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Expert Opinion

The idea that organs should be given first to people who have agreed to donate their own organs has a long and distinguished history.  The internet has made implementing this idea practicable.  Here are some quotations dating back to 1989.  Unless otherwise stated elsewhere, the authors have not endorsed LifeSharers.

David A. Peters
"A Unified Approach To Organ Donor Recruitment, Organ Procurement, and Distribution"
Journal of Law and Health, Volume 3, No. 2, 1989-90, pages 157-190

"...under conditions of scarcity...justice demands that those who have consented to be posthumous organ providers, i.e., those who have fulfilled the moral duty to consent, be given first priority access to the cadaver organ pool in the event of need.  Nonconsenters are to be given second priority access."

Michael J. Booker
”Justice and the Macroallocation of Human Donor Organs”
A Dissertation Presented for the Doctor of Philosophy Degree
The University of Tennessee, Knoxville
August, 1990

"The desire for justice is not simply a concern that the world be made into a nicer place; it is an attempt to see to it that, insofar as possible, people receive what they deserve.  This means that we must find terms in which it is meaningful to speak of a person being due the organs of a person who has recently died.”

“Justice would connect the business of organ procurement with the matter of organ distribution.  I propose the following:  that access to organs for transplantation be linked to the willingness to be an organ donor.  The right to receive a donated organ should be tied to the duty to donate organs.”

“Individuals who are willing to donate organs should certainly receive priority in the allocation of organs, since they alone can be said to deserve available organs.”

Dilip S. Kittur, M. Michele Hogan, Vinod K. Thukral, Lin Johnson McGaw, and J. Wesley Alexander
"Incentives for organ donation?"
The Lancet, December 7, 1991, Volume 338, Number 8780, pages 1441-1443

"Alternative methods of increasing donations were assessed in 1990 by a subcommittee of the Ad Hoc Donations Committee (established by UNOS)...The subcommittee conducted a nationwide survey to assess public attitudes about alternative methods to increase donation...Responders were asked whether some form of financial or non-financial compensation should be offered in the USA in an effort to increase the number of organs for donation; 52% of responders said it should. They were also asked to rank the various forms of compensation; preferred status was the top-ranked option.”

Irvin Kleinman, MD, and Frederick H. Lowy, MD
”Ethical Considerations in Living Organ Donation and a New Approach”
Archives of Internal Medicine, Volume 152, July 1992, pages 1484-1488

“We propose the development of an incentive-based Advance-Directive Organ Registry, in which all adults are encouraged to register their advance directive regarding organ donations.  Those individuals agreeing to permit usable organs to be taken at the time of death would receive priority for organs generated by the program, should a transplant become necessary when there is a shortage of organs.”

“The proposed system would allow individuals to exercise autonomy in deciding whether or not to participate.  We believe that in the event of a shortage of organs, it is reasonable that priority be given to those willing to advance the public good by participating in the responsibility for organ donation.”

“People die today because of a shortage of organs.  By increasing the supply, the proposed system decreases the total number of people who die."

"The proposed system is firmly founded on the principles of patient autonomy, beneficence, and justice.  Autonomy is served by the voluntary registration of an advance directive that will likely be honored.  The welfare of those who need transplants is served by increasing the supply of cadaveric donor organs, while the welfare of their family members is advanced by reducing the need for living organ donation, with its potential risks as well as ethical and psychological conflicts.  Justice is also served when more persons who need transplants get them.”

Dr. Rupert Jarvis
"Join the Club:  A Modest Proposal to Increase Availability of Donor Organs"
Journal of Medical Ethics, 1995; 21:199-204

"A...problem with the current system by which donor organs are rationed is that it takes no account of, indeed it encourages, the 'free rider': the individual who hopes to benefit from the cooperation of others even though he does not himself contribute to the socially desired end.  Although it is in each individual’s interest that donor organs should be available, it is in nobody’s interests to make his/her own organs available: the choice to donate postmortem is an entirely altruistic one.  We therefore have the current situation where demand is not matched by supply, and individual patients who could benefit from a transplanted organ are denied that treatment owing to a lack of suitable organs available for transplant."

"I suggest that legislation governing organ donation be amended such that all and only those who identify themselves as potential donors (perhaps by a card similar to the one currently in use, or by registration on a central computer) are eligible themselves to receive transplant organs."

"It hardly seems fanciful to suggest that the vast majority of people would elect to join the scheme, since it is so clearly in their interests to do so, with the potential gain (life) being infinite and the potential loss (postmortem dissection which, depending on the manner of their death, they might well have to undergo anyway) being zero."

Erich H. Loewy
“Of Community, Organs and Obligations: Routine Salvage With A Twist”
Theoretical Medicine, 1996; 17: 61-74

“One generally views responsibilities as reciprocal. Under a given set of circumstances, when I am in need of help and would expect another to be obliged to come to my help, I should be willing to reciprocate if conditions were reversed.”

“What I propose is a modification of routine salvage, ‘routine salvage with a twist,’ as it were. Under this proposal all usable organs or parts would be routinely salvaged from all newly dead persons unless such a person had rather early in their adult life refused such donation in writing. Such an opportunity would be given and would be made known to all citizens. Persons who refuse, however, would lose their own entitlement to receive organs should they ever be in need of them and changing one’s mind once disease had taken hold would not be accepted as a reason for transplantation. The personal views of individuals would therefore be taken into account and respected but the reciprocity of interests and obligations would likewise be safeguarded.”

Richard Schwindt and Aidan Vining
"Proposal for a Mutual Insurance Pool for Transplant Organs"
Journal of Health Politics, Policy and Law, Vol. 23, No. 5, October 1998, pages 725-741

"The proposal [for an organ mutual insurance pool] can be easily summarized:  An individual would receive priority for any needed transplant if that individual agrees that his or her organs will be available to other members of the insurance pool in the event of his or her death."

"The insurance benefit that the individual receives is the priority right to an organ if he or she subsequently falls into the recipient class."

"The premium, or 'price,' of this insurance is the commitment to provide one's own organs upon death, if they are usable."

"The main purpose [of this proposal] is to increase the supply of transplantable organs in order to save or improve more lives."

