educated individuals in society. To the extent that these models require individuals to be adequately informed about the option of donation and to have the opportunity to make their wishes known, they erect another potential barrier to health care, particularly among individuals who lack adequate access to the healthcare system (Siminoff and Leonard, 1999; Wigmore and Forsythe, 2004). It is worth noting that many people who believe that reciprocal obligation is an important moral underpinning of a system of organ donation nonetheless oppose proposals to replace the existing legal structure of allocation with one that either limits eligibility for transplantation to patients who have agreed to be donors or gives them legal priority in allocation (see, for example, Siegal and Bonnie, 2006).

The Information Problem

All proponents of preferred-access models concede that many people unregistered as donors—for example, children and adults who lack a decisional capacity—would nonetheless be entitled to equal access as potential recipients. Preferential access would be denied only to legally competent adults who had an opportunity to register and failed to do so. However, fair implementation of such a model would require aggressive public education so that everyone would be on an equal footing in deciding whether to register as a donor. People would need to be informed about the nature of organ donation and how to choose donation. A nationwide donor registry would need to be established and would need to rely unambiguously upon first-person (donor) consent. Without extensive education and a nationwide donor registry that is easily accessible to all citizens, a preferred-status system runs the risk of unfairly excluding people who have not been educated about donation or who lack easy access to donor registration (e.g., because they do not or cannot hold a driver’s license, which currently provides the most common opportunity to express donation wishes).

The Adverse Selection Problem

Any type of preferential access system based on a recorded willingness to donate presents what insurance experts call “adverse selection”; that is, that people who are most at risk for needing an organ will be disproportionately likely to sign up to be a donor. Should people be permitted to gain preferential access by agreeing to become donors only after they have discovered that they are likely to need an organ? If not, how should this rule be enforced? What about those who are not ill but who know that they are in a high-risk group? If people are permitted to register as potential donors after they already know that they are at higher risk of needing an organ, should they receive fewer allocation points than other people on the list

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