Frances Kissling

I think I instinctively knew what I had to do. I’d spent a lot of my time raising money, and I had that Bible verse “ask and you shall receive” burned into my consciousness. I decided to compose an e-mail about my need. In it, I shared my sense of the adventure before me and asked if anyone would like to give me one of their kidneys. I noted:

“To be dependent on the generosity of others is a new experience for me and I am thinking a lot about what it means to share one’s body with another person. Also trying to figure out how I ask for a gift that I really want without expectation or making friends and colleagues uncomfortable.”

I sent this off in batches to about 150 friends and colleagues whom I thought would want to know and might fit the criteria for donating. Within three days I had five offers. Within a month, 24 people, some I did not even know, came forward to donate. I was in the midst of a new phase in my life’s journey. I have always seen myself as an open person, but I have also been pretty circumspect about sharing my life. I never married, and I have no children. Now, not only was I planning on being part of the remarkable biotechnological revolution in which a part of someone else’s body would become mine, but I was also engaged with others in reflecting on the meaning of friendship. I was bowled over by how people responded. One friend wrote:

“I want you to know I am willing to consider being a donor. I am facing a different kind of provisional diagnosis of a rare inherited form of dementia, one that would take my life in the next two decades. Since I probably won’t need a kidney to last more than another 15-20 years, I am happy to share one of mine. I planned to donate my useable organs anyway, and it would be a blessing and a joy to see one of them help you.”

I had offers from an Episcopal woman priest, Roman Catholic nun, ACLU lawyer, Pulitzer Prize-winning author (OK, it is Anna Quindlen, who said she thought if we ever had to share an organ, it would be our spleens, but if it has to be a kidney, that’s fine). Susan Wicklund, a Montana physician who rides the circuit to provide abortions in states where there is no provider, offered a kidney. Former co-workers came forward. Many said I still had important work to do, and they wanted to be sure I got to do it. Most who offered, offered quickly, spontaneously and firmly. A few thought a longer time, asked for more details. Some said I will do this if you come down to no other offer, but I hope I don’t need to. Almost all who offered were women. Two men, Andy Merton, who wrote the great 1980s book “The Enemies of Choice” (he has a strong feminine side), and the director of a local NARAL chapter, whom I did not know, were the only exceptions. I am convinced that this is not just because I know more women than men. I think women, who carry life in their womb, are more attuned to sharing their bodies, and men — well, men are just weird about medicine and bodies. (Statistics seem to bear this out. Women are more proactive in seeking donors, and they provided 58 percent of living donations in 2007. The statistics reverse with cadaver kidneys.)

Just as touching as the people who offered to donate were the people who took the time to say no. One friend wrote:

“I know that is not what you would like to hear from me, but I believe I owe you a full disclosure; perhaps it might be good to help you to allow yourself some self-pity, not a very constructive feeling admittedly, but empowering nevertheless, in the sense of acceptance of weaknesses. I was also sad because I realized how limited my solidarity is. I know you also do not want me or anybody else to feel guilty but I was disappointed with myself to realize how unlikely it is that I will give you my kidney.”

I am crying as I read this, for indeed, this is solidarity. I was not the least disappointed. This friend is a cautious person, and her willingness to share how she felt about herself was very brave. I understood my own decision to share my need and my feelings widely as an intimate act on my part as well. I had succeeded in my desire to offer people the opportunity to share in my life without coming across as demanding or needy, and that taught me something.

But most people are not so lucky. They have no viable offers. My nephrologist told me the story of a senior surgeon at the hospital who had recently had a transplant. His kidney came not from a family member, friend or colleague — but from a Web site.

Some basics: According to the National Kidney Foundation, there are 485,000 Americans with end-stage renal disease. More than 341,000 are on dialysis; 140,000 have functioning transplants. About 87,000 people die each year from end-stage renal disease, some on the waiting list, others who could benefit from a transplant but never get on the list. Each year, through death or transplantation, more new people go on the list than get off the list. For example, in 2007 there were only 16,629 kidney transplants; 10,588 were from organs donated by 7,241 deceased people and 6,041 from living donors. In spite of all the heart-rending stories about the lady from Dunkin’ Donuts who gave her kidney to a customer and the millions of dollars the federal government has given to nonprofits charged with organ procurement to educate the public about the social good and medical ease of donating organs, the number of kidneys donated has risen only modestly over the last decade. In 2007 the number donated was the lowest since 2000.

Having had such a positive reaction to my own need, I was left wondering: What the hell is going on? Why are so few people donating kidneys to people they know? And is anyone doing anything about it? 

Answers to the first question are hard to come by. As I talked to people and read more about the issue, there were clues. People wanted to save their kidneys for their kids or their spouses. Some friends reported that other family members discouraged them from giving. Transplants are still a little creepy, and the idea of sharing your body with someone else is still science fiction. It’s scary. It’s not a simple procedure. And people who need kidneys stay quiet about it. A recent study of people considering transplant showed that 54 percent of them had not asked anybody to donate.

Publicity about improvements in dialysis has probably made people think it’s not so bad. We imagine people go sit in a nice chair for four hours three times a week, read a book and then go about their daily lives. In fact, as nephrologist Benjamin Hippen notes in the scientific journal New Atlantis, “Life on dialysis is a fragile, vulnerable existence.” Far too often, things do not go well, and people on dialysis are unable to work, experience multiple complications and die quickly. The average span of life once one goes on dialysis is eight years for a person 40-44 years old and 4.5 years for someone 60-64.