"By increasing the overall supply of organs, it is likely to help members and nonmembers of the pool alike.  This should assuage concerns about discrimination against those who, for whatever reason (imprudence, misestimation of risk, refusal to confront mortality, etc.), do not join the pool."

Charles J. Wheelan
”To Get an Organ, Offer to Give One”
Wall Street Journal, December 29, 1998

"There is an alternative solution to the problem that is equitable, simple and inexpensive….At age 18 (or 21), all men and women would be required, in the presence of a witness, to sign a statement declaring whether or not they are willing to be organ donors.  There would be no government pressure to decide one way or another.

However, one criteria for being eligible to receive a donor organ would be whether or not the individual is signed up as a donor himself.  Those who were not willing to donate organs would be placed lower on the waiting list than all individuals, however sick, who had agreed to be donors.

This program would solve several problems.  First, it would dramatically boost the number of organs.  Agreeing to 'give the gift of life' would no longer be an act of pure altruism; rather it would be an insurance policy.  Even the most selfish of individuals would be willing to become donors if it gave them greater access to the hearts or livers that might save their lives.

Second, the policy has an appealing fairness.  Those who benefit from organ transplants would be those who, had the circumstances been different, would have been willing to make the same sacrifice.  (Those who have moral or religious objections to donating organs cannot reasonably expect to gain from something they are not willing to do themselves.)"

"The golden rule is a good road map for life.  It might also help the thousands of people who are literally dying for donor organs."

Donald B. Ardell, Ph.D.
”My Grand Organ Donor Plan of a Wellness Nature”
January 3, 2001

“My plan is a two-part remedy.  Part one is ‘donate or don’t ask.’  That is, to be eligible for a donor organ someday, you must have signed a donor card before your own need for one is documented.  This, I believe, would do wonders to motivate folks to sign up as organ donors.  It would create an incentive beyond service to others for added meaning in life, general altruism, good will, and a love for humanity.  These motives rarely apply to more than a small segment of the population – and the need for organ donors is larger than the pool of available human compassion.”

Dr. Alexander Tabarrok
"A Moral Solution to the Organ Shortage"
The Independent Institute, February 19, 2001

"I propose that the United Network for Organ Sharing (UNOS) consider restricting organ transplants to those who previously agreed to be organ donors; in short, a 'no-give no-take' rule.  While it is understandable that some people may have misgivings about becoming donors for personal or religious reasons, why should someone who was not willing to give an organ be allowed to take an organ?

Signing your organ donor card should be thought of as entry into a club, the club of potential organ recipients.  Current UNOS policy is that organs are a 'national resource.'  This is wrong.  Organs should be the resource of potential organ donors, and signing an organ donor card should be tantamount to buying insurance.  Being willing to give up an organ, should it no longer be of use to you, is the premium to be paid for the right to receive someone else's organ if one of yours fails."

Robert Locke
”What To Do About America’s Organ Donation Crisis”, April 12, 2001

“What we actually need is legislation that would give priority for available organs to people who have themselves signed the organ donor card.  Those who have signed would go ahead in line of those who have not.  To keep people from waiting until they need an organ before signing the card, there should be a priority (adjusted for age, of course) for people who have been signed up longest.  This would give people an incentive to sign the card immediately in case they ever needed an organ later.  To get right to the point, fear is a very efficient motivator.

This way of getting more people to sign up is morally unimpeachable, as it makes the benefits of organ transplantation available to those who are willing to donate their own organs to others.  They are clearly more deserving of a transplant than someone who has refused, either deliberately or by neglect.  This would replace a system based on handouts with one based on individual responsibility...”

Merrill Matthews
"Organ Availability"
National Public Radio, All Things Considered, April 25, 2002

"Some years ago, Dr. Robert Sade of the Medical University of South Carolina, along with some of his colleagues, proposed an in-kind market for organs.  Every adult would have the opportunity to join a nationwide pool of organ donors.  All you would have to do is give permission to have your own organs removed at death.  Only those willing to donate their organs would be permitted to receive an organ if they needed one.  Those who declined to enroll in the program but ended up needing an organ would receive the best available medical care short of a transplant.

A membership pool would provide an incentive for people to donate their organs at death, and lead to immediate increase in the number of organs available.  Of course, not everyone’s organs would be suitable for transplant.  But even the unsuitable ones could be used in medical research.

What the concept of a donor pool does is refocus the ethical issue away from whether it’s right to be compensated for an organ.  Rather it asks whether those who need an organ should be allowed to receive one if they are unwilling to donate their own.  Or to paraphrase a more traditional and more accepted ethical standard:  Are you willing to do for others what you would have them do unto you?"

Charles Blankart, Christian Kirchner, and Gilbert Thiel
"Transplant Law - A Critical Analysis from a Legal, Economic, and Ethical Perspective"
Shaker publishing firm, 2002

"Healthy people who agree to posthumous organ donation should be given precedence over non-donors in case they themselves need an organ transplant, as far as medical conditions allow."

Jonathan Rackoff, JD
“A Reciprocity Obligation to Donate Cadaveric Organs: Re-Visioning Opting In”
ASBH Exchange, Fall 2002, Volume 5, Number 2

“The Uniform Anatomical Gift Act (UAGA) frames organ donation as gift giving, worthy of praise and gratitude. But this attitude is counterproductive if the goal is to save lives. The gift model of organ procurement has magnificently failed to satisfy rising demand for transplants.”

“In a healthcare system facing ever-rising pressures to ration care, a model of organ transplantation that deems all citizens to be eligible recipients but only the few volunteers to be eligible donors looks increasingly anachronistic. I propose an alternative tack: The opt-in system should be revisioned to incorporate a reciprocity obligation to donate cadaveric organs.”

“Ensuring the availability of effective transplantation services in the United States requires mutualism. To deny the reciprocal obligation to donate is to miss that, like it or not, we all live embedded in the larger community. It also represents a free-rider problem abhorrent to ordinary notions of fair play."

"Opting in is giving consent for both a benefit and a burden—for transplant eligibility bundled with organ-donor status. It scarcely impinges on autonomy to refuse to grant an entitlement if a closely related social obligation is not met."

