Both left libertarians, who support the redistribution of income and wealth through taxation, and right libertarians, who oppose redistributive taxation, share an important view: that, looming catastrophes aside, the state must never redistribute any part of our body or our person without our consent.Footnote ¹ Cécile Fabre rejects that view. For her, just as the undeservedly poor have a just claim to money from their fellow citizens in order to lead a minimally flourishing life (here Fabre sides with left libertarians), the undeservedly ‘medically poor’ have a just claim to help from fellow citizens in order to lead such a life. Such obligatory help may in principle involve even the supply of body parts for transplantation. The state ought to exact such resources from the medically rich whenever doing so would secure the prospect of a minimally flourishing life to the medically poor without denying that prospect to anyone else. Fabre criticizes Ronald Dworkin's belief in ‘a prophylactic line that comes close to making the body inviolate, that is, making body parts not parts of social resources at all’.Footnote ² For her, ‘Duties to help . . . do not stop at material resources: they involve the body . . . in invasive ways’ (p. 119).

These provocative ideas rest on a conception of justice that emphasizes sufficiency, autonomy and respect for persons. Chapter 1 of Whose Body is it Anyway? elaborates that conception, which I lay out below. Chapters 2–5 argue that the right to a minimally flourishing life substantiates a legally enforceable duty to rescue, a mandatory year-long civilian service assisting the frail and the old in hospitals and nursing homes, and the forced redistribution of both cadaveric and live body parts. While these burdens on the healthy would be quite onerous, only rarely would they be so onerous as to keep them from leading minimally flourishing lives. As Fabre argues, most life-plans are fully compatible with taking care of others for a year and with surrendering a single kidney to someone who has none.Footnote ³ In fact, she adds, losing 25–50 per cent of one's income in tax over many years often affects one's life-plans more extensively, but we do not regard taxation as excessively onerous and disproportionately intrusive. Fabre concedes that some of the intrusive measures that she recommends would thwart full self-control. But they allow the pursuit of many other plans that do not require full self-control. She also concedes that these measures would treat healthy citizens as means. But these measures serve urgent sufficientarian causes without plunging the healthy into insufficiency, so they cannot be said to treat them disrespectfully as mere means. Fabre warns that to counter her recommendations by invoking rights to bodily integrity, without also showing how such rights would protect someone's flourishing, begs the question. The upshot of her recommendations is precisely that a right to bodily integrity does not exist.

Fabre rejects what we may call ‘body exceptionalism’ – the view that we should treat the body and perhaps other elements of the self differently than we do material resources. Similar rejection of body exceptionalism informs Fabre's approach to trade in body parts and in services that are intimately bound up with the body and the self. Chapters 6–8 argue that financial trade in organs, in sexual services and in gestational services is often morally permissible and should be legally permissible – just like many other transactions. When the state forbids all such trade indiscriminately, it violates the autonomy of many potential buyers and sellers and, thus, justice and respect.

Underlying Fabre's recommendations is her ideal theory of justice. That theory encompasses a principle of sufficiency and a principle of autonomy. First, everyone must be allowed to enjoy sufficiency. Whenever possible, the state ought to secure the prospect of a minimally flourishing life for all: some opportunity to form, to pursue and potentially to revise a plan of life. The only justification for not offering that prospect for someone is that attempting to address her insufficiency would only exacerbate it or plunge another into insufficiency. Second, on all other matters the state must respect everybody's autonomous decisions, and not interfere. To illustrate the principle of sufficiency: justice can demand the redistribution of live kidneys because such redistribution offers end-stage renal patients who currently suffer on dialysis the prospect of minimal flourishing, without imposing insufficiency on anyone else: as Fabre points out, setting aside the risk from anaesthesia, the medical risk from properly performed kidney extraction is minimal. To illustrate the principle of autonomy: justice can demand legalizing the exchange of sexual services for money because such exchange need not push anyone below the sufficiency level, and so, autonomy forbids a blanket prohibition against such exchange.

