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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     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  | *This paper was prepared solely to aid discussion for the September 2006 meeting, and does not represent the official views of the Council or of the United States Government.*

**Staff Discussion Paper**
Organ Transplantation Policies and Policy Reforms
**By Sam Crowe and Eric Cohen**
**Organ Donation Policy**
**Outline**
**Introduction: The Human Goods at Stake in Organ Transplantation Policy**
**I. The Current Policy**
- State Laws 
-  Federal Laws 
- Federal Regulations 
-   United Network for Organ Sharing Policies

**II. Recent Policy Initiatives and Recommendations**
-  Federal Bills 
-  The Advisory Committee on Organ Transplantation Recommendations
-   United Network for Organ Sharing Policy Recommendations 

**III. Alternative Policies in Other Countries**
-  Presumed Consent in Spain 
- Sweden's Law of Mandatory Choice 
- Iran's Organ Market 
- Organ Conscription in China 

**IV. Potential Policy Reforms**
- The Expansion of Education Programs 
- Remove Disincentives for Living Donation 
- The Use of Expanded Criteria Donors 
- The Promotion of Organ Exchanges                   - List Donation 
  -  Paired Exchanges 
-  The Alteration of Consent Laws                   - First Person Consent 
  -  Family Consent 
  - Mandatory Choice 
  - Presumed Consent 
  - Organ Conscription 
-  The Legal and Clinical Redefinition of Death                   - Cardiopulmonary Definition 
  - Higher Brain Definition 
  - The Self-Definition of Death 
  - Criteria for Dying Donors 
-  New Rewards or Incentives for Organ Donation                   - Public Honors 
  - Gifts to Charity 
  - Preferred Status 
  - Health Insurance 
  - Life and Disability Insurance 
  - Funeral Expenses 
  - Cash Payment for Organs 
-  Promote Medical Alternatives to Transplantation                   - Preventive Medicine 
  - Xenotransplantation 
  - Regenerative Medicine 
Organ Donation Policy 
**Introduction: The Human Goods at Stake in Organ Transplantation Policy**
        No matter how one frames the issue, the supply of organs is not meeting        the demand.� With over ninety thousand people and rising on the organ        waiting list, there is widespread interest in finding novel ways to        boost the organ supply-ranging from modest reforms of the current        system, such as better education about the benefits of organ donation,        to more radical proposals, such as organ markets, the redefinition of        death, and the retrieval of organs from deceased individuals without        their prior consent.� Yet alongside this understandable drive to        increase the number of available organs, there is also growing concern        that we have inadequate data about the long-term health consequences of        being a living donor (see Working Paper #1), and there is renewed        debate about whether brain-dead individuals are truly dead (see Working        Paper #2).� In our desire to advance the best system for donating,        procuring, allocating, and transplanting organs, in other words, we        confront the many tensions that exist in seeking the best possible        policy in this complicated area of modern medicine.      

        Three human goods, in particular, seem to guide both our current organ        transplantation policies and the myriad calls for reform.� The first        and perhaps most obvious good is *health*-both promoting the        health of those who suffer and sometimes die waiting for organs, and        protecting the health of those who willingly become living organ        donors. Everyone aches at the misery of the sick, perhaps especially so        when a remedy (like transplantation) is possible but not available.�        And everyone recognizes the major contribution of organ transplantation        to the good of human health and the relief of human suffering.� In        modern societies, the pursuit of health is an aim that unites even        those who disagree about much else.      

        The second human good is *freedom*, a principle embodied in the        requirement of consent in order to procure organs from both living and        deceased donors.� In liberal democracies in general and the United        States in particular, individuals are generally free to make their own        choices and control their own bodies, including the decision about        whether or not to donate their organs.� No one is *required* to        donate their organs, even if such a requirement would improve many        lives at a seemingly minimal cost.� In some cases, it seems, the good        of freedom preempts the pursuit of health, or at the very least, the        right of autonomy preempts the obligation to serve the health of        others.      

