adding extra points for being a registered donor to the priority score used to allocate organs to recipients.

After a short review of the history of the current prohibition against the sale of organs, the chapter addresses direct payments for organs within free-market and regulated-market models. The chapter then examines the use of financial incentives to reward and induce donation. Finally, the chapter analyzes nonfinancial incentives, particularly preferred status on organ waiting lists, for people who record their willingness to be organ donors.

HISTORY AND CONTEXT

In the United States, organs from deceased individuals become available for use for transplantation through donation by express consent. In the 1960s, as it became possible to use organs from deceased individuals, it was sometimes unclear whose consent—the decedent’s, while he or she was alive, or the family’s after the person’s death—was necessary and sufficient for donation because of variability in state laws. Resolving this uncertainty, the Uniform Anatomical Gift Act (UAGA) of 1968 authorized express donation by individuals and, in the absence of the decedent’s prior choice, by the family. Although UAGA focuses on gifts or donations, it did not rule out transfer by sale; it simply did not address sales at all.

According to the chair of the UAGA drafting committee, the drafters did not intend to encourage or discourage payment for organs but instead left the matter entirely up to the states (or, preferably, individual conscience). He noted: “It is possible, of course, that abuses may occur if payment could customarily be demanded, but every payment is not necessarily unethical…. Until the matter of payment becomes a problem of some dimensions, the matter should be left to the decency of intelligent human beings” (Stason, 1968, p. 927). Sales had been illegal in some states prior to the UAGA’s adoption in the late 1960s and early 1970s. However, most of those statutes banning sales were repealed when UAGA was adopted, and the legal status of organ sales or purchases for transplantation “remained uncertain” in most states, although it remained legal to buy and sell blood and sperm (Hansmann, 1989, p. 59).

Little public debate about this matter occurred until the early 1980s, when organ transplantation entered a new era with the availability of much improved immunosuppressive medications and with improved outcomes after transplantation. As a result, concern about the chronic scarcity of transplantable organs increased and several congressional committees and subcommittees held a number of hearings on transplantation. These hearings addressed several topics, including a possible federal ban on organ sales. This topic became all the more urgent when a former physician in Virginia proposed to set up a brokerage firm to purchase organs, particu-



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