Kidney sales: how far do sellers exercise reasoned freedom?
Cases from Bangladesh
M. Shaiful Islam
Des Gasper
Pre-final version of chapter in: Exploitation: From Practice to Theory, eds. M. Deveaux and V.
Panitch; Lanham, MD: Rowman and Littlefield, 2017.
The advance of biotechnology facilitates extraction of “fresh” organs like kidneys from living
people, and their transplantation to sick people. The transplant trade has expanded the options for
life-saving treatment but it violates many traditional understandings regarding appropriate
market exchange. The kidney trade is the largest example, despite being the subject of heated
public debate and having no legal basis across most of the world. It has been both challenged
(Moniruzzaman, 2012; Mendoza, 2011; Awaya et al., 2009; Budiani-Saberi and Delmonico,
2008; Garwood, 2007; Scheper-Hughes, 2006, 2000) and defended (e.g., Hippen and Taylor,
2007; Taylor, 2007), on ethical, medical, social, legal and economic grounds. While the
controversy continues, the gap between policies and illegal practices widens. The trade is
expanding in Asia as well as in war-torn MENA areas (He, 2015).
Kidney sale is perhaps still under-theorized in some respects. In all discussions, the
sellers should sit at the center, for only the poor, destitute or socially disadvantaged sell, whereas
only the well-off and socially advantaged buy. Discussions have concentrated on: (1) goals of the
sellers, (2) varying benefits and harms they can experience, and (3) illegal informal arrangements
that facilitate the decision to sell an organ. But there is confusing evidence on consequences, and
limited connection between those discussions and the normative assessment of how far are
selling decisions the desperation behavior of people who possess too little real choice.
This paper explores kidney sellers’ perspectives and the process of decision-making in
some villages of Bangladesh. We examine the organ sellers’ degree of freedom in relation to
what they value to achieve, identify its limits, and see how those lead them to the choice of
organ-selling. Selling decisions are made in a context where some people lack adequate material
and social resources to secure a livelihood, face a never-ending quest for means to manage and
transform their lives, and are enmeshed in constraining relationships within social and economic
power systems. These conditions have contributed to the institutionalization of kidney-selling, a
form of bodily self-exploitation, as a now routine practice amongst the poorest groups in some
areas. Consistent with most other findings, we find in these locations that while kidney sale is
based on hope of resources to confront the precariousness of livelihoods, it is frequently
experienced as a nightmare of life-long disaster, that consequently remains often mentally buried
and/or untold.
We begin by situating our study within the existing debate and outlining our
methodology. We then examine concepts of exploitation, human freedom and capability gaps, in
relation to sellers’ decisions. Subsequently, the heart of the paper presents and analyses the
interviews. Finally, we discuss possible implications for the ethical appraisal of kidney sales.
Framing the debate - The ‘why’ and ‘how’ of selling
Why people sell their body parts is a fundamental question in the controversy (Boas, 2011;
Taylor, 2007; Wilkinson, 2003). The goals the would-be sellers seek can influence assessment of
whether selling is harmful or beneficial. A related question is: what living standard did they
enjoy, what precariousness of livelihood did they face, before deciding to sell an organ? These
aspects may enter arguments on either side of the controversy. The main motive found has been
for financial gain in situations of poverty and/or debt peonage (including to micro-credit
organizations) and of obligations to feed and support family members (Tong et al., 2012).
In contrast, the published research says less on process aspects, how the decision to sell is
formed (Cohen, 2014; Jecker, 2014; Koplin, 2014). Work here seems hitherto mostly limited to
identifying illegal and coercive informal institutions and the ways they influence decision
processes of poor would-be organ sellers. For example, in Bangladesh, an informal network of
affluent aspirant recipients and of hospitals, doctors, medical companies, media and brokers
operates to provide market signals to possible sellers (Moniruzzaman, 2012). Similarly in the
Philippines, a network of hospital owners, doctors, civil servants in various government
agencies, and beneficiaries of transplant tourism operates illegally (Mendoza, 2011). ‘Traders’
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provide inadequate or false motivating information about the impacts of selling on the would-be
sellers’ health and finances. There are also documented cases of some organized coerced
transplants (e.g., Scheper-Hughes, 2000). However, debate rages between proponents and
naysayers of the trade, regarding whether the deviant practices are due only to a remediable
absence of regulation (Taylor, 2007; Wilkinson, 2003), or are instead the fully predictable
consequences of highly unequal and exploitative social structures (Moniruzzaman, 2012;
Scheper-Hughes, 2006).
The literature thus focuses on two sets of factors to explain sales. One is the sellers’
anticipation of financial gains, in circumstances of poverty and aspiration. The second concerns
institutional arrangements which encourage and facilitate people to sell, and their operation in
relation to individuals who live in severe poverty. The actual gains (or losses) and actual details
of the transaction process are referred to in judgements on whether or not there is exploitation,
and of what type and degree, for example if (1) the seller is benefited, but gains much less than
the other parties involved and much less than he/she expected and contracted for, or (2) the seller
is not benefited or is even harmed. We suggest though that for considering the why and how of
selling decisions, some additional informational categories are needed.
Analysis of consequences-for-sellers remains inconclusive in its own terms, given
considerable empirical evidence on both sides of the argument regarding whether goals are
fulfilled or not fulfilled by selling organs. Further, Cohen (2014) reflects on why even though the
ambitions of most of the sellers in some studies (to buy a market stall, to provide a dowry, etc.)
went unfulfilled, this fails to translate into any prohibition of the sale. Could not, for example,
reliable information be spread out among the would-be sellers, so that inadequate or false
‘information’ would not survive long? Cohen argues that “We do not have a good sense of why
[many] sellers seem to be making this mistake in their estimation of how kidney sale will change
their welfare.” (Cohen, 2014, 20).
We must consider how informal institutions that lure people to sell emerge and endure, in
the breeding spaces set by structural inequality in particular contexts. While the informal
institutional arrangements that emerge in an unregulated space might in principle be subject to
regulatory reform, in a space of high structural inequality they persist permanently. We refer here
to strongly unequal distribution of land, savings, human capital and social capital; such that some
groups lack security of employment and income, cannot save to invest, cannot access cheap
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loans or government schemes, and cannot afford to keep themselves or their children long in
school or in training. However, institutional arrangements alone, that supply inadequate or false
motivating information to the rather desperate would-be sellers, do not necessarily entrap them to
sell; the sellers do not merely passively consume proffered ‘information’. Similarly, whereas
structural inequality is widespread, indeed typical, in Bangladesh, kidney sales and associated
illegal arrangements are prevalent only in a few adjacent villages or among a relatively few
people in certain classes.