The “is anyone doing anything about it” question is easier to answer. Some leaders in the field — transplant surgeons, nephrologists and policy analysts — have suggested that it’s time to provide donors with incentives, from health insurance to tax credits and pension contributions to promote donations. My friend Sally Satel has been in the forefront of promoting this idea, and she has been a thorn in the side of the kidney establishment, which has been moving around the deck chairs on the Titanic rather than face the core ethical questions in the debate: Do potential donors own their bodies and have a right to decide? Do we treat potential donors fairly? These questions take on special urgency when you realize that 23 percent of Medicare expenditures go to treating kidney disease and the number of people with end-stage renal disease in the U.S. is projected to reach 712,000 by 2015.

Even without incentives, no group of do-gooders is treated with more suspicion by the medical community than living organ donors. Even a free glass of orange juice or an unnecessary lollipop given to a donor is interpreted by some leaders in the field as a “bribe” or a crime. Appropriate concern for the international organ trafficking problem (WHO estimates that the annual total of internationally trafficked kidneys is about 6,000) has so distorted the concept of altruism and eroded the principle of mutual respect that potential kidney donors are denied the basic safety net that a just and giving society should provide people who offer to risk their own lives to save the lives of others. And let’s be clear. The best way to stop first-world people with money from exploiting poor people by bargain basement organ trafficking is to procure more organs from well-informed, healthy and autonomous people in the first world.

This insanity is so widespread that a new and creative transplant practice, known as daisy chains, needed federal legislation to assure hospitals and donors that they would not be arrested for performing them. In a daisy chain, two or more people who need kidneys but have potential donors who are not a match, trade donors. Those concerned worry that the 1984 National Organ Transplant Act (NOTA), which prohibits the sale or transfer of human organs for “valuable consideration” would be invoked. Would my trade of my donor’s kidney for another be a form of “valuable consideration”? Legislation to clarify this was introduced and failed in three successive sessions of Congress. It was not till 2007 when Rep. Charles Norwood died and the bill was named after him that Congress could get this bill passed.

Far more disturbing is the attempt by some transplant professionals and ethicists to so constrain government benefits to potential donors that the large number of low-income and minority candidates for transplant are almost automatically precluded from receiving kidneys while they are healthy enough to benefit from them. Almost half of those on the kidney waiting list are African-American or other ethnic minorities. African-Americans wait twice as long for kidneys as white people; other ethnic minorities wait longer than white people but not as long as African-Americans.

The donor costs of the kidney transplant are covered by the recipient’s medical insurance (most often Medicare) and the recipient can reimburse the donor for medical costs, travel and lost wages. Low-income recipients may not have the money to do that. Charitable funds for this purpose are woefully inadequate to meet the need and when they apply for funds donors wait months to find out if these costs will be paid.

More important, we financially abandon the donor almost immediately after we take their kidney. There is no provision for comprehensive long-term health insurance for donors, or for life and disability insurance. Opponents of any form of compensation or benefit to donors beyond costs directly attributable to the transplant itself fight efforts to provide these benefits. One example of such stinginess is the current “End the Wait” campaign of the National Kidney Foundation. In a grudging concession, the NKF supports post-transplant health insurance, but insists that it only cover medical expenses directly related to complications from the transplant. How mean can you be?

No matter. This over-scrupulosity has to stop. It’s time to rescue the debate about organ transplant policy from the deck chair rearranging and simply treat potential donors with the same generous spirit with which they have offered their kidneys. No donor should spend a single dollar in the process of giving an organ. And donors should have the safety net they need to stay healthy, to support their family if they cannot work and life insurance should they die. We can and should do even more; but health, life and disability are bottom lines. One member of Congress who gets it is Arlen Specter, who is circulating the Organ Trafficking Prohibition Act of 2009. The bill increases the penalties for really buying and selling organs, but makes clear that state and federal government can provide the kind of benefits donors deserve without going to jail. Anyone disagree?

My own story? I’m still waiting to hit the magic number when the transplant will be needed. Two potential donors were found to have kidneys not quite strong enough to share and are very sad. A third, my buddy Rita Nakashima Brock, is in the final stages of the rigorous testing, and it is looking good. I have no idea whether taking better care of donors will result in more kidneys available for transplantation, but I am very certain it is the right thing to do. My search has changed me and made me more willing to share myself. Rita and I have talked about writing a book that will guide people through the process. The 54 percent who could benefit from transplant and don’t ask anyone to give need all the encouragement they can get. 

These failures to make progress in the electoral and policy arena on abortion should come as no surprise. Politics is about the here and now. But if anything is ever to change the back-and-forth dynamic of so-called electoral solutions to the problem of abortion, Obama’s effort to get people to talk to each other has to be tried, outside of the Beltway.

That’s why I agreed to be one of four organizers of a public dialogue on abortion held at Princeton University in October, “Open Hearts, Open Minds and Fair-Minded Words.” Thirty-eight of the top scholars and some advocates were invited to talk to each other, not past each other, with an audience of 400 looking on and occasionally chiming in with tough questions. One would think the academy would be an easy place to have such a conversation, but Charles Camosy, the Fordham University professor who initiated the conference, was unable to get Fordham to agree to host the conference and turned to Princeton’s Peter Singer for help.

