|
Justin Chen Augmenting Altruism in America’s Organ Shortage Crisis The shortage of organ donors in the United States is no longer news. According to figures quoted in a recent op/ed piece in the New York Times, there are currently 80,000 Americans on a waiting list for new organs, and 17 people on that list die every day (Kristof 2002). That’s a loss of over 6,000 lives a year in the U.S. alone due to organ shortages. What makes such mortality statistics even much more egregious is the fact that they come in the face of profound advancements in medical technology that have made organ donation and transplantation safer than ever before. Clearly, there is a disconnect between the American public’s need for organs and its willingness to pledge them for society’s use. Numerous bioethicists have weighed in on the matter and suggested a variety of strategies for increasing the supply of viable organs in the U.S., from estate tax credits for families of donors to the aggressive system of organ procurement within hospitals currently in practice in Spain. While I find some of the more extreme solutions that have been proposed to be coercive and therefore unjustifiable, I would maintain that certain more moderate measures that have been hotly debated in the media are not only ethically permissible but also morally imperative for solving this steadily escalating problem. Without the immediate implementation of decisive public policy concerning the organ transplant debate—including an opt-out system for organ donation and a funeral credit for families of organ donors—thousands of Americans will continue to die for reasons of little more than logistical inefficiency. Up until now, the U.S. has relied entirely upon the altruism of the American people for procurement of the necessary organs—primarily kidneys, livers, and hearts. Some commentators have interpreted the fact that this method is not working as an indication that the public is simply not well enough informed about the safety of organ donation, not that altruism may simply be too weak a motivation. In a piece entitled “The Wait for Transplants,” for instance, Washington Post Editorials Editor Fred Hiatt wrote that “about half of all families approached after brain death is declared agree to donate their relative’s organs. But as many as two-thirds of such families are never approached” (Hiatt 2001). While such an argument certainly demonstrates the failure of the government to properly disseminate information about the possibilities for organ donation, it is not clear that contacting all eligible families would go a very long way toward fixing the problem. As the baby boom population approaches retirement and the average age of Americans increases, the need for viable organs will grow even more pressing. Indeed, an article in the Weekly Standard states that “in the 1990s, the number of patients on waiting lists for organs grew five times as fast as the number of transplant operations” (Smith 2001). Even if the other “two-thirds of families” described in Hiatt’s article were to be successfully contacted by transplant agencies, the increase in potential donors would not come close to matching the needed number of transplant surgeries. Thus, it grows increasingly clear that altruism, while representing the most ideal grounds for organ donation, is not sufficient in and of itself to provide the volume of available organs for transplantation required to fill the growing need in America. As Kristof bluntly states in his Times editorial: “Altruism isn’t working” (Kristof 2002). If we can accept this conclusion as fact, then it is also clear that other incentives must be formulated to encourage organ donation. The most ethically troubling solution that has seriously been proposed in the debate thus far is direct cash payment for organs. David Kaserman, an economist who proposed such a system in 1990, was accused by one reviewer of being “morally bankrupt.” Yet the fact that his solution remains a part of the public debate over organs is perhaps not so very surprising given the pervasive free-market paradigm that all Americans are by this point so used to encountering in every aspect of our lives, from higher education to baby formulas to health care. Last year the American Medical Association even endorsed testing various forms of incentives for organ donation. If an individual desperately requires a kidney, the argument seems to run, why not simply allow him or her to purchase it from someone who doesn’t need theirs as much? And to take this reasoning one step further, why can’t we simply begin a government-regulated commodity market that would ensure the matching of high quality organs between willing sellers and buyers? The primary reason that the commercialization of body parts is a bad idea, critics of such a system rightly argue, is that it would ultimately have an extraordinarily insidious effect on American society as a whole. Putting a price tag on a liver—let’s say $400—would only attract those segments of the population experiencing serious financial difficulties, since those of wealthier socioeconomic backgrounds would not have to endanger their physical well-being by donating an organ simply for the purpose of such relatively paltry monetary reimbursement. Thus, while the idea of purchasing organs does not represent de jure discrimination against the lowest socioeconomic groups, it is almost certain that with the passage of time such a policy would result in de facto disparities within our society, with those of the lowest economic means demonstrating a grossly inflated rate of organ donation as compared with their more affluent counterparts. To put it more simply, offering money for organs would ultimately result in unacceptable coercion of the lowest classes of society. Proponents of a system of commercialized organ donation have argued that it is unjustifiably paternalistic for the government to pass legislation eliminating the option of organ-selling as a means of upward economic mobility for the nation’s poorest. They argue