Organ and tissue transplantation has been a topic of heavy debate since the first organ
was successfully transplanted in 1954. Ethical dilemmas surround the topic on both the donor
and recipient sides of the exchange. The national transplant list has over 100,000 people just in
the United States waiting for an organ donor. However, only 17,000 organs from living and
deceased donors are transplanted annually, creating a growing shortage of life-saving transplants.
As a result of this insufficiency, patients are starting to turn to different methods of securing
organ transplants, many of which have ethical strings attached. This includes conducting
business exchanges with the organ market on a local and international level. The 1984 US
National Organ Transplant Act, however, prevents people from buying or selling organs in the US
or across the seas.
Sarah Satel, a psychiatrist and resident scholar at the American Enterprise Institute,
discusses organ transplants and the modernization of the bioethics surrounding the topics. The
1984 act’s creation originated from the leaking of the news that a Virginia physician was
recruiting indigent people from foreign countries to fly to the United States and have organs
donated in return for a small percentage of the profits. The outcry resulted in legislation against
the brokering of organs and their trade. Satel writes in her New York Times articles that the main
resistance against an organ market is that impoverished citizens will be coerced into selling their
organs out of desperation for short-term financial stability, an action that they will later deeply
regret. However, Satel also acknowledges that we must find a solution to this heightening issue if
organ markets are to remain closed. Satel supports the idea that donors should be granted some
form of incentive by the government in the form of tuition, retirement funds, or income tax. She
believes that such additions will help convince healthy young and middle-aged adults to give
their organs to a stranger.
Michael Sandel, a Professor at Harvard University, however, takes a firmer approach than
Satel to the debate. He supports the notion that the commercialization of organs has repressed the
expression of altruism and eroded community values. In his Boston Review article, he says that
“not only are there some things money can’t buy, but there are some things money shouldn’t
buy.” Sandel believes that the market scheme of organ trade has yielded injustice to people in
economically dire circumstances and that market corruption has further degraded the valuation of
products. He also hints that assigning a market value and brokerage claims to such life-sustaining
operations is harming the moral importance of the organs.
Emily Kelly, an executive editor for the Boston College International and Comparative
Law Review, supports in her journal article that illicit organ markets have been a disaster and
have created more harm than good on an international scale. She discusses organ, tissue, and cell
(OTC) trafficking and human trafficking along with their effects on the local communities in
organ hub countries. Kelly believes that instead of adopting a criminal law framework to combat
illicit organ markets, which has proven to be unsuccessful, countries need to tackle the issue
from the root: the shortage of organs. She suggests that countries should focus on introducing
and maintaining presumed and mandatory consent for organ transfers combined with public
information campaigns to educate families about their options. Kelly also supports Satel’s idea of
donors receiving governmental incentives for being organ donors to inspire greater participation
in organ donation programs.
Organ traffickers prey on the desperation of both the donor and the recipient for profits.
Around 80% of foreign donors live below the poverty line. This foreign demographic is a very
vulnerable source of organs as they often are looking for quick methods for cash to be used
towards food, supporting their families, and paying debts. As a result, they are easily coerced
into entering into the organ harvesting process. As Sandel says, “a peasant may agree to sell his
kidney or cornea to feed his starving family, but his agreement may not really be voluntary. He
may be unfairly coerced, in effect, by the necessities of his situation.” However, donor lives are
not improved at all by the organ donation process. They often only receive a small fraction of
revenue from the organ sale which is always below the promised amount. On top of that, the
illicit organ traffickers do not guarantee health care for the donors leaving them to fend for
post-surgical costs. The inaccessibility to healthcare leads donors to have worse outcomes than
before. They are faced with the chance of complications, have to take time off from work, and
may worsen their physical condition in the long term. All of these negative side effects may
cause the donor to take on more debts in the future as a result of their venture to cure their
short-term charges. Kelly stated that donor victims often regretted their decisions in hindsight
due to the pain and little benefit actually achieved. Overall, organ traffickers are misleading and
abusing troubled donor populations for their financial benefit.
Most of the dirty work is happening overseas. Since the previously discussed 1984 act
prohibits donors from receiving compensation for donating, organ traffickers have taken their
business overseas to foreign countries which are OTC trafficking centers such as the “kidney
bazaar” in Pakistan. US, Canadian, UK, and other wealthy recipients engage in “transplant
tourism” where they travel to foreign countries to receive transplants. However, recipients are
also harmed as they pay heavy tolls for the procedure, and incur a heavy infection risk as a result
of the surgery. In addition, when they return to their home countries, they are likely to bring
antibiotic-resistant bacteria from the foreign country which poses a global public health threat.