"By expecting full participation from those who wish to be eligible for benefits, a new opt-in scheme could increase the supply of transplantable organs while reminding people of the scope of their ethical obligations.”

Mehmet C. Oz, MD, Aftab R. Kherani, MD, Amanda Rowe, BA, Leo Roels, CPTC, Chauncey Crandall, MD, Luis Tomatis, MD, and James B. Young, MD
"How to Improve Organ Donation: Results of the ISHLT/FACT Poll"
The Journal of Heart and Lung Transplantation, 2003, Volume 22, pages 389–410

“We surveyed members of the International Society for Heart and Lung Transplantation (ISHLT) in conjunction with the Foundation for the Advancement of Cardiac Therapies (FACT)...We asked for opinions about how to improve organ donation...Among our membership, there seems to be a consensus belief that those unwilling to contribute to the donor pool of organs should not be able to draw from it.”

Adam J. Kolber
”A Matter of Priority:  Transplanting Organs Preferentially to Registered Donors”
Rutgers Law Review, Vol. 55, 2003

“I propose to encourage organ donation by offering registered organ donors preferential access to the organ supply.  This policy would motivate people to register and better recognize the contribution that registered donors make toward easing the organ shortage.”

“While it may initially seem unsettling to give preference to some people over others in a life or death situation, current allocation policy already reflects a variety of non-medical, value-laden preferences. Our choice is really to decide which set of preferences to give and how they should be weighed against each other."

"While there are many reasons to support priority allocation, the most important reason is that doing so will increase the number of organs donated and the number of lives saved through transplantation.”

"The benefits of registering under a priority incentive program clearly exceed the costs. Even after registering, it is extremely unlikely that a registrant will donate organs because it is rare to die with organs medically eligible for transplantation. We have far more organ recipients than donors because each body used in transplantation provides organs to several individuals. Under a priority scheme, potential donors can make the trade off between the very remote possibility of becoming an organ donor and the not-quite-so remote possibility of needing an organ. Understandably, neither the role of donor nor recipient is particularly appealing to think about. If you are in the latter category, your life is threatened, and if you are in the former category your life is over.  But, under a priority system, you have an incentive to register because you are more likely to be rewarded by the system than made to contribute to it.  More importantly, the actual rewards of registering under a priority scheme (and thereby increasing one's life expectancy) far outstrip the costs, if any, of having some organs removed after death. Despite the discomfort one may have about registering to donate, an actual donation will only be made when one is dead and unaware, while the process of needing an organ occurs only while one is alive and usually very much aware."

"The importance of increasing organ supply can hardly be overstated. Doing so will save lives by making more organs available. Those who receive priority are helped for obvious reasons. And, depending on the extent of the priority involved, it can help those who do not receive priority if donations induced by a priority system sufficiently increase organ supply to offset their reduced priority. An increased organ supply will also improve the quality of life of those who need an organ, not necessarily to live, but to live free of debilitation. Most notably, this group includes many of those who spend hours each week undergoing the ordeal of kidney dialysis. Lastly, increasing the supply of cadaveric organs will reduce pressure on living people to donate kidneys or parts of other organs to their relatives or friends on waiting lists, in operations that can generate significant health risks to donors and the potential for deep intrafamilial strife.”

"[The] UNOS ethics committee has taken the position that priority incentives could be implemented without changing existing legislation."

“Nearly half of those who would not donate organs would still accept an organ if they needed one. These people are willing to benefit from a common resource without investing anything to create it. On Monday, Alfred can express his religious or aesthetic opposition to organ donation, and on Tuesday, perhaps after being diagnosed with life-threatening liver failure, immediately enter a waiting list for a new liver. Betty, on the other hand, may have expressed a lifelong willingness to donate, may have encouraged her family and friends to declare their intentions to donate, and, under the current system, will enter the waiting list under the same terms and with the same waiting time as Alfred. If we are skittish at all about giving Betty preference over Alfred, we must remember that the entire system of organ donation depends on donors and families of donors who are more like Betty than they are like Alfred. In a world of Alfreds, there would be no organ donation at all.”

“Priority incentive schemes do not favor registered donors because registered donors are somehow more virtuous than others; rather, they favor registered donors in order to create an incentive to join a mutual insurance pool. Those who deliberately decline to join are not entitled to the full benefits of others' contributions.”

Hartmut Kliemt
”Clubs and Reciprocity in Organ Transplantation”
Paper prepared for the meetings of the Japan Economic Policy Association
November, 2003

“Organ socialism treats donated organs as a common pool resource of the public at large while denying individuals the right to specify a desired posthumous allocation of their organs during life time.  Economic inefficiency and normative incoherence characterize the result.”

"Those who want to give priority to those who were and still are willing to donate need not want to exclude other people from organs.  All that is needed is an interest in furthering and rewarding morally fair contributions to practices that lie in the interest of all.  People may feel compassion with those who do not contribute as well as with those who do contribute but still may feel the need to give priority to those who are contributors if a choice must be made due to scarcity. And this is an ethically entirely respectable motive.”

“As in socialism in general, in organ socialism the criterion is need and not contribution thereby wiping out incentives to contribute.  If there are no incentives to donate or at least to think about donation seriously then no donations will be forthcoming.  This is obvious but the remedy for this 'missing incentives problem' is obvious as well....Organs should be given with priority to those who are themselves willing to donate with priority for other donors.”

“Potential organ donors would start to think about their desire to live on.  They would be interested in priority of access to an organ to further their own survival.  Rather than to imagine their own death and the prospect of unselfishly bequeathing organs in case of their death they would be made to think about living on now.”

Jonathan D. Sackner-Bernstein and Seth Godin
"Increasing Organ Transplantation - Fairly"
Volume 77, Number 1, January 15, 2004

“People are motivated more by self-interest than by altruism.  To increase organ donation, the incentive needs to be aligned with self-interests.  Therefore the authors propose that the priority to receive a transplant should be based on prior willingness to be a donor:  to get, you have to be willing to give.”

“The commitment to the system of transplant – being a willing donor – is the fairest way to prioritize recipient status.  Such a system will encourage more donation as people on the donor list start to receive transplants themselves, especially when the transplant takes place quickly, before risk becomes excessive.”

