Is America Ready for an Organ-Donor Market?

Probably not. But, in what is either a very odd coincidence or some kind of concerted effort to get out the organ-market message, there are OpEds in both the N.Y. Times and Wall Street Journal today arguing the case.

The first one, headlined “Death’s Waiting List,” is by Sally Satel, a psychiatrist and American Enterprise Institute scholar. Satel herself received a kidney transplant and is now arguing that the delivery system is terrible and that the Institute of Medicine’s new report, “Organ Donation: Opportunities for Action,” is even worse. “Unfortunately,” Satel writes, “the report more properly should be subtitled ‘Recommendations for Inaction.” Satel’s main point is that the conventional argument against an organ market — i.e., that no part of the human body should ever be “for sale” — has been made obsolete, and then some, by the “markets for human eggs, sperm, and surrogate mothers.”

The WSJ piece, headlined “Kidney Beancounters” (abstract only), is by Richard Epstein, the University of Chicago legal scholar and Hoover Institution fellow. Epstein is even more hostile to the IOM’s report (though maybe the Journal just let him get away with more than the Times let Satel get away with), saying the report is “so narrowminded and unimaginative that it should have been allowed to die inside the IOM.” Epstein writes further that “The major source of future improvement lies only in financial incentives; yet the IOM committee (which contains one lawyer but no economist) dismisses these incentives out of hand … The key lesson in all this is that we should look with deep suspicion on any blanket objection to market incentives — especially from the high-minded moralists who have convinced themselves that their aesthetic sensibilities and instinctive revulsion should trump any humane efforts to save lives.”

Though his OpEd doesn’t say so, I am pretty sure that Epstein is an advisor to LifeSharers, a self-described “non-profit voluntary network of organ donors” that seeks to use non-financial incentives to encourage organ donation. A while ago, we received an e-mail from David Undis, the executive director of LifeSharers. He wrote:

Incentives are missing in organ donation. That’s one of the reasons so many people are dying waiting for organ transplants.

A free market in human organs would save thousands of lives a year, but politically speaking it’s a pipe dream. There’s very little likelihood Congress will legalize buying and selling organs in the foreseeable future.

I formed LifeSharers to introduce a legal non-monetary incentive to donate organs — if you agree to donate your organs when you die then you’ll receive a better chance of getting an organ if you ever need one to live.

It is surprising to me, and to many people much closer to the subject than me, that so little headway has been made in reforming the organ-donation process. I have never heard a single person say they were happy with the way things are — and, while I am sure Undis is right when he writes that a free market in organs is, politically speaking, a pipe dream, it seems that things are starting to move at least a bit in that direction. As Satel writes in her Times piece today, “Ethics committees of the United Network for Organ Sharing, the American Society of Transplant Surgeons and the World Transplant Congress, along with the President’s Council on Bioethics and others, have begun discussing the virtues” of offering organ donors incentives such as “tax breaks, guaranteed health insurance, college scholarships for their children, deposits in their retirement accounts, and so on.”

It is interesting that, while all these incentives are financial, none of them are in the form of cold hard cash, which may make them more palatable.

I wouldn’t be surprised if, between these two OpEds, at least a few minds are changed today.


Wasn't there a study where blood donations fell when donors were paid?

Economic incentives might harm the donor market.

Incentives in the organ market might make more sense, I like the idea of priority for regestered donors. A really strict varient would be a totally opt-in market, an adult must have been regestered for at least one year to qualify for any donation. This also has a certian "rightness" since it doesn't seem fair to allow people to benift from something they are unwilling to do.


The dysfunctional state of the human organ market also points out additional reasons to support stem cell research. Setting aside the problem of the organ shortage and its myriad causes, organ transplants carry with them the risk of rejection. Thus, anyone who has an organ transplant now (and for the foreseeable future) must take powerful immunosuppressant drugs for the rest of their life, thus compromising their immune system. Transplantable organs created from people's own stem cells might not create a rejection risk; but even if that problem is not overcome, creating organs for transplant from stem cells could eliminate the availability problem.

Laura Bennett

Why does money have to be involved? Why not make it that you automatically opt in to the donor pool and have to opt out to not donate your organs. If you did that, you'd have too many organs...


