Organ donation

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Organ donation is the donation of biological tissue or an organ of the human body from a living or dead person to a living recipient in need of a transplantation. Transplantable organs and tissues are removed in a surgical procedure following a determination, based on the donor's medical and social history, of which are suitable for transplantation. Such procedures are termed allotransplantations, distinguish them from xenotransplantation, the transfer of animal organs into human bodies. As of June 21, 2013, there are 118,617 people waiting for life-saving organ transplants in the U.S. Of these, 96,645 await kidney transplants. While views of organ donation are positive there is a large gap between the numbers of registered donors compared to those awaiting organ donations on a global level.

The youngest organ donor was a baby with anencephaly, born in 2015, who lived for only 100 minutes and donated his kidneys to an adult with renal failure.[1] In the same year, researchers from the Ganogen Research Institute transplanted human fetal kidneys from therapeutic abortions, including from fetuses with anencephaly, into animals for future transplantation into human patients.[2] The animals were able to survive on the human kidney alone, demonstrating both function and growth of the human organ. [3]

Legislation and global perspectives

The laws of different countries allow potential donors to permit or refuse donation, or give this choice to relatives. The frequency of donations varies among countries.

Opt-in versus opt-out

There are two main methods for determining voluntary consent: "opt in" (only those who have given explicit consent are donors) and "opt out" (anyone who has not refused is a donor). Opt-out legislative systems dramatically increase effective rates of consent for donation (the so-called default effect).[4] For example, Germany, which uses an opt-in system, has an organ donation consent rate of 12% among its population, while Austria, a country with a very similar culture and economic development, but which uses an opt-out system, has a consent rate of 99.98%.[4][5]

However, because of public policies, cultural, infrastructural and other factors, this does not always translate directly into increased effective rates of donation. In terms of effective organ donations, in some systems like Australia (14.9 donors per million, 337 donors in 2011), family members are required to give consent or refusal, or may veto a potential recovery even if the donor has consented.[6] Some countries with an opt-out system like Spain (36 effective donors per million inhabitants[7]) or Austria (21 donors/million) have high donor rates and some countries with opt-in systems like Germany (16 donors/million) or Greece (6 donors/million) have lower effective donation rates.[citation needed] The president of the Spanish National Transplant Organisation has acknowledged Spain's legislative approach is likely not the primary reason for the country's success in increasing the donor rates, starting in the 1990s.[8]

Consent process

One way organizations are attempting to gain more donors. There are two types of consent being looked at. Explicit consent consists of the donor giving direct consent through proper registration depending on the country.[9] The second consent process is presumed consent, which does not need direct consent from the donor or the next of kin.[9] Presumed consent assumes that donation would have been permitted by the potential donor if permission was pursued.[9] Of possible donors an estimated twenty five percent of families refuse to donate a loved one’s organs.[10]

United States

Over 121,000 people in need of an organ are on the U.S. government waiting list.[11] This crisis within the United States is growing rapidly because on average there are only 30,000 transplants performed each year. More than 6,000 people die each year from lack of a donor organ, an average of 19 people a day. Between the years 1988 and 2006 the number of transplants doubled, but the number of patients waiting for an organ grew six times as large.[12] It has been estimated that the number of organs donated would double if every person with suitable organs decided to donate. In the past presumed consent was urged to try to decrease the need for organs. The Uniform Anatomical Gift Act of 1987 was adopted in several states, and allowed medical examiners to determine if organs and tissues of cadavers could be donated. By the 1980s, several states adopted different laws that allowed only certain tissues or organs to be retrieved and donated, some allowed all, and some did not allow any without consent of the family. In 2006 when the UAGA was revised, the idea of presumed consent was abandoned. In the United States today, organ donation is done only with consent of the family or donator themselves.[13] In some cases doctors are reportedly removing pieces of tissue from already dead patients without consulting the patient of their families' consent. This is completely legal procedure. According to economist, Alex Tabarrok the shortage of organs has increased the use of so-called expanded criteria organs, or organs that used to be considered unsuitable for transplant.[14] Due to the lack of donation it is leading some countries to try unconventional practice, creating a lot of controversy and loss of money. The University of Maryland's School of Medicine there were five patients that received kidney transplants that obtained cancerous or benign tumors that were withdrawn from the organ. This raised many questions for the head surgeon, Dr. Michael Phelan who explained that "the ongoing shortage of organs from deceased donors, and the high risk of dying while waiting for a transplant, prompted five donors and recipients to push ahead with the surgery."[14] Doctors are becoming desperate and are having to use organs from patients who are over the age of 60. These donors have had multiple medical problems and are more likely to fail than those of a younger healthier donor.The certainty remains true that are more than 100,000 people waiting for a transplant. The number of recipients is growing faster than there are donors.

Several organizations such as the American Kidney Fund are pushing for opt-out organ donation in the United States.[15]

Financial reward

In 1994 a bill was signed into law in Pennsylvania which proposed an idea that would increase the supply of organs for everyone. They decided to start paying $300 towards room and board and $3,000 to go towards funeral expenses to a donor’s family. Officials went back and forth for eight years before deciding on this program. It is the first of its kind. Procurement directors and surgeons across the nation are now looking at Pennsylvania’s program and watching for success.[16] Some[who?] are already planning to follow in its footsteps if this new incentive proves itself. There has already been at least nineteen families that have signed up for the benefit and there are more expected to come. There are people[who?] out there who oppose this plan fundamentally. One argument is it will disproportionately affect the poor.[17] The $300–3,000 reward will act as more incentive to the poor as opposed to the rich who may not find that amount of money to be worth it. Others[who?] may say that this new law in Pennsylvania violates the integrity of the self.