How the sellers are valued in the exchange, and how this influences their decision
formation, also seems mostly absent in existing consequentialist and institutionalist categories
and discussions (Jecker, 2014). Yet “certain kinds of exchanges not only distribute things, but
also distribute power and shape the kind of people we become” (Satz, 2010: 181). An exchange
becomes ‘noxious’ and ethically flawed if it fails to respect the equal value of persons engaged in
it. In some exchanges one’s own preferences, goals and ends may be subordinated to another
person’s wealth and power and established higher status. Fear that this happens in the organ trade
arises since, as we noted, only poor and socially disadvantaged people sell organs, and only the
well-off and socially advantaged buy.
So, the study of the organ trade requires additional categories and types of information
regarding why and in which ways people decide to sell their body parts. The needed categories
include the effective degrees of knowledge and freedom that potential sellers have, the value
assigned to persons engaged in the exchange, and the unintended as well as intended
consequences of such decisions in particular circumstances.
The study: What sort of freedom do sellers have in their decision formation?
Against this background we investigate how decisions to sell a part of one’s body are formed. As
both a descriptive category and a priority value, we use the concept of human freedom offered in
Sen’s capability approach—whether people are actually able to do and to be what they (have
reason to) value to do and to be. We attempt to describe and explain the realities the would-be
organ-sellers face in achieving what they value to achieve, that lead them to the choice of organ
selling: (1) what are the capability gaps they face before selling their kidneys? (2) in which ways,
why and to what extent are the capability gaps connected to the decision to sell one's living
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organ? We thus seek to go beyond the use of notional examples such as sometimes constructed
by philosophers, and also beyond the examination of real cases without attention to the full
context, including of interpersonal relations and institutional and political landscape (Gasper
2000).
The study was conducted by the first author in Kalai, a rural sub-district in northwestern
Bangladesh, where he worked in the local government during 2013-15. The area is heavily
agricultural and a surplus food-producing zone. According to various newspaper reports and
popular perception in the country, it is the only concentrated kidney sellers’ zone in Bangladesh
outside Dhaka. According to the local administration, and corroborated by this investigation, the
number of kidney sellers has already exceeded 6-7% of the population in four adjacent villages,
surpassing the estimates given by the local and international media. As of 2015, many more
people were in the queue to sell organs.
The study attempted to find respondents amongst, first, would-be organ sellers, but
experienced difficulty to do so, though a few were interviewed. People tended to hide their
intentions and were unsure about whether they would really sell an organ. Substantial difference
was found between declared intentions and actual occurrence of selling organs. The study also
interviewed previous organ sellers. They showed comprehensive awareness of what were their
expectations from the sale, their actual gains, sufferings and trade-offs, and a willingness to
evaluate their experience: including the difference between their pre-sale and post-sale condition,
and the causes thereof. They also in general showed eagerness to share information. Here we
concentrate on the cases of seven actual organ sellers, though against the background of other
interviews and conversations, and use these cases to view the continuum from pre-sale to
decision-making through to post-sale conditions.i
Respondents were selected through snowball sampling, while seeking a representation of
different gender, age and occupational groups. A very difficult task though was to identify a
female kidney-seller willing to be interviewed. Even though many names were mentioned,
including two women in one family who had sold kidneys, they were unwilling even to be
introduced. One woman seller, here called Khaleda, was willing to talk. Her case does not allow
generalizations about women sellers, but gives an indication of women’s capability gaps and of
the risks of being driven to become an organ seller. Similarly, while our study as a whole is
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small, it allows identification of some important aspects that ethical theorizing and policy debate
must attend to.
The main interviews were done by a well-briefed local research assistantii, and were
preceded and followed up in other conversations involving the lead author. No blunt questions
were asked about why people sell their kidneys, or what set of beings and doings the would-be
sellers value most. Rather the discussions with organ sellers were conducted as a mix of semistructured and open-ended interviews, to put them at their ease, to map out their life-context and
capabilities, and then to gradually explore their decision-making story. We use pseudonyms for
the respondents.
Attempts were also made to triangulate data: where deemed necessary, local school
teachers, elected representatives, and representatives of different public agencies were
interviewed in a semi-structured manner to verify the data given by the sellers. As further
indication of care in use of the data collected, we mention at the outset one case that has a special
status. ‘Aftabul’, his elder brother, sister-in law, father, and his former wife each sold a kidney.
The sales had not revived the family fortunes. Aftabul was ready to talk only if paid. He had
become drug-addicted, and earned money by interviews with journalists, national and
international, since the family had become a media-target. However, his reports seemed to us
unreliable and biased toward what he considered journalists wanted; so they are not used further
in what follows.
The analysis of exploitation
When can we say a kidney seller becomes exploited? Interestingly, exploitation literature, while
focused on interaction between individuals that results in exploitation of one party, seems more
occupied with the exploiters’ side. For Wertheimer, for instance, (1) “A exploits B when A takes
unfair advantage of B” (Wertheimer, 1996, p. 10); (2) “A engages in harmful exploitation when
A gains by an action or transaction that is harmful to B”, and also (3) “A engages in mutually
advantageous exploitation when…A gains unfairly or excessively by an action or transaction that
is beneficial to B” (Wertheimer, 1996, p. 207). Or similarly, “if you take advantage of a person
and harm that person, show lack of respect for that person, or treat that person unjustly, then you
have exploited that person” (Resnik, 2003, p. 235); and, exploitation is “wrongful behavior” of a
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person that violates “the moral norm” of “protecting the vulnerable” (Goodin, 1988, p. 147). In
these treatments the focus seems more on the exploiters, who could take unfair advantage, inflict
harm, disrespect, be unjust, and not protect. Analysis of exploitees and their actual and attainable
beings and doings appears secondary.
Although current explanations are helpful, they often seem not to emphasise structural
analysis or the agency of poor, marginalized people and possible exploitees (see also, Sample,
2003, pp. 8-9, ten examples of exploitation). Exploitation cannot be reduced to only “a function
of the way in which A treats B or the effects of A’s treatment of B on B” (Wertheimer, 2007,
p.259, in his critique of Sample, 2003). Our argument is that exploitation can be understood
better if we consider also the agency of possible exploitees, placing it in context, and exploring
how norms, rules and structures influence agents’ actual beings and doings and their attainable
alternative beings and doings.
We do not reject the evaluative question whether A’s treatment towards B happens in a
harmful, degrading or disrespectful manner. But we suggest that great emphasis should be given
to: (i) whether B lacks command of necessary basic beings and doings; and (ii) whether B's
decision to sell something like a kidney or ova comes from such a lack. The transaction itself
could occur in a way disrespectful or degrading towards B; however, that B will be disrespected
or disgraced by A is not a necessary condition to treat a phenomenon as exploitation.