The 'offer to donate to get priority in receiving' plan makes a lot of sense. A danger with a'money for organs' scheme of any kind is suggested by a number of science-fiction stories by Larry Niven, in which he postulates a black market for organs, fueled by kidnapping and murder. If a donated heart is worth $20,000 and each kidney brings $5,000, then any random stranger is worth $30,000 to the unscrupulous, even ignoring the value of everything else.


Organ transplants should be banned because leliathomas once met a jerk who had a transplant. Oh, you also might get rabies from it.


As the recipient of a kidney transplant, and the founder of a non-profit organization to increase organ donation, ( I'd like to add a few comments and clarifications.

First, the prospect for cloned organs, though exciting, is not likely for at least a decade. Immediate solutions need to be explored and tested in order to save over 7000 lives per year.

Second, cadaver organs can only be harvested from people who die while in the hospital and do not have any condition that would render their organs unusable. There simply aren't enough people who die under these conditions to satisy those waiting for an organ.

Third, the fear of a black market in organs relies upon urban legend and medical ignorance. No one is going to be kidnapped, have their kidneys removed, and wake up in a bathtub full of ice. Organs have to be carefully removed, tested and prepared for an identified recipient. Moreover, if there were a government regulated marketplace, the need of a black market to satisfy unmet demand would be elminated.

And why don't you ask any of the 1500+ athletes at next month's Transplant Games in Louisville, KY if their transplant is a false security.

Transplants represent the only life-saving option for over 90,000 people. We have the ability to eliminate the transplant waiting lists entirely yet the entrenched medical and political potentates reflexively refuse even to consider the introduction of incentives that could save thousands of lives. From a dialysis patient's perspective, their ethical niceties and aesthetic reservations are, quite simply, monstrous.



From the piece in the Times:

"This Op-Ed article originally misstated the frequency with which Americans on the transplant waiting list die. It is one death every 90 minutes, not every 90 seconds."

Now that's what I call a BIG mistake!

As an interesting aside, though she doesn't mention it in her Times piece, Sally Satel can thank the blogosphere for her kidney donation. The blogger Virginia Postrel read about Dr. Satel's plight on the latter's blog and agreed to donate one of her kidneys.

In the long run, however, organ transplants are far from the ideal solution. More research into stopping organs from failing in the first place is really the only answer.


I can't let this one go without comment. The answer to our critical organ shortage is NOT research on the "root cause" of organ failure.

There are simply too many causes - some preventable and some not - and will never be eliminated entirely (the cause of my own sudden and total kidney failure, for example, has never been identified).

The ideal short term solution is a transplant. That fact is simply inarguable.

The transplant waiting list can be eliminated, lives saved and families restored. Read how at

Paul Turnbull

While the risks of a black market in organs are very overstated I think any legalisation of an organ donor market should be approached with care. The experience of China in this area suggests there is a high risk of abuse and exploitation. I'm also leery of any system that determines your likelihood of getting a transplant by the size of your bankroll.

That said, anything that may increase the available number of organs available for transplant deserves exploration.


leliathomas is against organ donation because he/she dislikes one person who benefited from it.

I think that his/her argument is so strong that we should not allow water to be sold because it kept Hitler alive for so many years.


The experiences of a black market in China simply confirm that in the face of artificially imposed restrictions on critically desired organs, market forces will emerge to address enduring and increasing demand.

However, the U.S. is not an ethically barren dictatorship. With proper oversight (similar to the current system that oversees cadaver organ distribution), the system could provide a fair, fast and safe solution to the nearly 70,000 people waiting years for a kidney transplant.

What we're suggesting is not an open auction for available organs, but a government sponsored and monitored system that provides incentives for organ donation. The wealth of any waiting dialysis patient would have no effect on their place on the waiting list.


Vrimj - Here's a study that supports your concern:

It would also indicate that the "damage" might be undone by allowing donation to sent directly to charity.

Regardless, I would challenge the idea that organ donation is comparable to blood donation. One comes to your office or school, and you can drop in and do it, or at most schedule just an hour away. The other is debilitating, invasive surgery. It would be extrapolating data about cars and trucks from bicycle info.

I would urge you all to consider the questions framed this way, should a rich man live and a poor man die? Or should they both die? These seem to be the options.


I would assume that we are mostly talking about cadaver donations, possibly bone marrow, but not live organ donation like a kidney.

I think live organ donation works and would not want to really see a change here. I don't like economic incentives because they would be silly in this case. You can't take it with you. While you do need family consent the primary audiance is the person who is going to be dead.