Map showing the coverage of 3 international European organ donation associations: Balttransplant, Eurotransplant and Scandiatransplant

Within the European Union, organ donation is regulated by member states. As of 2010, 24 European countries have some form of presumed consent (opt-out) system, with the most prominent and limited opt-out systems in Spain, Austria, and Belgium yielding high donor rates.[18] In the United Kingdom organ donation is voluntary and no consent is presumed. Individuals who wish to donate their organs after death can use the Organ Donation Register, a national database. The government of Wales became the first constituent country in the UK to adopt presumed consent in July 2013.[19] The opt-out organ donation scheme in Wales went live on 1st December 2015 and is expected to increase the amount of donors by 25%.[20] In 2008, the UK discussed whether to switch to an opt-out system in light of the success in other countries and a severe British organ donor shortfall.[21] In Italy if the deceased neither allowed nor refused donation while alive, relatives will pick the decision on his or her behalf despite a 1999 act that provided for a proper opt-out system.[22] In 2008, the European Parliament overwhelmingly voted for an initiative to introduce an EU organ donor card in order to foster organ donation in Europe.[citation needed]

Landstuhl Regional Medical Center (LRMC) has become one of the most active organ donor hospitals in all of Germany, which otherwise has one of the lowest organ donation participation rates in the Eurotransplant organ network. LRMC, the largest U.S. military hospital outside the United States, is one of the top hospitals for organ donation in the Rhineland-Palatinate state of Germany, even though it has relatively few beds compared to many German hospitals. According to the German organ transplantation organization, Deutsche Stiftung Organtransplantation (DSO), 34 American military service members who died at LRMC (roughly half of the total number who died there) donated a total of 142 organs between 2005 and 2010. In 2010 alone, 10 of the 12 American service members who died at LRMC were donors, donating a total of 45 organs. Of the 205 hospitals in the DSO's central region—which includes the large cities of Frankfurt and Mainz—only six had more organ donors than LRMC in 2010.[23]


The rate of organ donation in Japan is significantly lower than in Western countries.[24] This is attributed to cultural reasons, some distrust of western medicine, and a controversial organ transplantation in 1968 that provoked a ban on cadaveric organ donation that would last thirty years.[24] Organ donation in Japan is regulated by a 1997 organ transplant law, which defines "brain death" and legalized organ procurement from brain dead donors.


India has a fairly well developed corneal donation programme however donation after brain death has been relatively slow to take off. Most of the transplants done in India are living related or unrelated transplants. To curb organ commerce and promote donation after brain death the government enacted a law called "The Transplantation of Human Organs Act" in 1994 that brought about a significant change in the organ donation and transplantation scene in India. [25][26][27][28] [29][30][31][32][33] Many Indian states have adopted the law and in 2011 further amendment of the law took place.[34][35][36][37] [38] Despite the law there have been stray instances of organ trade in India and these have been widely reported in the press. This resulted in the amendment of the law further in 2011. Deceased donation after brain death have slowly started happening in India and 2012 was the best year for the programme.

Map shows Indian states that have done Deceased Donation Transplantation in India
Table 1 - Deceased Organ Donation in India - 2012.
State No. of Deceased Donors Total no. of Organs Retrieved Organ Donation Rate per Million Population
Tamil Nadu 83 252 1.15
Maharashtra 29 68 0.26
Gujarat 18 46 0.30
Karnataka 17 46 0.28
Andhra Pradesh 13 37 0.15
Kerala 12 26 0.36
Delhi-NCR 12 31 0.29
Punjab 12 24 0.43
Total 196 530 0.16

Source: Indian Transplant News Letter of MOHAN Foundation (Vol 2 Issue No. 37 of 2013)

The year 2013 has been the best yet for deceased organ donation in India. A total of 845 organs were retrieved from 310 multi-organ donors resulting in a national organ donation rate of 0.26 per million population(Table 2).

Table 2 - Deceased Organ Donation in India – 2013
State Tamil Nadu Andhra Pradesh Kerala Maharashtra Delhi Gujarat Karnataka Puducherry Total (National)
Donor 131 40 35 35 27 25 18 2 313
* ODR (pmp) 1.80 0.47 1.05 0.31 1.61 0.41 0.29 1.6 0.26
Heart 16 2 6 0 - 0 1 0 25
Lung 20 2 0 0 - 0 0 0 22
Liver 118 34 23 23 23 20 16 0 257
Kidney 234 75 59 53 40 54 29 4 548
Total 388 113 88 76 63 74 46 4 852

* ODR (pmp) – Organ Donation Rate (per million population)

In the year 2000 through the efforts of an NGO called MOHAN Foundation state of Tamil Nadu started an organ sharing network between a few hospitals.[39][40] This NGO also set up similar sharing network in the state of Andhra Pradesh and these two states were at the forefront of deceased donation and transplantation programme for many years.[41][42] As a result, retrieval of 1033 organs and tissues were facilitated in these two states by the NGO.[43] Similar sharing networks came up in the states of Maharashtra and Karnataka; however the numbers of deceased donation happening in these states were not sufficient to make much impact.