"Using a person’s generosity as a part of subsequent ranking is already part of the renal transplant system.  A living donor receives points that would subsequently elevate them on the waiting list if they were to develop renal failure necessitating a transplant.”

“The major questions surrounding organ transplantation focus on increasing organ donation and ensuring fair allocation of this scarce resource.  We believe that the highest priority should go to those who are most committed to such a therapy.  Establishing this as a primary factor in determining priority will be a major incentive to increase organ donation from both altruists and those who want to protect their own future.  Making this the major basis for receiving a transplant is fair and equitable, limits the impact of arbitrary or subjective criteria, and provides an incentive for greater organ donation, thereby adding to the fairness of organ allocation.”

David Steinberg
“An ‘Opting In’ Paradigm for Kidney Transplantation"
American Journal of Bioethics
Volume 4, Number 4, 2004

"An 'opting in' paradigm would reward people who agree to donate their kidneys after they die with allocation preference should they need a kidney while they are alive. An 'opting in' program should increase the number of kidneys available for transplantation and eliminate the morally troubling problem of 'organ takers' who would accept a kidney if they needed one but have made no provision to be an organ donor themselves. People who 'opt in' would preferentially get an organ should they need one at the minimal cost of donating their kidneys when they have no use for them; it is a form of organ insurance a rational person should find extremely attractive."

"A system that offered preference in organ allocation to those who chose to 'opt in' would be a very attractive form of organ insurance. You would not be presumed to be a kidney donor until you voluntarily 'opted in' and agreed to donate a kidney. If you became ill, you would more quickly receive an organ that would substantially improve the quality of your life or save your life, and at the minimal cost of promising to donate your organs after you die, have no use for them, and can no longer suffer. It is an opportunity a rational person should willingly accept as very attractive."

J. D. Jasper, PhD, Carol A. E. Nickerson, PhD, Peter A. Ubel, MD, and David A. Asch, MD, MBA
“Altruism, Incentives, and Organ Donation - Attitudes of the Transplant Community”
Medical Care, 2004, Volume 42, pages 378–386

“This study investigated the attitudes of the transplant community toward the current policy of altruistic organ donation and 6 alternative policies offering incentives to the donor family...Surgeons and coordinators believed a policy offering preferred status to be morally neutral; nurses believed this policy to be morally inappropriate.”

"[S]urgeons and nurses believed that [preferred status] would increase the likelihood of organ donation by the public relative to the current policy of altruistic donation...[C]oordinators also believed [preferred status] would increase the likelihood of donation.”

Percentages of Respondents in Each Profession Advocating Implementation of Preferred Status

Transplant surgeons 45%
Transplant coordinators 34%
Critical care nurses 40%

Steve P. Calandrillo
”Cash for Kidneys?  Using Incentives to End America’s Organ Shortage”
George Mason Law Review, Fall, 2004

“By giving priority to Americans who are willing to donate organs themselves, we could overcome the paradox between the widespread public support for donation and the reality that relatively few people affirmatively sign up today.”

“Basing waiting list priority on the patient’s own willingness to donate may inspire millions of Americans who have previously not taken the trouble to sign up to instead choose to opt in to donation. This concept has been put into practice by LifeSharers, a nonprofit organization formed just over two years ago that aims to utilize a person’s internal motivation to save their own life in order to save the lives of others. LifeSharers incentivizes people to become organ donors (and to become a LifeSharers member) by giving them the return promise that all members of the organization agree to donate their organs first to other members before they go into the nationwide waiting pool. In this manner, people are encouraged to opt in to donation who otherwise might not, if only from a selfish desire to increase the likelihood that they will be able to find a suitable organ should their own organs fail sometime in the future. To prevent adverse selection (i.e., people joining only because they are currently in need of an organ), LifeSharers imposes a six-month moratorium between the date one joins the organization and the date that they are entitled to priority to other members’ organs.

LifeSharers’ concept is an appealing one from an intuitive and distributive justice perspective: it seems only fair that people who agree to donate organs should receive priority if they ever need one. Scholar Alexander Tabarrok agrees, proposing a 'no give, no take' policy with respect to organs: if one does not agree to be a donor, one should not be allowed to receive the benefit of donated organs. Ironically, approximately 70% of today’s transplanted organs go to recipients who are not donors themselves, while thousands of those who are willing to be donors go without. All else equal, the scarce supply of human organs should be allocated first to individuals who themselves are willing to sacrifice to save other people’s lives. While LifeSharers has implemented this priority access concept on a grass roots basis, UNOS could modify its allocation rules to implement it immediately on a national scale.

Nevertheless, critics charge that the incentive scheme offered by LifeSharers discriminates against certain populations who cannot donate because of religious or cultural reasons, and who would therefore be disadvantaged by their inability to join. Further, some argue that it gives members false hope, primarily because there are not enough people on the organization’s membership roster yet to constitute a reliable supply of organs. However, membership has more than doubled in each of LifeSharers first two years of existence. If LifeSharers continues to grow at this exponential rate, there would be more than one million members – all potential donors – by 2013.”

Steve Heilig, MPH, and Lisa Nyberg, MD
“Organ Donation: Closing the Gap by Putting Donors First: Too Many Preventable Deaths”
San Francisco Medicine, 2004; volume 77, number 9

“…although over 75 percent of Americans not only support transplantation in concept and also state that they wish to donate their own organs upon their death, too many do not take the procedural steps needed to ensure that this occurs. Less then half of potential donors now do so. Demand for organs, however, keeps rising. Thus, a chronic and tragic shortage of organs relative to need results in much unnecessary suffering and death.”

“We believe that a ‘donor-first/confirmed consent’ incentivized system can be implemented with minimized logistical and ethical problems. This system would offer priority to those individuals who have previously committed to organ and tissue donation at the time of their own death. After development and adoption of a suitable policy and program, a widespread public education effort would be needed to inform people about their newly heightened interests in donating their organs. Ideally, the program could effectively nullify itself if many new donors respond to the new incentive. Only a fraction of those who have not yet offered organs but who say they would intend to would need to do so in order to fulfill current demands for organs. Thus, the waiting lists could diminish so much as to make the ‘triaging’ inherent in current practice, and this proposed policy, moot. Although this is a lofty goal, it could be attained with a full commitment to implementation of and education about this policy.