This is why I like a all opt-in market, you can bargin something you don't need, organs after death, in exchange for a chance at something you do need. The nice thing about an organ for organ exchange is that they have the same value for everything.


I can't say it any better than Richard Epstein in his WSJ column today. Epstein wrote:

Some argue that the price mechanism will drive out the altruists. Thank heavens. All markets have a few people who are willing to supply goods at a low price, or indeed for no price at all. But no one says that the market for food or medical services is defective when these inframarginal suppliers receive something extra when prices rise. That increase in cash only counts as a transfer payment that neither adds to nor detracts from overall social welfare.

The key social changes come from the lives saved through the increase in supply. Only a bioethicist could prefer a world in which we have 1,000 altruists per annum and over 6,500 excess deaths over one in which we have no altruists and no excess deaths. In any event, the altruists don't disappear.


"I can't let this one go without comment. The answer to our critical organ shortage is NOT research on the “root cause” of organ failure.
There are simply too many causes – some preventable and some not – and will never be eliminated entirely (the cause of my own sudden and total kidney failure, for example, has never been identified).
The ideal short term solution is a transplant. That fact is simply inarguable."

Well I said that research into preventing organ failure is the ideal thing *in the long run.* Transplants may save lives, but even if there were no waiting lists they're far from a perfect solution.

We're not talking about a zero-sum game. Supporting increased research into preventing organ failure does not mean that one also must be unconcerned about the shortage of organs for transplant.


It's a terrific, feel-good sentiment, but shifting the focus from increasing the number of living organ donors to increasing research into preventive care does actual harm. In many ways, it is a zero sum game. We must necessarily gain Congressional support to change existing prohibitions on transplant incentives. Focus and funds are limited and must remain concentrated on those pursuits that will generate the most positive impact.

In my mind, the immediate effort to save 70,000 lives is paramount.

Dave Undis

Financial incentives would increase the supply of organs and save thousands of lives every year. Until financial incentives are legalized, a non-financial incentive that is already legal is the best way to increase organ supply -- give organs first to people who have agreed to donate their own organs when they die.

Giving organs first to organ donors will convince more people to register as organ donors. It will also make the organ allocation system fairer. About 60% of the organs transplanted in the United States go to people who haven't agreed to donate their own organs when they die. People who aren't willing to share the gift of life should go to the back of the waiting list as long as there is a shortage of organs.

Anyone who wants to donate their organs to others who have agreed to donate theirs can join LifeSharers. LifeSharers is a non-profit network of organ donors who agree to offer their organs first to other organ donors when they die. They do this through a form of directed donation that is legal in all 50 states and under federal law. Anyone can join for free at or by calling 1-888-ORGAN88. No one is excluded due to age or pre-existing medical condition.

David J. Undis
Executive Director



To approach a family of a deceased individual and offer them cash in exchange for their consent to a donation that they would otherwise not consent to is tantamount to a bribe. To place the family in a position to contradict the known wishes of the individual or their own values is a selfish insult to the values and morals of our community. The likely social consequences of such a market-based approach is the creation of a social caste of the destitute, bribed to become paid donor families or living donors whose body parts (the term "gifts" would be antiquated) benefit those fortunate enough to have the health insurance and stable family/social structures that are required to ensure the organ is cared for.

We have seen the result of paying for organs in third world countries, and we saw the results of paying for blood in this country; neither was pretty nor good for the health of the donors and recipients in the long run.

Fundamentally, we have a very real organ shortage which would remain in perpetuity even if every one of the 13,000 who suffer brain death, plus the estimated 1,300 potential Donors after Cardiac Death -- each year could and did donate. First, it would take five years to catch up with the existing waiting lists. More importantly, as more organs became available, transplant physicians would list more patients -- patients for whom they have no hope for an organ today, but might if rates moved from today's nearly 60% consent rate range to 100%. Some cardiologists have estimated that if enough hearts were available there would be 250,000 heart transplants a year!

Unfortunately, the solution is beyond payment and it is beyond a perfectly benevolent and generous community. The future lies in advancements in treatment for organ diseases, artificial organs, cloning, and xeno-transplantation. Meanwhile, we professionals work with families every day to help them see the good that we know comes from the decision to donate life. Across the country, we have seen a huge increase in deceased donation the past two years as a result of the HHS Organ Donation Breakthrough Collaborative.