In 2008, the Government of Tamil Nadu put together government orders laying down procedures and guidelines for deceased organ donation and transplantation in the state.[44] These brought in almost thirty hospitals in the programme and has resulted in significant increase in the donation rate in the state. With an organ donation rate of 1.15 per million population, Tamil Nadu is the leader in deceased organ donation in the country. The small success of Tamil Nadu model has been possible due to the coming together of both government and private hospitals, NGOs and the State Health department. Most of the deceased donation programmes have been developed in southern states of India.[45]

The various such programmes are as follows-

In the year 2012 besides Tamil Nadu other southern states too did deceased donation transplants more frequently. An online organ sharing registry for deceased donation and transplantation is used by the states of Tamil Nadu ( and Kerala ( Both these registries have been developed, implemented and maintained by MOHAN Foundation.

Organ selling is legally banned in Asia. Numerous studies have documented that organ vendors have a poor quality of life (QOL) following kidney donation.However a study done by Vemuru reddy et al shows a significant improvement in Quality of life contrary to the earlier belief.[46] Live related renal donors have a significant improvement in the QOL following renal donation using the WHO QOL BREF in a study done at the All India Institute of Medical Sciences from 2006 to 2008. The quality of life of the donor was poor when the graft was lost or the recipient died.[46]

Sri Lanka

Organ donation in Sri Lanka was ratified by the Human Tissue Transplantation Act No. 48 of 1987. Sri Lanka Eye Donation Society, a non-governmental organization established in 1961 has provided over 60,000 corneas for corneal transplantation, for patients in 57 countries. It is one of the major suppliers of human eyes to the world, with a supply of approximately 3,000 corneas per year.[47]


Since 2008, signing an organ donor card in Israel has provided a potential medical benefit to the signer. If two patients require an organ donation and have the same medical need, preference will be given to the one that had signed an organ donation card. This policy was nicknamed "dont give, don't get". Organ donation in Israel increased after 2008.


A campaign by Sport Club Recife has led to waiting lists for organs in north-east Brazil to drop almost to zero; while according to the Brazilian law the family has the ultimate authority, the issuance of the organ donation card and the ensuing discussions have however eased the process.[48]

New Zealand

New Zealand law allows live donors to participate in altruistic organ donation only. In 2013 there were 3 cases of liver donation by live donors and 58 cases of kidney donation by live donors.[49] New Zealand has low rates of live donation, which could be due to the fact that it is illegal to pay someone for their organs. The Human Tissue Act 2008 states that trading in human tissue is prohibited, and is punishable by a fine of up to $50,000 or a prison term of up to 1 year.[50]

New Zealand law also allows for organ donation from deceased individuals. In 2013 organs were taken from 36 deceased individuals.[51] Everyone who applies for a drivers license in New Zealand indicates whether or not they wish to be a donor if they die in circumstances that would allow for donation.[52] The question is required to be answered for the application to be processed, meaning that the individual must answer yes or no, and does not have the option of leaving it unanswered.[52] However, the answer given on the drivers license does not constitute informed consent, because at the time of drivers license application not all individuals are equipped to make an informed decision regarding whether to be a donor, and it is therefore not the deciding factor in whether donation is carried out or not.[52] It is there to simply give indication of the person's wishes.[52] Family must agree to the procedure for donation to take place.[52][53]

A 2006 bill proposed setting up an organ donation register where people can give informed consent to organ donations and clearly state their legally binding wishes.[54] However, the bill did not pass, and there was condemnation of the bill from some doctors, who said that even if a person had given express consent for organ donation to take place, they would not carry out the procedure in the presence of any disagreement from grieving family members.[55]

The indigenous population of New Zealand also have strong views regarding organ donation. Many Maori people believe organ donation is morally unacceptable due to the cultural need for a dead body to remain fully intact.[56] However, because there is not a universally recognised cultural authority, no one view on organ donation is universally accepted in the Maori population.[56] They are, however, less likely to accept a kidney transplant than other New Zealanders, despite being overrepresented in the population receiving dialysis.[56]


Only one country, Iran has eliminated the shortage of transplant organs - and only Iran has a working and legal payment system for organ donation. [54] It is also the only country where organ trade is legal. The way their system works is, if a patient does not have a living relative or who are not assigned an organ from a deceased donor, apply to the nonprofit Dialysis and Transplant Patients Association (Datpa). The association establishes potential donors, those donors are assessed by transplant doctors who are not affiliated with the Datpa association. The government gives a compensation of $1,200 to the donors and aid them a year of limited health-insurance. Additionally, working through Datpa, kidney recipients pay donors between $2,300 and $4,500.[14] Importantly, it is illegal for the medical and surgical teams involved or any ‘middleman’ to receive payment.[57] Charity donations are made to those donors whose recipients are unable to pay. The Iranian system began in 1988 and eliminated the shortage of kidneys by 1999. Within the first year of the establishment of this system, the number of transplants had almost doubled; nearly four fifths were from living unrelated sources.[57][55] This system has exhibited a way to stop organ shortage. Which is to reimburse living donors for their organs. Other countries need to observe this method in the hopes that they will be able to alleviate the lack of organ donors. Nobel Laureate economist Gary Becker and Julio Elias estimated that a payment of $15,000 for living donors would alleviate the shortage of kidneys in the U.S.[14]

Bioethical issues

Deontological issues

Certain groups, like the Roma (gypsies), oppose organ donation on religious grounds, but most of the world's religions support donation as a charitable act of great benefit to the community.[58] Issues surrounding patient autonomy, living wills, and guardianship make it nearly impossible for involuntary organ donation to occur.

