who registered before knowing that they were at higher risk? Should people with less desirable or extended-criteria organs receive a lower priority? In the committee’s view, there is really no way to substantially reduce the adverse selection problem without requiring everyone who signs up to be a donor to turn over their medical records and take a medical examination at the time of registration. Any significant degree of adverse selection erodes one of the strong moral arguments for reciprocity-driven approaches: the emphasis on a mutuality of interest and the effort to prevent free riding.

The Unfair Allocation Problem

Any type of preferential access based on donor registration introduces a criterion for organ allocation that is not related to medical need. Major institutional stakeholders such as UNOS and the American Medical Association have avoided the use of non-need-based criteria (Sanchez, 2003); for example, criteria that would give lower priority to patients with alcoholic cirrhosis, patients without dependents, or older patients. Although some factors unrelated to need, such as geography, are taken into account, the preeminent considerations relate to medical need and the predicted outcome. To the extent that reciprocity-based allocation embraces the idea that some patients merit a transplant (rather than need a transplant) more than others because they are willing to contribute their organs, these models would effect a significant change in the existing criteria for organ allocation. If society is going to step onto that slippery slope (Gillon, 1995), it is not clear why a willingness to contribute organs should be paramount. Why should not other contributions to society be taken into account?

Some of the people most in need of an organ will be people who have never been medically eligible to donate, so their willingness to donate would be an empty gesture. What should be done in such cases? Is it fair to exclude people who could never have been donors, that is, those who were free riders from birth or adulthood? Not surprisingly, reciprocity-driven proposals typically grant equal access to potential recipients who are medically ineligible to be donors, recognizing that the reciprocity principle requires some qualification. What, then, about people who have a strong emotional or religious concern about donating their own organs? Should religious objection to donation preclude equal access to organs when they are needed? What if the religious objector had made other major contributions to society? The reciprocity argument also fails to take into account the lack of trust that some people from historically disadvantaged groups have in the healthcare system. A person who has inadequate access to health care and fears that organ donor status might increase his or her chances of receiving suboptimal treatment in a life-threatening health situation may be reluctant to be an organ donor, even though he or she would like to receive an organ



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