Let's keep putting our energies into tactics that have raised donation rates nearly 20% in the past 2 years and encourage the approximately 5,200 non-consenting eligible deceased donor families per annum to say "yes" to donation. These tactics include expanded public education that inspires people to register on their state donor registries; instituting the processes (e.g. DMV linkage) that make such registration easy and accessible for all; training family care coordinators who approach families; and expanding the Collaborative's best practices to all hospitals. And by encouraging the development of transplant center-based paired kidney exchanges that cross-match pairs of incompatible family members so both families can benefit from living donation, many more kidney transplants will be enabled. Initiatives like these are achievable, have track records of success, and do not impose radical change on a system that has heretofore enabled hundreds of thousands of people to live longer, fuller lives through transplantation.

The tactics above as preferable to creating a class of organ breeders who sell their body parts -- who sell a part of themselves that they can never, ever get back -- simply for economic gain. We owe it to our good nature -- our capacity to help and give to one another, across ethnic and class lines, freely and without expectation of reward other than the joy that it brings to others and ourselves -- to aim higher than that. In 2005, the capacity to give inspired nearly 7,600 deceased donors/families and almost 6,900 living donors to help those in need. And that kind of giving is something we should all be thankful for, one family, one individual and one legacy at a time.



Here's an externality of the sad current organ donation system: potential donors like me now refuse to donate. I used to be tagged a donor on my driver's license until a friend's story made me change.

My friend's father is a surgeon specializing in organ transplants. One day the father saw his son's driver's license and its organ donation sticker. The father flipped out and demanded his son remove the sticker.

Why on earth would a organ transplant surgeon demand his son remove the organ donor designation? The reason is both simple and appalling.

The surgeon believes that some patients known to medical staff as organ donors receive lesser life-saving medical care in order to make organs available. I've never asked the surgeon about his belief--and I certainly have many questions about it--but I'm no longer an organ donor.


I am appalled, though not surprised, that the greatest impediments to change in the current organ procurement system are the entrenched, anointed overseers who direct the transplant bureaucracies. From the UNOS executives (like the embarrassing Dr. Francis Delmonico), the National Kidney Foundation officials and the transplant directors themselves, we encounter assiduous opposition to anything but the most tepid changes to a system that is obviously and demonstrably failing.

The latest example of this institutional hubris is Thomas Mone's post on the Freakonomics blog (under the name tdmone) regarding the creation of an organ donor market. Mone is the CEO of OneLegacy, the organization that oversees organ donation and distribution in Southern California. For a man responsible for the welfare of over 8000 patients waiting for life-saving transplants, Mone displays an appalling lack of urgency and a disturbing facility to avoid evidence and logic.

Mone states, correctly, that even if we were able to procure organs from every available cadaver, our shortage would still remain in perpetuity. So what's his solution? More of the same unsuccessful efforts to raise awareness and solicit more cadaver organs (the vocabulary of the anointed is replete with such terms as 'sensitizing,' 'enlightening,' or 'educating' others).

Wait a minute. Didn't he just admit that this would never solve the problem? Yes, but he would feel better if we had more of it anyway. He then attempts to obfuscate the success of deceased organ solicitation with a fabricated statistic, claiming that deceased organ donations have increased 20% in the last two years. Pretty impressive, no.

Actually, no. The real increase in the past two years is 17.5% (I do hate to nitpick, but this was so easy to check) which represents an increase of just over 1100 donors. That would be great if the waiting list during the same period hadn't increased by over 10,000. Anyone else see a problem here? And, more importantly, why doesn't Mone see a serious problem here that requires the application of imagination and initiative to resolve?

The danger of people like Mone and his overseers within the transplant plantation is not that they're ignorant, but that they're insulated. They are engaged with each other in endless discussions, conferences and seminars that provide them a forum to display their verbal nimbleness and satisfy their noblesse oblige, then reach decisions for others while paying no cost for being wrong.

Well they are wrong. And we live with their consequences. They are wrong to impose their fragile ethical sensibilities on over 90,000 people condemned to a tortuous wait or lingering death. They are wrong to dismiss the potential of an organ market out of hand. And they are wrong if they think they can continue to console themselves with the certainty of their good intent while refusing to acknowledge the enormous potential of imaginative projects that could eliminate the transplant waiting list.

Seldom have so few cost so much to so many.