The topic of organ donation prompts us to consider many ethical issues, such as resource allocation, xenotransplantation (the transplantation of animal organs into humans), futility of care, and the complex issues raised by having a child in order to produce a suitable organ for transplantation into an ill relative. All of these issues are driven by the fact that there is indeed a shortage of human organs for transplantation; therefore, this article will focus on identifying and evaluating some suggested methods for alleviating the critical shortage of organs that is of concern to both society and the medical profession alike.

Many of these suggestions clearly take the concept of “donation” out of organ donation and move us away from the spirit of altruism toward the commodification of human body parts and other venues through which organs are obtained apart from their being freely donated. The proposed shift from a system in which transplantable organs are freely donated to a system in which they are not reflects our culture and the moral relativism it espouses. We are witnesses to a lack of moral consensus as a result of the breakdown in the traditional Judeo-Christian value system. In the past 50 years we have seen serious challenges to Hippocratic/covenantal medicine, in which physicians are committed to caring for and, when possible, curing their patients. We are also currently witnessing an incredible explosion in scientific and technological advancements. Such advances can be very problematic within a culture steeped in philosophies and ethical systems that deny the existence of God (or, at best, the relevance of God) and instead esteem the reason and wisdom of human beings.

Since 1968, when the Uniform Anatomical Gift Act was originally sent to all 50 state legislatures, organ donation has been governed by altruistic public policies and principles. It has been established as the unselfish giving of a gift, given to save another person’s life. Giving gifts with the pure motive of love is very much in line with the biblical narrative. Although donating one’s organs is not morally obligatory (that which God requires us to do), it is morally praiseworthy when it is characterized as an unselfish altruistic deed protected by public policy.

Since 1967 when Christian Barnard performed his famous heart transplant, transplantation medicine has become less and less science fiction and more and more the treatment of choice for many end-stage organ diseases. With the advances in surgical techniques and the development of anti-rejection drugs and organ preservation solutions, organ donation is often no longer seen as an experimental intervention, but standard treatment. Thousands of people who would have otherwise died just fifty years ago are now living healthy, normal, and productive lives thanks to someone having given them the “gift of life” (cadaveric donor) or having shared their life (living donor).

Though we welcome the advances in transplantation medicine, the news is not all good. With the success of organ transplantation came the problem of supply and demand. Unfortunately, although the demand for transplantable organs is continually increasing, the supply has remained constant. Given the increase in public educational and awareness efforts, why is this the case? It is my contention that the general public views organ donation in a negative manner because they do not believe that organ donation policies are firmly rooted in altruism. A February 1993 Gallup poll taken to assess the American public’s attitudes toward organ donation and transplantation supports this premise, as the results indicated that “more than half of Americans disagree [with the statement] that a poor person has as good a chance as a rich person of receiving an organ” and that “more than one third of Americans believe that organs are available for purchase on the black market.” Non-white respondents to the survey agreed that failure to receive an organ needed for transplant may be the result of racial discrimination. Some people have suggested that the current organ shortage problem could be resolved by providing compensation to the donor and/or his family, thereby increasing the incentive to donate. A 1984 federal law, the National Organ Transplant Act, prohibits the buying and selling of human organs or body parts, but permits deceased donors’ families to receive some remuneration for burial costs. It has also been suggested that living donors should receive financial remuneration to help defray costs due to loss of work during post-surgical recuperation. It is my contention that to provide financial compensation for organ donation would be to introduce serious problems into a system that should continue to operate on an altruistic basis. If people were financially compensated for donating their organs, we would certainly see an increased marginalization of certain individuals. For example, a poor widow with children to support likely would feel more pressure to donate an organ than would a wealthy businessman if compensation was offered. Similarly, the Gallup poll cited earlier showed that young respondents (18-24 years) and non-whites would be likely to donate their organs in response to financial incentives. The survey also indicated that less educated people would likely be more receptive to financial incentives than college graduates. In addition to placing certain groups at risk of exploitation, financial compensation for organ donation would also foster greed and self-interest – the very opposite of altruism. Organ donation should be motivated by the desire to freely give a gift – not by the lure of financial incentives.

Another proposed method of addressing the critical shortage of transplantable organs is through the notion of “presumed consent.” With presumed consent, unless a person has explicitly stated that he does not want to become an organ donor, it is presumed that he wishes to donate his organs. It is not difficult to imagine the serious problems that would inevitably arise with such a system. For example, if a man is killed in an accident and does not have his “I don’t want to be a donor card” on him, he would likely be swept off to the operating room to have his organs harvested for transplantation. The surgeons would learn too late that this person did not want to be an organ donor, and the repercussions to them/the hospital would likely be severe.

In addition to financial compensation and presumed consent, other troubling solutions have been proposed to address the organ shortage problem. The first of these proposed solutions is to record a person’s desire to be an organ donor on his advance directive. (An advance directive is a legal form that permits a person to express in advance his wishes concerning medical intervention in the event that he becomes unable to speak for himself.) In his book Life on the Line, John F. Kilner questions the efficacy of such a solution by stating that “One of the major reasons that people resist signing organ donor cards is that they fear that a need for their organs might induce caregivers to cease treatment too soon. Linking organ donation and treatment termination in the same document [may further] discourage people from choosing either provision.”

Another worrisome potential response to the critical shortage of transplantable organs is to increasingly restrict the number of people who are regarded as suitable recipients. A growing number of patients are not receiving the medical treatment they need because their physicians are deeming such care “futile.” In his November 30, 1998 Weekly Standard article, Wesley J. Smith laments the fact that “when a patient reaches a certain predefined stage of age, illness, or disability, any further care other than pain relief is [sometimes deemed] ‘futile’ and should be withheld, regardless of the desires of the patient or family.” We can easily anticipate the damage done to the traditionally altruistic system of organ donation when people are denied transplants because of such criteria.

In conclusion, although we should indeed be concerned about the critical shortage of human organs for transplantation, we must not rush to endorse all proposed solutions. We must actively seek only ethically sound solutions that do not distort the traditional concept of “donation,” exploit the donor, or discriminate among those in need of transplants. Though such solutions may not present themselves as readily as those discussed in this article, society will nevertheless be best served if organ donation remains firmly rooted in altruism.