So, we focus here not on the actions of possible exploiters, but on the degree of agency of
exploitees and their capacity/incapacity to negotiate within existing structures. In doing so, we
will draw from Sen, to look not only at potential exploitees’ actual beings and doings but also at
their attainable alternative beings and doings; and draw from Dasgupta, for a concept of bodily
self-exploitation. This reflects a structural approach to understanding exploitation, combined
with an emphasis on sellers’ agency and what has moulded and constrained it. Bodily selfexploitation arises when a person has insufficient resources to maintain his/her household’s basic
beings and doings, and resorts and/or is forced to use his/her body for acquisition of goods,
through excess bodily labor and/or the sale/rent of their own body parts. It arises when (s)he is
incapable to transform the surrounding social-economic structures into an enabling form, indeed
where the struggle to conquer constraints can even reinforce their unbearable pattern. So his/her
sets of attainable beings and doings become thin, precarious, and perhaps continuously
downgraded, leading to a decision that his/her body is the only asset through which to survive or
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to transform this. To be clear, the resulting self-exploitation is typically the result and expression
of exploitation by others.
Using Sen’s capability approach to consider capability gaps and organ sale
decisions
Sen’s approach focuses on individuals’ capabilities: their freedom to achieve what they have
reason to value achieving. The approach sees capabilities and their formation as conditional on
multidimensional relationships of structure and agency, and it attends systematically to how
social circumstances influence the lives of the individuals. Using this approach and other
relevant literatures, we sketch a conceptual framework focused on capability gaps and their
relation to acts of selling one’s kidney.
Sen’s concept of human freedom relies on two other concepts: functionings and
capabilities.
(i) Valuable functionings: Functionings refers to multiple diverse aspects of life that
people value (or have reason to value) to do or to be. Functionings can be material, such
as being nourished, or immaterial, such as participating in political decisions. They can
be self-regarding, valued in terms of benefit to oneself, or other-regarding, aimed to
benefit others. Valued functionings, persons’ reasoned choices, can reasonably vary
between persons.
(ii) Capability refers to a person’s or group’s freedom to achieve valuable functionings.
“It represents the various combinations of functionings (beings and doings) that the
person can achieve. …reflecting the person’s freedom to lead one type of life or another
… [and] to choose from possible livings” (Sen, 1992, 40).
Sen uses the term agency in regard to “someone who acts and brings about change, and
whose achievements can be judged in terms of her own values and objectives” (Sen, 1999, 1819). We will use the term with the following attributes (Crocker and Robeyns, 2009, 80-82), to
examine the process and consequences of kidney sales decisions:
(a) Self-determination. Agency in Sen’s sense requires that an individual personally
decides to perform the act in question: self-determination of behavior.
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(b) Reason-orientation and deliberation. The approach presents “persons as reasoning
agents with the right to make choices” (Gasper, 2007, 336-7). For Sen, freedom exists
“when a person acts on purpose and for a purpose, goal, or reason”. Sen maintains that
agency involves “not merely freedom and power to act, but also freedom and power to
question and reassess the prevailing norms and values” (Drèze and Sen, 2002, 258). An
agent's decision should not be based on whim or impulse, but on reasons and goals.
(c) Action and its impact. Agency requires action. Someone may get what he or she
intends, for instance, the elimination of famine, without any deliberate action; but then he
or she is not an agent in this case. An agent’s action, moreover, must bring some impact.
The more it makes a difference in the world, the more fully does the agent exercise
agency.
For Sen thus, agency is embodied in capability.
Over time, Sen has elaborated a “two-way relation between (1) social arrangements [such
as economic, social and political opportunities] to expand individual freedoms and (2) the use of
individual freedoms...to make the social arrangements more appropriate and effective” (Sen,
1999, 31). Human agency, and lack thereof, can help explain capabilities and their gaps (Martins,
2011; Oosterlaken, 2011; Smith and Seward, 2009). Agency is conditioned rather than fully
determined by social structure. Agency in turn can help to reproduce or transform social
structure.
An individual’s capability gaps can be understood as arising where an agent does not (a)
identify a set of valuable functionings by using well-reasoned valuation, and/or (b) possess
achievability of functionings from the chosen sets, and where the agency-structure relationships
seriously constrain exercise of human agency. We use this conception of capability gaps to
examine the decision process of a would-be organ seller, as shown in the following diagram. A
person may suffer deficiencies while exercising agency and in navigating social structure and the
agency-structure interrelations.
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Diagram 10.1: - Capability set: valued functionings and their achievability
The left-hand side of the diagram shows the inputs, meaning any resources of material or nonmaterial type, used to create one's capability set. The diagram places these inputs inside the
relationship matrix of agency-structure, unlike in the widely used but unidirectional Robeyns
diagram (Robeyns, 2005, p.98) where they are outside the matrix. Agency creates social
resources, like social capital, and more material resources, by bringing change into existing
structures or by other purposeful action; and structures facilitate or impede agency.
The priority focus in the approach is not resource inputs but the creation of capabilities,
namely achievable valued-functioning sets. As suggested in the middle of the diagram, we
identify the capability gaps by considering how far the would-be sellers are able to choose
valued functionings which are prioritized, coercion-free and well-reasoned, and able to undertake
actions that achieve those valued functionings.
The right-hand side of the diagram indicates the linkage between sets of capabilities,
agency, structure, and exercise of agency or actual actions. It leads to the questions: In what
ways could the sets of valued functionings, and the conditions for their practical achievability,
lead prospective sellers to the decision to sell their own body parts? How far and in what ways
are their valuations, reasoning, agency and its exercise socially moulded?
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Inadequate input resources vis-à-vis valued functionings
The functionings that respondents valued most covered a wide variety of doings and beings that
were perceived as achievable by selling one’s own kidney, ranging from repaying debt, through
income-generating investment, to securing relational ties. Their priority lists are influenced by
their capacity to exercise reasoned judgement to identify target functionings, by the socioeconomic structures and interrelationships, and by social values and beliefs and how these are
affected by social equality/inequality.
Of these valued functionings, repaying debt to microcredit NGOs and informal
moneylenders was very prominent. As Khaleda, a 34-year-old part-time housemaid and part-time
tailor, put it: “I was indebted to [several microcredit NGOs and informal moneylenders] for
about 70,000 taka, and I wanted to get rid of the loan burden”. Karim, another kidney seller, is a
father of three school-going children, in his late 30s. He has worked as a seasonal agricultural
laborer and part-time van driver for the last two decades. Being indebted for around 80,000 taka
to six microcredit NGOs and many informal moneylenders, he decided to sell a kidney: “I was
afraid for the future of my kids and wife. I didn’t want to let them fall into the cycle of loans and
to be indebted for my loans”. He continued, “The peace in my family was ruined due to the
pressure of NGOs. They threatened us always with rough talk and they could seize all the
belongings in my family. Even it happened that I ran away from my house, keeping me and my
family hungry for around two days, due to fear of Grameen Bank.” The agents of microcredit
NGOs can be no less harsh to the poor in Kalai than are their Shylock-like informal moneylender
counterparts. Together they inject a sense of urgent priority to repaying debt, and unitedly drive
the borrowers to quest for anything yet to be capitalized in order to repay.