An ever-increasing number of families and friends are suffering the emotional anguish of seeing their loved ones suffer and sometimes die while thousands of potentially lifesaving organs are being discarded....[A] large number of potential donors would have consented if the issue had been adequately discussed prior to their death. The ‘donor-first/confirmed consent’ incentivized program will encourage discussion of choices and attitudes regarding organ and tissue donation and thus could potentially save thousands of lives. Even if there are problems with the policy, they are unlikely to be as tragic as the existing instances of preventable suffering and deaths.”

Mark S. Nadel and Carolina A. Nadel
”Using Reciprocity to Motivate Organ Donations”
Yale Journal of Health Policy, Law, and Ethics
Volume V, Issue 1: Winter 2005

“It has long been argued that organ donation should be motivated solely by altruism, but relying only on such generosity leaves half of the suitable organs in cadavers unused. Sadly, approximately 6,000 deaths occur annually due to lack of an organ. There are two main reasons why suitable organs are not transplanted. First and foremost, most people are not sufficiently motivated to commit to donate. Although more than two-thirds of Americans express a willingness to donate their own organs, less than half of the public has formally committed to do so. Second, hospitals and doctors also often fail to honor a deceased’s directions to donate.”

“Fortunately, a relatively simple adjustment to the organ donation rules would likely alleviate the two central problems with the current system by inducing many more commitments to donate and deterring families from challenging those wishes. Instead of asking individuals to act purely altruistically, UNOS/OPTN should formally recognize those who commit to donate organs at death by significantly increasing such individuals’ chances of receiving an organ should they later need one.”

“Under the reciprocity policy proposed here, those who committed to donate would receive a significant advantage in the organ allocation process, if they later needed a transplant. This would enable them, like military veterans seeking a government job, to be placed ahead of nondonors of slightly superior qualifications on the waiting list.”

“There are good reasons to believe that, by making it in a person’s self interest to commit to organ donation, a priority policy would produce significantly more donations. In fact, the policy would respond to both current problems deterring donations: It should convince more people to sign up to donate and make it more likely that those wishes will be honored, even if the donors’ families would prefer to override them."

"Today, family members may well regard a donor’s decision to donate as a unilateral charitable impulse, whose revocability should continue after their death, even though the law is otherwise. Once a transplant specialist had politely informed them about the basic concept of a priority policy, however, most family members would likely recognize that the donor’s decision to donate was part of a quid pro quo agreement. Most would probably understand that it would be wrong for them to try to renege on the donor’s death-triggered promise. Thus, one would expect fewer families to attempt to override a donor directive, and it should be easier for transplant specialists to overcome any resistance offered."

"The substantial health benefit of a system of reciprocal organ donation incentives and its minimal cost (for maintaining registries) should combine to lead many people—encouraged by their families, their physicians, and the media—to overcome the factors that currently inhibit organ donation. In addition, families should be less likely to attempt to override a deceased’s decision to donate if they understand it as a binding portion of an ‘insurance’ arrangement, based on reciprocity. Relying purely on altruism for organ donations would certainly be ideal, but it is not worth the loss of thousands of lives annually.”

Aaron Spital
“Should people who commit themselves to organ donation be granted preferred status to receive organ transplants?”
Clinical Transplantation, 2005; volume 19, pages 269-272

“Granting preferred status for transplantation to people who commit themselves to posthumous organ donation is an intriguing proposal designed to increase the pool of cadaveric organ donors. Under one version of this plan, all competent adults who had previously consented to having their organs removed and transplanted upon their deaths would be given priority to receive organs, should they ever need them, over potential recipients of equal need who had not agreed to donate.”

“To investigate current public attitudes toward granting preferred transplantation status to people who consent to removal of their organs upon their deaths, I contracted Harris Interactive, a respected national polling organization, to conduct a telephone survey about this issue. One thousand fourteen adults living in the continental United States, all at least 18 yr of age, were interviewed in September 2003. The subjects were chosen by a random digit dialing technique that reaches people with listed and unlisted phone numbers. The responses were weighted by known proportions for age, geographic region, sex, and race among the U.S. adult population. This method is designed to produce a sample of respondents that is representative of the general adult public. The introduction and question were written by the author and pretested for understanding on 10 members of the lay public.

Introduction: ‘Transplantation is a highly successful life-saving treatment for people with failing organs. Most transplanted organs come from people who have just died. Unfortunately there are not enough of these organs for all who need them, in part because many families say no when asked for permission to take organs from a loved one who has just died. Several plans have been suggested in the hope of making more organs available. One of these is to give people who agree to donate their organs after death priority to receive organs should they ever need a transplant themselves.’

Question: ‘Should people who have agreed to donate their organs after death be given priority to receive organs if they themselves should ever need them over people who have not agreed to donate their organs after death?’

Participants could choose from the following possible responses: yes, probably yes, probably no, no, do not know, or refuse to answer.

Fifty-three percent of the respondents believed that people who have previously agreed to donate their organs after death should be granted priority to receive cadaveric organ transplants over those who have not agreed to donate; 33% thought that donors definitely should receive such priority and 20% thought they probably should. Forty-one percent of the respondents said they would oppose preferred status; 30% definitely would oppose the plan and 11% probably would. Five percent said they didn’t know and one percent refused to answer.”

“These data suggest that a program that grants preferred status to receive an organ transplant to people who have agreed to be organ donors after death would likely be acceptable to at least half of the U.S. public and strongly opposed by at most one third.... Furthermore, there is precedent for the concept of linking ranking of potential transplant recipients to past behavior: in the United States, living organ donors are given priority to receive a cadaveric transplant should they ever need one.

Of course, acceptability does not equal efficacy. Only an actual trial can tell us how effective a preferred status plan would be. Given favorable ethical arguments, the severe shortage of life-saving organs available for transplantation, the expectation that a preferred status program would increase the pool of committed donors, and the fact that such a plan may be acceptable to most people, the work involved in conducting such a trial may be effort well spent.”

