TCS Daily

Have a Heart

By Jay Currie - February 19, 2004 12:00 AM

Rob Raffety recently discussed the need to encourage greater human organ donation in an article on TCS and noted that the 1984 National Organ Transplant Act (NOTA), PL 98-507, makes illegal the "transfer of any human organ for valuable consideration for use in human transplantation." The intention of NOTA was to prevent a marketplace allocation of organs where a good liver went to the highest bidder regardless of other medical issues. Given the growth of the organ business in Asia -- particularly in China where the organs of executed prisoners are harvested regardless of consent -- this is a reasonable law to have in place.

Rafferty refers to a couple of relatively passive incentive programs to increase the supply of organs. But there are other means that could radically increase the number of potential donors without violating the intent of NOTA. Given the nearly one hundred thousand people waiting for transplants, real incentives should be looked at very seriously.

The simplest is a direct cash signup bonus when a person signs a donor card or ticks off a donor agreement on his driver's license renewal. Calculating the annual value of that signup bonus should keep an actuary busy for a day or two but, in principle, a person's heart, lungs, liver, kidneys and so on should have a determinable economic value which, sadly, declines over time to a value of zero at the end of that person's life expectancy. Then one would calculate the likelihood of the person's dying in a way that will allow his organs to be harvested.

These calculations in hand, a cash value for agreeing to be a donor can be determined.

Where would the cash come from? At this point while the surgeons, nurses, operating theatres, drugs and tests involved in a transplant operation are all accounted for and billed, the star of the show -- the organ -- appears nowhere on the recipient's bill. A transplant operation typically costs between $100,000 and $400,000 and a donor incentive surcharge set at a fixed percentage of the operation's total cost would make sense.

Using the back of the proverbial envelope, in 2001 there were 21,000 transplants performed in the United States. If the average cost was $150,000 and the organ surcharge was set at 15% then the pool of money available for donor incentives would be $472,500,000.

In 2001 there were a little over 80,000 people on waiting lists for all forms of transplants. As a given donor can often supply many organs, to clear the back log would likely require something on the order of 22,000 new donors, which, in turn would need, say, 2.6 million people to sign up if the mortality distribution was even across the population. But, in fact, it isn't.

In 2001 the overall death rate in the United States was 854/100,000. However, the 854/100000 death rate is skewed towards unsuitable donors -- namely the elderly. (Disturbingly, the median age of organ donors has risen relative to the median age of the American population as a whole.)

In fact, the most advantageous group to offer an incentive to join to would by young people from 18 -- 34. These people are generally healthy but have a greater than average likelihood of dying by accident. If the incentives were skewed to this demographic, a signing bonus of several hundred dollars might be offered as well as yearly payments to remain in the program. (This amount would be reduced significantly for people over 34 as well as smokers and the obese.)

Such an incentive system would tend to be economically quite efficient as the amount available for incentives would depend upon how many transplants were performed in the proceeding year. As waiting lists began to decline, the total amount of money for incentives would fall and the value of the incentive would decline in line with the decline in the demand for transplants.

This incentive system would act as reverse insurance offering money now to individuals who, statistically, are more likely to be offering their organs for transplantation. Depending on the rate of uptake, once a person was enrolled in the incentive program they might well earn several thousand dollars between the ages of 18-34 at exactly the time in their lives where extra cash is most welcome.

People will likely object to this cash-on-the-barrel approach because it will increase the cost of transplant operations. However, the cost of not getting a needed transplant, from the patient's perspective, is more or less infinite. So a modest increase in the actual cost has to be weighed against the potential benefit of increasing the donor pool.

As to NOTA, no organ is being sold directly or indirectly. The consideration is being offered to become part of the donor pool. With luck, and the progress which is being made in the engineering of organs, this sort of incentive program would be a stop-gap until we have the technology to grow human organs to order.

Jay Currie is a frequent TCS contributor living in a Galiano Island, Canada. Find him online at


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