My post on two options for increasing the availability of organs for transplantopt – opt-in and repealing the ban on payments to donors – drew the following response from a reader with serious credentials in the field (but whose job doesn’t allow further identification)
It’s not as simple as changing the law.
Comparison of countries with different approaches suggest that soft variables are much more important: public attitudes, hospital staff attitudes, dissenting relatives ability to get publicity or court access, support of opinion leaders. A well designed and funded PR campaign would have to accompany any change to opt-out or donation rates would remain essentially the same. It could maybe even replace payment for organs).
Unlimited payment size raises complex ethical issues about rich and poor. It’s not just that the rich would have more options (see Wikipedia on organ donation), but at the legal edges.
1. Should the government pay for free organs for paupers? Who actually pays taxes and their opportunity cost is complex. My own analysis is that it ultimately comes out of K-12 education, a bad tradeoff for keeping the chronically ill at the public tough longer (few can ever resume employment).
2. Will it increase pressure on doctors to certify the dying prematurely or on legislatures to alter the definition of death?
3. Will the politically influential benefit more than the rich? The Singapore cases all involved important politicians (although they were also rich). If being rich is merely one precondition to receiving a transplant, then I’m probably against it.
4. Need is nonrandom by demography. Closer immunological matching produces greater success rates. In the US, because of the distribution of disease; Black (females) have a higher rate or need for kidney transplants. For historical and cultural reasons, Black Americans have lower donation rates. Hence, a worse mismatch of supply and demand. It’s unclear that paying for donations would be more efficient than paying selected clergy to preach that organ donation is a Christian duty and paying for a support network to provide a chorus.
5. What are the implications of economic cycles? Do organs become easier to obtain in a recession, or merely cheaper? The ethical implications are entirely different. E.g., the army attributes its current ability to meet enlistment quotas to improved advertising, pressuring its recruiters to make quota, opportunities for promotion during wartime (versus the economy having something to do with it).
Xenotransplantation probably looks more promising in the long run. Humanized mice are quite advanced and rapidly becoming less antigenic. Very little work is done in pigs because of cost, but they’re the best candidate. A few million $/year for a decade has a decent probability of paying off better than paying for organs.
Another reader points to Kieran Healy’s work suggesting the limited (but non-zero) value of opt-in, an argument embodied in (at increasing length) a Crooked Timber post, this paper, and a book, Last Best Gifts: Altruism and the Market for Human Blood and Organs.