        The third human good, perhaps the hardest to define but in some ways        the foundation of the others, is human *dignity*.� Because human        beings possess such dignity, they are worthy of care and protection;        their health matters to us as an urgent moral concern.� And because        human beings possess such dignity, they are entitled to a sphere of        personal freedom; only in extreme circumstances would society as a        whole contemplate the conscription of an individual's body or body        parts.� Yet this distinctly human dignity also, at times, acts as a        limitation on the pursuit of health and the scope of freedom: there are        some things, we tend to believe, that even free individuals ought never        do, such as giving away all one's organs while still living.� Such an        act would no doubt help or save the lives of many organ recipients; it        would serve the health of many others at the cost of a single self.�        Yet such an act, even freely chosen, seems to be beneath our dignity as        human beings, and beneath the dignity of the surgeons who would be        called upon to perform the lethal act of procurement.� Saving the most        lives, it seems, is not the only concern when it comes to medical        ethics in general and organ transplantation policy in particular.      

        Often, in the context of organ transplantation, these three human goods        serve one another, as when an individual freely agrees to give his or        her organs at death as an act of altruism toward fellow citizens in        need.� At times, however, these human goods may come into conflict.� At        the very least, we must decide how much weight to give the pursuit of        health, whether to preserve or loosen the limits on freedom, and what        human dignity really demands of us.� As we consider the range of        specific policy proposals in the area of organ transplantation, we need        always to reflect on these more fundamental human goods and their        relationship to one another.      

        The purpose of this working paper is to inform Council members of the        current policies on organ transplantation and to provide them with a        brief sketch of the potential options for policy reform.� It consists        of four basic parts.� Part I highlights the most noteworthy laws and        regulations of the current system, and explains how these laws and        regulations combine to form existing U.S. policy on organ        transplantation.� Part II describes recent congressional and regulatory        proposals to alter the current system.� Part III briefly surveys the        organ transplantation policies that govern in other countries, looking        in particular at Spain's version of presumed consent, Sweden's use of        mandatory choice, Iran's organ market, and China's practice of organ        conscription.� Part IV describes a range of potential policy reforms        that the Council might consider for recommendation, from slight        adjustments to the current system to more radical changes in its        guiding principles and practical workings. This section aims to        categorize these various reforms and to offer a preliminary assessment        of the strengths and weaknesses of each option.      

**I. The Current Policy**
        There are four main kinds of rules governing the organ transplantation        process: state laws, federal laws, federal regulations, and United        Network for Organ Sharing (UNOS) policies.� The *state laws*        primarily cover issues pertaining to the donation process, such as the        criteria for declaring death, the consent requirements for being a        donor, the scope of public education programs, and the composition of        donor registries.� With a few notable exceptions, these laws do not        differ significantly from state to state.� The *federal laws*        primarily outline the processes of organ procurement, allocation, and        transplantation by establishing the Organ Procurement and        Transplantation Network (OPTN) and guidelines for organ procurement        organizations (OPO).� OPTN is the national organization that        coordinates, implements, and monitors the organ transplantation system        as a whole; OPOs are local or regional organizations responsible for        retrieving organs and notifying potential recipients.� The federal law        also sets boundaries on how organs might be transferred from one person        to another by prohibiting the buying and selling of organs.� The        *federal regulations* expand on the federal laws by describing how        the OPTN, OPOs, and transplant hospitals should function.� More        specifically, they explain the internal structure of the organizations        and the nature of their principal operations.� *UNOS rules*        further define the functions of the OPTN, and describe the policies        OPOs and transplant hospitals must follow in order to be members of the        OPTN.� Collectively, these laws, regulations, and rules affect every        group and every individual involved or potentially involved in the        donation, procurement, allocation, and transplantation of organs.� This        part of the essay describes in more detail the most significant state        laws, federal laws, federal regulations, and UNOS policies.      