that if the rich are allowed to engage in dangerous sports and recreations, the poor should be have the right to assume “the lesser risk of kidney selling for greater rewards…[of] extricating themselves from poverty and debt” (Redcliffe-Richards et al 1998).Yet as Columbia’s David Rothman has observed, such reasoning is a primary example of the notion of “false liberty” described by Nobel Prize winner Amartya Sen. Granting the poor the “right” to sell their organs is not justifiable because these people would do so with a false understanding of the implications of their own actions. In this case, the government must adopt a paternalistic view to safeguard the welfare of some of its most vulnerable citizens. Indeed, as Goyal et al conclude in their seminal article entitled “Economic and Health Consequences of Selling a Kidney in India” in the Journal of the American Medical Association, “The sale of kidneys by poor people in India does not lead to a tangible benefit for the seller” (Goyal et al 2002). In their study, these researchers observe that nearly all of the people who made the decision to donate their kidneys in exchange for monetary reimbursement did so in order to pay off debts, and 95% of them said that “wanting to help a sick person with a kidney disease” was not a major factor in their decision to sell. Here, altruism has been supplanted almost entirely by financial motivations. But despite the one-time cash amount that the study’s participants received in exchange for their kidneys, which varied between $450-$2660, “many of the participants reported a worsening of their economic status” following the donation process. In fact, “among all participants, the average annual family income declined from $660 at the time of nephrectomy to $420 at the time of the survey, a decrease of one third” (Goyal et al 2002). Given that the poverty line for Tamil Nadu, the city in which the investigation was conducted, was $538 per year for an average-sized family, Goyal et al’s findings indicate that nephrectomy actually plunged already-struggling families directly into poverty status. Far from extricating economically disadvantaged families from their financial woes, then, the organ donation process actually worsened the earning capabilities of the donor and resulted in overall greater impoverishment of donors’ families. As Cohen notes, “decisions to sell a kidney appear to have less to do with raising cash toward some current or future goal than with paying off a high interest debt to local moneylenders” (Cohen 1999). Furthermore, a poor family will be far less capable than a rich one of countenancing a situation in which the primary breadwinner of the family sells a kidney for financial profit, but then experiences a failure of the sole remaining kidney. The coercion factor comes into play when one considers that families in dire economic straits really have little or no choice in the matter when substantial amounts of money are offered in exchange for certain propositions—a phenomenon that is already taken into consideration in the design of psychology or medical experiments that target such populations. A significant percentage of those surveyed revealed that their spouse had also sold a kidney, yet 79% stated that they would not recommend that others sell a kidney. These facts, when taken together, suggest that the promise of monetary rewards was able to induce economically disadvantaged individuals into undergoing an undesirable operation, again lending credence to the conclusion that a system of organs-for-cash would result in a stratification of society in which the lowest-income groups underwent medically risky operations for nothing more than temporary financial gain. If the goal of public policy is to safeguard the interests of all segments of the populace, then such an outcome is clearly unacceptable. If direct payment is so morally insidious, the question then remains: What are we to do about the persisting organ shortage in America? My answer to this question is twofold. First, I believe that an opt-out system of organ donation is ethically justified and necessary. Such a system would assume that all Americans were willing to donate their organs in the event of an incapacitating accident that resulted in brain death. The main benefit of this solution is that it would place the onus of responsibility for one’s own organs squarely on the shoulders of each individual American to a far greater degree than is currently the case. Such a system would not be coercive because it would still guarantee everyone, for any reason, the ability to refuse to donate their organs in the event of an incapacitating injury—hence the term “opt-out.” An ancillary benefit of this approach would be that physicians would no longer need to worry about the ambiguity that results when individuals do not specify their wishes for their organs before falling victim to an incapacitating accident. In many such cases, the parents or other immediate family members are consulted regarding the deceased’s organs. Yet this default procedure is extremely inefficient because family members are often difficult to track down in the critical moments when physicians might be able to preserve an accident victim’s organs for later transplantation. Additionally, consultation with the next-of-kin sometimes results in ethically troubling outcomes. One such example would be the case of an individual who believes firmly that his organs should be donated, but whose parents, because of opposing religious or moral viewpoints, are able to overrule these wishes and forbid any tampering with the body—simply by virtue of their next-of-kin status. This particular scenario would seem to do even greater violence to the memory of the deceased than a simple opt-out system. In practical terms, Americans would be given the opportunity to opt out at the time that they receive or renew their driver’s licenses. There is currently a rudimentary system in place that allows individuals to sign the backs of their driver’s licenses as a measure of