TCS Daily

The Limits of Altruism and the Power of Self-Interest

By Lloyd R. Cohen - August 23, 2005 12:00 AM

For the last thirty years, many well-meaning organizations have spent lots of time and money trying to convince more Americans to donate their organs after they die. These efforts have relied exclusively on appeals to altruism, and they have failed. It's time to use self-interest to relieve the organ shortage.

The demand for organ transplants has skyrocketed, but the number of donated organs has remained relatively flat. As a result, over 89,000 people are on the waiting list for an organ transplant in the United States. Another 40,000 names will be added to the list in the next twelve months. In 2004, 6,529 people on the waiting list died waiting for a transplant. Another 1,594 were removed from the list because, while they were waiting, they became too sick to undergo a transplant. More than half of the people who need transplants in the United States die before they get one.

Less than half of the cadaveric organs that could save lives and relieve suffering are recovered. The rest -- about 20,000 transplantable organs every year -- are buried or burned. Every year tens of thousands of people in this country suffer and die while the organs that could restore them to health are fed to worms or turned to ash.

It is no great indictment of the charitable nature of the American people that the current system succeeds in yielding us something between 25 and 50 percent of the salvageable organs. It is true that not everyone is selfless, but there is more to it than that. The request to donate always comes at the wrong time, either too early or too late. It comes when applying for a driver's license, when one can hardly be faulted for not wanting to think too hard about being dismembered following a sudden, violent, and early death. Or it comes when one has just suffered the horror of the sudden, probably violent, loss of a child or spouse. This is hardly a time when one is inclined to feel a great surge of altruistic generosity, hardly a time when one wants to weigh the merits of dismembering a loved one's body to provide a benefit to strangers.

There's a better way. We need to appeal to self-interest. After all, we use the incentive of self-interest to increase the supply of food, clothing, shelter, and transportation. There is every reason to think it will also increase the supply of organ donors.

Debate about the use of self-interest to reduce the organ shortage has focused on legalizing financial incentives. But a non-financial incentive that is already legal also has the potential to alleviate the organ shortage. We can create a very powerful incentive to donate by changing the way we decide who gets the organs that are donated. Let's make this the new rule: people who have signed up to donate their organs when they die shall be the first to get organs if they ever need them to live.

A simple thought experiment shows how effective this could be. Imagine that UNOS, which runs the national organ allocation system, made the following announcement: "Beginning January 1 of next year, no human organ will be made available for transplantation into any person who has not been a registered organ donor for at least two years unless no registered organ donor would benefit from receiving that organ."

This announcement would cause millions of people to sign organ donor cards, and millions of parents to sign them on behalf of their minor children. Everyone who didn't sign one would know they would be near the bottom of the waiting list if they ever needed an organ transplant.

This quid pro quo would have the additional benefit of encouraging all involved to treat the signing of a donor card as a moral commitment, if not quite a contract. What the public does not appreciate is that under the current regime the signing of an organ donor card carries almost no weight in the organ retrieval process.

No Congressional action is needed to implement this idea. UNOS has the authority to change its organ allocation scheme to recognize a potential organ recipient's status as an organ donor. In fact, UNOS has already done so for live organ donors. It can do the same for those who commit to being cadaveric donors.

Abandoning a purely altruistic organ donation system makes some people uncomfortable. They say it offends human dignity. They worry about a slippery slope. They say it might not work. But those are not good reasons to let people die. For the sake of the people dying on the transplant waiting list, let's give this a try.

Lloyd R. Cohen, Ph.D., J.D., is a Professor at the George Mason University School of Law. David J. Undis is Executive Director of LifeSharers.


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