Clearly not everyone has an open mind on abortion. Yet most views have legitimate counterviews. Each side has an Achilles’ heel. For those opposed to legal abortion it’s usually the fact that they are willing to force women who don’t want to be pregnant to stay pregnant and deliver a child they don’t want. For those of us in favor, there’s the reality that abortion does take life — human life, and sometimes well into the fifth month of pregnancy.

A lot of energy goes into keeping our hearts and minds closed to the hard truths about the unintended and unavoidable negative consequences of either position. And bad things can happen when people who disagree about abortion get together. About 30 years ago Ellie Smeal invited Feminists for Life to dialogue with NOW. After what was by all accounts a civil meeting, at the post-meeting press conference, one of the pro-life attendees placed on the table a jar containing a dead fetus. Smeal said, “Never again.”

While few think there is much common ground on abortion to be found between, say, the Catholic bishops and NOW, the damaging effect of abortion conflict on the political process has pushed moderates on all sides toward more civil debate, which was a goal of the conference. And some cross conflict but civil conversations at the conference made my head spin. One of the most electric happened at the speakers’ dinner where place cards ensured that those who never rub elbows would break bread together. Just before dessert, there was an opportunity for a group discussion. The first to speak was Rachel MacNair, a “consistent ethic of life” advocate, who opposes war, capital punishment and abortion. MacNair described her prior work with combat veterans who suffer from post-traumatic stress disorder as a result of acts of violence and recent work with abortion doctors whom she believes suffer the same syndrome.

Almost immediately, Rebecca Gomperts, a former Greenpeace staff doctor, stood up and calmly noted that she found the remarks offensive; she was an abortion doctor and did not consider what she did an act of violence.

Forks dropped. Had MacNair committed a social faux pas? Should Gomperts have let it pass?

Before I could process it all, one of Gomperts’ dinner companions rose, somewhat agitated, but also sweet seeming, and expressed his amazement and mild discomfort at finding himself consuming asparagus crepes with someone who performs abortions. He regularly prays and pickets (politely, he assured us) with his children at an abortion clinic near his home. He concluded by noting that neither he nor the doctor had fangs.

Surely something subtle changed for each of us. Perhaps, as Peter Singer, another of the organizers, had hoped, it was one on those moments when those on different sides of the issue learned that not everyone who disagrees with them is either “stupid or evil.” Or simply that we are all human and things are complicated. In a blog post on the conference, MacNair expressed surprise that the two abortion providers she saw at the conference were young women, not old male doctors. “What brought them to a conference of this kind is still a question I’m mulling through,” she said. 

Others are thinking about a remarkable argument by the Pulitzer Prize-winning civil rights historian David Garrow, who passionately defended the Roe v. Wade core holding on liberty as correctly decided. Garrow, a hard-liner on a woman’s right to choose with no limits, suggested that it’s time to think about post-12-week abortions differently than those under 12 weeks. Poignantly, Garrow acknowledged that a second-trimester abortion policy that reinstituted the pre-Roe state ethics committees that occasionally granted an abortion if women could prove they were crazy, or carried severely deformed fetuses, or had other severe health problems, would mean humiliation for some women and no abortion for others. 

On the other side of the debate, Cathleen Kaveny, a pro-life lawyer and ethicist at Notre Dame, declared, “I do not think the American law should prohibit abortions in the case of rape, or where necessary to protect the life or health of the mother. I think that unborn life is equal in dignity to the rest of us. But I don’t think the law can rightly require a woman to bear the significant burdens associated with continuing a pregnancy in such instances.”

Such deviations from parallel orthodoxies are the stuff that gives one hope that the absolutism of politics can be transcended. 

Not all dialogue was forward moving. Whether intentionally or innocently, even the best-willed can set each other off, and make it difficult to hear with an open heart what is being said, or identify what is positive in the other’s ideas. In a debate on the moral status of the fetus, the natural law philosopher John Finnis, who has mentored many of the bright lights of the Federalist Society, castigated all for using the “F word” — and he meant the fetus. “As used in the conference program … it is offensive, dehumanizing, prejudicial, manipulative. Used in this context, exclusively and in preference to the alternatives, it is an F-word, to go with the J-word, and other such words we know of, which have or had an acceptable meaning in a proper context but became in wider use the symbol of subjection to the prejudices and preferences of the more powerful.”

The J-word, it seems, is “Jew” and it was the first reference to the not useful and incorrect comparisons of pro-choice supporters to Nazis.

Garrow, in turn, used the “C” word, closing off dialogue with the “Catholics” who oppose abortion by claiming that their goal was not the protection of life, but outlawing contraception and moralizing about sex and gays. And while that is certainly true in Catholic officialdom, the sighs from the audience made clear that for many Catholics and evangelicals, banning birth control is the furthest thing from their minds.

Helen Alvare, who is best known for her tenure as the spokesperson on abortion for the Catholic bishops, set pro-choice feminists’ teeth on edge when she answered a question about women who decide to have an abortion. “Sometimes,” she said, “what women think they need now, is not in their best interest in the long term.” It was a line quoted over and over again in bewilderment and annoyance in conversations among pro-choice participants. 

The singular focus of each side, one on women and the other on fetuses, was a complicating factor in achieving understanding at the Princeton meeting. It is perhaps an eternal divide, but it is becoming a richer and less polarized division as more partisans recognize that there are blind spots on both sides of the divide. 