alerting emergency room personnel of an intent to become an organ donor. But despite this clear assertion of individual preference, a physician will nevertheless refrain from removing the organs unless an organ bank has the next of kin's consent (Reinert 1997). The organs of those individuals who lack full adult faculties, including minors and the mentally handicapped, would be under the jurisdiction of the next of kin, just as currently we allow parents to determine most medical treatment for their children. And of course, the process for determining brain death would be kept strictly separate from the system of determining eligibility for organ donation to prevent any conflict of interest on the part of the physicians from arising when determining the health status of unfortunate accident victims. I believe that this system would go a long way toward shoring up the supply of available organs in the United States. Furthermore, as medical technology continues to improves, the viability of transplantation surgery among live donors will continue to increase, and thus the number of available organs should also be bolstered as a result. As President of the American Society of Transplant Surgeons (ASTS) Marc Lorber put it in a letter to the Washington Post, “Advances in medicine have allowed live donation to offer an alternative for thousands of people who languish on waiting lists” (Lorber 2001) Yet the possibility still exists that altruism alone will not provide enough of an incentive to attract the sheer volumes of donors necessary to resolve the organ shortage crisis in America. It therefore seems worthwhile to me to supplement the commencement of an opt-out system with a non-cash reward to the families of organ donors in the form of a substantial funeral credit. Such an idea has already gained significant backing because it does not possess the insidious coercive qualities that have been shown to accompany a straight fee-for-organs system. Indeed, Francis Delmonico and Lorber of the ASTS explain in a letter to the Wall Street Journal that the purpose of reimbursement for funeral expenses is not to make a direct payment for the organ, but rather “to express the appreciation of society for the donor’s altruistic gift” (Lorber 2002). Such rhetoric stresses the altruism of the donor rather than any monetary gain that might come from the transaction. In a 2002 press release, the National Kidney Foundation expresses a strong objection to “any effort to legalize payment for human organs” (Schlam 2002), but it does not address the issue of indirect monetary awards such as funeral credits. Indeed, although NFK representatives continue to stress the importance of altruism and the despicability of any attempt to equate organs with set monetary sums, as Kristof writes in his Times editorial, “Nobody is talking about payments to live donors, only to the estates of the dead” (Kristof 2002). Delmonico of the ASTS agrees, stating, “We don’t wish to intrude on altruism. But perhaps there are some individuals who might be receptive to an appreciation from society” (Kristof 2002). The likening of a funeral reimbursement to a thank-you gift stresses that no economically disadvantaged family would be coerced into any detrimental medical decisions simply for the sake of financial gain, and also ensure that the realm of discussion is limited to deceased patients rather than live donors, such as the ones in the study in India. A funeral credit of $2,000, which is the most commonly cited figure, would also be cost-effective. Dialysis, the medical procedure currently used to sustain the health of those with kidney failure, costs a great deal more than the transplantation operation itself. Increasing the organ supply by offering a thank-you gift of the type described above would allow more patients to obtain the transplants they require, freeing up needed hospital resources and funds for other patients. Thus, the awarding of funeral reimbursements to the families of organ donors would ensure that the institution of altruism remained in place while simultaneously avoiding the exploitation of the lower classes that would inevitably result from more direct forms of payment. In light of the many arguments against direct cash payment for organ donation, the American Medical Association should immediately cease its investigations into creating such a system in the United States. The Goyal et al report clearly demonstrates that financial incentives for organ donation only result in an aggravation of already disadvantaged economic circumstances, an outcome that would result in a greater harm of American society than good in the form of an increased organ supply. Instead of such coercive means, policymakers must focus on shifting responsibility for determining the fate of one’s own organs onto individual Americans by switching to an opt-out system. And, to ensure that donors are recognized for their contributions to medicine and society, they should be awarded a gift to help defray the family’s funeral costs. In this way, America can ensure that altruism remains the primary reason for performing any charitable act for society, including donating one’s organs to save other lives.
Sources Cited in this Paper Kristof, Nicholas D. “Psst! Sell Your Kidney?” The New York Times. 11/12/02. Hiatt, Fred. “The Wait for Transplants.” The Washington Post, Editorial. 7/9/01. Smith, Wesley J. “The Ethics of Organ Donation: Mere boosterism won’t be enough to encourage this ultimate charitable act.” The Weekly Standard. 2001. Redcliffe-Richards J., Dar A.S., Guttman R.D., et al. “The case for allowing kidney sales." Lancet. 1998;351: 1950-52. Rothman, David J. “Ethical and Social Consequences of Selling a Kidney.” Journal of the American Medical Association. 288(13). 10/2/02. Goyal, Madhav, Ravindra L. Mehta, Lawrence J. Schneiderman, Ashwini R. Sehgal. “Economic and Health Consequences of Selling a Kidney in India.” Ibid. Cohen, L. “Where it hurts: Indian material for an ethics of organ transplantation.” Daedalus. 1999; 128:135-65. |