think it's a very fine idea. I just think in terms of practical politics, it is impractical right now and it would postpone the solution or at least an approach to the transplant problem.

Also, if I could just open for discussion for another time the – I wonder if there are people here who could tell us a little bit about the history of the routinization of autopsy because I see autopsy as sort of the model for the violation of the body. I don't know what the laws are to date in different States on whether it's routine, whether there's opting in or opting out, but I'd be interested. I think that could inform our discussion of this issue to see how the initial violation of the body, if you will, was routinized and accepted and how it's regulated today. I think it might give us a few insights into this issue.

PROF. MEILAENDER: Let me just comment on that real quickly because autopsies which were fundamental in understanding modern medicine essentially are not done any more. And the reason they're not done anymore is because nobody will pay for them except in criminal situations. For example, the American Board of Internal Medicine requires that you can't have a training program unless there are at least 10 or 15 percent autopsies done on the people who die and many centers cannot do this any more because the pathologist does not get paid for it.

So if you look all over the country, autopsies from the standpoint of science alone, it's a great tragedy that we can't find the mistakes and so forth that we do. So we struggle to get autopsies and namely make it now because of legal requirements for unexplained deaths or quick deaths that occur. It's gone away.

CHAIRMAN KASS: The hour is late. Let me make – let me see if I correctly get the sense of this group. This is obviously – this is our first crack at this topic, very, very fine and rich things were said. We have a lot on our plate in terms of what we've agreed to do or been asked to do, but unless I hear to the contrary, I will assume that this is a topic that can remain alive for us to be revisited in meetings ahead. We can get additional information as to what the Secretary's committee has done and we can send out some additional materials and find some additional information. But if this Council could think its way towards some kind of policy recommendation, if it was so inclined, that might be a useful thing, and at the very least, we can keep this issue from being reduced, simply to the question of supply which I think has been the brunt of the remarks all around the table.

We're adjourned until 2 o'clock. It's about an hour and 20 minutes, rather than what we should have had, but that should be enough.