In the opening panel of the conference I noted that my greatest concern about the public debate on abortion has been that its stark yes or no legal focus has coarsened people on both sides. I left the conference still believing that is true. Opponents of legal abortion have written much about their fear that society has been insensitive to the value of fetal life — in research, pregnancy and into the neonatal arena. We need to hear that. 

Much less has been written about a coarseness toward women that has developed among those opposed to abortion as they pursue efforts to make it illegal. There was as little recognition of coarseness toward women and their lives by pro-lifers as was there was of concern for the fetus by pro-choicers. This is not to say that pro-lifers don’t care about women; they just seem to care in very different ways than those of us who are pro-choice do. Most pro-life speakers at the conference wanted to protect women from themselves; most pro-choice speakers wanted to see women acknowledged as “moral agents” with the same moral status as other persons. There is, they believe, no “need” for abortion. Abortion is not healthcare. Adoption is absolutely and always a “positive.” Alvare dismissed a question about deaths from botched abortion in the developing world with a flick of her wrist and the claim that she was unfamiliar with the data.

Frustration on this matter followed several early panels that focused on the “moral status of the fetus” or asked speakers to accept that the fetus had the same moral status accorded to persons and to justify abortion on other grounds. Pro-choice attendees and speakers repeatedly asked why women seemed invisible on the program. Was their moral status to be considered? Lynn Paltrow, an advocate for pregnant women who among other things are shackled during delivery if they are unfortunate enough to have babies while imprisoned, asked about the moral status of women twice in a panel on fetal pain. Several speakers asked it in other sessions. In all but one case the question was ignored. Charles Camosy was the lone male of the 13 pro-life men on the program to answer the question and he noted that he had not considered the question of whether women’s moral status was an unresolved issue until recently and was still reflecting on the matter. 

But a conference like Open Hearts also suggests pro-choice folks need to attend to our own house. We could start by not apologizing for or excusing women and girls who are sexually active and do not use contraception. Making babies is serious business, and sex is a pleasurable and meaningful activity with social consequences. We need to create a social and cultural movement around abortion that both acknowledges women’s rights and the seriousness of reproduction for all of society, not just women.

Not even the reproductive justice movement, the newest and best of abortion rights frames, adequately addresses the fact that abortion is a serious decision precisely because it involves how we, as humans, will foster respect for life, even if ending it is justified and not the same as taking the life of a person. Can we acknowledge that abortion is not just a medical procedure like having one’s tonsils out but entails many losses, including the inability to bring life one has created to fruition? 

Is it possible that such acknowledgments might result not in greater restriction of abortion, but in a public that trusts us, and trusts women, even more?

I have a feeling that that suspicion was part of Obama’s call for open minds and his hopefulness about finding some common ground among advocates on both sides of the divide. Obama’s way of talking about abortion, separate from his policy actions, was and is brilliant. During his campaign and early in his presidency, he talked about abortion in a way most leaders who favor a woman’s right to choose have avoided. 

In the Democratic Compassion Forum at Messiah College he set the bar for a new pro-choice approach when he acknowledged, “There is a moral dimension to abortion, which I think that all too often those of us who are pro-choice have not talked about or tried to tamp down. I think that’s a mistake because I think all of us understand that it is a wrenching choice for anybody to think about.”

The assumption of the Open Hearts conference was that that bar should be set higher for both those who are pro-life and those who are pro-choice. Perhaps some issues are “wrenching” enough or involve complex enough “choices” that the ways in which philosophers approach them in the academy are not that different from the way women and men sitting at their kitchen tables wrestle with decisions. Those who came to Princeton had the audacity to hope that way of thinking might have relevance to the political process as well.

And so the question becomes: What next? For me the answer is simple and straightforward. I will not vote for or provide financial support for any candidate for public office until the Hyde Amendment is repealed. I will not contribute to any pro-choice or women’s organization that does not make the repeal of the Hyde Amendment its major political priority.

Some will say this is foolish or self-defeating. Pro-choice public officials do many good things. The only way we were able to pass healthcare reform was by getting a Democratic majority in Congress, and the only way we could get that majority was to include Democrats who oppose abortion. You could say that to sit out elections on the basis of the Hyde Amendment’s repeal is to ensure that the Democratic majority will be lost.

But I see a flaw in that argument. The President, who says he supports the repeal of the Hyde Amendment, and the Democratic Congress can save that majority by working vigorously to repeal the Hyde Amendment. The choice regarding who will control Congress is now in their hands. They can restore federal funding for abortion by repealing Hyde, stay in power and have the opportunity to continue to do good. Or they can wring their hands, maintaining they do not have the votes — by doing so, they will lose my support and I hope that of many others. They will also lose my respect and the sympathy I currently feel for the difficult choice they had to make this sad Sunday. 

I invite other pro-choice supporters to join me and to publicly let the President and members of congress know of their resolve.

Frances Kissling is a visiting scholar at the Center for Bioethics at the University of Pennsylvania. She is the former president of Catholics for a Free Choice.

At one point I looked at DeLauro and both of us welled up with tears over the dilemma we knew she and others would face. About 20 antiabortion Democrats, mostly Catholics, with the full lobbying power of the Catholic bishops behind them, were very likely to force the inclusion of Rep. Bart Stupak’s antiabortion amendment to the Affordable Health Care for America Act, the inaptly named House bill. I did not envy the choice DeLauro and others would have to make. I knew the likeliest, and probably the right choice, would be to vote for passage of the bill.