*A. State Laws*

        The widespread uniformity among key state laws is not a result of        chance.� In 1968, the National Conference of Commissioners on Uniform        State Laws (NCCUSL)1        disseminated the Uniform Anatomical Gift Act.� The 1968 Act offers a        few main clarifications of how the donation process might occur.� It        declares who has the right to keep and to use a dead body.� It        proclaims that any eighteen year old with a sound mind may donate his        or her body after death to be used for medical research or as a source        of transplantable tissues and organs.� The Act also defines the        priority list of those who might donate the body if the person who died        did not declare a preference for or against donation.� By 1972, all        fifty states and the District of Columbia had adopted the 1968 Act.2

        In 1987, the NCCUSL revisited the issue with the intention of        increasing participation in organ donation.� It revised the 1968 Act in        a few main ways.� First, the 1987 Act explicitly states that the        declaration of a gift does not require any witnesses, whereas the 1968        Act required witnesses for the gift to be valid.� Second, the document        of a gift is sufficient for the removal of organs, which means the        procurement team does not need the consent of the spouse or the family        in addition to the document of gift.� Third, the 1987 Act requires that        hospital and medical personnel ask patients upon admittance if they        would consider being organ donors. This practice is commonly called        "routine inquiry."� Fourth, when a person who is dead did not        officially declare an interest or a lack of interest in donating his or        her organs upon death, hospital or medical personnel are required to        discuss with that person's relatives or surrogates whether or not they        would be interested in donating that person's organs.� This practice is        commonly referred to as "required request."� Fifth, the 1987 Act        permits the removal of organs by medical personnel without explicit        consent from a potential donor or from a relative of the donor, so long        as the appropriate medical personnel or authorities have made a        "reasonable effort" to discover any objection by the donor or the        donor's family.� Finally, the 1987 Act forbids the buying and selling        of organs, which reiterates the federal ban enacted in 1984.3� Since the promulgation of the        1987 Act, twenty-four states have adopted it.4

        In general, most states have similar laws regarding organ donation, as        a few examples will demonstrate.5� Every state recognizes the driver's license as a document of        gift.� Every state claims there are two loci of consent, the individual        person and that person's family.� Every state declares that an eighteen        year old can consent without needing parental permission.� Every state        has some form of an organ donation education program.� Most states have        a first person consent law, which means the document of gift is        sufficient evidence for proceeding with the procurement of organs.6� Most states have donor        registries.� Either the Department of Motor Vehicles (DMV) provides the        local OPO with donor information collected from driver's licenses or        the OPO collects the information itself.7� Finally, most states subscribe to the same        ways of determining death.8� These states base their definitions on the NCCUSL's Uniform        Determination of Death Act.9

        That said, there are a few exceptions to the uniformity of state laws        on organ donation.� The location of the donor laws within the different        state codes is one exception worth noting.� Thirty-four states        categorize their anatomical gift laws under a title that includes the        word "health," but the remainder of the states put their donor laws        under a variety of titles.� Louisiana uses the title "Education."�        Florida uses the title "Civil Rights."� Colorado and Kentucky put their        laws under a title that includes the word "professions."� New        Hampshire, Washington, and Wisconsin have their laws under titles that        include the phrase "human remains" or "dead bodies."� Alaska, Georgia,        Illinois, Indiana, Maryland, Minnesota, Montana, Ohio, Oregon, and        Pennsylvania encode their laws under a title that includes the words        "estates," "probate," or "property."� It might be worth considering        what each of these categories implies about decedents, their worth, and        their relation to the living.�      

        Another exception to the uniformity of state laws on organ donation is        the choice of some states to have anatomical gift funds.� Nineteen        states currently have gift funds for increasing public awareness about        the need for organ donation.� Ohio, which has some of the most donor        friendly laws of all the states, uses its fund not only to promote        awareness of need but also to support local and statewide programs that        publicly recognize donor families for the gift their deceased relative        has given.� In addition, Kentucky, Maine, and New York each dedicate a        day or a week to publicly recognize organ donors for their sacrifice.�        These are the only states that have such programs, though.      

