Special Section: Open Forum Why we are not allowed to sell that which We Are encouraged to donate BARBRO BJORKMAN Introduction It is a reality today that people die waiting in line for transplant organs Something needs to be done to remedy this dire situation and allev broadly g, barring scientific progress that might mal ial organs and stem cell therapy viable alternatives, three options are available to us: increase voluntary donation, compel access to organs via government policy, or open up for a commercial market in organs ks It has proven hard to explain why so many of us are convinced that donation the only morally permissible form of transaction when it comes to organs from the living. This is particularly surprising in light of the fact that we live in a liberal, capitalist society that has seen fit to not only commodity, but indeed, also commercialize just about everything else. Naturally it would be a different matter altogether if organs were nontransferable, that come what may no human being could be allowed to part with his/her organs. But this is not so-quite the contrary, the citizens of the Western world are exposed to campaigns encouraging donations. It is quite difficult to come up with other examples of objects that we are encouraged to donate and at the same time morally forbidden to sell. Bearing in mind the current organ shortage, ethical questions relating to organ procurement are becoming increasingly pressing what can we allow ourselves, and others to do with our bodies? In this paper I attempt to show that virtue ethics could provide an explana- tion of why it is morally permissible to donate but not to sell organs which seems to correlate with our moral intuitions on this matter. The position defended here is that it is morally wrong to sell organs because this is omething a virtuous person would not do. Given the choice between selling 4.d donating an organ the virtuous agent would choose the latter, and this is why it is not permissible to sell ones organs. I, first, however take a closer look at some standard arguments for and against the selling of organs. Then I move on to a discussion about whether virtue ethics can give us the necessary tools for explaining why we are not allowed to sell that which we are encouraged to donate. The purpose is to show that a strong case can be made that, given the choice, a virtuous person would donate rather than sell his or her organs article could not have been written without the help of Dr. Martin Petersson and Professor Ove hans tarterly of Healthcare Ethics(2006), 15, 60-70. Printed in the USA. G 2006 Cambridge University Press 0963-1801/06 $16.00
Special Section: Open Forum Why We Are Not Allowed to Sell That Which We Are Encouraged to Donate BARBRO BJÖRKMAN Introduction It is a reality today that people die waiting in line for transplant organs. Something needs to be done to remedy this dire situation and alleviate the suffering. Broadly speaking, barring scientific progress that might make artificial organs and stem cell therapy viable alternatives, three options are available to us: increase voluntary donation, compel access to organs via government policy, or open up for a commercial market in organs. It has proven hard to explain why so many of us are convinced that donation is the only morally permissible form of transaction when it comes to organs from the living.1 This is particularly surprising in light of the fact that we live in a liberal, capitalist society that has seen fit to not only commodify, but, indeed, also commercialize just about everything else. Naturally it would be a different matter altogether if organs were nontransferable, that come what may no human being could be allowed to part with his/her organs. But this is not so—quite the contrary, the citizens of the Western world are exposed to campaigns encouraging donations. It is quite difficult to come up with other examples of objects that we are encouraged to donate and at the same time morally forbidden to sell.2 Bearing in mind the current organ shortage, ethical questions relating to organ procurement are becoming increasingly pressing— what can we allow ourselves, and others, to do with our bodies? In this paper I attempt to show that virtue ethics could provide an explanation of why it is morally permissible to donate but not to sell organs, which seems to correlate with our moral intuitions on this matter. The position defended here is that it is morally wrong to sell organs because this is something a virtuous person would not do.3 Given the choice between selling and donating an organ the virtuous agent would choose the latter, and this is why it is not permissible to sell one’s organs. I, first, however take a closer look at some standard arguments for and against the selling of organs. Then I move on to a discussion about whether virtue ethics can give us the necessary tools for explaining why we are not allowed to sell that which we are encouraged to donate. The purpose is to show that a strong case can be made that, given the choice, a virtuous person would donate rather than sell his or her organs. This article could not have been written without the help of Dr. Martin Petersson and Professor Sven Ove Hansson. Cambridge Quarterly of Healthcare Ethics (2006), 15, 60–70. Printed in the USA. 60 Copyright © 2006 Cambridge University Press 0963-1801/06 $16.00