Investing for future income-generation is another valued 'doing' that motivates would-be
sellers. Milon, a 37 years old rickshaw-puller, sold his kidney three years back, aiming to invest
in a CNG vehicle (a three-wheeler driven by compressed natural gas) for greater and more secure
earning. This is a popular route to modest earning in Bangladesh. According to Milon, “The
[kidney] receiver asked me what I can do for you. I asked for a CNG vehicle. … with a CNG
vehicle, I can pay for my family’s feeding and expenses.” Another seller, Jahangir, similarly
wanted to sell a kidney to buy such a vehicle: “I was driving CNG on rent. If I have one, this will
ensure the livelihood of my family.”
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A third highly valued functioning, associated with repayment of debts and intended
income generation, thus was financial security and guaranteed welfare for family members.
Khaleda announced boldly, “I don’t have even a single bit of remorse ever for selling my organ.
Do you know why? [silently weeping]. Because I love my family, my husband, and my two
kids”. For Mohammad Titu, 33, a farmer and occasional rickshaw puller, who sold his kidney to
a rich businessman, his most valued target ‘be-ing’ was a permanent solution of his family's dayto-day insecurity of livelihood. He put it bluntly: “This is not a one-stop trade. And I don’t want
one either.” He explained, “I took monetary help several times. He [the businessman] sends me
money regularly by bikash [electronic transfer] …and I spend the money for feeding and regular
chores”.
The fourth important valued functioning that the study identified was an extension of the
third: having a secure relational tie with rich and powerful people, a tie that gives a possibility of
financial insurance. For Titu, “I donated, did not sell. I donated to my friend, who though he is
rich has built a generous friendship with me for around seven years.” He continued: “[Even
before selling] I sit with billionaire, eat with him, talk with him, he did so many things for my
family. No one of my family and kin (some of whom have the ability, though most have no
ability) do anything for me ever.” He said further: “However, even if I have money, even more
than the receiver, I would give him kidneys, because he is such a nice person”. He fumbled when
faced with the harder question whether he would still have donated a kidney if the potential
receiver were poor.
Another important functioning is securing dignified status for women in the household,
as seen in Khaleda's case. “I was indebted hugely and my husband knew it. But when public and
NGOs hugely pressurized me to repay the debt, my husband declared that he did not know
anything about the loan. He distanced himself from this and even was thinking to divorce me. I
then became determined to repay the loan by myself and would come back to this family
(songsar) with dignity.”
The last set of valued functionings that were emphasized concerned building a home and
laying the basis for children’s success by putting them through school. As expressed by Khaleda,
“If you don’t have a house how you can think of a minimum good life? I struggled hard to send
my two kids to school. But when they went to higher classes, I struggled even harder to continue
their educational expenses.” She continued: “My father-in-law had two decimels of land.iii The
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house had three rooms for four families. My father-in-law, we, my family, sister-in-law and
brother-in-law were living together there before selling kidneys. We cannot rear up a goat or
some hens.” “My husband is of good mind. He suggested me not to sell organ. I told him that
your father did not do anything for you. But you can’t do the same with your children. … A good
house and good education for them.” She went on: “We could not afford the marriage of my
daughter if we were in our earlier financial situation. Here a marriage of a daughter costs around
at least two lakhs (200,000 taka). So my daughter is committed not to get married, and adamant
to continue education. I am also thinking to spend the money for my daughter’s education
instead of spending the money for marriage.”
For achieving their goals, the material and immaterial resource stocks of prospective
sellers are far behind what is required. They all belong to the lower rungs of the society in terms
of human capacity, profession, and material wealth. Milon and Khaleda had no educational
qualification or formal skills, and possessed only unskilled physical labor to sell. Only Jahangir
among our cases had completed secondary education, or had a driving license. They all worked
in low-grade informal professions: rickshaw-pulling, driving a CNG vehicle, working as a
housemaid. Moreover, they are far behind in terms of land ownership. Milon’s father did not
have any land either to cultivate or to extend the house for the families of Milon and his brother.
Only his mother has 33 decimels of agricultural land, which is equally distributed between Milon
and his brother, and this is next to nothing to feed a family for the whole year. The same is the
case for Jahangir and Khaleda. We saw that Khaleda had lived in her father in-law’s house with
two further families, a tiny muddy three-room house built on only two decimels of land.
So, all our cases of sellers lacked strong agency and an agency-enabling structure. All
had a widening gap between their available material and non-material input resources and their
valued functionings, a gap so large as almost to suggest the irrelevance of thinking in terms of
those functionings and to instead adapt their preferences, however modest, drastically
downwards. The questions arise: how did their notions of valued functionings emerge and
persist?; and why and how did they come to the idea, and then the decision, of selling an organ?
The following sections explore kidney sellers' valuation of functionings and insufficient
possession of the means to achieve them. Exploring the structural inequalities in rural Kalai and
especially the tales of the sellers revealed four key areas: (a) informality of work, (b) relational
social capital, (c) the rural finance system, and (d) the growing social acceptance of kidney sale.
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The agency-structure relationships constrain the would-be organ sellers in valuing appropriate
sets of functionings and in their ability to achieve, and force them to try to mobilize resources.
Informality and uncertainty of livelihood
One important structural feature is the informality and uncertainty of livelihoods. The
respondents were (and are) mired in inadequate earning, at high risk of being unemployed, and
largely without skills transferable to serious income-generating or human capacity developing
ventures. Milon, for example, said, “I tried my luck in all available ways, particularly
considering the future of my daughters; I was rickshaw puller in three cities, Dhaka, Moulvibazar
and Sylhet, also tried some part-time businesses of selling spices and clothes. Yet still I could not
afford to give them adequate food and think of their education.” He continued: “I even started
working as domestic worker in others’ houses. But no change, the education of my two
daughters has been stopped several times, I also could not accumulate some money from my
earnings to buy a van so that my earning could be increased”. Informal employment like
rickshaw pulling or domestic work, and micro-business like street hawking, is not adequate even
to ensure decent food, let alone for education or training or income-increasing investments like
purchase of a van.