That is just what happened when Democrats voted Saturday night for the act, which passed with the broadest restrictions on funding for abortion since the Hyde Amendment was enacted in 1976.  The Stupak amendment forces insurance companies that currently provide abortion coverage to choose between continuing that coverage, or dropping it for all women if they want to participate in health insurance exchanges, and sell their product to government-subsidized consumers. If Democrats don’t get over their lust for a majority at any cost, this health insurance reform will haunt them the rest of their lives.

Ezra Klein of the Washington Post gets it exactly right.

Because of the limits placed on the exchanges, most of the participants will have some form of premium credit or affordable subsidy. That means most will be ineligible for abortion coverage. The idea that people are going to go out and purchase separate “abortion plans” is both cruel and laughable. If this amendment passes, it will mean that virtually all women with insurance through the exchange who find themselves in the unwanted and unexpected position of needing to terminate a pregnancy will not have coverage for the procedure. Abortion coverage will not be outlawed in this country. It will simply be tiered, reserved for those rich enough to afford insurance themselves or lucky enough to receive it from their employers.

Many Democratic women were shocked, and a wave of revulsion and anger at the Democrats who voted for these restrictions has ensued. The strongest advocates for choice in the House have moved quickly to pledge to reverse the restrictions. The Progressive and Pro-Choice Caucuses, led by Rep. Diana DeGette, announced they have 41 signatures on a letter to Pelosi that says they will not vote for a final bill if the restrictions on abortion go beyond current law.

President Obama is once again silent. Robert Gibbs refused in today’s press conference to offer any assurances that the president would stand up for choice. And, shockingly, Sen. Claire McCaskill, one of Obama’s “feminist” campaign surrogates, pushed the party’s flawed decision to sell out women for a Democratic majority, extolling the party’s commitment to “moderates.” So now anti-choice Democrats are moderate? McCaskill went further and pooh-poohed the restrictions, claiming most women would still get their coverage from employers and the bill would affect only a few women.

We started down this road in 1976 when the Hyde Amendment passed and when, in 1980, the Supreme Court upheld the principle that the federal government had the right to enact policies that favored childbirth over abortion by restricting funding for abortion. Most Democrats saw that giving antiabortion taxpayers greater moral standing than women who choose abortion was a political power play. After all, taxpayers don’t get any other say in how their taxes are used. Pacifists’ dollars support war; anti-bailout Americans saw their taxes go to banks just this year. Except on the issue of abortion, if you want to be a tax resister, the only thing to do is not pay your taxes and go to jail.

Clearly, the antiabortion right was using poor and powerless women as surrogates for their inability to control all women’s access to abortion. Sadly, a few pro-choice Democrats agreed with the antiabortionists that abortion should be legal but was morally repugnant, and should not be supported with federal dollars. Joe Biden, Jimmy Carter and Al Gore (who later changed his mind) were in that camp.

While efforts to overturn Hyde from 1976 to 2004 were sporadic and unsuccessful, at least some legislators tried. Most pro-choice legislators and advocates continued to agree that it was immoral to deny public funding to poor women for a service that was legal. All that changed with the Democratic defeats in 2004, which led the Democratic Party to falter seriously in its commitment to choice. Party leaders courted antiabortion Democrats as candidates for the House and Senate in conservative districts and states.

Howard Dean, then party chair, initiated an outreach plan to integrate anti-choice Democrats into the party. In fact, they were able to hold their press conferences in the Democratic National Committee building. Democrats for Life has proved to be radically antiabortion, and its members have been congressional ringleaders of the effort to exclude abortion coverage in health insurance reform. The party stopped calling them anti-choice and adopted the language they preferred, “pro-life.” In many ways, the message was sent that being pro-choice and antiabortion were equivalent, morally and politically. Deeply held beliefs were not to be critiqued, they were simply to be accepted so that Democrats would be seen as sensitive to religious values.

Religious groups that were broadly in alliance with the positions of the Democratic Party, but disagreed with the party on abortion, stepped up and began to “advise” the party on how to talk religion and gain the votes of the small percentages of anti-choice Catholics and evangelicals who are progressive on other issues. Democratic operatives promoted the new antiabortion progressives with deep-pocket party donors who were searching, post-2004, for new groups to support to reach out to “people of faith.” Most of those same groups have worked for the Stupak amendment, including Sojourners, Catholics United and Catholics in Alliance for the Common Good. They are now among the religious voices listened to on the Hill and in the White House.

Obama himself contributed to the rehabilitation of the immoral positions on abortion and poor women taken by these groups when he adopted the common-ground approach to abortion. The president chose to emphasize the “good will” and deeply held beliefs of those opposed to abortion and funding for poor women as opposed to a clear critique of the immorality of restricting a woman’s right to decide whether abortion was a moral decision for her, personally. The White House pushed pro-choice leaders to acquiesce to this form of diplomacy by creating a “dialogue” among all players, with no reference to the merits of various positions on abortion, simply a so-called shared commitment to “reducing abortion.” The president presented his own pro-choice position as just one view among many.