This theory of justice rests, in turn, on an interest theory of rights and it relates to respect for persons. The state is under a potential duty to confiscate single kidneys from the healthy to help end-stage renal patients because the interest of these patients in pursuing a plan of life (something that reliance on dialysis grossly undermines) is important enough to generate claim rights (not, say, because such policy serves collective utility or retribution). Inability to pursue a plan of life would thwart these patients' opportunities to develop a basis for self-respect. Likewise, interference in transactions that do not jeopardize sufficiency disrespects autonomous adults and thwarts their fundamental interest in self-respect.

Fabre offers ingenious responses to many potential objections to the forced extraction and to the commodification of certain services and organs. For instance, according to one objection to these practices, they treat the person as a mere means. But Fabre points out that treating a part of a person, perhaps a kidney or a person's sexuality, as a mere means need not treat the entire person as a mere means. To the objection that organs and certain services are not simply resources, Fabre responds that they are resources ‘in some respects’ – for example in having instrumental value for beneficiaries – and that their confiscation or commodification treat them only as such: as resources among other things. Concerning the confiscation of cadavers, Fabre admits that some religious and other plans of life demand post-mortem bodily integrity. But she stresses that not all do, so violating post-mortem integrity permits many the pursuit of some plan of life. A common objection to trade in organs, sex and babies is that such trade is necessarily exploitative. But Fabre shows that such trade often does not meet Alan Wertheimer's conditions for being exploitative. Feminists worry that female prostitutes usually stand in inferior relations to their clients, and that their encounters entrench stereotypes and discrimination against women. Fabre answers that female nurses and schoolteachers have more frequent hierarchical encounters, and that surely we should not abolish their professions.

The quality of Fabre's argumentation is so high that several chapters would make fruitful starting points for future discussions of their topics. Since the book defends provocative claims with exemplary rigour, it could also be used in advanced philosophy classes (although the style might be too pedantic for some students). Another impressive aspect of the book is that it weaves together themes that span ethics, bioethics and political theory. The author, moreover, seems truly concerned about both philosophical accuracy and people's needs, which is a somewhat rare combination.

Fabre's examination of possible objections is fairly comprehensive, but she neglects two important arguments for body exceptionalism. According to one argument, the body, the self and their parts are natural primary goods, and not social primary goods to be forcibly redistributed and traded. By contrast, pre-tax income is clearly social, in that it would not exist without prior social cooperation. Income tax merely forces taxpayers to receive a small gift from society, instead of a big gift – a wholly legitimate encumbrance in the light of other citizens' greater need of social assistance. But our kidneys, for instance, start out inside us. They are not gifts that society can legitimately decide to withhold without our consent. Moreover, to have access to them the state would have to actively confiscate them, whereas certain omissions and certain ground rules would maintain the state's access to income that would have otherwise reached us. The norms that govern gifting and omission differ from the ones that govern confiscation and commission. Now I am sceptical of this argument. It moves facilely from establishing that the body and the self are non-social in a descriptive sense (other members of society were not born with them) to concluding that the body and the self are non-social in a normative sense (others should not take them without the person's permission). The argument also ignores the dependence of our body, our health and our skills on prior social cooperation, for example, on the social supply of food, medical care and education: the adult body largely consists in previously ‘social’ molecules that the person consumed, often using her ‘social’ income. Intuitively we retain our rights over our body parts even on those rare occasions in which others have access to them without performing actions (say, because our blood sample slips onto their lap). However, this weak argument sways many political theorists, and Fabre would have done well to address it.