From the standpoint of deontological ethics, the primary issues surrounding the morality of organ donation are semantical in nature. The debate over the definitions of life, death, human, and body is ongoing. For example, whether or not a brain-dead patient ought to be kept artificially animate in order to preserve organs for procurement is an ongoing problem in clinical bioethics. In addition, some have argued that organ donation constitutes an act of self-harm, even when an organ is donated willingly.

Further, the use of cloning to produce organs with an identical genotype to the recipient has issues all its own. Cloning is still a controversial topic, especially considering the possibility for an entire person to be brought into being with the express purpose of being destroyed for organ procurement. While the benefit of such a cloned organ would be a zero-percent chance of transplant rejection, the ethical issues involved with creating and killing a clone may outweigh these benefits. However, it may be possible in the future to use cloned stem-cells to grow a new organ without creating a new human being.

A relatively new field of transplantation has reinvigorated the debate. Xenotransplantation, or the transfer of animal (usually pig) organs into human bodies, promises to eliminate many of the ethical issues, while creating many of its own.[citation needed] While xenotransplantation promises to increase the supply of organs considerably, the threat of organ transplant rejection and the risk of xenozoonosis, coupled with general anathema to the idea, decreases the functionality of the technique. Some animal rights groups oppose the sacrifice of an animal for organ donation and have launched campaigns to ban them.[citation needed]

Teleological issues

On teleological or utilitarian grounds, the moral status of "black market organ donation" relies upon the ends, rather than the means.[citation needed] In so far as those who donate organs are often impoverished[citation needed] and those who can afford black market organs are typically well-off,[citation needed] it would appear that there is an imbalance in the trade. In many cases, those in need of organs are put on waiting lists for legal organs for indeterminate lengths of time — many die while still on a waiting list.

Organ donation is fast becoming an important bioethical issue from a social perspective as well. While most first-world nations have a legal system of oversight for organ transplantation, the fact remains that demand far outstrips supply. Consequently, there has arisen a black market trend often referred to as transplant tourism.[citation needed] The issues are weighty and controversial. On the one hand are those who contend that those who can afford to buy organs are exploiting those who are desperate enough to sell their organs. Many suggest this results in a growing inequality of status between the rich and the poor. On the other hand are those who contend that the desperate should be allowed to sell their organs and that preventing them from doing so is merely contributing to their status as impoverished. Further, those in favor of the trade hold that exploitation is morally preferable to death, and in so far as the choice lies between abstract notions of justice on the one hand and a dying person whose life could be saved on the other hand, the organ trade should be legalized. Conversely, surveys conducted among living donors postoperatively and in a period of five years following the procedure have shown extreme regret in a majority of the donors, who said that given the chance to repeat the procedure, they would not.[59] Additionally, many study participants reported a decided worsening of economic condition following the procedure.[60] These studies looked only at people who sold a kidney in countries where organ sales are already legal.

A consequence of the black market for organs has been a number of cases and suspected cases of organ theft,[61][62] including murder for the purposes of organ theft.[63][64] Proponents of a legal market for organs say that the black-market nature of the current trade allows such tragedies and that regulation of the market could prevent them. Opponents say that such a market would encourage criminals by making it easier for them to claim that their stolen organs were legal.

Legalization of the organ trade carries with it its own sense of justice as well. Continuing black-market trade creates further disparity on the demand side: only the rich can afford such organs. Legalization of the international organ trade could lead to increased supply, lowering prices so that persons outside the wealthiest segments could afford such organs as well.

Exploitation arguments generally come from two main areas:

  • Physical exploitation suggests that the operations in question are quite risky, and, taking place in third-world hospitals or "back-alleys," even more risky. Yet, if the operations in question can be made safe, there is little threat to the donor.
  • Financial exploitation suggests that the donor (especially in the Indian subcontinent and Africa) are not paid enough. Commonly, accounts from persons who have sold organs in both legal and black market circumstances put the prices at between $150 and $5,000, depending on the local laws, supply of ready donors and scope of the transplant operation.[65][66][67] In Chennai, India where one of the largest black markets for organs is known to exist, studies have placed the average sale price at little over $1,000.[60] Many accounts also exist of donors being postoperatively denied their promised pay.[68]

The New Cannibalism is a phrase coined by anthropologist Nancy Scheper-Hughes in 1998 for an article written for The New Internationalist. Her argument was that the actual exploitation is an ethical failing, a human exploitation; a perception of the poor as organ sources which may be used to extend the lives of the wealthy.[69]

Economic drivers leading to increased donation are not limited to areas such as India and Africa, but also are emerging in the United States. Increasing funeral expenses combined with decreasing real value of investments such as homes and retirement savings which took place in the 2000s have purportedly led to an increase in citizens taking advantage of arrangements where funeral costs are reduced or eliminated.[70]