The local healthcare in these foreign countries is also worsened as a result of illicit organ
trafficking markets. Local doctors spend more time caring for lucrative, wealthy patients who
just received a transplant rather than treating the ailments of the surrounding community.
With a ban on organ markets, and altruism not doing the job, I think it is time that the US
government enact policies to reduce the developing gap of the organ crisis. As concluded by
Satel, altruism simply is not cutting it. People are dying by the day as they wait for five to six
years for a compatible organ donor match. A simple solution is to make amends to the 1984
National Organ Transplant Act. It should be permissible for donors to at least receive some
indirect benefits for their significant donation. A charitable fund could be set aside by the
government to assist donors with tax breaks, education, healthcare, or retirement. Adding
benefits might push healthy people to continue with the act of altruism and donate.
However, will simple benefits still convince enough people to donate organs? After all,
more noticeable compensation for the donors in the thousands could make the issue turn a new
leaf. This would be possible with an organ market system in the US. However, to prevent illicit
trade actions, the websites and organizations would be run by the government. Donors would
have to go through a rigorous background, physical, psychological, and emotional screening
along with a six-month wait time before they are eligible to become donors. The wait time would
allow the donors to fully evaluate the weight of their proposed actions and then act with full
consent. There already are successful websites that allow for donation matching to occur. These
model systems could be applied to a controlled, monetary organ market system. Adding a market
system would significantly decrease the wait time for patients to receive life-saving transplants
and the national organ wait list would be nearly sliced in half. This would also benefit the donors
as they would be guaranteed their side of the bargain in a controlled system rather than having
their organs brokered by illicit organizations.
The issue with markets though is the corruption of product valuation. As open markets
become more popular, the prices of products become inflated along with investors. This critique
posed by Sandel regarding open organ markets is that the price of organs would skyrocket
leaving accessibility only to those with full wallets. However, my counterargument to the open
market critique presented here is that the government could keep full control of the prices and
prevent the organ trade from being a truly open market. With standardized pricing, the market
still won’t be accessible to everyone, but at least a majority of the population would not be cut
off from dramatic price shifts. There is also an ethical dilemma here when placing a price tag on
life-saving treatments. The system of donation altruism is set up to allow people to stand for their
community, and introducing financial benefits would erode that meshing with people acting out
instead with self-interest.
Another counterargument to solving the organ shortage crisis brewing in the United
States would be to convert to an opt-out system rather than opening controlled organ markets.
The US currently operates on an opt-in system which means that adults have the mandated
choice to opt-in to become organ donors in the case of death when filing taxes or renewing their
driver’s license. The issue with this system is that everyone starts by default as not being organ
donors, and then convincing young, healthy adults to opt in can prove to be challenging. Instead,
some European countries such as Spain, France, Italy, Norway, etc. utilize the opt-out system,
where everyone is automatically an organ donor unless the person goes out of their way to
remove themselves from the organ donation list for personal, religious, or cultural reasons.
Countries with a successful opt-out system paired with outreach education systems about
becoming donors have a high organ donation rate. However, the problem with both systems is
that people rarely die in methods that preserve the viability of vital organs causing a degree of
insufficiency with this proposal. Various noncommunicable diseases, physical traumas, or
infections can render organs unusable. In addition, time is a major factor for the viability of the
organ transfer and the cadaver would have to be brought immediately for processing. As a result,
the consideration for an organ market system remains high.
In conclusion, the organ shortage in the United States is a developing issue that demands
action by the government. The rise in demand for organs and the stalling number of annual
transplants are causing desperate patients to turn to more illicit methods for life-saving
treatments. However, policy action can be taken to prevent organ trafficking which entails
solving the root cause. The availability of organs can be improved with further monetary benefits
to donors by amending the 1984 US National Organ Transplant Act and creating a governmental
controlled market system for organ donation matching and selling. These solutions, along with
the support of an opt-out system and educational outreach programs for becoming an organ
donor, can help turn the tide against organ trafficking on a local and international scale. Though,
it might be wishful thinking to believe the government could manage these solutions effectively.
Jaisimar Singh is a 3rd Year student at the University of Virginia studying Global Public Health. He is also an Emergency Medical Technician.
Kelly E. International Organ Trafficking Crisis: Solutions Addressing the Heart of the Matter.
https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2144900. Published May 1, 2013.
Sandel M. How Markets Crowd out Morals.Boston Review.
Published August 27, 2021.
Satel S. An internet lifeline, in search of a kidney. The New York Times.
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Satel S. Why people don't donate their kidneys. The New York Times.
eys.html. Published May 3, 2014.