Common ground was featured and promoted even on Web sites devoted to choice, when RHRealityCheck.org dedicated a special site to providing a platform for both pro-choice and antiabortion views, further legitimating the idea that the legality and morality of abortion rights were debatable. We were treated to glowing descriptions of the “good” pro-lifers like Alexia Kelly of Catholics in Alliance for the Common Good, who compared abortion to torture and capital punishment, as well as the “bad” old pro-lifers like Doug Johnson of the National Right to Life Committee and the Catholic bishops. Following the vote on the Affordable Health Care for America Act, Catholics United issued a press statement in which they allied themselves with the bishops: “We are proud to stand with the US Catholic Conference of Bishops, the Catholic Health Association and other Catholic groups who have lent their unified support to this bill.” (How any progressive Catholic group can be proud to stand with a religious institution that just opened its doors to every homophobic and misogynistic Anglican to come on over and join our church is beyond me.)

Some pro-choice leaders warned that the party’s strategy, in the name of morality, muted the moral justice inherent in the pro-choice position. Former NARAL president Kate Michelman argued with Chuck Schumer and Howard Dean about anti-choice Democratic candidates to no avail. Party leaders were reassuring and adamant: If we could get a Democratic majority and a Democratic president, we would save choice.

So far, at least when it comes to health insurance reform, Dean and Schumer have been wrong. Let’s hope that the wrath that has gripped women in the face of this vote, and the immediate move by the Progressive and Pro-Choice Caucuses to adopt the take-no-prisoners strategy of the anti-choice crowd, saves the Democratic Party from itself. 

In some ways this is nothing new. The U.S. Roman Catholic Church began reordaining married Episcopal priests in 1981. About 100 married Episcopal priests crossed over into Catholicism. At the time, news reports noted what seemed to be an injustice: Catholic priests who wanted to marry and have children needed to leave the priesthood while these ex-Episcopalians seemed to be getting a pass on the whole celibacy thing because of their conservative theological views. The ex-Episcopalians even had the right to get divorced and remain in the Catholic priesthood; in 1995, Father William Shields became the first married Roman Catholic priest to get divorced. His wife kept the five kids and in the divorce settlement it was agreed that the Roman Catholic Church did not have to pay any support for them.

But this latest gambit appears to be part of Benedict’s larger attempt to increase Catholicism’s market share without compromising on his version of theology. The invitation to the Anglicans, like Benedict’s earlier outreach to the once shunned ultra-right Lefebvrists, seems designed to grow conservatism in the European Catholic Church by scooping up dissidents on the right. But the danger is that Benedict’s push to pump up the church’s numbers will alienate as many as it attracts. As some customers come in through the sanctuary, many others will be fleeing out the side door.

The head of a conservative Anglican group in Britain, the Right Rev. John Broadhurst, estimates about 1,000 Anglican priests in the U.K. are disaffected and if the COE goes ahead and ordains women as bishops others think the numbers might grow. For Benedict XVI, a German who has railed against European secularism and called on Europeans to return to their Christian roots, adding 1,000 or so new clergy, a few more conservative bishops and possibly a few whole congregations would be a shot in the arm. Increasing market share by getting consumers to switch brands is a tried and true corporate strategy. (The unhappy U.S. Episcopalians for whom the installation of Gene Robinson, an openly gay priest, as bishop was the last straw have already formed their own Anglican church in America. Meanwhile, African Anglicans are considerably more conservative than even Rome so they are likely to stay put.)

But just as with the church’s latest mass-conversion offer a quarter-century ago, there are questions being raised about the pope’s plan. At an Oct. 20 press conference the Vatican said more information would be released within several weeks, but some elements of the agreement were explained. There will be a new, unified international procedure that will permit mass conversions rather than a case-by-case evaluation of each potential convert. The new Anglican-Roman Catholic priests and bishops will have their own leaders and not be part of the normal diocesan structure. It is expected that these leaders will be former Anglican priests and they may oversee individual priests, whole congregations or even new dioceses composed entirely of converts.

So eager is the pope to add to his army that he has agreed to allow the Anglicans to keep their liturgical practices as well as their wives and children. What, one wonders, might they have to give up? Well, they do have to accept the pope. And, if they are bishops and married, they can no longer serve as bishops. Married Anglican priests will not be able to climb the corporate ladder and become bishops but perhaps they can divorce and then be bishops.

Not yet clear is what they will do about sex with their wives. It is anticipated that they will need to take the vow of chastity — not celibacy, chastity. That means they can only have sex with their wives. In the early church, priests were married, but the ideal was for the priest and his wife to live like “brother and sister.” Contraception is another matter. Anglicans can use it. Roman Catholics can’t. If the crossover priests and bishops must follow Catholic rules on contraception, will the church be able to support all those kids? Parish priests don’t take a vow of poverty, so perhaps we will find the crossover guys will be more demanding about pay scales or take second jobs — or their wives will go out and get jobs.

And then there’s the case of Florida’s Father Cutie. Known in South Beach as Padre Oprah, Father Cutie left the Catholic priesthood earlier this year and became an Episcopal priest so he could marry the woman he loved. Can Father Cutie now come home again and be a Catholic married priest? What a slap in the face to the one in three Catholic priests who left the priesthood to marry and can’t even get the pope to answer a letter or their local bishop to provide them with a pension for the years they were priests.

This week the pope meets with the Lefebvrists, those “traditionalists” who broke with Rome over the reforms of Vatican II and whom Benedict has been courting along with the homophobes and misogynists of the Anglican communion. It was just a few months ago that he lifted the excommunication of four of their bishops and then discovered that one was a Holocaust denier and the others part of a system that consistently issued anti-Semitic statements. It seems he thinks they are worthy of religious leadership. 