Brain death versus cardiac death

Brain death may result in legal death, but still with the heart beating, and with mechanical ventilation, all other vital organs may be kept alive and functional for a certain period of time. Given long enough, patients who do not fully die, in the complete biological sense, but who are declared brain dead will usually, either after a shorter or longer interval, depending upon the patient's case and the type and extent of trauma and their age and prior health, start to build up toxins and wastes in the body, and the organs (especially sensitive ones like the brain, nerves, heart, blood vessels, lungs, liver, intestines, and kidneys) eventually can dysfunction, have coagulopathies or fluid and electrolyte and nutrient imbalances, or even fail- partially, or completely and irreversibly. Thus, the organs will usually only be sustainable and viable for acceptable use up until a certain length of time (most organs that are transplanted fortunately have widely used and agreed upon parameters, that are measurable and reliable, when determining their welfare and level of function). This will depend on how well the patient is maintained, any other comorbidities, the skill of the medical, nursing, and surgical teams, and the quality of the care and the facilities- and once removed, the time and the mode of transport and how smoothly the transplant procedure (and the care before, during, and after the operation[s]), goes.[71][unreliable medical source?] Given optimal care and oversight, and with the person's (through a directive or driver's license) and/or guardian or next of kin or power of attorney's informed consent, certain cases can provide optimal opportunities for organ transplantation. A major point of contention is whether transplantation should be allowed at all if the patient is not yet fully (biologically) dead, and if brain death is acceptable, whether the person's whole brain needs to have died, or if the death of a part of the brain (i.e., the cerebrum- which makes us human in our intellectual, and indeed all, conscious capacities; or the brain stem- which controls vital organic functions needed for life, like breathing and precise heartbeat regulation) is enough for legal and ethical and moral purposes.

Most organ donation for organ transplantation is done in the setting of brain death. However, in Japan this is a fraught point, and prospective donors may designate either brain death or cardiac death – see organ transplantation in Japan. In some nations (for instance, Belgium, Poland, Portugal and France) everyone is automatically an organ donor, although some jurisdictions (such as Singapore, Portugal, Poland,or New Zealand) allow opting out of the system. Elsewhere, consent from family members or next-of-kin is required for organ donation. The non-living donor is kept on ventilator support until the organs have been surgically removed. If a brain-dead individual is not an organ donor, ventilator and drug support is discontinued and cardiac death is allowed to occur.

In the United States, where since the 1980s the Uniform Determination of Death Act has defined death as the irreversible cessation of the function of either the brain or the heart and lungs,[72] the 21st century has seen an order-of-magnitude increase of donation following cardiac death. In 1995, only one out of 100 dead donors in the nation gave their organs following the declaration of cardiac death. That figure grew to almost 11 percent in 2008, according to the Scientific Registry of Transplant Recipients.[72] That increase has provoked ethical concerns about the interpretation of "irreversible" since "patients may still be alive five or even 10 minutes after cardiac arrest because, theoretically, their hearts could be restarted, [and thus are] clearly not dead because their condition was reversible."[72]

Political issues

There are also controversial issues regarding how organs are allocated to recipients.[clarify] For example, some believe that livers should not be given to alcoholics in danger of reversion, while others view alcoholism as a medical condition like diabetes.[citation needed]

Faith in the medical system is important to the success of organ donation. Brazil switched to an opt-out system and ultimately had to withdraw it because it further alienated patients who already distrusted the country's medical system.[73]

Adequate funding, strong political will to see transplant outcomes improve, and the existence of specialized training, care and facilities also increase donation rates. Expansive legal definitions of death, such as Spain uses, also increase the pool of eligible donors by allowing physicians to declare a patient to be dead at an earlier stage, when the organs are still in good physical condition.

Allowing or forbidding payment for organs affects the availability of organs. Generally, where organs cannot be bought or sold, quality and safety are high, but supply is not adequate to the demand. Where organs can be purchased, the supply increases.[74]

Iran adopted a system of paying kidney donors in 1988 and within 11 years it became the only country in the world to clear its waiting list for transplants.

Healthy humans have two kidneys, a redundancyTemplate:Http:// that enables living donors (inter vivos) to give a kidney to someone who needs it. The most common transplants are to close relatives, but people have given kidneys to other friends. The rarest type of donation is the undirected donation whereby a donor gives a kidney to a stranger. Less than a few hundred of such kidney donations have been performed. In recent years, searching for altruistic donors via the internet has also become a way to find life saving organs. However, internet advertising for organs is a highly controversial practice, as some scholars believe it undermines the traditional list-based allocation system.[75]

The National Transplant Organization of Spain is one of the most successful in the world, but it still cannot meet the demand, as 10% of those needing a transplant die while still on the transplant list.[76] Donations from corpses are anonymous, and a network for communication and transport allows fast extraction and transplant across the country. Under Spanish law, every corpse can provide organs unless the deceased person had expressly rejected it. Because family members still can forbid the donation,[77] carefully trained doctors ask the family for permission, making it very similar in practice to the United States system.[78]

In the overwhelming majority of cases, organ donation is not possible for reasons of recipient safety, match failures, or organ condition. Even in Spain, which has the highest organ donation rate in the world, there are only 35.1 actual donors per million people, and there are hundreds of patients on the waiting list.[73] This rate compares to 24.8 per million in Austria, where families are rarely asked to donate organs, and 22.2 per million in France, which—like Spain—has a presumed-consent system.