Respondents had tried their luck by shifting occupation frequently. Besides selling spices
and clothes in the street, and pulling rickshaws in several districts across Bangladesh, Milon tried
farming on another’s land. Jahangir, once a van driver in Kalai transporting people and
agricultural products, became a CNG driver. Khaleda tried tailoring for villagers and worked as a
maid in Dhaka. Shifting occupation never appeared successful as a path to clearly increased
earning levels.
Moreover, they could at any moment become unemployed. Milon, while a street hawker
of spices and clothes, found that “during some strike days of [i.e. led by the] opposition party, I
could not run the business. But how to feed my family members in that time? I spent my capital
and even became indebted to feed them.” Karim said: “[With microcredit I] purchased a van.
However, immediately after purchasing it, my income fell due to very heavy rainy season. … I
could not immediately find any work on the land of others, since all landowners had hired labor.
So I sold the van, to spend the money for feeding the family.”
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Skills of the would-be organ sellers that have value in the market are few. For Khaleda, “I
sewed clothes for others before selling my organ, but did not make that much money, since I did
not have any training on sewing and could sew only few types of basic clothes.” She “could not
afford any training due to money shortage, my illiteracy, and most of all I could not spend any
day for training since every day was our struggle for that day’s livelihood”. She then started as a
housemaid in Dhaka city. Jahangir was driving a CNG in Kalai: “I was driving CNG on rent.
After paying rent money, I have inadequate amount remaining for my family’s livelihood”. Yet:
“How could I buy [a CNG]? I could not accumulate 5,000/- taka ever from my earning”.
In sum, all the respondents are involved in selling their labor in the informal economy.
They compete in the lower skill-reaches of this economy, since they are mostly illiterate and
unskilled. As a result, their earnings are poor and unreliable. Although they work hard, they
always confront uncertainty in ensuring even a subsistence livelihood, let alone in fulfilling their
other ambitions. The work is also very precarious, as in rickshaw pulling in Dhaka or driving a
CNG vehicle where one could sometimes be attacked by criminals or harassed by law enforcers;
and when they are unable to get to work due to the frequent strikes or to illness, they do not earn
on that day. The informal economy provides the would-be organ sellers with much exposure to
desirable functionings, but little ability to achieve them.
Decayed relational resources and the longing for a patron
According to the respondents, another key structural feature concerns their relations with other
persons, including with kin and with rural power-holders. It is commonly expected that relational
ties in rural communities are beneficial for individuals during a livelihood crisis (Hossain,
2009a). Relational ties are popularly called social capital (Putnam, 2001). Potentially they could
ensure an individual or family’s livelihood when it is threatened by hardship, due for example to
agricultural hazards or governance malfunctioning. However, the stocks of relational capitals in
Kalai, both between close kin and with neighborhood residents, are inadequate to support each
other during any crisis.
Jahangir reported: “All in the neighborhood are my relatives, many of whom are rich,
political leaders or elected representatives. We have good relations with all. But support? No, in
village, none supports others.” He continued, “I didn’t get (or hope for) any help from my
15
community during periodic financial suffering before selling my kidney; I only get shaming now
for having sold”. Khaleda’s experience was similar: “Before selling my kidney, when my family
was very vulnerable, I begged for some money to my rich cousin, [pleaded] also an employment
for [my] husband to our Union Chairman, but nobody offered anything, not even a drop of
sympathy.” Karim reported, “The Chairman of Upazila Parishad [the subdistrict council] is my
kin, gave me only hope but did not provide anything.” Relations among even very close kin also
in some cases cannot be relied on when an individual faces shocks and crisis, as when Khaleda
was being forced to repay her debts to numbers of local NGOs and moneylenders and her
husband stepped back. In Aftabul’s family, his elder brother provided him a financial loan, but
with interest due.
The respondents perceived a specific type of relation as valuable, easily convertible into
resources at times of livelihood shocks, but not accessible for them: ties to a local political
patron. In Khaleda’s case: “I tried earlier several times to get rice [from the Vulnerable Group
Feeding-VGF program] and card [for entitlement under the Vulnerable Group DevelopmentVGD program] from the Union Parishad [locality council], but did not get anything. These all
are for their supporters, not for common poor like us”. Karim echoed this: “Before selling
kidney, I along with my wife went several times to member and chairman of Union Parishad for
support (VGF rice and VGD card). They said they don’t have any support to give me. Even after
selling my kidney, I went to them, but they refused. I told them, I am disabled [partial paralysis
of the legs], but they told me that I am fit and I don’t need any support. I know that they only
give support to their party men and others in exchange for political support and bribe.”
This type of politics in disbursing governmental welfare support is common at local level
in Bangladesh and elsewhere: support is disbursed primarily on the basis of a recipient’s political
affiliation, to maintain and increase the base of the ruling party (Khan, 1995; Mirza and Prichard,
2013; North et al., 2013). If a prospective recipient does not belong to either the ruling or main
opposition party, she or he will not receive any support through a cash/food/work programme or
land distribution programme. Further, the expectation by members of the bottom-of-the-ladder
group, that they will not get entry into the rural political settlement and its network of powersharing and resource distribution, conditions their exercise of agency. Their perception plus the
actual entry-barrier mean they exert insufficient pressure, via either the informal political
networks or the official channels like the office of the PIO (Project Implementation Officer,
16
undertaking relief and rehabilitation programs in the sub-district) or the Union Chairman’s
office, to access opportunities such as work in the 40-days employment program. With decayed
traditional relational ties and the emergence of unwelcoming new relations of rural political
settlement, the poor's livelihoods are insecure.
The more the potential sellers face relational resources gaps, and exclusion from the
political settlement, the more they see a need for a personal patron to help them in times of crisis.
The longing for and attachment to a rich patron was visible in several emotional post-sale
statements. Milon fondly named as a great man his patron in Moulvibazar, who provided him
lodging and food, trained him how to pull a rickshaw, and gave him one. Habibul when a
rickshaw-puller in Dhaka city developed a friendship with a RAB (Rapid Action Battalion; a
Bangladesh Police elite unit) official. “Driving rickshaw I became familiar with a RAB official.
He asked me for a person from Kalai who could donate organ. Then I offered him my kidney. I
told him it is his wish how much money could he offer.” “I have seen my friend as very gentle,
generous and nice behaving person”, so “I didn’t sell organ for financial reasons”. “The man did
not pressurize me to sell. He frequently asked me to reconsider. The man promised me that if
something happened to me, he will look after my two kids and family.”
Titu, another rickshaw-puller in Dhaka city, in his mid-30s and with a child of seven,
developed friendship relations with Khokon, a big businessman who imports and sells cars. He
sold his kidney to Khokon, but declined to see this as a sale, calling it instead a donation to his
best friend. “I did not sell the kidney, since I was driving as rickshaw puller for many years and
came to know that he is a good man. He suddenly informed that his two kidneys have been
damaged. I gave full consent in donating kidney.” “The friend did many things for me. He
helped me much continuously. … He is simple and I am also simple.”