The pope is, as usual, unconcerned about how the Catholic people will react to his willingness to open his heart to homophobes and misogynists and anti-Semites in the name of corporate survival. A few die-hard optimists who still think justice can emanate from Rome are making soothing sounds. Sister Christine Schenk, the executive director of Future Church, a Catholic group that favors married priests, thought the Vatican ploy was “very interesting and probably somewhat encouraging in the sense of, yes, there is flexibility, there is openness.” 

But for other Catholics a serious question has been raised about how long to stick it out. Mary Hunt, a Catholic feminist theologian not known for drinking the Kool-Aid, was blunt: “Let history record this theological scandal for what it is,” she wrote in Religion Dispatches, “the joining of two camps united in their rejection of women and queer people as unworthy of religious leadership.”

I personally am left asking at what point fighting to reform a corrupt system becomes the same as contributing to it. Bishop Martyn Minns, a leader of the dissident Anglicans in the U.S., rejected Rome’s offer out of hand. “I don’t want to be a Roman Catholic. There was a Reformation, you know.” If you are Roman Catholic, like me, you are still waiting for the Reformation.

Worldwide, 1 million people die each year from end-stage renal disease. About 600,000 live in such undeveloped countries that even dialysis is not available. But about 40 percent of the 1.2 million people on dialysis will also die and most of those lives could have been saved had a healthy kidney been available for transplant when they were first diagnosed. Right now the shortage of kidneys means that just under 70,000 people a year will get a transplant. The magnitude of this problem is lost in the COE/U.N. report’s rather single-minded focus on brokers and middlemen, the traffickers who are responsible for between 3,000 and 7,000 black market kidney transplants each year. When you realize that 1 million people need kidneys, it becomes clear very quickly that the problem is huge and the black market is small, and altruism is not enough to bridge the gap between them.

Everyone with kidney disease who has some control over their lives and some options confronts the reality of supply and demand. The way the system works in the U.S. is that patients who want to get a transplant in a timely manner are on their own to recruit a living donor. If you count on getting a deceased person’s kidney off the waiting list, your chances of dying on dialysis are higher than getting a kidney. I’m one of those people. I’m not yet in renal failure or on dialysis but I’m aware that the clock is ticking. My prospects for a living donor are great, since many friends have offered, although the first few tested did not make it. I need a younger person with stronger kidneys. So I must ask: Is there a way I could pay someone for their kidney that would be non-exploitative even if illegal? Of course there is.

I’ve considered three scenarios in which I would pay for a kidney. Two involve a degree of altruism combined with financial interest and the third is purely in the economic interest of the donor. Scenario one developed in response to the reaction of colleagues in the Latin American women’s movement to my search for a donor. Several friends offered to find a colleague who would like to give me a kidney but could also benefit from financial support for their work in the movement. So many people work for justice for organizations with little money and make next to no salary and have no pension. My friends felt that I could help such a person with a contribution to their work or an investment in their pension. I loved this idea. Reciprocal generosity. I would rather receive a kidney from someone who needed my help than from a friend who is well off. The second idea was to offer something meaningful to my well-off friends — I would contribute $50,000 to the charities of their choice. Their donation of a kidney would result in two goods — I would get a kidney that would enable me to live and a charity would be able to do better work.

The third option would put me in the realm of organ trafficking. I’m a well-connected, international person. I could beat the system and find a colleague in the health field in the countries where transplant tourism occurs. I could insist on a donor who meets U.S. medical standards, be admitted to a good hospital and get good care. In return, I could meet the donor’s real need. I have enough money to lift the donor out of poverty and into the middle class and I have enough money to guarantee any continued healthcare the donor would need if there were complications from the surgery. I could not promise the donor that he or she would not die, but I cannot promise that to an altruistic donor either. And the risk of death is considered small enough that kidney transplants are legal in the U.S.

None of the above options are optimal ways of saving my life or anyone else’s. And I am painfully aware of my financial privilege and how unfair it is to others. But people like me are forced to think about such options because altruism is not enough — because so few people have been convinced or motivated purely by the love of others to donate a kidney. The very people who are working to motivate donation via government transplant programs and nonprofit organizations have not themselves donated kidneys. Primary-care doctors routinely discourage healthy patients who want to donate a kidney from doing so. Two very healthy friends who told their doctors they were considering donating to me were told to forget it — that they should not take the risk. Neither doctor provided any information to them on what that supposed risk was. In a survey of primary-care physicians in Spain, only 21 percent approved of living kidney donation. The leading U.S. ethicist on organ transplantation, Arthur Caplan, a coauthor of the U.N. report, describes living donation as “maiming.” Caplan has said that the only possible justification for allowing someone to decide to “maim” themselves is if “the donor chooses to undergo the harm of surgery solely to help another.” Does Caplan think that conceptualizing living donation in this way, as something akin to martyrdom, is going to encourage people to donate organs?

There is no doubt that transplant policy needs to have as a top priority protection of donors against exploitation and fairness in the distribution of organs, but it must also recognize that the lives of millions of potential organ recipients are at stake. While a fine philosophical argument can be made that allowing people to receive direct compensation from the government in exchange for organ donation is fair and just, the concern we rightly have for the potential abuse of such a system and the vehemence of the professional and medical lobby’s opposition to such a system speaks against it. But there are viable policy positions that lie somewhere in-between the demand for absolute altruism and the drive toward a free but regulated market in organs. Just as we need to get out of our head the idea that organ donation must be pure, we should also shed the market mentality. 