Another argument for body exceptionalism holds greater promise. People usually see trespass into a person and into objects that they associate with a person – especially into a person's body – as utterly disrespectful towards that person and her autonomy. People also perceive trade either in a person or in objects that they associate with a person – especially a person's body, and above all its solid internal parts – as a cue that that person or people like her can be treated as commodities. Such perceptions are almost visceral, not something that valid philosophical argumentation could easily shift. As I argue below, that consideration counts heavily against some of the policies that Fabre recommends. With respect to organ confiscation, it is very ill-advised to ignore the ‘prophylactic membrane’ that surrounds our bodies within deep and widespread perceptions about disrespect. That membrane informs our intuitions in many contexts. For example, human rights conventions view corporal punishment, which violates bodily integrity, as utterly degrading and opposed to human dignity. They present it as far more degrading than long imprisonment, although minor corporal punishment may well be more compatible with the pursuit of life-plans. Physically benign trespass – for example, imposing beneficial medical care on someone or touching someone who does not want to be touched (not necessarily in a sexual way) – is also widely considered disrespectful of autonomous beings. By analogy, invading the air space of a sovereign nation is seen as disrespectful of its sovereignty, whether or not one thereby harms that nation (say, by bombing it). While physically harmful or sexual trespass appears even worse and more disrespectful than fully benign trespass, both appear somewhat disrespectful.

Trespass deep into the body is often seen as particularly disrespectful and wrong. Usually, it is thought, only a special emergency can justify such transgression. For example, imposing skin biopsy on a patient in order to detect cancer seems problematic; imposing colonoscopy, which protrudes deep into the body in order to detect cancer, seems worse. Yet when both examinations are performed with sedatives, colonoscopy is not substantially more painful or risky than skin biopsy. Similarly, intentionally flying above the capital of a sovereign nation without permission is usually seen as a greater offence to its sovereignty than intentionally flying above its border area without permission.Footnote ⁴

Forced kidney extraction involves trespass deep into the body, and most of us are likely to see it as disrespectful. It also deliberately shuffles about solid internal parts and confiscates others in the service of other people's plans. It somewhat harms and it definitely maims the body. Claiming that so long as it remains medically safe it remains in line with prevailing norms surrounding respect is a bit like saying that someone who lands without permission at the heart (so to speak) of a nation's capital, moves around some public statues, confiscates others, and then flies away appears perfectly respectful of its sovereign dignity because the physical damage is not so grandiose as to thwart that nation's flourishing. I am aware that for Fabre the sufficientarian intention behind organ confiscation, taking someone off dialysis, makes a crucial difference. Below I briefly comment on whether certain intentions prevent all disrespectful appearance. For now, notice that usually we view the confiscation of healthy organs as disrespectful for reasons other than the determinate intentions behind it. Compare having a lot of money stolen (but remaining financially viable) with having a single kidney stolen (but remaining medically fine because the thieves deliberately kept medical risk at a minimum). Most of us would probably perceive such instances of theft as very different from each other. Having one of our kidneys stolen would affect most of us emotionally much more than having a lot of money stolen, the similar motive behind the two instances of theft – financial gain – notwithstanding.

I do not deny that forced kidney extraction for altruistic purposes can be a medically quite safe procedure, and in that way fully compatible with the continual pursuit of many plans. However, we may still perceive it as humiliating to the patient. Patients may so perceive it too. I now argue that, on Fabre's own premises, such potential perceptions matter, and they lend support to body exceptionalism.

Underpinning Fabre's theory of justice is concern about self-respect. She opposes acts that thwart someone's opportunity for self-respect, no matter how helpful these acts may be for other people (pp. 28–30). Fabre may therefore be committed to rejecting policies that most people would persistently perceive as disrespectful, including, potentially, an altruistic policy of organ redistribution. Actions broadly seen as disrespectful of someone are likely to be seen in that way by that person as well and to undermine her opportunity for self-respect. Whether or not organ confiscation is truly disrespectful, Fabre may have to concede that its widespread and intractable perception as a humiliating violation counts heavily against it, because it can thwart opportunities for self-respect.

Moreover, acts broadly seen as disrespectful of someone may impose severe ‘dignitary harms’ on that person and violate the sufficiency principle even without thwarting her self-respect. Acts that many citizens so perceive could reinforce third parties' disrespectful feelings towards that person, provoking stigma or dehumanization. Such responses may impede her social inclusion and undermine consideration and deference toward her, potentially translating into material loss or even violence against her. The perception that the state treats someone with disrespect may also weaken a society's general culture of respect, and affect the treatment of other people. Citizens may become less mindful of each other's material interests, or the interests of members of specific social groups. Consider the spectre of a state-sanctioned market in organs and the potential perception that the poor sell their own organs for a trifle. The poor (and not just individual vendors) might come to be seen as ‘our pool of organs’, a cheap resource to be exploited, not complete persons to be guarded from adversity.Footnote ⁵ The consequences for poor people, even in terms of leading a minimally flourishing life, could be dire.