Why We Are Not Allowed to Sell organs Some Common Arguments in Favor of Organ Commodificati A number of arguments in favor of allowing for a market, especially in kidneys, have surfaced in the increasingly heated debate surrounding trans- plant organs. Broadly speaking, such arguments can be split into two groups consequence-and rights-based ones. It should be noted that very few people, however, go all the way and propose an unregulated global market for organ transplantation. Arguments are commonly put forward in defense of a limited market, one that is rigged such that the active participants can be protected against the most blatant forms of harmful exploitation. For example, one could imagine a scenario where both the buyer and the seller had to be part of the same healthcare system, where there would be only one procurement unit in che system, where the prices would be set and nonnegotiable, and where the queuing system for the recipients remained the same as today. Such a limitation is said to be especially reasonable from a consequentialistic standpoint, as it is assumed to have more favorable consequences than its unregulated counter part. Whether such a system would, in fact, provide protection for the esp ially vulnerable is, of course, an empirical question. It is, however, doubtful if any of these arguments are convincing in the sense of being capable of giving an account of people's moral intuitions Consequentialist arguments are often structured along the following lines: It is fact that most people do not donate their organs, at least not to the extent that is required to make up for the organ shortage. It is said to follow that we ought to create a market for selling and buying organs because that would have the best consequences in the sense that fewer people would suffer, and die, in line for a transplant. The underlying assumption is that payment would result in more available organs. It is suggested that many people who are not prepared to part with their organs given the current legislation might well rethink their decision if they were paid. Evidently this is an empirical assumption, but it does not seem to be too far-fetched 5 A standard critique is to draw a parallel with the case made for blood donation by Titmuss in his book The Gift Relationship. b In that text, he argued that paying for blood would not increase the supply significantly, as those who had previously donated would be repulsed by the introduction of money in this transaction. The available empirical data do not suffice to determine whether this is true in the case of organ transplantation. However, it should be noted that donations are in this case-contrary to blood donation -essentially restricted to close relatives. It is a plausible hypothesis that the choice of giving one's kidney to a close relative is less influenced by a parallel market than the act of donating one's blood to an unknown recipient. Moreover Titmuss argued hat such a financial compensation would attract the wrong kind of people, for example, drug addicts, and thus threaten the quality of the blood. The scientific progress made since the 1970s has made it possible to test for a much larger range of diseases, a development that disqualifies Tit tmuss' s concerns that commercialization would increase the spreading of infectious diseases The second broad category of arguments consists of rights-based ones. The underlying assumption is that we have a right to our own bodies such that we are also entitled to sell parts thereof that we can make do without. It is suggested that the ruling out of a market in organs is, in fact, a grave violation of peoples most fundamental rights. Briefly, the gist of the argument is the
Some Common Arguments in Favor of Organ Commodification A number of arguments in favor of allowing for a market, especially in kidneys, have surfaced in the increasingly heated debate surrounding transplant organs. Broadly speaking, such arguments can be split into two groups: consequence- and rights-based ones. It should be noted that very few people, however, go all the way and propose an unregulated global market for organ transplantation. Arguments are commonly put forward in defense of a limited market, one that is rigged such that the active participants can be protected against the most blatant forms of harmful exploitation. For example, one could imagine a scenario where both the buyer and the seller had to be part of the same healthcare system, where there would be only one procurement unit in the system, where the prices would be set and nonnegotiable, and where the queuing system for the recipients remained the same as today. Such a limitation is said to be especially reasonable from a consequentialistic standpoint, as it is assumed to have more favorable consequences than its unregulated counterpart.4 Whether such a system would, in fact, provide protection for the especially vulnerable is, of course, an empirical question. It is, however, doubtful if any of these arguments are convincing in the sense of being capable of giving an account of people’s moral intuitions. Consequentialist arguments are often structured along the following lines: It is a fact that most people do not donate their organs, at least not to the extent that is required to make up for the organ shortage. It is said to follow that we ought to create a market for selling and buying organs because that would have the best consequences in the sense that fewer people would suffer, and die, in line for a transplant. The underlying assumption is that payment would result in more available organs. It is suggested that many people who are not prepared to part with their organs given the current legislation might well rethink their decision if they were paid. Evidently this is an empirical assumption, but it does not seem to be too far-fetched.5 A standard critique is to draw a parallel with the case made for blood donation by Titmuss in his book The Gift Relationship. 