Conflicting opinions on the ethics of organ donation have existed as long as organ transplantation has been medically feasible. Eligibility requirements, reason for transplant, and international organ tourism continuously resurface as difficult medical policy and ethics issues. One issue about which there is little dispute is demand for organs far exceeding the supply of donors. Demand for kidneys exceeds the current supply of deceased donor organs and altruistic donors. Approximately 73,000 people sit on the waiting list for a kidney — 18 of them will die by tomorrow and 6,000 more patients join the list every year. By 2010, over 100,000 Americans will wait for a kidney donation. A kidney transplant in the United States generally requires a five-year wait.
The development of a transparent, regulated market for live organ donation is currently prohibited by the National Organ Transplant Act of 1984 (NOTA), which imposes criminal penalties of up to $50,000 and five years in prison for any person who “knowingly acquire[s], receive[s], or otherwise transfer[s] any human organ for valuable consideration for use in human transplantation.”
The establishment of a transparent, public market to permit the sale of organs from live donors will transform organ procurement from a lengthy, stressful, medically damaging waiting game into a safer, more efficient, routine, life-saving process. Such a market would have both economic and moral merit; it would deliver more and better organs at less cost than alternative options, and will result in more lives saved.
A model of direct payment for organs is available in the experience of Iran, which has allowed compensation since the late 1980s. Singapore plans to introduce direct compensation in 2009. What can be learned from a study of this process and its potential role in the modern American medical landscape? The deliberate choice to rely on altruism has been unsuccessful and fails to reflect the advances that have been made in transplant techniques. Technology and success rates have improved; why has policy remained largely unchanged? The tide, however, is beginning to turn. Individual states are experimenting with indirect payment systems to increase the number of live donors.
Moral outrage ought to be directed not at the tension between markets and altruism, but at the needless loss of life as transplant waiting lists continue to grow. In that spirit, this paper offers two policy proposals to support the development of payment systems — both direct and indirect — for procurement of organs. The most expedient route to a transparent regulated market requires a repeal of section 301 of the National Organ Transplant Act of 1984.