Charles B. Blankart
“Donors Without Rights - The Tragedy of Organ Transplantation”
Perspektiven der Wirtschaftspolitik vol. 6, nr. 2, 2005, pp. 275-301.  Paper submitted at the European Public Choice Society Meeting 2005

“The number of organs is not independent from the distribution of organs. This paradigm leads to the provision principle – A person has the right to make a statement as the following to a trustee: ’I hereby state, that my organs, post-mortem, should be given primarily to patients who are also willing to donate.’”

“The provision principle…offers a return: a conditional insurance against the consequences of an organ malfunction. The individual will contrast the advantages to the costs and decide whether to donate post-mortem or not….If the individual refuses to declare her willingness to donate and it turns out that she does not receive an organ when she needs one, then the detriment is not imposed but generated by her.”

“Transplantation medicine solely depends on the willingness of donors. Without donors there are no recipients. Consequently it would be unfair, even discriminating, to distribute organs irrespectively of whether the patient was a live donor or at least a declared post-mortem donor. Treating unequals equally seems as false as treating equals unequally. A fairness solution therefore requires that the government gives priority to the distribution of organs to former living donors and also to the declared post-mortem donors….If out of two patients one has filed a donation declaration and the other didn’t, then fairness requires giving it to the one showing her willingness to donate and not the other one, given that only one organ is available. This principle seems to be based on a broad ethical consensus.”

Stephen Giles
“An antidote to the emerging two tier organ donation policy in Canada: the Public Cadaveric Organ Donation Program”
Journal of Medical Ethics, Volume 31, Issue 4, April 2005, pp. 188-191

“…not enough people are signing up to donate their kidneys after death. Why is this so?  One simple reason I suggest is that people do not see the benefit for themselves in consenting to be a cadaveric donor. That is they receive nothing, or at least not enough, out of such an act.”

“Why not say that those who are willing to give and sign up for kidney donation upon their death will receive the benefit of having a priority to receive a kidney transplant if they require one during their lifetime? Acknowledging the limits of altruism and volunteerism, this idea recognises the self motivated desire for giving.”

“The main principle here is that if you are willing to donate, you will receive priority for transplantation if you should require it. This model is based on the argument that while people are healthy, donation is not appealing—which may offer another reason for the lack of increase in general rates of organ donation. If this model was publicised, people who were not willing to donate to traditional cadaveric donation programmes may reconsider when they realize that they will not receive preferential treatment."

Robert D. Truog, M.D.
“Are Organs Personal Property or a Societal Resource?”
The American Journal of Bioethics, July-August 2005, Volume 5, Number 4

"Simply put, giving those who are willing to donate organs first priority for receiving organs is both ethically sound and an outstanding way to increase the overall pool of organ donors."

"UNOS should simply incorporate 'willingness to be a donor' as a heavily weighted factor in determining priority on the waiting list."

Donald W. Landry, M.D.
“Voluntary reciprocal altruism: a novel strategy to encourage deceased organ donation”
Kidney International, 2006, Volume 69, pp. 957-959

"Clearly, we need to develop a new strategy to encourage the donation of deceased organs...

The strategy must engage the self-interest of the prospective donor in order to overcome the natural reluctance to face one’s mortality...

The strategy must yield a structure in which the pursuit of self-interest leads to just results. The obvious injustice in the current system falls on recipients who languish on waiting lists while organs are discarded that could have been donated, and this will be redressed if the strategy effectively increases donation. Another is embodied in the lack of fairness of the many recipients who at one time refused to agree to donate but now receive organs ahead of those who bore the burden of agreeing...The strategy for promoting donations must align the self-interest of the prospective donor with the fair and just decision to agree to donate...

Altruism can be conceived as an adaptive strategy that is reinforced the greater the possibility of reciprocity. Altruism, if supported by 'strong reciprocity' that incorporates a propensity to reward altruists and punish the violators of altruistic norms, can operate anonymously in social structures to favor cooperation. Reciprocity must be highlighted in the strategy and an element of strong reciprocity incorporated.

A strategy involving persons that regards efficiency as the sole good to be optimized devalues the individual and affronts human dignity. The strategy should not be coercive or exclusive. It must incorporate flexibility. For example, participation in any novel element must be voluntary. Participants must be able to change their minds without undue penalty.

But can these sometimes conflicting considerations be harmonized on the back of a driver’s license? I propose a synthesis based on providing an option that reinforces the strong reciprocity that bolsters anonymous altruism. The resulting strategy, voluntary reciprocal altruism, is embodied in two questions:

(1) I would want an organ transplant to save my life. Check one:

  • yes
  • no

(2) In the event of my death, I agree to the donation of my organs. Check one:

  • yes
  • no
  • yes, with a preference to donate to those who agree to donate their organs

The first resolution in one stroke moves the issue of reciprocity front and center: to do unto others as you would have them do unto you. This resolution is non-binding but is designed to arouse the conscience. The second resolution raises a doubt in the mind of the respondent: Is there a penalty for choosing 'no' (selfishness) rather than the unqualified 'yes' (altruism) or the qualified 'yes, but reciprocally' (strong reciprocity)? And there is a penalty for a negative response: in the event that the 'no' responder needs an organ, perhaps the strong reciprocators will have restricted enough of their organs to affect adversely the possibility of transplantation. Conversely, the unqualified affirmative response obtains a reward in the form of access to a new pool of organs created by the strong reciprocators. The drive found in many for strong reciprocity may by itself increase the numbers of donors, because 'yes, but reciprocally' now becomes a mechanism to reward social cooperation and punish the violator of norms. Game theory allows us to sketch utility curves, but a quantitative analysis is not needed to appreciate how self-interest biases the decision and shifts the preferences toward donation. The novel element in the system, the third choice, is voluntary, and those who aspire to pure altruism can shun it….

Could such a simple paradigm really succeed? An unscientific survey argues yes.

A sample of 115 first-year medical students were told that a new strategy to encourage donations was under consideration. When question 1 as above ('I would want an organ transplant to save my life') was presented, 100% responded yes; no one would decline transplantation in this population. When question 1 was followed by question 2 as above ('In the event of my death, I agree to the donation of my organs,' the total yes votes for question 2 rose to 94% (74% unqualified yes, 20% yes but reciprocally, 2% no, 4% no decision). The baseline agreement to donate by this group was 59%. The increase in both unqualified and qualified affirmative responses suggests that voluntary reciprocal altruism could be a robust strategy to increase donations."