6 In that text, he argued that paying for blood would not increase the supply significantly, as those who had previously donated would be repulsed by the introduction of money in this transaction. The available empirical data do not suffice to determine whether this is true in the case of organ transplantation. However, it should be noted that donations are in this case—contrary to blood donation—essentially restricted to close relatives. It is a plausible hypothesis that the choice of giving one’s kidney to a close relative is less influenced by a parallel market than the act of donating one’s blood to an unknown recipient. Moreover Titmuss argued that such a financial compensation would attract the wrong kind of people, for example, drug addicts, and thus threaten the quality of the blood. The scientific progress made since the 1970s has made it possible to test for a much larger range of diseases, a development that disqualifies Titmuss’s concerns that commercialization would increase the spreading of infectious diseases. The second broad category of arguments consists of rights-based ones. The underlying assumption is that we have a right to our own bodies such that we are also entitled to sell parts thereof that we can make do without. It is suggested that the ruling out of a market in organs is, in fact, a grave violation of people’s most fundamental rights. Briefly, the gist of the argument is the Why We Are Not Allowed to Sell Organs 61
Barbro bjorkman following: We do not live in a fair world, resources and opportunities are not evenly distributed, and, as a result, the vast majority of the worlds population lives in poverty. We should all do our best to lessen poverty and suffering and make the world a more equal place. This is not done, however, by denying them what might be their best option to improve their lives, which well could be to sell an organ. In the words of Janet Radcliffe -Richards et al.,"feelings of repugnance among the rich and healthy, no matter how strongly felt, cannot justify removing the only hope of the destitute and dying"(p. 1950). To do so, it is said, is to violate their rights, rob them of their autonomy, and, to make matters even worse, will do nothing to alleviate the real problem. Julian Savulescu takes the argument one step further and calls a ban on organ selling paternalism in its worst form"(p. 139). He advocates that people should be allowed to make this choice(on the condition that it is informed consent)if it provides them with the means to realize what they value in life. Although the arguments outlined above might seem reasonable on one level (i.e, that people should not have to die queuing for an organ if there are alternatives), they fail to correlate with most people's moral intuitions on this matter. It appears that we have strong intuitions, in the sense that they are stable and withstand the test of time, that the selling of organs is plain wrong and no reasonable consequence- or rights-based argument can make it more alatable Naturally this could just mean that we are wrong. It is unclear what the difference, if indeed there is any, between moral intuition and emotional aversion actually consists of and moreover if people's emotional aversion should carry moral weight. It is far from obvious that the fact that we(the rich and healthy, presumably) are repulsed by something truly means that it is also morally reprehensible. Perhaps this reveals an inconsistency in our views on the relationship to ones own body. However, given that the purpose of normative ethics is to help us to bring some order to and explain our stable moral intuitions, the above-mentioned theories do not seem to be adequate tools for doing just that. Few of us sincerely feel that creating a market for transplant organs would make the world a better place from a moral point of view, even if the consequences were favorable and important rights would be protected. 9 Some Common Arguments against Organ Commodification Before moving on to the virtue ethics analysis, three of the most frequently voiced arguments against selling organs are explored First, it is said that commodification of organs is wrong because it implies themselves. Such arguments draw on Kantian ideas of not using people iin that we use people as means to an end rather than allow for them to be ends means to an end and that selling even the smallest part of ourselves would open the door for slavery Or in Kants own words, "a man who sells himself makes himself a thing and as he has jettisoned his person it is open to deal with him as he pleases"(p. 124). Thus Kant effectively states that any form of selling dignity by introducing a new way of thinking both about others and ourselves that some humans would come to serve as toolboxes for others
following: We do not live in a fair world, resources and opportunities are not evenly distributed, and, as a result, the vast majority of the world’s population lives in poverty. We should all do our best to lessen poverty and suffering and make the world a more equal place. This is not done, however, by denying them what might be their best option to improve their lives, which well could be to sell an organ. In the words of Janet Radcliffe-Richards et al., “feelings of repugnance among the rich and healthy, no matter how strongly felt, cannot justify removing the only hope of the destitute and dying” (p. 1950).7 To do so, it is said, is to violate their rights, rob them of their autonomy, and, to make matters even worse, will do nothing to alleviate the real problem. Julian Savulescu takes the argument one step further and calls a ban on organ selling “paternalism in its worst form” (p. 139). He advocates that people