        There is a final major exception to the uniformity of state laws on        organ donation.� A few states have laws that aim to limit or remove the        disincentives potentially faced by living organ donors.� A disincentive        here means any financial cost the donor might incur during the donation        process.� A few states choose to give state employees paid leave while        they donate organs.� The leave varies from two days in Colorado; to        thirty days in Delaware, D.C., Maryland, Missouri, Utah, and Virginia;        to six weeks in Ohio.� While Arkansas does not grant state employees        paid leave, it requires that private employers must grant unpaid leave        of absence for organ donation, and that if the employer grants paid        leave then the employer is entitled to a tax credit of 25% of the        regular salary paid to the employee.� Georgia law also grants a tax        deduction, but directly to donors for un-reimbursed donation costs of        up to $10,000.� Iowa uses 50% of its donor awareness trust fund to        cover the costs of living donors, recipients, and transplant        candidates.�������������      

        As the previous account demonstrates, state laws primarily cover the        process of donation, from the education of potential donors, to the        consent requirements to be a donor, to donor registries, and finally to        determining when a potential donor has died.� While state laws focus        mainly on the donation process, federal laws and regulations establish        the boundaries of acceptable practice for the procurement, the        allocation, and the transplantation of organs.10

*B. Federal Laws*

        The federal laws on organ transplantation are primarily found in Title        42 of the United States Code, which is called "The Public Health and        Welfare."11� This section        will describe five of the most important federal laws.12� These five laws frame the American        system of organ transplantation by establishing the organization that        guides the procurement, allocation, and transplantation of organs; by        recording the long-term effects of organ transplantation; by        restricting how organs might be transferred from one person to another;        and by assisting federal employees who become living donors.      

        Section 6327 of Title 5 of the United States Code declares that an        employee of any executive agency shall be entitled to take a leave from        work without a loss of pay in order to serve as a bone marrow or an        organ donor.� The employee may have seven days of paid leave to serve        as a bone marrow donor, or thirty days of paid leave to serve as an        organ donor.� The employee may take the paid leave only once per        calendar year.� This law supplements those laws at the state level that        reduce some of the costs, or disincentives, of organ donation.� It is        one of only a few laws at the national level that explicitly addresses        the situation of the organ donor and the process of organ donation.      

        There are two main laws that establish the organizational structure for        organ transplantation.� These laws are 42 USC Section 273 and Section        274.� Section 273 explains the guidelines to be a qualified OPO that        can receive federal grants.� To be eligible for a federal grant, an OPO        must be a nonprofit entity, have an agreement with the HHS Secretary to        be reimbursed for the costs of procuring kidneys, have methods to        receive payment for non-renal organs provided to transplant centers,        have a defined service area that assures effective procurement and        equitable allocation, and have met federal regulation performance        standards.� The OPO should also have agreements with most of the        hospitals in its area to identify potential donors, arrange for the        acquisition and the preservation of organs, have a system to allocate        the organs in an equitable manner, and participate in the OPTN.      

        Section 274 establishes the OPTN.� The OPTN serves as the main national        body that governs the procurement, allocation, and transplantation of        organs in the United States.� The OPTN must be a private nonprofit with        a board of directors.� It must establish a national list of people who        need organs, and a national system that matches organs and people on        the list.� It also must establish any membership criteria and medical        criteria for the allocation of organs, maintain a telephone service to        aid in the matching of organs with those who are on the list, assist        OPOs in the fair nationwide distribution of organs, and carry out        studies on how to improve organ procurement and allocation.� The HHS        Secretary must contract the establishment and operation of the OPTN.�        Since the enactment of this law, the United Network for Organ Sharing        (UNOS) has had this contract.      

        Section 274a establishes the Scientific Registry.� The Registry is a        national database on organ transplantation that includes national        transplant statistics, transplant center-specific reports, and        transplant research resources.� Similar to the case of the OPTN, the        Secretary of HHS must contract the development and maintenance of the        Registry to another party.� Currently the Arbor Research Collaborative        for Health, which was known as the University Renal Research and        Education Association until July 4, 2006, administers the Registry.�        The Arbor Research Collaborative for Health has conducted a few        significant research projects for the Registry.� They are: "Waitlist        and Transplant Activity for Liver, Kidney, Heart, and Lung 1995-2004,"        "Patient Survival Until Five Years After Transplant -- Patient        Transplant, 1998-2004," "Living and Deceased Donors -- All Organs,        1995-2004," "Number of ECD & DCD Kidney Donors By Year," "People        Living with a Functioning Graft at Year End by Organ, 1995-2005," "One        Year Unadjusted Graft Survival by Year," "Living and Deceased Donor        Kidney & Liver Transplants," "One Year Unadjusted Patient Survival        by Year," "Living and Deceased Donor Kidney & Liver Transplants,"        "One Year Unadjusted Graft Survival by Year, Heart & Lung," and "One Year        Unadjusted Patient Survival by Year, Heart & Lung."13� As this list of projects        demonstrates, the Scientific Registry offers one of the most        comprehensive sources of data on organ transplantation available.      