Katrina A. Bramstedt, PhD
“Is it ethical to prioritize patients for organ allocation according to their values about organ donation?”
Progress in Transplantation, 2006; volume 16, page 170-174

“An innovation in preferred status is the directed donation plan designed by an organization called LifeSharers. Directed donation is allowed by federal and stat law (and UNOS), although some restrictions may apply in certain states.”

“The foundational philosophy of LifeSharers is that giving organs first to those consenting to be organ donors creates the incentive for people to become organ donors.”

“LifeSharers presents a level playing field for all members as the ‘benefit’ offered is the same for everyone, no matter their age, gender, ethnicity, religion, or financial status. In fact, the only benefit is the potential for priority organ allocation amid the concept of directed donation. There is no membership fee to join the organization, and no option to pay for additional benefits. In addition, the LifeSharers philosophy can potentially motivate people to become organ donors, something that benefits even nonmembers who are waiting for a transplant, because they too are potentially exposed to more organ matches. A net increase in organs available for transplantation will exist, because not all organs donated by LifeSharers members will match with LifeSharers patients who are waiting for transplants.”

“LifeSharers does account for the medical urgency of its members who are in need of transplantation in that those members who have greater urgency and are a clinical match receive organ allocation prioritization among the member pool. LifeSharers, however, does not consider the medical urgency of nonmembers because nonmembers do not share the value commitment to organ donation. It would be possible that a LifeSharers member who is listed for a transplant might receive a directed donation from a deceased LifeSharers member and the recipient may be healthier than the nonmembers who are also in need of an organ transplant. This fact is no different from UNOS permitted directed donation transplants that currently occur outside of the LifeSharers member network. Any ethical arguments against a preferred status model that does not reflect on medical urgency would also have to address the fact that directed donations currently allowed by UNOS do not reflect on medical urgency. In these latter cases it is usually a personal relationship or emotional feelings that are driving the donation – matters not equivalent to or necessarily reflecting on medical urgency, but matters that prompt organ donation in some cases.”

"In a setting in which preferred status is operational amid an allocation program that does not consider medical urgency, those who actively choose not to register as organ donors place themselves in a position of lower priority for organ allocation. Because organ transplantation is not a human right, and organs are very scarce, viewing free riders as having a lower priority in organ allocation is ethically permissible.”

“Does LifeSharers play favorites? Yes. And in the case of organ scarcity it is appropriate to favor fellow organ donors (actual or prospective) over free riders. When it is time to allocate a scarce resource, it is fair to assign priority to people who are willing to both give and receive. Preferred status does not need to operate merely as a tiebreaker when all other variables are equal. Further, preferred status should not cease to operate when nonpreferred patients are more severely ill, because this would devalue willingness to donate.”

Vivekanand Jha and Kirpal S Chugh
"The case against a regulated system of living kidney sales"
Nature Clinical Practice Nephrology, September 2006; Volume 2, Number 9, pages 466-7

"There are other strategies apart from organ sales that can increase donation rates, such as public awareness campaigns, a ‘presumed consent’ law, use of marginal donors and performing ABO-incompatible or paired-exchange transplantations. An element of reciprocity could also be injected into the system, so that—for example—people can choose to donate organs only to those who have in turn indicated their willingness for the same."

Christopher Tarver Robertson, J.D.
"From Free Riders to Fairness:  A Cooperative System for Organ Transplantation"
Jurimetrics, Fall 2007; Volume 48, pages 1-41

"There is a significant and fairly evenly distributed chance that, at some point in our lives, any one of us (or our loved ones) may have an organ failure that could be rectified by a transplant. There is likewise a fairly evenly distributed chance that any of us could die in such a way that makes our organs available for transplantation. Thus, the cadaveric organ system can be understood as one of cooperation, where participants agree to share their organs upon death, not knowing who will die first, so as to create a functioning organ transplant system to protect themselves while living. The transplant system is a public resource that creates a safety net for almost all persons.

However, as it turns out, less than half of us actually support the organ transplant system by volunteering as cadaveric donors. Less than half of those who die with transplantable organs actually donate them, and even fewer have registered in advance to be cadaveric organ donors. So, it appears that most of us are benefiting from an institution that we do not contribute to. Given these facts, we should not be surprised to find a shortage.”

“A large-scale cooperative scheme is designed to fail if it allows individuals to reap its benefits (as potential organ recipients) without paying its costs (as potential suppliers of organs).”

"The status quo system gives cadaveric organs to people who have not agreed to be organ donors. These free riders take organs that could otherwise be given to willing organ donors, some of whom ultimately suffer and die from not receiving an organ.

This allocation of scarce organs to free riders violates a principle of justice: Given equal opportunity and equal means for anyone to support a cooperative enterprise, the benefits of the cooperative enterprise should first be distributed to those who instantiate the enterprise."

“The principle of equity is straightforward. Just as one person is entitled to at least minimally sustain himself by reaping what he sows from his private property, those who support a large-scale cooperative enterprise are entitled to sustain themselves by its fruits before any surplus is distributed to others who chose not to contribute. Those who are able but unwilling to cooperate in creating the enterprise in the first place are at best entitled to charity. The abstainers cannot claim a right or an entitlement to take from the system ahead of those who contribute to that system."

"Those who voluntarily choose not to contribute to a social enterprise thereby waive any entitlement to the fruits of that enterprise, at least to the extent that their taking would harm those who do contribute to the enterprise. Justice clearly proscribes the free riding that the status quo organ system permits.”

“It has long been recognized that justice does not require that all persons be treated exactly the same. Rather those who are similar in relevant respects must be treated similarly, and those who are different in relevant respects must be treated differently.... Racial discrimination is wrong because race has no relevance to the purposes or functions of the organ transplantation system.

In contrast, the willingness of individuals to provide organs is critically relevant to the organ system. Because those persons instantiate the system that procures organs in the first place, they have a special claim, or legitimate expectation, to receive any available organs, if they someday need one.