Prison inmates

In the United States, prisoners are not discriminated against as organ recipients and are equally eligible for organ transplants along with the general population. A 1976 U.S. Supreme Court case[79] ruled that withholding health care from prisoners constituted "cruel and unusual punishment". United Network for Organ Sharing, the organization that coordinates available organs with recipients, does not factor a patient's prison status when determining suitability for a transplant.[80][81] An organ transplant and follow-up care can cost the prison system up to one million dollars.[81][82] If a prisoner qualifies, a state may allow compassionate early release to avoid high costs associated with organ transplants.[81] However, an organ transplant may save the prison system substantial costs associated with dialysis and other life-extending treatments required by the prisoner with the failing organ. For example, the estimated cost of a kidney transplant is about $111,000.[83] A prisoner's dialysis treatments are estimated to cost a prison $120,000 per year.[84]

Because donor organs are in short supply, there are more people waiting for a transplant than available organs. When a prisoner receives an organ, there is a high probability that someone else will die waiting for the next available organ. A response to this ethical dilemma states that felons who have a history of violent crime, who have violated others’ basic rights, have lost the right to receive an organ transplant, though it is noted that it would be necessary "to reform our justice system to minimize the chance of an innocent person being wrongly convicted of a violent crime and thus being denied an organ transplant"[85]

Prisons typically do not allow inmates to donate organs to anyone but immediate family members. There is no law against prisoner organ donation; however, the transplant community has discouraged use of prisoner's organs since the early 1990s due to concern over prisons' high-risk environment for infectious diseases.[86] Physicians and ethicists also criticize the idea because a prisoner is not able to consent to the procedure in a free and non-coercive environment,[87] especially if given inducements to participate. However, with modern testing advances to more safely rule out infectious disease and by ensuring that there are no incentives offered to participate, some have argued that prisoners can now voluntarily consent to organ donation just as they can now consent to medical procedures in general. With careful safeguards, and with over 2 million prisoners in the U.S., they reason that prisoners can provide a solution for reducing organ shortages in the U.S.[88]

While some have argued that prisoner participation would likely be too low to make a difference, one Arizona program started by Maricopa County Sheriff Joe Arpaio encourages inmates to voluntarily sign up to donate their heart and other organs.[89] As of mid-2012, over 10,000 inmates had signed up in that one county alone.[90]

Religious viewpoints

All major religions accept organ donation in at least some form on either utilitarian grounds (i.e., because of its life-saving capabilities) or deontological grounds (e.g., the right of an individual believer to make his or her own decision).[citation needed] Most religions, among them the Roman Catholic Church, support organ donation on the grounds that it constitutes an act of charity and provides a means of saving a life, consequently Pope Francis is an organ donor. One religious group, The Jesus Christians, became known as "The Kidney Cult" because more than half its members had donated their kidneys altruistically. Jesus Christians claim altruistic kidney donation is a great way to "Do unto others what they would want you to do unto them."[91] Some religions impose certain restrictions on the types of organs that may be donated and/or on the means by which organs may be harvested and/or transplanted.[92] For example, Jehovah's Witnesses require that organs be drained of any blood due to their interpretation of the Hebrew Bible/Christian Old Testament as prohibiting blood transfusion,[93] and Muslims require that the donor have provided written consent in advance.[93] A few groups disfavor organ transplantation or donation; notably, these include Shinto[94] and those who follow the customs of the Gypsies.[93]

Orthodox Judaism considers organ donation obligatory if it will save a life, as long as the donor is considered dead as defined by Jewish law.[93] In both Orthodox Judaism and non-Orthodox Judaism, the majority view holds that organ donation is permitted in the case of irreversible cardiac rhythm cessation. In some cases, rabbinic authorities believe that organ donation may be mandatory, whereas a minority opinion considers any donation of a live organ as forbidden.[95]

Organ shortfall

The demand for organs significantly surpasses the number of donors everywhere in the world. There are more potential recipients on organ donation waiting lists than organ donors. In particular, due to significant advances in dialysis techniques, patients suffering from end-stage renal disease (ESRD) can survive longer than ever before. Because these patients don't die as quickly as they used to, and as kidney failure increases with the rising age and prevalence of high blood pressure and diabetes in a society, the need especially for kidneys rises every year.

As of March 2014, about 121,600 people in the United States are on the waiting list, although about a third of those patients are inactive and could not receive a donated organ.[96][97] Wait times and success rates for organs differ significantly between organs due to demand and procedure difficulty. As of 2007, three-quarters of patients in need of an organ transplant were waiting for a kidney,[98] and as such kidneys have much longer waiting times. At the Oregon Health and Science University, for example, the median patient who ultimately received an organ waited only three weeks for a heart and three months for a pancreas or liver — but 15 months for a kidney, because demand for kidneys substantially outstrips supply.[99][citation needed]

In Australia, there are 10.8 transplants per million people,[100] about a third of the Spanish rate. The Lions Eye Institute, in Western Australia, houses the Lions Eye Bank. The Bank was established in 1986 and coordinates the collection, processing and distribution of eye tissue for transplantation. The Lions Eye Bank also maintains a waitlist of patients who require corneal graft operations. About 100 corneas are provided by the Bank for transplant each year, but there is still a waiting list for corneas.[101]