        42 USC Sec. 274e prohibits the buying and selling of organs.� Given        this law's significance to the current debate, it will appear here in        its entirety.

        -STATUTE-      

            (a) Prohibition                          It shall be unlawful for any person to knowingly acquire, receive, or            otherwise transfer any human organ for valuable consideration for use            in human transplantation if the transfer affects interstate commerce.        

            (b) Penalties                          Any person who violates subsection (a) of this section shall be fined            not more than $50,000 or imprisoned not more than five years, or both.        

            (c) Definitions                          For purposes of subsection (a) of this section:        

 (1) The term "human organ" means the human (including fetal)              kidney, liver, heart, lung, pancreas, bone marrow, cornea, eye, bone,              and skin or any subpart thereof and any other human organ (or any              subpart thereof, including that derived from a fetus) specified by the              Secretary of Health and Human Services by regulation. 

 (2) The term "valuable consideration" does not include the reasonable              payments associated with the removal, transportation, implantation,              processing, preservation, quality control, and storage of a human organ              or the expenses of travel, housing, and lost wages incurred by the              donor of a human organ in connection with the donation of the organ. 

 (3) The term "interstate commerce" has the meaning prescribed              for it by section 321(b) of title 21. 

            -SOURCE-       (Pub. L. 98-507, title III, Sec. 301, Oct. 19, 1984, 98 Stat. 2346;            Pub. L. 100-607, title IV, Sec. 407, Nov. 4, 1988, 102 Stat. 3116.)
-COD-      
        CODIFICATION      
            Section was enacted as part of the National Organ Transplant Act, and            not as part of the Public Health Service Act which comprises this            chapter.        

        -MISC1-      

        AMENDMENTS      
 1988 - Subsec. (c)(1). Pub. L. 100-607 amended par. (1) generally.�            Prior to amendment, par. (1) read as follows: "The term 'human            organ' means the human kidney, liver, heart, lung, pancreas, bone            marrow, cornea, eye, bone, and skin, and any other human organ            specified by the Secretary of Health and Human Services by            regulation."14

        These five laws outline the legal structure for the federal system of        organ transplantation.� The majority of this structure focuses on the        organizations that procure, allocate, and transplant human organs.�        This structure also establishes boundaries for the transferring of        organs.� Only those who provide the necessary services involved in        transplantation may receive payment for their contributions to the        process.� While living donors may receive reimbursement for the costs        of giving, organs must be given as gifts and without payment.�        Ultimately, however, the federal law is simply a framework and thus        necessitates supplementation.� The Department of Health and Human        Services has supplemented the law by creating a set of federal        regulations on organ transplantation.

*C. Federal Regulations*

        Title 42 (Public Health) of the Code of Federal Regulation has two main        parts on transplantation.� Part 121 of Title 42 describes the        regulations of the OPTN.� These regulations are called the "Final Rule"        and were first implemented on October 21, 1999.� The Final Rule has        guided the working of the OPTN since that time.� The second part        addresses the regulation of OPOs and transplant hospitals, and is found        under the heading of the Centers for Medicare and Medicaid Services        (CMS).� These rules explain what OPOs and transplant hospitals must do        in order to receive Medicare and Medicaid coverage.� One of the most        significant rules is that OPOs and transplant hospitals must be members        of the OPTN and abide by its policies in order to receive coverage.15� This section of the        working paper will focus on a few of the rules that describe the        functions and responsibilities of the OPTN so that the reader might        have a better sense of its significance in the organ transplantation        process.16

        42 CFR 121.4 lists a few kinds of policy the OPTN Board of Directors is        responsible for developing.� The categories are: policies for the just        distribution of cadaveric organs, policies for the testing of donors to        avoid the spread of infectious diseases, policies that shrink        inequities caused by socioeconomic status, and policies regarding the        training of transplant surgeons and physicians.� These policy        categories assist the implementation of the official mission of the        OPTN.      