Karim reported similarly, “Even after [the recipient’s] death, her husband (a tax
advocate) gives me more money regularly. Otherwise, how can I feed my family? Even he gave
me a job in his office, with 8-10,000 taka per month. I gave it up. Then the husband set me up in
a local store”. He feels his security is assured through the husband: “My dulavai (the husband)
assured me frequently that he will be responsible for any life hazards and future of my kids”. “He
is a famous tax lawyer and he introduced me to everyone that I am his brother-in-law. He
didn’t…hesitate to introduce me as his kin, even though I am illiterate and poor, and don’t know
manners. I was in fever once in his house, he took care of me through the whole night”. He
17
continued: “The lady recipient, Lipi, who died, deposited [a great amount] for me in bank
account. This was discovered after her death. But I valued the relation with the recipient’s
husband, my dulavai [literally, brother-in-law]. I gave back the money to Lipi’s son, so that the
relation still remains solid with dulavai.”iv
Decaying relational ties with neighbours and kin do not stop people from seeking
supportive relations. Stories of good relations with rich patrons are abundant and popular. A
would-be organ seller needs a patron, who should be rich and eager to provide support in any
applicable form, whether by providing cash, setting up a business, giving a job or bearing the
educational expenses of the seller’s children. The patron is to be the seller’s social security, his
substitute for personal agency.
Abundant credit flow, and the eventual reckoning
The third important structural feature, identified by all the kidney sellers, was the finance system
providing abundant credit flow in rural Kalai. All the respondents had taken huge credits and
become heavily indebted to microcredit NGOs and informal rural moneylenders (mohajon).
Where employment and own resources prove inadequate to achieve valued functionings, and
social relations whether from kin or government provide little or no support, abundant credit fills
the vacuum. According to Khaleda: “Till now, I did not receive any support from the
government for any purpose” and “I borrowed huge, since my family did not have house or any
land to build house. Did not have anything required for a family.” Karim, who also took huge
loans, said: “There are at least hundred NGOs in our locality, and informal mohajons are
however many, many.” NGOs and local mohajon moneylenders offer finance in easily accessible
ways. Various governmental agencies also sell finance, but more conservatively and only to
those who could reliably be expected to repay the loan.
Jahangir recalled: “I went to Krishi Bank hearing that they provide cheap loan. The Bank
manager asked for many papers, like agricultural land title documents; and political dalal
(dealmaker) asked me for money; I came back as I had none”. A local banker remarked: “How
can I give credits to people who are not trustworthy to repay, and who are very poor? If the loan
is not repaid, this will bring my discredit as the local head of the Bank.” For Karim: “NGO or
mohajon loans are easier, since they don’t require any papers or any bribe”. Let us follow his
18
loans saga further: “I took loan around 2,800/- from Grameen and purchased a van. However,
immediately after purchasing van, my income fall down due to heavy rainy season. So I sold the
van, spent the money for feeding the family. Then the rainy season was over, and I took loan
from BRAC, and purchased the van again. However I did not repay the debt for either of the two.
This cycle [of taking loans to purchase a van] continued. Sometimes I repaid the debt by taking
loans from other NGOs and other neighborhood and kin mohajon.” A local leader of the ruling
party explained: “The mohajons are increasing here. For instance, in dull season, the rice millers
invest their money, taken in the form of cheap credit from the bank, in informal moneylending
with huge interest rate.” The principal of a famous local religious institution observed that: “You
will find many, hundreds, thousands people of mainly lower income category, here, all over the
sub-district, for whom taking credits from mohajon is the norm, even if it goes beyond their
powers of repayment.”
According to all the information from the sellers, there are around 20 registered and nonregistered NGOs that operate micro-credit, and numerous informal moneylenders in the three
villages in this study. The local mohajon or moneylenders come from neighbours, kin, and
various occupational groups, from school and college teachers, local representatives, rural
politicians, farmers and businessmen, and from both men and women. The headmaster of the
only nearby high school said “Who doesn’t do this business? Everyone does it, from primary
school teachers to elected ward members, from college teachers to rice processors, almost
everyone who has cash money. Even the ones who borrowed from government agencies at cheap
rate, also invest that money here at higher interest rate.” Responding to the huge demand for easy
flow of credit, providing loans is a profitable and popular business.
Not poverty reduction but profit becomes the driving force for most of the NGO microcredit business. According to the kidney sellers, the NGOs know that borrowers are poor and, in
most cases, do not invest loans in income-generating activities. They do not bother about or
monitor where the credit is invested, and only seek repayments. Karim shared that “No NGO
ever monitors whether I spend the loan money for the said purpose. The NGO official only
examined the pass book and checked whether I paid the installment regularly. And nothing else
did they monitor.” “Both NGOs and mohajon know that credit taken from one source usually
goes to the other source to repay the debt or to fulfill immediate household needs”. In response to
why NGOs give microcredit, he added “This is their business”. In Khaleda’s view, “Getting loan
19
from mohajon is much easier, though repaying is very difficult, since they charge highest interest
rate. I continued repaying mohajon for around 2 years for loan and its interest. My paid interest
for mohajon quickly equaled to the same amount as the credit. However, I repaid the mohajon
loan by taking credit from NGOs”.v
The potential organ sellers embraced easy access to credit in their never-ending quest for
means to achieve necessary and valued functionings. For example, Khaleda took loans from six
NGOs including Grameen Bank, BRAC, GUK, Palli Daridra, ASA, and Buro Bangladesh, to a
total of 45,000/- taka. She also took loans from four mohajon, to a total of more than the NGO
loans. As we saw, she invested the money to purchase land for a house, “since my family did not
have house or any land to build house. … This is eight decimel land and I purchased this with 80
thousand taka all collected by loans.”
Karim started taking loans twenty years back. Before he sold his kidney he was indebted
to at least six NGOs and eight mohajon. After the sale he could repay 50,000/- taka due as
interest to a single NGO, Grameen Bank. He could not acquire any valuable resources or do any
valuable investment. He still has only 1.5 decimel of land, inherited from his father.
There is a huge credit market in rural Kalai but little entry by public agencies who
provide cheap credits. Access to NGO and mohajon credit is much easier, but these credits are
costly, especially the latter. The credit receivers seek freedom to achieve valued functionings, but
all fall into a cycle of debt: taking credit from one in order to repay to others. Some resort then
even to organ sale, as in Khaleda’s apparently successful case of buying a piece of land to build a
house. In contrast Karim struggled to fulfil even basic day-to-day beings and doings, and had not
acquired significant assets even after his kidney sale.