Fabre might concede that, causally, actions like organ confiscation would thwart opportunities for self-respect or impose other burdens much in the ways I describe. But she might insist that a medically safe procedure to promote important ends is not truly disrespectful, however we may perceive it: while dramatic and frightening, organ confiscation rarely would thwart plans of life.Footnote ⁶ One possible response to this claim is that some acts of contempt are medically safe. Spitting at someone, discriminating against her and cursing her usually communicate disrespect even when they do not preclude health and minimal flourishing. Indeed, some thinkers say that violations of bodily integrity are disrespectful of our dignity as ends even when they do not inflict physical harm.Footnote ⁷ But my main response is different. I have argued that the widespread perception that an act or a policy is deeply disrespectful of someone jeopardizes the self-respect and the flourishing of the person and of other members of society, and so is morally problematic from Fabre's own point of view. That argument does not assume that that act or policy is always truly disrespectful or that it always gives that person sound reason to lose self-respect. Fabre's own principle of sufficiency seems to forbid severe psychological harm, and especially harm to victims' sense of self-respect, even when that harm results from victims' own unsound reasoning; accordingly, Fabre supports exempting some irrational conscientious objectors from cadaveric organ donation (pp. 91–4) and all persons with needle phobia from live organ donation (p. 111) simply because these measures would devastate them psychologically.

The same point is borne out by Fabre's detailed account of the moral difference between rape and forced organ confiscation (pp. 111, 118–23). Fabre accepts that rape is a hideous wrong partly owing to its sheer psychological impact on victims. Rape usually imposes devastating mental pain, a sense of humiliation and loss of self-respect, and it often thwarts the victim's psychological ability to pursue her plans. Fabre notes that rape is wrong for additional reasons. However, as I now argue, to account for the carpet prohibition of all rape she must rely especially on that tendency of rape to harm psychologically. Fabre notes that rape may impose unwanted pregnancy and physical pain, but presumably she would condemn rape that, by virtue of a rapist's unusual measures, carried little risk of pregnancy and physical pain. She points out that rapists seek sexual gratification or the humiliation of a fellow human being, while altruistic organ redistributors promote truly sufficientarian goals. But surely Fabre would condemn rape even when its purpose is to break an enemy's spirit in a war that sufficiency requires winning. Finally, Fabre says that unlike altruistic organ confiscation, rape is done out of contempt. But rapists presumably use rape (and not handshaking or bowing) to express their contempt because there is something about gross violations of bodily integrity that is independently liable to humiliate. Indeed, if we should ascribe contempt (and never merely lust or hate) to rapists, as Fabre does, without examining their individual intentions, the reason would probably be that the act ‘itself’ is usually taken to communicate contempt, regardless of the culprit's determinate intention.

Hence, Fabre must accept that even the sheer devastating psychological impact of rape – the potential for mental pain, loss of self-respect and inability to pursue plans – suffices to proscribe rape across the board (although usually rape is proscribed on further grounds). But that psychological impact causally stems from the victim's perception of rape as gross humiliation, and not from the truth value of that perception. By a similar token, Fabre must accept that our non-idiosyncratic and pretty unavoidable perceptions of forced organ extraction as disrespectful and the impact of these perceptions on our self-respect, on the social culture of respect, and so forth count against forced organ extraction virtually across the board.