What might such a middle ground look like? The foundational principle would be generosity. The act of giving a kidney or part of one’s liver is an inherently generous act. Right now, it is treated in public as extraordinarily generous and in private as so crazy and dangerous no government should encourage it. A more temperate view would be for society to honor, and be generous toward, those who give organs. At a minimum donors should receive free and comprehensive health, disability and life insurance following transplant.

Sound sensible? Organizations like the National Kidney Foundation actually oppose such largess. They operate on the principle that a donor’s altruism should be so pure that she is not in any way better off as a result of transplantation and if insurance is provided it be limited to insurance for medical issues directly related to the transplant. Other possible acts of generosity toward donors might include tax credits and educational benefits similar to those received by military personnel. None of these should be conceptualized as payment for organs or as an incentive to convince or coerce people to give an organ. These are instead things that we should do out of a sense of fairness and appreciation for a good deed, whether or not they result in a single additional organ being donated.

Instead, we have the new U.N. report, which is no more helpful than past reports when it comes to solutions. It acknowledges that we will not end organ trafficking unless we end the shortage of organs for transplantation; it acknowledges that the methods tried up to now have not worked. It then insists that the same principles that have led to the failure to solve the problem and the same tired half measures that have failed are the only ones we can use. If the U.S. government adopts the values and solutions outlined in this report, it will have condemned people with ESRD to death as surely as has our policy in Darfur.

Perhaps the most damaging recommendation of the report is its insistence that efforts to expand organ donation should focus on more organs from dead people and that living donors should be viewed as a “complement” to that effort. There are simply not enough healthy kidneys available from dead people to meet the need. In the U.S., which has a sophisticated and efficient system for gaining consent to use deceased kidneys, about 10,000 are used annually in transplantation. Perhaps improvements in our consent process could yield another 5,000 kidneys. With 345,000 people on dialysis, 15,000 kidneys is a drop in the bucket.

Moreover, it is ethically and medically irresponsible for the U.N. report to favor the use of kidneys from deceased persons over living donation. The report notes that of the three types of kidneys used in transplantation, kidneys from living donors last the longest. More than 80 percent are still working after five years. Only 69.8 percent of kidneys from deceased persons are still working — and in a growing category of deceased kidneys that come from people who are much older or had conditions such as high blood pressure that would have disqualified them from use 10 years ago, the survival rate goes down to 55.1 percent.

How can the U.N. and the Council of Europe claim that such results are “excellent” and that we should favor deceased donation over living donation? Such advice might make sense if transplants had high complication rates for the donor. In fact, they are remarkably safe. The death rate in kidney removal is three for every 10,000 procedures — fewer than in liposuction. Other complications are rare. If the transplant field were not tied in knots by the ambivalence toward the ethics of living donation, it would strongly urge that living donation be the method of choice and efforts should be focused on increasing living donation and on educating health professionals and the public about its safety and efficacy. Instead of spending more millions of dollars on campaigns to get people to sign organ donor cards for donation when they die, let’s urge people to donate now.

The most confusing sections of the report attempt to address a difference between “trafficking in organs, cells and tissues” and trafficking in human beings “for the purpose of removing their organs.” The latter is clear and well-defined in various U.N. and Council of Europe documents and the report is right to absolutely and unequivocally condemn trafficking in persons for the purpose of removing their organs as an egregious violation of the “prohibition of making financial gains with the human body or its parts.”

But a problem is created if the report — and it is unclear on this point — wants to use trafficking prohibitions to criminalize any form of compensation or reward offered by government to organ donors. The U.N.’s 2000 anti-human-trafficking protocol defines trafficking as “the recruitment, transportation, transfer, harbouring or receipt of persons, by means of threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person for the purpose of exploitation.” Only one country has eliminated kidney waiting lists — Iran — and it has accomplished this by offering those who give kidneys free health insurance and a government payment of less than $2,000. (At the same time, it has criminalized brokers.) Ninety percent of kidney transplants in Iran are from living donors. Because there is no shortage of organs, poor people with renal disease get organs as frequently as the wealthy.

And an expansion of the prohibition on financial gain related to the human body or its parts cannot be the position of the Council of Europe, for its member states have already approved using the body for financial gain. They have legalized prostitution in the Netherlands, Germany, Austria, Switzerland, Greece, Turkey, Hungary and Latvia while criminalizing trafficking in sex workers. It also cannot be the position of the U.S., which allows the sale of eggs and sperm for fertility treatments and in some cases the use of eggs for embryonic stem cell research. Third parties from doctors and hospitals to commercial drug companies have patented other people’s genes with a view to making profits, and this is legal in the U.S. Volunteers for drug trials or other medical experiments are paid for their participation. Would the authors of the report like to see all these activities legally banned and punished? Or are only organ donors expected to be altruistic in the extreme?

No doubt some special circle of hell is reserved for traffickers in human beings, with a particularly nasty corner dedicated to those who prey on the poor and rob their organs. But it is not enough to wring our hands or shake our fists at these people. It is not enough to put them in jail and take away as much of their money in fines as we can. We must do something meaningful to motivate people who are in good health and want to save lives to see living donation of a kidney as something they can safely do now, not after they die. And we need not shy away from being generous to such donors in return. The idea that generosity is coercive is absurd. Sadly, no international body has yet figured this out and the reports they issue and policies they suggest are not only not helpful, they are damaging.