Establishing acceptance of kidney sale
As we have seen, under the given social structures many in the poorest groups in a sub-district
like Kalai exist in a ceaseless desperate quest to achieve their necessary and valued functionings.
Yet kidney sale is not prevalent in all such districts. The final key structural element then is the
institutionalization of selling organs, offering an apparently easy salvation route for people like
rickshaw pullers in Dhaka city and the heavily indebted in Kalai.
20
Titu explained that “In my society/village, I knew before my selling that many sold their
kidneys. I hated it and preferred begging instead”. “But I was slowly thinking about it, and at the
same time about my friend’s suffering from his damaged kidney. I was then considering that
many have sold kidneys in my locality, so if I sell what is the problem?”. “Since Kalai people are
famous for being bad (as the sellers of kidneys), and since I find myself as one other Kalaian,
taking decision to sell my organ was easy; and yes it’s not good, if I were man of other areas I
could not sell organs. [He would not have courage] to give organs even for a generous friend, as
was in my case.”
Similar remarks were made by the other sellers. Khaleda had found that organ sale is
popular among the housemaids of Dhaka city. Milon thought that selling a kidney was popular
among Dhaka city rickshaw-pullers, “But now, after five years since I sold kidneys, all the
people are highly interested to sell organs if they are highly paid.” “At least 300-400 people
came to me to help plan their kidney-selling and manage a better price for their kidney.” Habibul
admitted that “I don’t know the function of kidney well; but since I have seen that many people
gave kidneys in Kalai, that’s why I decided to sell kidney.” The same was echoed by Jahangir: “I
know that giving kidney is not good at all. But I was thinking that many of my fellow people in
Kalai sold kidneys, and they are quite ok.”
How does the process work to convince people to sell their own organ, something that
has been socially taboo? Certain kidney sellers seem to become advocates or exemplars after
selling their kidneys. In contrast, others, especially sellers with a negative experience, remain
quiet. Responding to a question whether he felt an obligation to advise prospective sellers, Titu
said “I understand my own goods and bads, so how can I tell other would-be sellers whether this
will be right or wrong for them?”. While at other points he extolled the virtues of his kind
friend/patron/buyer, he eventually revealed “I did a great mistake and there is no way to undo
this, however I don’t need to share my experience and wrongdoing with others in the society”.
He felt that doing so would further decrease his dignity in the society. Likewise Jahangir: “Even
though my workload and mental pressure is much higher than before, I cannot share this with
others. Now if I come to my house with a kg of rice and a fish on the basis of my earning, it
seems to me that people still perceive that I purchased this by selling kidney. And if I share my
pains with them, this will not bring any good for us, instead my family's dignity if anything of it
still remains will be destroyed”. “At least if I know when my physical suffering will be
21
unbearable, I can purchase a bottle of poison”, Jahangir shouted, and continued: “Why shall I
alert others? I don’t get any hope [from that] of any help from my community other than
shaming me. They will intensify my shaming if I tell them the truth”. He declared “My suffering
is such that if I would die, this is better. However, I don’t tell this to people. Because no one will
have any single drop of sympathy for me.”
The rise of resort to kidney sale seems partly based on the spread of positive stories
combined with the ex-post coping mechanism of individual sellers that means negative
evaluations are not shared. After the kidney sale, those sellers keep to themselves, not exposing
themselves to further ridicule and indignity by publicising their sufferings after the sale. This
study’s sample is too small to essay generalizations. It is conceivable that other contented donors
did not bother to seek to come forward to tell their story in the way that Khaleda and Karim did;
one expects though that others too would have sought to justify their choice. The findings here
about the self-silencing of bad news, as by Titu and Jahangir (and perhaps Aftabul), match the
main pattern in Moniruzzaman’s larger study (2012). From his set of 33 cases in Dhaka,
Moniruzzaman concluded that: “the poor sellers, most of whom do not understand the function
of the kidney, … are tempted to ‘donate’ because of the buyers’ fraudulent claim that kidney
‘donation’ is a safe, lucrative, and noble act.” (2012: 82). Many sellers subsequently did not
receive the full amounts that had been promised to them. Regarding outcomes,
“[Moniruzzaman’s] and other existing studies document that kidney sellers’ health deteriorated,
their economic conditions worsened, and their social standing declined in a serious manner after
they sold their kidneys. Moreover, Bangladeshi kidney sellers reveal that selling a kidney has
profound psychological and psychosocial impacts on them, especially in relation to their
selfhood.” (Moniruzzaman 2012: 79). Many sellers also become physically weaker and require
expensive medicines, hence some become brokers for future sales.
Kidney selling has become established in the context that we discussed. Firstly, there is a
decay of traditional relational ties and the emergence of a rural political settlement which
excludes many of the poor. These trends bring a growing sense of individualization of
responsibilities, with the poor left to hunt around for livelihood. Secondly, for many of them the
informal economy does not provide any hopeful space for this quest. It provides subsistence at
best, but with much insecurity and uncertainty. In this situation, thirdly, the large credit flows
from non-government and informal sources are embraced. But the local finance system enables
22
no more than survival in, not escape from, that quest for security (Wood, 2001). Even though
obtaining credits appears an expression and booster of the agency of the questers, they fall into a
cycle of indebtedness: taking from one source in order to repay others. This fall even erodes the
priority of securing a basic need like housing; credit repayments become the first priority. In this
setting, some people resort to selling body parts. Organ sellers whose post-sale experience has
been bad don’t consider the wellbeing of prospective new sellers. They have become absorbed in
their own woes; other-regarding functionings wither. Currently the choice to sell organs is not
made across all of Kalai, but exclusively in some adjacent villages; however the trend is
spreading. A cycle of socialization appears underway, making the environment more conducive
for other people with insecure livelihoods to decide to sell organs. Cases of suffering and regret
seem to be kept underground; only stories of financial gains and good health are spread.
Conclusion – desperation resorts to bodily self-exploitation
We have looked at a locality in Bangladesh where many poor people do not have effective
freedom to achieve necessary and valued functionings and where positive stories of organ-sale
cases now circulate. Their capability gaps motivate some of these people to sell their own
kidney. That many people with certain occupational, income, and social characteristics lack the
effective freedom to choose well-reasoned and valuable functionings, and to achieve the
functionings they value most, was supported by our review of primary and secondary material.
One of their priority functionings is to repay debts to microcredit NGOs and informal
moneylenders. Even though the creditors know that borrowers mostly do not invest the credit in
income generation, and the loans will be spent for daily needs, they readily provide the loans to
eager takers. The borrowers are soon forced to prioritize repaying debt over other elements of
their welfare.