should be allowed to make this choice (on the condition that it is informed consent) if it provides them with the means to realize what they value in life.8 Although the arguments outlined above might seem reasonable on one level (i.e., that people should not have to die queuing for an organ if there are alternatives), they fail to correlate with most people’s moral intuitions on this matter. It appears that we have strong intuitions, in the sense that they are stable and withstand the test of time, that the selling of organs is plain wrong and no reasonable consequence- or rights-based argument can make it more palatable. Naturally this could just mean that we are wrong. It is unclear what the difference, if indeed there is any, between moral intuition and emotional aversion actually consists of and moreover if people’s emotional aversion should carry moral weight. It is far from obvious that the fact that we (the rich and healthy, presumably) are repulsed by something truly means that it is also morally reprehensible. Perhaps this reveals an inconsistency in our views on the relationship to one’s own body. However, given that the purpose of normative ethics is to help us to bring some order to and explain our stable moral intuitions, the above-mentioned theories do not seem to be adequate tools for doing just that. Few of us sincerely feel that creating a market for transplant organs would make the world a better place from a moral point of view, even if the consequences were favorable and important rights would be protected.9 Some Common Arguments against Organ Commodification Before moving on to the virtue ethics analysis, three of the most frequently voiced arguments against selling organs are explored. First, it is said that commodification of organs is wrong because it implies that we use people as means to an end rather than allow for them to be ends in themselves. Such arguments draw on Kantian ideas of not using people as means to an end and that selling even the smallest part of ourselves would open the door for slavery. Or in Kant’s own words, “a man who sells himself makes himself a thing and as he has jettisoned his person it is open to deal with him as he pleases” (p. 124). Thus Kant effectively states that any form of selling is degrading because it implies that a human being is property, a commodity like any other.10 It is also feared that such a practice might reduce human dignity by introducing a new way of thinking both about others and ourselves— that some humans would come to serve as toolboxes for others. Barbro Björkman 62
Why We Are Not Allowed to Sell organs The second argument against commodification is that it is presumed to lead to increased exploitation of th and already vulnerable members of societ The main concern is that the seller would be an individual at the bottom of society, often a resident of the Third World, and the buyers rich Westerners who had taken ill due to their affluent lifestyle. In short, it would be exploit ative. It appears valid to argue that whenever the First World deals with people who do not have their basic needs fulfilled, exploitation is just around the corner. As pointed out above, however, one could naturally imagine a regu lated, presumably less exploitative, version of the market The third argument is that people might be encouraged to take risks they would not otherwise take just to get some money. On the other hand, we allow people to take huge risks(from which they might otherwise have refrained)in exchange for money in other areas such as boxing and Formula 1 driving Further to the point, we praise those who take the risk to donate without compensation; suddenly the act of risk taking seems not only permissible but in fact admirable lI It should now be clear that the current debate consists of arguments, few of which actually manage to shed light on the selling versus donation dilemma. This state of affairs is quite problematic-although most of us agree that commodification should be kept at the gates, an exhaustive and coherent account of why this is the right standpoint is lacking. I believe that virtue ethics, by pointing to the fact that a virtuous person would donate rather than sell, can help in creating an ethical position strong enough to explain why organ selling should be ruled out Virtue ethics Just like other ethical theories, virtue ethics can be accounted for in various ways. In this section, an outline will be given of those components of virtue ethics that I deem essential to the position I wish to defend in this paper. Although virtue ethics is primarily occupied with what kind of person one ought to be, that is not to say that it is incapable of competing with, for example, utilitarianism as a theory of the right action. It is indeed central to the argument put forward here that virtue ethics can be action guiding. Rather than saying that virtue ethics is unable to live up to the demands of a comprehensive ethical doctrine and therefore needs to be supplemented br another theory of the right and wrong action, I believe that a strong case can be made that virtue ethics can be an action-guiding, stand-alone theory. It seems reasonable to assume that we can have an intuitive understanding of how irtuous person would act when facing a problem. At any rate the appeal what a certain person would do"is used, and appears to work reasonably well, in many other situations, for example, in healthcare and in the courts. In addition it is not clear that virtue ethics needs to claim that there is but one true account of what a virtuous person would do. Admittedly, it is not unusual to combine virtue ethics and healthcare ethics. In fact there is a relati standing tradition of care theory, a philosophical approach often associated with feminist ethical theories. 13 Most mainstream moral theories, such as utilitarianism Kantian ethics, and contract theories, occupy themselves with the issues of rightness and obliga- tion virtue theory, on the other hand, approaches ethics by asking"what traits