"To an economist, this is a basic supply-and-demand gap with tragic consequences."[102] Approaches to addressing this shortfall include:

  • donor registries and "primary consent" laws, to remove the burden of the donation decision from the legal next-of-kin. Illinois adopted a policy of "mandated choice" in 2006, which requires driver's license registrants to answer the question “Do you want to be an organ donor?” Illinois has a registration rate of 60 percent compared to 38 percent nationally.[103] The added cost of adding a question to the registration form is minimal.
  • monetary incentives for signing up to be a donor. Some economists have advocated going as far as allowing the sale of organs. The New York Times reported that “Gary Becker and Julio Jorge Elias argued in a recent paper that 'monetary incentives would increase the supply of organs for transplant sufficiently to eliminate the very large queues in organ markets, and the suffering and deaths of many of those waiting, without increasing the total cost of transplant surgery by more than 12 percent.'”[102] Iran allows the sale of kidneys, and has no waiting list.[104] The primary argument against this proposal is a moral one; as the article notes, many find such a suggestion repugnant.[102] As the National Kidney Foundation puts it, “Offering direct or indirect economic benefits in exchange for organ donation is inconsistent with our values as a society. Any attempt to assign a monetary value to the human body, or body parts, either arbitrarily, or through market forces, diminishes human dignity.”[105]
  • an opt-out system ("dissent solution"), in which a potential donor or his/her relatives must take specific action to be excluded from organ donation, rather than specific action to be included. This model is used in several European countries, such as Austria, which has a registration rate eight times that of Germany, which uses an opt-in system.[103]
  • social incentive programs, wherein members sign a legal agreement to direct their organs first to other members who are on the transplant waiting list. One example of a private organization using this model is LifeSharers, which is free to join and whose members agree to sign a document giving preferred access to their organs.[106] "The proposal [for an organ mutual insurance pool] can be easily summarized: An individual would receive priority for any needed transplant if that individual agrees that his or her organs will be available to other members of the insurance pool in the event of his or her death. … The main purpose [of this proposal] is to increase the supply of transplantable organs in order to save or improve more lives."[107]

In hospitals, organ network representatives routinely screen patient records to identify potential donors shortly in advance of their deaths.[108] In many cases, organ-procurement representatives will request screening tests (such as blood typing) or organ-preserving drugs (such as blood pressure drugs) to keep potential donors' organs viable until their suitability for transplants can be determined and family consent (if needed) can be obtained.[108] This practice increases transplant efficiency, as potential donors who are unsuitable due to infection or other causes are removed from consideration before their deaths, and decreases the avoidable loss of organs.[108] It may also benefit families indirectly, as the families of unsuitable donors are not approached to discuss organ donation.[108]

The Center for Ethical Solutions, an American bioethics think tank, is currently working on a project called "Solving the Organ Shortage," in which it is studying the Iranian kidney procurement system in order to better inform the debate over solving the organ shortfall in the United States.[109]


The United States has two agencies that govern organ procurement and distribution within the country. The United Network for Organ Sharing and the Organ Procurement and Transplant Network (OPTN) regulate Organ Procurement Organizations (OPO) with regard to procurement and distribution ethics and standards. OPOs are non-profit organizations charged with the evaluation, procurement and allocation of organs whithin their Designated Service Area (DSA). Once a donor has been evaluated and consent obtained, provisional allocation of organs commences. UNOS developed a computer program that automatically generates donor specific match lists for suitable recipients based on the criteria that the patient was listed with. OPO coordinators enter donor information into the program and run the respective lists. Organ offers to potential recipients are made to transplant centers to make them aware of a potential organ. The surgeon will evaluate the donor information and make a provisional determination of medical suitability to their recipient. Distribution varies slightly between different organs but is essentially very similar. When lists are generated many factors are taken into consideration; these factors include: distance of transplant center from the donor hospital, blood type, medical urgency, wait time, donor size and tissue typing. For heart recipients medical urgency is denoted by a recipients "Status" (Status 1A, 1B and status 2). Lungs are allocated based on a recipients Lung Allocation Score (LAS) that is determined based on urgency and wait time. Livers are allocated using both a status system and MELD/PELD score (Model for End-stage Liver Disease/Pediatric End-stage Liver Disease). Kidney and pancreas lists are based on location, blood type, Human Leukocyte Antigen (HLA) typing and wait time. When a recipient for a kidney or pancreas has no direct antibodies to the donor HLA the match is said to be a 0 ABDR mismatch or zero antigen mismatch. A zero mismatch organ has a low rate of rejection and allows a recipient to be on lower doses of immunosuppressive drugs. Since zero mismatches have such high graft survival these recipients are afforded priority regardless of location and wait time. UNOS has in place a "Payback" system to balance organs that are sent out of a DSA because of a zero mismatch.

Location of a transplant center with respect to a donor hospital is given priority due to the effects of Cold Ischemic Time (CIT). Once the organ is removed from the donor, blood no longer perfuses through the vessels and begins to starve the cells of oxygen (ischemia). Each organ tolerates different ischemic times. Hearts and lungs need to be transplanted within 4–6 hours from recovery, liver about 8–10 hours and pancreas about 15 hours; kidneys are the most resilient to ischemia.[citation needed] Kidneys packaged on ice can be successfully transplanted 24–36 hours after recovery. Developments in kidney preservation have yielded a device that pumps cold preservation solution through the kidneys vessels to prevent Delayed Graft Function (DGF) due to ischemia. Perfusion devices, often called kidney pumps, can extend graft survival to 36–48 hours post recovery for kidneys. Recently similar devices have been developed for the heart and lungs, in an effort to increase distances procurement teams may travel to recover an organ.