        Section 121.5 of the same title explains the rules an OPTN member must        obey when including a person on the organ waiting list.� There are        three main rules.� The member transplant hospital may list a person        only for a designated transplant program.� The transplant hospital must        assure that candidates declared for transplantation are listed.� The        OPTN member must pay a registration fee to the OPTN for each person it        places on the organ waiting list.      

        The next section, 121.6, describes the requirements and tests for        determining the suitability of donated organs.� The OPTN member that is        retrieving the organs must guarantee that laboratory tests and clinical        examinations of the potential donors are conducted to determine if the        donation is safe to receive.� The transplant programs themselves must        establish the criteria for accepting a donated organ, and they must        provide these criteria to the OPTN.� These tests must also specifically        avoid the acquisition of organs from individuals infected with HIV.� It        is the responsibility of the OPTN to adopt the necessary standards for        this practice.�      

        42 CFR Sec. 121.7 explains how the OPTN identifies an organ recipient,        allocates the organ, and transports it to the recipient.� The OPTN        member must use the OPTN computer match program to identify and to rank        potential recipients.� The OPTN determines the order of rank of the        recipient by using its established organ specific allocation criteria.�        The procurement organization arranges for the transportation of the        organ to the hospital and assures that the organ is packaged properly.�        The transplant hospital has the right to reject the organ, and if it        does so, the procurement organization must offer the organ to the next        most eligible recipient.      

        Section 121.8 describes how the Board of Directors should develop        allocation policies to guarantee that they are both efficient and just,        and allocation performance goals to ensure the best possible use and        most equitable allocation of organs.� The policies must be based on        sound medical judgment. They must preserve the transplant program's        right to decline an organ.� They must be organ specific.� And they must        avoid wasting organs.� A few performance goals aimed at ensuring        equitable allocation include: the standardization of the criteria for        determining the suitability of candidates, the setting of priority        rankings expressed through objective and measurable medical criteria,        and the allocation of organs over as large a geographic area as        possible.      

        42 CFR Sec. 121.11 describes the recording and reporting requirements        of the various groups involved in the transplantation process.� The        OPTN and the Scientific Registry, as appropriate, must use a system for        managing information about transplant candidates, recipients, and        donors.� The OPTN and the Scientific Registry, as appropriate, must        submit to the HHS Secretary a report at least once every year on the        organ transplantation process.� The OPTN must provide to the Scientific        Registry information on transplant candidates and recipients.� They        must also provide information to the public on the performance of        transplant programs.� OPOs and transplant programs must maintain any        records pertaining to each potential donor, each retrieved organ, and        each recipient, and submit that information to the OPTN, Scientific        Registry, and HHS Secretary when necessary.      

        Section 121.12 establishes the Advisory Committee on Organ        Transplantation (ACOT).� The HHS Secretary may ask for ACOT's opinion        on proposed OPTN policies and any other issue the Secretary deems        necessary.� Part II of this essay lists a few of the most significant        ACOT recommendations.      

*D. United Network for Organ Sharing (UNOS) Policies*

        While federal regulation explains the framework of the OPTN and its        relationship with its member OPOs and transplant centers, this        regulation is only a small portion of the policy that dictates the        responsibility and action of the OPTN and its members.� The United        Network for Organ Sharing (UNOS) creates these other policies.17� UNOS is the organization that        administers the OPTN through a contract with HHS.� HHS awarded UNOS the        first contract for the management of the OPTN on September 30, 1986,        and UNOS has maintained control over the OPTN since that time.� While        UNOS and the OPTN are legally distinct, they are in practice the same.�        They have the same Board of Directors and the same policies.�        Basically, UNOS provides the substance that composes the OPTN.      

