The Ethics of Organ Donation
By Benjamin R. Scoblionko, Emily Clark
Organ donation represents one of the most contentious and important topics in bioethics and modern biomedical discourse. As of 2009 more than 100,000 candidates were waiting for a compatible organ from a donor. Many individuals die before receiving an organ and outside of major advances in biotechnology allowing for in vitro organ development, no current technological solution exists for alleviating the shortage. In this Opposing View- points we present two perspectives on alternatives to the current organ donation system. A free market system compensating organ donors is presented in the first viewpoint and a required donation-benefits viewpoint is presented in the second. TuftScope welcomes letters on your opinions and thoughts on this issue.
The Free Market Solution
A wide range of possibilities exists for how to procure and allocate organs for transplant in a society, and a variety of policies regarding transplantation are used across the globe. Every system of organ procurement upholds certain societal values and disregards others. Our current system relies almost entirely on the altruism of individuals to give away an organ they do not need (such as a kidney), or to denote themselves as postmortem donors. This policy supports individual autonomy as well as cultivating altruistic behavior in society, however it also violates the principle of preserving human life because it fails to supply enough organs. More than 100,000 people are currently on the waiting list for an organ, and in 2008 nearly seven thousand died before they could get a transplant. 1 The best solution for resolving the organ shortage crisis must at once increase the supply of organs and uphold other relevant societal values. Allowing organs to be sold in a free (though not unfettered) market, with prices based on supply and demand is the most ethical solution to the current crisis, and is a policy with high potential for success.
Not only does our system create organ shortages, but the lack of available organs often drives people to more dangerous solutions. Medical tourism, in which individuals go abroad to buy an organ for transplant has flourished. 2 The quality of these surgeries often below western standards, and by sanctioning this practice we are supporting the exploitation of those whose organs are used in countries like India and Pakistan where black markets thrive.3 Unrestricted black markets are dangerous for live donors because the harvesting operations themselves are often lethal, taking place in illegal facilities.3 The health of the donor is largely ignored.
While not widespread, the policy of a free market for organs has already come into practice in several countries including Iran. A free market solution would by definition raise the level of organ supply to the necessary level by virtue of “the invisible hand”. Demand for organs would determine the price level, which would in turn lead to enough people wanting to sell their organs. In the case of kidney donations, it would be possible for “living donors” to be paid for their organ. For other types of organs, a free market system would either compensate the person while still alive (via a futures transaction) or compensate their family. Since the implementation of this program in Iran, there have been no organ shortage associated deaths.
The idea of allowing human organs to be bought and sold seems horrifying and debasing to many. As a society, we often express disgust at the thought of commoditizing the human body, and to do so this blatantly would undoubtedly challenge some of our deepest cultural values. Yet before rejecting outright the proposal for an organ market, it is interesting to question why we feel this disgust. There are already many examples of the body being objectified and commoditized without engendering public outrage. Do we not allow people to buy and sell sperm and eggs? Or allow a surrogate mother to “rent” her uterus? Perhaps the risks are not as severe in these cases, but the benefits are also not nearly as urgent.
The proposal of a free market solution also raises several other ethical considerations, including potential exploitation of the economically disadvantaged, as well as concern over whether it is acceptable for people to sell the organs of a deceased family member. In practice, the latter would be a nonissue, since any wishes an individual expressed while still alive would be respected regardless of the family’s financial need. Secondly, the outcome of a free market system, whereby potential donors would be carefully screened by doctors, is much less exploitative than is the current practice of allowing Americans to fuel the exploitation of destitute members of less developed countries through the black market.4 One final concern involves those who must “buy” an organ. Would a free market system make getting an organ transplant prohibitively expensive for some? The answer seem to be no, mostly because the cost of getting any transplant operation already accounts for purchasing the organ from a procurement agency. Additionally, in the case of the Iranian system, a common government fund pays for organs. 4
Various alternatives to a free market solution do succeed in reducing some of the negative effects of our current system, but they have ethical considerations of their own. One policy that has already been put into use in this country is “paired” or “cross” exchanges whereby the incentive for donating an organ is that an individual or a family member is more likely to get an organ of their own. Yet this system has clearly not succeeded in solving the shortage crisis. Another proposal is to offer indirect benefits for donating an organ (such as compensation for funerals, tax credits, insurance). 5 However this policy is essentially a way for the government to “buy” organs while evading the question of whether or not commoditization of the body is acceptable to society. In addition, it is not clear that such a policy would substantially raise the supply of organs to the necessary level. A final policy that has been put into place in many European countries is a system of “presumed consent” whereby people are automatically assumed to be donors unless they specify otherwise. 5 Ethically, this policy clearly violates the respect of an individual’s wishes and the wishes of their family. After a thorough review of many policy options, it seems clear that pursuit of a free market policy has the greatest potential to resolve the many ethical dilemmas surrounding the issue of organ procurement and allocation.
Expanding the Role of Organ Donors
Benjamin R. Scoblionko
In 2008, over 100,000 people needed an organ transplant, but only a quarter of those waiting on the transplant list received one. Every day, over a dozen people whose illnesses or diseases have been diagnosed die because they do not receive a transplant in time. 1 Less than half the people in America who qualify to be donors actually are. 1 The current transplant system needs reform. Some feel that the organ donation and transplant system should be a free market system. This idea, however, would not address the main problem which is that there are consistently not enough organ donors. The free market system is an attempt to solve a social problem with an economic solution, without addressing the underlying issues. In times of high demand and prosperity, the free market system has potential to work, however, in a recession, most people on the recipient list might not be able to afford such transplants.
The underlying problem is simply that not enough people are registered organ donors. One way to change the current system would be to implement a system of presumed consent, in which individuals are considered donors unless otherwise stated. 2 Currently, most people do not consider organ donation until the question comes when they are receiving a driver’s license. Without considering about the repercussions of their actions, many give a quick answer, not thinking that one day this decision may help save a life.
The presumed consent system would have many advantages over the current system. Not only would presumed consent increase the number of donors in the country, but it would also raise awareness of the current organ crisis and educate people more about the transplant system.^3^ This system would remove the burden of making the important “to be or not to be” decision that currently plagues families already dealing with the death of a family member. Such a system has been proven to work in multiple countries around the world including France, Spain, Portugal, Italy and Belgium.^3^ To complement the presumed donor system, an addition change that would help increase the number of available organs would be to give priority to those people who are organ donors themselves. 2 Doing so would encourage individuals to remain donors in the event that they ever were to need a transplant themselves.
The combination of presumed consent and donor
Every twelve minutes another name is added to the transplant waiting list.^5^ The United States faces an organ donor shortage. A free market system may potentially increase the amount of donors, but it would not be the most efficient, consistent or ethical way to do so. The best way to effectively change our current system would be to implement a presumed consent-priority system. This system would reinforce that priority would be determined by moral guidelines as opposed to financial criteria. Tens of thousands wait every day, hoping for a transplant. The current system must be changed.
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