Organ Donations: The Failure of Altruism
Fentiman, Linda C., Issues in Science and Technology
Voluntary organ donation should be replaced with a system of compensated presumed consent.
The U.S. organ transplantation system is in crisis. At a time when transplant survival rates are at an all-time high, the waiting list for organs grows longer every day. More than 26,000 individuals are now on waiting lists to receive a kidney, and more than 2,900 are waiting for a heart transplant. In all, nearly 36,000 individuals are waiting for one or more vital organs, including livers, lungs, intestines, and pancreases. Since 1988, according to a 1993 General Accounting Office (GAO) report, more than 10,000 people have died while on a waiting list to receive an organ. Thousands more never even made it to a list.
For many persons, organ transplantation holds out the only hope of survival; for many others, it promises the only hope of survival with a good quality of life. Although initially expensive, the use of a transplant rather than drugs or artificial organs to prolong a life is ultimately cost-effective. The average kidney transplant procedure costs $80,000 for the surgery and first year's care (in 1990 dollars); thereafter, the annual cost of maintaining a transplant recipient on immunosuppressive drugs drops to $7,000. (More than 90 percent of kidney transplant recipients are still living two years after the operation.) In contrast, maintaining an individual on kidney dialysis, a much less successful, palliative technology employed while waiting for a kidney to become available, costs an average of $33,000 annually.
Tremendous pressure exists to reform the present organ transplantation system, which has been faulted for failing to tap the potential pool of transplantable organs as well as for failing to allocate fairly the organs that become available. Although legislation has been proposed to address the allocation issue, the underlying problem--the shortage of available organs--cannot be addressed until our society rethinks its approach to organ donation. This will require that we stop treating organ donation merely as an act of altruism and begin viewing it as a community obligation.
Obstacles to donation
Since the late 1960s, when the development of immunosuppressive drugs made possible transplants from donors who were not biologically related to the recipient, academics and policymakers have collaborated on a number of mechanisms to encourage the donation of organs and tissues for transplant. These have achieved only limited success. The Uniform Anatomical Gift Act (UAGA), first proposed in 1968, has been adopted by every state and the District of Columbia. The UAGA's goal was to appeal to Americans' altruism and to make it easy to volunteer to donate one's organs and tissues by signing a donor card (usually when obtaining or renewing a driver's license). The card declares the individual's intent to donate his or her organs at the time of death. In theory, this would allow physicians to retrieve organs for transplant upon the individual's death without requiring the consent of the next of kin.
The UAGA has had only a minimal effect in increasing the supply of organs and tissues for donation. Although repeated polls show that a majority of people in the United States are willing to donate their organs upon death, and an even greater number indicate their willingness to donate the organs of a loved one, fewer than one-fifth actually sign donor cards. This may be for reasons as complex as the unwillingness to confront death or as simple as procrastination.
In addition, very few organ transplants are accomplished solely on the basis of a donor card. Often the card cannot be found upon a person's death. Even if it is, few physicians or nurses will retrieve organs for transplant without the consent of the donor's next of kin--despite the fact that the UAGA explicitly protects those who rely on a donor card from legal liability. Further, many health care providers are reluctant to approach grieving families with a request for organ donation. …