If this is correct, then it is not only permissible but obligatory to screen those who refuse to share their cadaveric organs from receiving priority access to organs. Just as it is wrong to treat similar cases differently, it is wrong to treat different cases similarly."

“There is no need to morally judge those who refuse to share their organs; that is not the point of the argument from justice. Considerations of moral fault are distinct from considerations of legitimate expectations under the social institution that is the organ transplant system. Assessing individuals’ moral blameworthiness—whether they are generous or callous for example— is not our concern here.

If the transplant surgeons were merely giving away organs out of generosity, then perhaps an exclusive emphasis on need (or some other moral criterion) would be appropriate. However, as the common law recognizes, 'one must be just before being generous.' Given that these organs do not appear ex nihilo, the organ system has special obligations to organ sharers that must be discharged before dispensing charity to those who are unwilling to share organs....To the extent that doctors are performing the function of rationing health goods (in this case, organs), they must first of all be fair. As we have seen above, fairness in distribution recognizes the contributions of those that make a common good possible. In short, justice recognizes that we have special obligations to those engaged in social institutions of reciprocal cooperation."

“It is rather easy to exclude those who refuse to donate organs from receiving organs, because organs must be distributed one at a time, person by person. Under such an alter[n]ative system, one is free to choose not to share her cadaveric organs, and thus autonomy is respected. But unlike the status quo, when one makes such a decision, it may have consequences for one’s self. As such, the organ choice is reconceptualized as opting into or opting out of the organ system as a whole. The organ system would be a cooperative project open to all those choosing to share cadaveric organs with each other. In all other ways, the organ allocation system would be unchanged with the same multifactor algorithm for determining who receives a given organ.

Would such a system work? Unlike the status quo, it would not depend on a persuasive public relations campaign. When a person chooses to be in the system, she makes her future cadaver’s organs available for transplantation, and thus increases the supply of organs. When someone chooses to withdraw from the system, he disqualifies himself from receiving an organ and thus decreases the demand on organs. Either decision helps resolve the shortage. If any organs remain, they should not be wasted, but rather should be given, as a matter of charity, to those who want to have it both ways, refusing to give but willing to take organs.

When there is a rough parity between organ demanders and organ suppliers, we can expect the shortage to be minimized as far as possible. Some studies suggest that if every viable organ were harvested, the shortage would be eliminated for some organ types but not others. Facing these facts, persons considering whether to join the organ system would have no guarantee of someday receiving a needed an organ, but their chances inside the system would be vastly better than outside the system and better than under the status quo where they would be forced to compete with free riders.”

"“We must continue to honor individuals’ autonomous choices and laud those who do choose to share their organs, because they are instantiating a system that can do so much good. Beyond those individual choices, the question is between institutional systems. We can choose to perpetuate the status quo, even though it often fails to respect autonomous choices, even though altruism does not redeem it, even though it allows unjust free riding, and even though it leaves 100,000 people waiting for organs, many of whom will die for their lack. Or, we can minimize the tragic shortage by transitioning to a fair and effective system of reciprocal cooperation.”

Richard A. Epstein
"Altruism and Valuable Consideration in Organ Transplantation"
Essay in “When Altruism Isn’t Enough”, edited by Sally Satel, MD; The AEI Press, 2008

“At present, UNOS allows an individual to make a directed donation to any person he or she chooses, irrespective of position on the waiting list. But this policy does not satisfy many critics of UNOS, who think that a communitarian ethic should be followed by requiring every altruistic donor – living or deceased – to give his or her kidney to the first person on the list. I disagree. Not allowing donors to choose their donees goes against every principle of charitable giving. The best way to nourish altruism is to permit individuals to connect to whomever they choose. It hardly helps to condemn generous individuals for making gifts to the ‘wrong’ people. What matters is the completed kidney transfer, not some refined discussion of whether a particular donor is selfish or generous. Without directed donations, many prospective donors will just keep their kidneys. Yet allowing a directed donation removes one person from the queue, thereby shortening it for everyone who remains. Directed donations let everyone gain and no one lose. They do not create some dubious loophole for UNOS to close."

Alexander Tabarrok
"Life-Saving Incentives: Consequences, Costs and Solutions to the Organ Shortage"
The Library of Economics and Liberty; August 3, 2009

"The economics of common resources provides another perspective on the shortage of organs. Resources owned in common tend to be under-supplied and over-utilized. No one wants to pay to restock a lake, for example, when the benefits of restocking flow to everyone regardless of whether or not they helped to pay for the restocking. As a result, open fisheries are almost always driven to depletion. The solution is to close the fishery to those who do not help to restock the lake.

UNOS considers organs to be a "national resource," owned in common. The result, as in other areas, is a tragedy of the commons. Everyone wants to fish in the organ pool but no one has a direct incentive to "restock the lake" by signing their organ donor card. As with fishing lakes, a solution to this problem is to close the organ pool to non-donors.

Consider a no-give, no-take policy for organs. Under this system in order to receive an organ you must have previously signed your organ donor card. Under no-give, no-take, signing your organ donor card can be thought of as joining a club, the club of people who have agreed to share their organs. Or one can think of signing the organ donor card as the price that you pay for organ insurance.

An advantage of the no-give, no take policy is that it satisfies most people's moral intuitions. Many people find the idea of paying for organs distasteful but nevertheless are comfortable with the morality of reciprocity, those who are willing to give should be the first to receive.

A variant of no-give, no-take can be implemented quite easily within the current system by giving those who have previously signed their organ donor cards extra points that would advance them on the queue. In fact, a similar program is already in place. People who have previously been live organ-donors are given extra-points should their one remaining kidney fail them. No-give, no-take simply extends this idea from actual donors to potential donors.

Something like no-give, no-take is currently being implemented privately. is an "organ club." Anyone can join. Members agree that if their organs should become available they will go first to a fellow LifeSharers member. (If everyone joins LifeSharers, it becomes equivalent to no-give, no-take.)

Although reciprocity proposals like no-give, no-take have moral advantages it is important to remember that their primary purpose is to increase the incentive to donate and therefore to increase the total number of organs available."





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