The second argument against commodification is that it is presumed to lead to increased exploitation of the poor and already vulnerable members of society. The main concern is that the seller would be an individual at the bottom of society, often a resident of the Third World, and the buyers rich Westerners who had taken ill due to their affluent lifestyle. In short, it would be exploitative. It appears valid to argue that whenever the First World deals with people who do not have their basic needs fulfilled, exploitation is just around the corner. As pointed out above, however, one could naturally imagine a regulated, presumably less exploitative, version of the market. The third argument is that people might be encouraged to take risks they would not otherwise take just to get some money. On the other hand, we allow people to take huge risks (from which they might otherwise have refrained) in exchange for money in other areas such as boxing and Formula 1 driving. Further to the point, we praise those who take the risk to donate without compensation; suddenly the act of risk taking seems not only permissible but in fact admirable.11 It should now be clear that the current debate consists of an array of arguments, few of which actually manage to shed light on the selling versus donation dilemma. This state of affairs is quite problematic—although most of us agree that commodification should be kept at the gates, an exhaustive and coherent account of why this is the right standpoint is lacking. I believe that virtue ethics, by pointing to the fact that a virtuous person would donate rather than sell, can help in creating an ethical position strong enough to explain why organ selling should be ruled out. Virtue Ethics Just like other ethical theories, virtue ethics can be accounted for in various ways. In this section, an outline will be given of those components of virtue ethics that I deem essential to the position I wish to defend in this paper. Although virtue ethics is primarily occupied with what kind of person one ought to be, that is not to say that it is incapable of competing with, for example, utilitarianism as a theory of the right action. It is indeed central to the argument put forward here that virtue ethics can be action guiding. Rather than saying that virtue ethics is unable to live up to the demands of a comprehensive ethical doctrine and therefore needs to be supplemented by another theory of the right and wrong action, I believe that a strong case can be made that virtue ethics can be an action-guiding, stand-alone theory.12 It seems reasonable to assume that we can have an intuitive understanding of how a virtuous person would act when facing a problem. At any rate the appeal “what a certain person would do” is used, and appears to work reasonably well, in many other situations, for example, in healthcare and in the courts. In addition it is not clear that virtue ethics needs to claim that there is but one true account of what a virtuous person would do. Admittedly, it is not unusual to combine virtue ethics and healthcare ethics. In fact there is a relatively longstanding tradition of care theory, a philosophical approach often associated with feminist ethical theories.13 Most mainstream moral theories, such as utilitarianism, Kantian ethics, and contract theories, occupy themselves with the issues of rightness and obligation. Virtue theory, on the other hand, approaches ethics by asking “what traits Why We Are Not Allowed to Sell Organs 63
Barbro Bjorkman of character make one a good person? Traits or qualities one is born with do not qualify as virtues. Rather, it has to be something that one can induce oneself to achieve or learn through proper upbringing and education. Note, however, that this does not imply a total disregard for the actual action as such, nor for its consequences. We can well imagine cases where the virtuous agent so should we be. a key claim made by virtue ethicists is that we ought to do what a(fully informed) virtuous person would have done. So how can we meet this requirement and how do we determine whether virtuous persons would donate rather than sell their organs? Broadly speaking, there are two answers to this question, the classic Aristotelian approach and a more modern one. Aristotle claimed that the virtuous character traits are those we need to live humanly flourishing/fulfilled lives. He argued that it is only when we live virtuously that our rational capacity can guide our lives. Character traits have to be stable-that is, the disposition has to be firm and unchanging -and should, in this context, be understood as something that is manifested in habitual action. However, habitual should not be interpreted as"automatic Describing an action as habitual does not necessarily mean that it is also effortless or spontaneous, although it could well be; in fact, most decisions would be reached through deliberation. In short, moral virtues are those virtues that are good for everyone to have. The more modern approach, partly seeking to avoid references to human nature, claims that the virtues come from the commonsense views about which character traits we typically find admirable, traits manifested by people we look up to. These are the kind of people we ought to model ourselves on when seeking to act virtuously. It seems plausible to argue