To be fair, most ethicists are wary of letting widespread perceptions affect their recommendations. Instead of deferring to such perceptions, they usually suggest ignoring or correcting them.Footnote ⁸ Fabre herself expresses confidence that, coupled with the paucity of physical pain, clarifying to patients the non-malignant purpose behind confiscating their organs would usually pre-empt any loss of self-respect (p. 111). However, that piece of empirical speculation is probably false. A rapist who said, ‘Don't take this personally. This is about my lust (or my army's sufficiency-protecting war with yours), and not about your dignity’, would nevertheless inflict humiliation on most victims and across cultures. (If I told you that in a distant country or many years ago, someone raped or tortured or cannibalized the organs of some enemy in order to humiliate the enemy's people, you would not be nearly as puzzled as if I told you that he did so in order to make the enemy's people feel proud, or sleepy, or wise.) The widespread tendency of certain violations of bodily integrity to instil a sense of humiliation is no coincidence. Its roots may be socio-biological, and in the foreseeable future it will likely persist, no matter what philosophers may tell us about how we should feel.

Alternatively, Fabre might concede that forced organ extraction would have negative psychological impact on many patients but insist that that impact would be very weak in comparison with that of rape. The likelihood that confiscating someone's organs altruistically would devastate her in the way that rape often devastates victims is low. Whether or not this empirical speculation is correct, on Fabre's own interpretation of the sufficiency principle, imposing any risk of insufficiency greater than the one that individuals ‘standardly incur . . . in their everyday life’ violates that principle (p. 116). In particular, Fabre condemns any policy that carries the risk of devastating or even diminishing self-respect. Following Jonathan Wolff, she repeatedly condemns all selective benefits, simply on the following ground. Selective benefits force poor welfare recipients to reveal shameful facts about how they came to be poor or ill, and that requirement somewhat demeans them (p. 37 and elsewhere). Fabre thus opposes acts that impose even a fairly small risk of harm to self-respect, apparently without regard to their potential merits (in Wolff's context, slashing the cost of universal benefits). For Fabre, all actions that ‘dent [a person's] self-respect . . . make it that much more difficult for them to flourish’, undermining their ‘opportunities’ to ‘respect themselves’ enough for justice to prohibit all such actions. Although, as she admits, ‘the relationship between being respected by others and respecting oneself is important but contingent’, justice completely prohibits even actions that merely ‘dent [a person's] perception of themselves as someone to whom others grant proper respect’ (pp. 28–9). Surely organ confiscation carries at least some remote risk of denting both that self-perception and self-respect.

Moreover, unlike a single instance of organ confiscation, a long-term policy of organ confiscation that touches the lives of many individuals involves high risk of devastating someone's sense of self-respect and flourishing. Given the variety of individual characters, we can safely assume that some would feel utterly humiliated and lose self-respect if they were forced to surrender a kidney. Chances are, therefore, that a long-term policy of forced kidney redistribution would plunge some into insufficiency.

Fabre might also answer that neglecting to save kidney patients from insufficiency only in order to save the medically rich from hurt to their self-respect is itself disrespectful toward kidney patients when there is no rational justification for that hurt to self-respect. For Fabre espouses ‘justificatory liberalism’, which says, among other things,

Fabre could add that it is disrespectful for society to heed healthy individuals' irrational, if expected, psychological hurt from having to surrender a single kidney to the sick, who need that kidney in order to live a minimally flourishing life; therefore, society must overlook that rationally unjustified (but potentially severe) dignitary harm. Despite Fabre's potential response, if the sheer psychological impact of rape justifies prohibiting rape – as I argued it must – then surely the (admittedly smaller) sheer psychological impact of organ confiscation somewhat counts for prohibiting the latter.

More fundamentally, can Fabre's very economical conception of justice, which incorporates only a principle of sufficiency and a principle of autonomy, accommodate an element of justificatory liberalism? How does that element fit together with these two principles? Fabre's book suggests two potential answers, but neither successfully accommodates Fabre's justificatory liberal response to my challenge, within the book's general framework. One answer is that, at the most fundamental level, justice demands only respect. The demands for sufficiency and autonomy, as well as the demand for rational justification, are only derivative. These three demands obtain only because respect requires sufficiency, autonomy and rational justification. In this spirit, Fabre offers the following defence of her justificatory liberalism:

In this excerpt, Fabre assumes that the values of sufficiency, autonomy and rational public justification rest on respect. There is, however, a problem with this answer. If justice demands more than honouring sufficiency and autonomy – if for example it makes demands on public justification – then the floodgates are open for further, and completely independent, requirements of justice, potentially including intuitive requirements that would nevertheless block the policies that Fabre supports. Fabre resisted the intuition that organ confiscation and like policies are unjust on the basis of her restrictive conception of justice, which heeds only sufficiency and autonomy. Now that this restrictive conception of justice flies out of the window, that intuition may have to prevail.