A second valued doing, investing for future income generation, remains in most cases in
Kalai limited to the option of buying a CNG vehicle. This requires less training and ensures
steady earning, but through a relatively huge investment. Borrowers do not opt for other
investments which could also bring steady earning and require less money but which would
require serious training. They cannot afford the money or time for such training, and they lack
the prerequisite education. They also do not access any of the current skill-enhancing or
23
entrepreneurship-building training offered by the state. Their prioritization of valued
functionings is limited by their current capacities, and by lack of public policy suited to help
them.
A third highly valued functioning is a secure relation with a rich patron. Many kidney
sellers seek guaranteed welfare by a patron-client relationship with an organ recipient. Their lack
of resources and poor skills-set prevent them from entering even middle economic tiers. While
the informal economy has at least the capacity to incorporate people with low skill-sets, some
people give credence to stories that a secure relation with a rich person is the best way to ensure
their welfare. This belief is attractive given their poor skills, lack of economic resources, and the
structural barriers they would face to enhance skills and accumulate resources. Whether it has
sufficient general validity can be doubted; for a mechanism of reporting good and not reporting
bad experiences seems to be at work.
Another valued functioning, seen in Khaleda’s case, is to counteract extreme gendered
inequality in the household. There is a gendered division among microcredit borrowers: women
are the majority of credit recipients, normally spend the money for immediate household needs
and/or give it to the husband. Khaleda in contrast courageously invested the credit money to
purchase house land, without any direction from her husband. And there is a gendered division
of importance, such that Khaleda was still no more than a disposable woman in times of financial
stress. These types of gendered inequality frame women’s lives, and constrain what they can
achieve.
The attainability of the last of the priority desired functionings (sets) that we
characterised—building a home and sending children to school—is similarly constrained by
social structures, personal agency and their interrelations. Building a home requires a minimum
of a few decimels of land, which most potential kidney sellers do not possess hereditarily and
cannot purchase through earning in the informal economy. Moreover, under the current political
order, they cannot get lands or a home through governmental schemes; their perception is that
they will not get entry into the networks of political patronage. This limits their attempts to
access government-provided opportunities for land allocation, skill training, cheap credits,
equipment like a power tiller, or the 40-days employment program. Where they do have access
to state-provided services is for free education for girls up to higher secondary level and free
primary education for boys up to the eighth grade. Yet Khaleda and others considered that this
24
free education is ‘underclass education’ (as described in Hossain, 2009b). Many parents of even
a low income level attempt to send their children to costly private tutors.
The functionings that the potential organ sellers prioritize indicate in many ways their
weakness of agency. Poor people’s agency and the societal structures condition each other in
ways that limit their capacity in choosing what to reasonably value and how to achieve it. The
ambitions that are formed are stereotyped, in moulds already seen in the people of the same
group, say to become a CNG vehicle driver/owner. In terms of reasoned choice, poor people
typically lack the “freedom and power to question and reassess the prevailing norms and values"
spoken of by Drèze and Sen (2002). The agency attributes they show are determination and
reasoning in making their limited choice, heavily constrained by the social structures.
Individuals’ agency here does not remedy social arrangements, to make them more effective and
appropriate, but instead facilitates their constraining role. This reflects people’s lack of
resources, education and training, their low perception of their own status, and other weak
agency attributes.
Agency of the poor is expressed in (a) shifting between occupations, (b) looking for a
patron, and (c) taking relatively huge credits from both microcredit NGOs and mohajon. These
forms of agency show struggles to reconstruct and gain from structural arrangements, but also
reveal the actors’ vulnerability and compliance within the social order. They do not make the
social structure ‘enabling’ or ensure achievability of the valued functionings. For example, the
attempts toward achieving basic welfare through taking credits, such as for gaining housing, add
a ‘Trojan Horse’ priority functioning of repaying debts and even push it towards first place. It
can displace or downgrade other reasoning over appropriate functionings, and eventually make
the debtors desperate to regain control.
Against this background, kidney-selling spreads when real-life information of suffering
and problematic actual financial achievement remains unseen, and only storytelling of fortunes is
abundant. Some of the kidney-sellers abandon concern for others, and hide information of their
actual sufferings and financial history. They shrink into preoccupation with their own woes.
Socialization in favor of kidney sales grows. In this ‘market’ the would-be buyers are affluent,
and have the freedom and confidence to participate in the illegal kidney trade and to arrange
transplantation. The would-be sellers enter with very weak capabilities. The exchange is ethically
flawed: ‘noxious’. People are in effect valued differently.
25
The resort to bodily self-exploitation is consistent with the pattern analysed by C.T.
Kurien and Partha Dasgupta for many poor people, especially in South Asia (Kurien, 1996;
Dasgupta, 1993). Dasgupta’s An Inquiry into Well-Being and Destitution showed how market
equilibrium wages for rural labour often do not cover the subsistence needs of the worker and
his/her dependents. The workers survive but only by declining to a body weight and activity
level which are consistent with their low level of consumption. Their malnutrition brings higher
rates of sickness and shorter life expectancy. Their children grow up with sub-normal physical
and mental capacities. In the worst cases the workers eventually lose the strength to do the
manual work required of them, so are no longer hired and must resort to scavenging or begging.
Since the research that was synthesized by Kurien and Dasgupta, a new resort has become
available: to sell a body part. In many cases even this bodily self-exploitation through kidney
sale (or quasi-sale within a patron-client relationship) does not lead to fulfillment of livelihood
needs, for even the medium-run. It represents, in the terms used by Sample or Deveaux (Sample,
2003; Deveaux, 2016), a new venue of exploitation, by others who take advantage of the sellers’
hopes and necessities. Nevertheless, it feeds an ongoing cycle of recruitment of desperate
aspirants.
To comprehend how exploitation by a kidney purchaser occurs, one must investigate a
seller’s decision to engage in bodily self-exploitation. This is what we have tried to do. A person
with few capabilities and restricted agency, in a setting of unbearable structural constraints, is
unsuited to choose to transact his/her body parts with another person who possesses sufficient
freedom and powerful agency. In the transaction the seller exploits himself/herself bodily, and, in
the cases we examined, becomes exploited by the recipient/purchaser. The two aspects of
exploitation are simultaneous and connected.
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i
These seven interviewees gave recorded permission for recording and use of their interview.
ii
Mr. Abu Zaeed Aziz, a M.A. graduate of Jahangirnagar University, independent filmmaker,
social worker and activist, and a skilled and experienced interviewer.
iii
A decimel is 1/100 of an acre.
iv
The amount cited was taka 475,000/-. At official exchange rates this is around US$ 6000, but
has a local purchasing power that is perhaps three times greater than in North America.
v
In many cases, to get credit repayment NGOs seek help from the local mohajon; these typically
keep local goons or are themselves able to exert muscle to ensure repayments.
29