How Can We Ethically Increase the Supply of Transplantable Organs?

The waiting list for solid organ transplantation in the United States now exceeds 92 000 persons (approximately 67 000 of whom need a kidney transplant), and the list grows longer each year (1). In 2005, more than 28 000 solid organs, mainly kidneys (16 477 kidneys), were transplanted (1, 2). Not surprisingly, given this gap between supply and demand, vigorous debates have erupted about how best to increase and to allocate the supply of transplantable organs.

In May 2006, the Institute of Medicine (IOM) released a new report, “Organ Donation: Opportunities for Action” (2), prepared by a committee charged with studying how to increase the rates of (postmortem) organ donation. This committee, which I chaired, was established at the request and with the support of the Health Resources and Services Administration and the Greenwall Foundation. It examined several proposals to increase the supply of transplantable organs in order to determine their likely effectiveness and compatibility with basic U.S. principles and values.

The committee concluded that it is currently unwise to promote financial incentives, give priority for an organ to persons who have registered their decision for postmortem organ donation if they ever need an organ transplant, require people to signify a positive or negative decision about donation (often called mandated choice), or presume consent to postmortem organ donation (an opt-out policy). The committee's reasons varied but included ethical concerns along with worries about effectiveness and even counterproductivity. Several European countries have adopted presumed consent, but the committee judged that the United States is not yet ready socially or culturally for presumed consent. Instead of these strategies, the committee identified several potentially effective and less controversial ways to increase the supply of transplantable organs: enhancing education about organ donation, altering the sociocultural atmosphere to support an expectation of donation, providing a wider …