        UNOS has four main functions.� First, it facilitates the        transplantation process by ensuring that organs are procured and        allocated as quickly and as fairly as possible through the Organ        Center.� The Organ Center matches donors to recipients and organizes        the distribution process across the country with UNet, a nationwide        transplant computer system that the OPOs can access directly or through        the Organ Center.� Once the donor organ information is inputted into        UNet, it then lists the potential recipients who are ranked according        to the standards UNOS has created for each organ type.18� When a match is made and the potential        recipient's transplant hospital agrees to receive the organ, the        procuring OPO delivers the organ.�      

        Second, UNOS stores and disseminates information on organ        transplantation.� It collects data on each transplantation in the        United States and analyzes that data.� This process is similar to the        process performed by the Scientific Registry.� UNOS also promotes the        need for organ donation, which is a task it shares with the states.�      

        Third, UNOS develops policies for the OPTN.� The policy process has        multiple steps.� First a UNOS committee develops policy proposals.�        Then the committee writes and disseminates an initial brief explaining        the need for the proposed policy changes.� Next the committee asks for        public comments on the policy proposals.� The committee then responds        to the comments by the public and submits a final proposal to the Board        of Directors.� The Board votes on the proposal, and if the Board        approves the proposal it becomes UNOS/OPTN rule.� The Board can also        submit an approved proposal to the Secretary of HHS, and if the        Secretary approves the policy it is incorporated into official        regulation.�      

        Fourth, the UNOS Evaluation and Quality Department monitors OPTN        members to ensure their compliance with UNOS/OPTN policies.� While some        of the UNOS policies become official regulations, many do not and        remain "voluntary."19�        That said, OPOs and hospitals must abide by all of the policies if they        desire to remain members of the OPTN,20 so the policies are only voluntary if the OPOs or        hospitals do not desire to be members of the OPTN.� Most do because of        the conditions for receiving Medicare and Medicaid benefits.� So while        the policies are officially voluntary, they are in reality mandatory.      

        There are two main ways to distinguish UNOS membership: the type of        member and the region to which it belongs.� There are three different        types of members: OPOs, transplant hospitals, and histocompatibility        centers, with each member type having its own laws, regulations, and        rules that every member must follow.21� The members also belong to a specific region, which is        based on the members' geographic location.� There are currently eleven        regions.22� While these        categories divide the members, UNOS requires that each member obey all        of the UNOS rules that apply to it.      

        **

        These state laws, federal laws, federal regulations, and UNOS policies        comprise the bulk of policy on organ transplantation.� The state laws        cover primarily the process of donation, from the encouragement of        donation at local DMV offices, to documents of gift, to donor        registries, to the determination of death.� While a few federal laws        address donor issues, they primarily focus on the procurement,        allocation, and transplantation of donated organs by establishing the        OPTN, which governs these three processes.� The HHS is responsible for        creating regulations to guide the functioning of the OPTN, but leaves        the details of implementation of the OPTN to UNOS.� UNOS collects data        on transplantation; lists potential recipients; makes policies        governing the procurement, allocation, and transplantation of organs;        and monitors and enforces compliance to its rules and federal        regulations.� These four levels of policy govern the practice of organ        transplantation both region by region and nationwide.��      

        These four levels of policy also reveal a few of the main principles        and guidelines of the U.S. system of transplantation, each of them        serving in different ways the goods of health, freedom, and dignity        introduced above.� First, organ donation is a civic good and should be        supported; it ameliorates suffering and saves lives.� Second, personal        autonomy is central to the American experience and should be emphasized        in the consent laws that govern who donates.� Third, the family has        needs and wishes that should also be respected in the donation process,        especially in the first moments of mourning.� Fourth, citizens have        equal political rights, and this equality should be at least partially        reflected in the laws that determine the allocation of organs.� Fifth,        one important purpose of government is to protect citizens, and thus it        should ensure that the transplantation process is both safe and free        from coercion.� Finally, all human beings have a certain moral worth,        and this worth should be considered when defining how organs are given        and taken.� These guidelines, like the goods that they reflect,        sometimes support one another and sometimes are in tension with one        another.� Each of these guidelines plays an integral role in shaping        the current laws, regulations, and rules, as well as in many of the        recommendations for policy reform.

