AMA Journal of Ethics^®

In a perfect world, altruism would be all that would be needed. The fact is that we're losing the battle. 
Dr. Phil Berry Jr, liver transplant recipient¹

In 1954 the United States opened the door to organ transplantation with the first kidney transplant, starting a growing and controversial trend that continues to engage American society in an ethical debate today.

By 1980, the number of kidney transplants alone had gone from 1 to 3400 and with the use of cyclosporine, a drug that reduced the threat of organ rejection, successful transplantation became commonplace in the medical world. However, the success rate that accompanied the advent of cyclosporine created a demand for organs that greatly exceeded the supply. What ensued was the disorganized and inequitable allocation of organs, leading to controversy over the lack of rules on the distribution of organs.

The US Congress responded to this growing controversy by passing the National Organ Transplant Act (NOTA) in 1984, creating a system to regulate the procurement, distribution, and transplantation of scarce organs. NOTA established an organ procurement network in 1986, operated by a non-profit organization, United Network for Organ Sharing (UNOS), to maintain a national computerized list of patients waiting for organ transplants and to allocate procured organs. By late 1987 NOTA had created a registry to gather data and track service on transplant operations performed since October 1, 1987.

The system established by NOTA forbids provision of "valuable consideration" to organ donors, ruling out any form of financial incentives such as tax credits to donors.² Thus, altruism, defined as acting with the absence of any personal benefit beyond the satisfaction of giving, is the only ethically sound motivation for donation, according to UNOS. While the concept of altruism has been debated widely (eg, does altruism in fact provide benefit to the individual who is acting altruistically or to the species), it nonetheless is the central tenet of appeal for the current organ donation system. Hence, most of the methods used to encourage organ donation such as educational campaigns, voluntary donor card programs, and other motivational mechanisms have tried to appeal to a person's altruistic interest in saving lives of others.

Yet, under the current system about 6,000 patients per year with end-stage organ failure die waiting for organ transplants. Each year only 35-50 percent of potential donors (brain dead and medically suitable patients) consent to donation. The need for organs is nearly 5 times that of the actual cadaveric donations: the rate of increase in number of patients on waiting lists has averaged 14.1 percent per year, while the rate of increase of donors has averaged 2.9 percent per year.²

Addressing this issue at its annual meeting in June, the American Medical Association (AMA) adopted a report on Cadaveric Organ Donation: Encouraging the Study of Motivation from its Council on Ethical and Judicial Affairs. This report encourages the medical and scientific communities to re-examine donor motivation in order to better understand the central values in cadaveric organ donation and to assess the potential impact of incentives on the rate of cadaveric donation.² These research studies, which cannot be implemented until after congressional waivers of the NOTA prohibitions are in place, will look at organs from cadavers only, not from living donors. The CEJA report does not call for any change in the current UNOS system.

The topic was intensely debated at the AMA's House of Delegates meeting, where delegates voiced concern that financial incentives could undermine donors' altruism. The delegates discussed the challenges in introducing financial incentives into the conversation with the families of newly deceased patients, expressing their apprehension that the recommended study of motivation might set off a trend that could lead to body parts being treated as commodities. Delegates also worried that linking organ donation to economics could further a negative image of the medical profession.

From the inception of the technological possibility of organ transplantation, the medical community and society as a whole have been faced with ethical questions that continue to persist. The most basic question is whether organ transplantation should be considered at all since, in a sense, it extends the natural course of life, a question also present in the end-of-life debate about whether and for how long machines should keep people alive. Some ask whether the campaign for organ donation should be replaced with a campaign that encourages people to care for their organs. For those holding this opinion, the transplant option creates a "moral hazard," one that allows people to pursue risky behaviors and unhealthy lifestyles (in this case, abusing their organs) in hopes that replacement organs will be available.

Of course, not all organ failure is the result of poor lifestyle choices, and, even when it is, our society does not deny patients effective, available treatment for ailments they had some part in creating. So we come back to the task of designing the best system for meeting the ever-increasing demand for organs. The current system is noble in intent, but research studies are needed to understand the values and factors that encourage people to donate organs. It is critical to determine the impact that financial incentives may have on the rate of donation. If 16 people must die each day from lack of an organ transplant, we should at least be certain that there were not 16 or more available organs that we just didn't know how to ask for properly.