that it is more admirable to donate than to sell ones organs-we look up to those who take personal risks not for the sake of economic compensation but simply because the pesu ably this could be the see"that helping their fellow man is a fine and worthwhile thing to do. Pr practical expression of a number of virtues such as unselfishness, generosity kindness, beneficence, and so forth. There is quite a bit of disagreement with regards to what the virtues are and eir relative order. Central virtues for the ancient thinkers were, for example, courage, wisdom, generosity, and truthfulness. The list could, of course, be extended to include many other qualities such as moderation, justice, benevo- lence, loyalty, tolerance, patience, and so forth. Would it then be fruitful to talk of the good person? Is there a single set of virtues that are desirable for, or ndeed essential to, everyone? The Aristotelian reply is that there is a catalog of virtues that would be required by all people in all walks of life because of basic facts about our human condition impossible to mitigate by social convention It should be noted that Aristotle was less concerned with connecting the virtues to the solutions to normative problems. He proposed that the virtues, rather, would help us to find the right path, the golden mean, in life and perhaps assist us in staying on it. Equipped with the combination of practical wisdom and the virtues, we would "see" what should be done and then desire to act accordingly. It is quite possible that there are no fully virtuous persons in existence, but the point is that we could imagine what such a person would be like and thus aspire toward that ideal. Human flourishing should, however, not be understood as having instrumental value-we should all aim to flourish simply because that is the best thing to do. The fulfilled life is the best life any
of character make one a good person?” Traits or qualities one is born with do not qualify as virtues. Rather, it has to be something that one can induce oneself to achieve or learn through proper upbringing and education. Note, however, that this does not imply a total disregard for the actual action as such, nor for its consequences. We can well imagine cases where the virtuous agent would, in fact, be highly concerned with the consequences and then, naturally, so should we be. A key claim made by virtue ethicists is that we ought to do what a (fully informed) virtuous person would have done. So how can we meet this requirement and how do we determine whether virtuous persons would donate rather than sell their organs? Broadly speaking, there are two answers to this question, the classic Aristotelian approach and a more modern one. Aristotle claimed that the virtuous character traits are those we need to live humanly flourishing/fulfilled lives. He argued that it is only when we live virtuously that our rational capacity can guide our lives. Character traits have to be stable—that is, the disposition has to be firm and unchanging—and should, in this context, be understood as something that is manifested in habitual action. However, habitual should not be interpreted as “automatic.” Describing an action as habitual does not necessarily mean that it is also effortless or spontaneous, although it could well be; in fact, most decisions would be reached through deliberation. In short, moral virtues are those virtues that are good for everyone to have.14 The more modern approach, partly seeking to avoid references to human nature, claims that the virtues come from the commonsense views about which character traits we typically find admirable, traits manifested by people we look up to. These are the kind of people we ought to model ourselves on when seeking to act virtuously. It seems plausible to argue that it is more admirable to donate than to sell one’s organs—we look up to those who take personal risks not for the sake of economic compensation but simply because they “see” that helping their fellow man is a fine and worthwhile thing to do. Presumably this could be the practical expression of a number of virtues such as unselfishness, generosity, kindness, beneficence, and so forth. There is quite a bit of disagreement with regards to what the virtues are and their relative order. Central virtues for the ancient thinkers were, for example, courage, wisdom, generosity, and truthfulness. The list could, of course, be extended to include many other qualities such as moderation, justice, benevolence, loyalty, tolerance, patience, and so forth. Would it then be fruitful to talk of the good person? Is there a single set of virtues that are desirable for, or indeed essential to, everyone? The Aristotelian reply is that there is a catalog of virtues that would be required by all people in all walks of life because of basic facts about our human condition impossible to mitigate by social convention.15 It should be noted that Aristotle was less concerned with connecting the virtues to the solutions to normative problems. He proposed that the virtues, rather, would help us to find the right path, the golden mean, in life and perhaps assist us in staying on it. Equipped with the combination of practical wisdom and the virtues, we would “see” what should be done and then desire to act accordingly. It is quite possible that there are no fully virtuous persons in existence, but the point is that we could imagine what such a person would be like and thus aspire toward that ideal. Human flourishing should, however, not be understood as having instrumental value—we should all aim to flourish simply because that is the best thing to do. The fulfilled life is the best life any Barbro Björkman 64