Another answer that the book offers to this challenge preserves the restrictive conception of justice that heeds only sufficiency and autonomy. On that alternative answer, justice forbids disrespect only in so far as, by denting the victim's self-respect, disrespect would plunge the victim into insufficiency. Indeed, section 1.3.1, which Fabre mentions, states that ‘self-respect is central to how someone's life is going; accordingly a just society is one where individuals respect one another as persons’ (p. 28; my italics). On this (arguably incompatible) answer, respect merely subserves sufficiency. Fundamentally, justice demands only sufficiency and autonomy. The need for respect is derivative – a mere means to protect the opportunity for self-respect, itself a mere contributor to the sufficiency that the restrictive conception of justice demands. Nevertheless, this alternative answer defeats Fabre's purpose. Plugging it into the argument undermines Fabre's justificatory liberal objection to heeding the dignitary harm to healthy citizens. The objection now states that a sufficient reason to ignore the potentially severe blow to the standing, the self-respect and the flourishing of healthy citizens forced to surrender their kidneys is that taking their anguish into account would undermine kidney patients' standing, self-respect and flourishing. However, surely the potential dignitary harm to the healthy tends in this case to exceed the one to kidney patients. Being forced by the state to hand over one's kidney is likely to cause considerable psychological injury, including injury to many healthy citizens' sense of self-respect; the far more abstract and philosophical observation that the state heeds these citizens' irrational sense of humiliation unjustifiably is far less likely to cause severe psychological injury to a great number of other citizens. Fabre, in any case, offers no empirical evidence to the contrary. In sum, appeal to justificatory liberalism is not a recommended response to my basic worry about dignitary harm. Neither potential answer to my challenge accommodates justificatory liberal responses comfortably within Fabre's framework.

Finally, Fabre could concede that, owing to the potential dignitary harm from policies like organ confiscation, there currently is a case for body exceptionalism: in practice, the state should avoid organ confiscation, and perhaps other policies that Fabre defends; but Fabre could insist that at the fundamental, philosophical level, body exceptionalism remains wrong. In some possible worlds, the state should confiscate organs for transplantation. Such concession would save Fabre's fundamental principles of justice.

Indeed, Fabre already admits (somewhat sporadically and too late in the book) that she recommends policies like organ confiscation and commodification only as a matter of justice and right, not as actual policy. In the actual world, enforcing these rights could be counter-productive or too costly.Footnote ⁹ Besides, she adds, her recommendation is intended only for ideal worlds, not for the unjust actual world (p. 108 and elsewhere), in which extracting kidneys involves a risk from anaesthesia that is greater than the one that individuals standardly incur in their everyday lives (pp. 116, 118). But the concession would commit Fabre to saying that even in many ideal worlds, where justice prevails and kidney extraction poses no physical risk whatever, not even from the anaesthesia, policies like organ confiscation would fail at the bar of justice and right. They would still impose severe risk of dignitary harm and insufficiency. In other words, the concession is quite disastrous. It sacrifices Fabre's distinctive contention that, in ideal conditions, we lay certain highly invasive claims on one another.

To summarize, on Fabre's own conception of justice and rights, policies like the altruistic confiscation of organs would often be unjust, and a forbidden rights-violation, even in ideal conditions. My criticism is an internal one. I do not share Fabre's conception of justice and rights.Footnote ¹⁰ Whether and when policies like altruistic organ confiscation are justified is an open question. This critical comment on Fabre's book notwithstanding, Whose Body is it Anyway? remains an excellent contribution to political theory, ethics and bioethics. Opponents of the contentious policies that Fabre defends will do well to take her powerful arguments seriously.