People committing suicide have a higher rate of donating organs than average. One reason is lower negative response or refusal rate by the family and relatives, but the explanation for this remains to be clarified.[110] In addition, donation consent is higher than average from people committing suicide.[111]

Attempted suicide is a common cause of brain death (3.8%), mainly among young men.[110] Organ donation is more common in this group compared to other causes of death. Brain death may result in legal death, but still with the heart beating, and with mechanical ventilation all other vital organs may be kept completely alive and functional,[71] providing optimal opportunities for organ transplantation.


In 2008, California transplant surgeon Hootan Roozrokh was charged with dependent adult abuse for prescribing what prosecutors alleged were excessive doses of morphine and sedatives to hasten the death of a man with adrenal leukodystrophy and irreversible brain damage, in order to procure his organs for transplant.[112] The case brought against Roozrokh was the first criminal case against a transplant surgeon in the US, and resulted in his acquittal.

At California's Emanuel Medical Center, neurologist Narges Pazouki, MD, said an organ-procurement organization representative pressed her to declare a patient brain-dead before the appropriate tests had been done.[108]

In September 1999, eBay blocked an auction for "one functional human kidney" which had reached a highest bid of $5.7 million. Under United States federal laws, eBay was obligated to dismiss the auction for the selling of human organs which is punishable by up to five years in prison and a $50,000 fine.[113]

On June 27, 2008, Indonesian Sulaiman Damanik, 26, pleaded guilty in a Singapore court for sale of his kidney to CK Tang's executive chair, Mr. Tang Wee Sung, 55, for 150 million rupiah (US$17,000). The Transplant Ethics Committee must approve living donor kidney transplants. Organ trading is banned in Singapore and in many other countries to prevent the exploitation of "poor and socially disadvantaged donors who are unable to make informed choices and suffer potential medical risks." Toni, 27, the other accused, donated a kidney to an Indonesian patient in March, alleging he was the patient's adopted son, and was paid 186 million rupiah (US$21,000).

Social media

The United States Department of Health funded a study by the University of Wisconsin Hospital to increase efforts to increase awareness and the amount of registered donors by pursuing members of the university and their family and friends through social media.[114] The results of the study showed a 20% increase in organ donation by creating support and awareness through social media.[114]

Becoming a donor

Adding one's name to a statewide organ donor registry is the recommended method for ensuring the decision to become an organ, eye and tissue donor is honored. Methods to join the donor registry vary somewhat by state. The most common way to register is through the DMV (Department of Motor Vehicles) or similar agency, typically when renewing a driver's license or ID card.

Alternately, most states also have online portals to their donor registries, which can be accessed through Donate Life America or the U.S. Department of Health and Human Services.

Sharing one's decision to donate with family members is very important, also. Although most states honor First Person Authorization (through donor registries, signing the back of a driver's license, living wills, etc.), the family's cooperation is vital in order to obtain medical and social background information to help determine the health of the donor's organs and tissues. Family challenges to the donor's legally documented decision to donate can cause delays, and may mean fewer organs can be transplanted as the organs deteriorate in the time after death is declared. To be considered as a living organ donor a person should contact a hospital with a transplant center/program. If the desire is to donate to a particular patient, then that patient's transplant center is the one which should be contacted. A list of transplant centers can be found through the Organ Procurement and Transplantation Network.

In the United Kingdom, one signs up to be an organ donor through the NHS Blood and Transplant Service, or on an application for a driving license. This is shown on the photocard part of the license as a code (115).[115]

Public service announcements

There is a need for more participants in organ donation. Marketing for organ donation must walk a fine line between stressing the need for organ donation and not being too forceful.[116] If the marketing agent is too forceful, then the target of the message will react defensively to the request. According to psychological reactance theory, a person will perceive their freedom threatened and will react to restore the freedom. According to Ashley Anker, the use of transportation theory has a positive effect on target reactions by marketing attempts.[116] When public service announcements use recipient-focused messages, targets were more transported. Individuals who watched recipient-focused messages were more transported because potential donors experience empathy for the potential recipient. Future public service announcements should use recipient-focused stories to elicit relationship formation between potential donors and recipients.

Awareness about organ donation leads to greater social support for organ donation, in turn leading to greater registration. By starting with promoting college students’ awareness of organ donation and moving to increasing social support for organ donation, the more likely people will be to register as organ donors.[117]


Currently more than 100,000 people are waiting for an organ transplant, yet there is a shortage of donors. Over the years people worldwide have stopped registering to be organ donors, resulting in the deaths of numerous people each year. The shortage often creates unethical situations where payments are made in return for the sale of the organs and donors often do not receive appropriate post-operative care. Although most organs may only be taken from donors that have been declared dead (brain-dead), kidneys have remained an exception with their potential for live donor transplants and as such are often the target of illegal harvesting and black market transactions. Many countries have now started to move towards a system of donation by default on death ("Opt Out" system) unless a signed objection is registered with the relevant authorities in order to relieve the burden being placed on the health care system at the moment.

See also


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