**II. Recent Policy Initiatives and Recommendations**
        While many of the state laws, federal laws, federal regulations, and        UNOS rules have proven useful and good, policymakers at all levels are        currently considering how to improve existing policy on organ        transplantation. This part of the working paper describes the most        important policy initiatives and recommendations at three of the four        levels of governance: federal bills, regulatory recommendations, and        UNOS proposals.23�      

        Central to many of these recommendations is the governance of organ        donation from living donors.� A couple of the federal bills described        below propose to further remove the disincentives a living donor might        face, while one bill proposes to expand the possible ways of being a        living donor.� A few of the regulatory recommendations argue for better        monitoring and oversight of the process of living donation, and one of        the two UNOS proposals described below recommends that transplant        hospitals should more closely monitor the health of living donors.�      

        Other significant themes include continued support for the prohibition        on the buying and selling of human organs, which is stated in one of        the bills and in one of the regulatory recommendations, and the desire        to alter the consent laws, the most notable example being the        regulatory recommendation that promotes the exploration of presumed        consent policies by the states.� The promotion of presumed consent is        the only policy recommendation considered in this section that would        radically alter the current policy system, though many of these        proposals are indeed significant.���      

*A. Federal Bills*

        In the 109th Congress, the House of Representatives and the        Senate have so far introduced twelve bills or resolutions that directly        address organ transplantation.� The House has introduced seven of these        bills or resolutions, the Senate has introduced four, and there is one        concurrent resolution.� Three of the bills presented in the House are        analogous to bills being presented in the Senate.� Of the twelve, this        essay will describe the most noteworthy.24

        The Living Organ Donor Job Security Act of 2005 (H.R. 1993) was        presented in the House on April 28, 2005.� It intends to amend the        Family and Medical Leave Act of 1993 by allowing leave for individuals        who provide living organ donations.� The following procedures are        included: tests used to determine whether the potential donor is        medically suitable; evaluations of the potential donor; pre-transplant        outpatient services; postoperative transplantation services; travel        connected with the tests, the evaluations, and the services; and        recuperation consistent with the type of transplantation.      

        The Living Organ Donor Tax Credit Act of 2005 (H.R. 2474) was presented        in the House on May 19, 2005.� It intends to amend the Internal Revenue        Code of 1986 to provide a credit to living individuals who donate        organs.� During the taxable year when the transplantation occurs, the        donor can receive the credit sum of the un-reimbursed costs and of any        lost wages as long as the credit does not exceed $5,000.      

        The Gift of Life Congressional Medal Act of 2006 (H.R. 4753, S. 2283)        was presented in the House and in the Senate on February 14, 2006.� It        intends to establish a congressional commemorative medal for organ        donors and their families.� The entity controlling the OPTN (currently        UNOS) must establish an application process that requires the relevant        OPO to submit documentation supporting eligibility.      

        The Living Kidney Organ Donation Clarification Act (S. 2306) was        presented in the Senate on February 16, 2006.� It intends to amend the        National Organ Transplant Act to clarify that kidney paired donation        and kidney list donation do not involve the transfer of a human organ        for valuable consideration.      

        House Resolution 794, which was presented on May 3, 2006, recognizes        the 17th anniversary of the massacre in Tiananmen Square.�        It describes China's policy of harvesting organs from executed        prisoners as "barbaric."� It calls for the Chinese government to "end        organ harvesting and ensure that its organ donor programs proceed only        on a purely transparent, voluntary, and non-commercial basis."      

*B. The Advisory Committee on Organ Transplantation        Recommendations*

        The Advisory Committee on Organ Transplantation (ACOT) was created by        42 CFR 121.12.� Its task is to advise the HHS Secretary on organ        donation, procurement, allocation, and transplantation.� One of its        most important functions is to advise the Secretary on "ways to        maximize Federal efforts to increase living and deceased organ donation        nationally."25� It also        reviews OPTN policies submitted to the Secretary.� ACOT has a list of        42 recommendations to the Secretary that it produced during annual        meetings from 2002 through 2005.� This section will list 20 of these        recommendations that seem most noteworthy.26� The recommendations will be repeated        verbatim from the ACOT Summary Recommendations to the Secretary.27

**Recommendation 1**: That the following ethical        principles and informed consent standards be implemented for all living        donors. The person who gives consent to becoming a live organ donor        must be:      
-  competent (possessing decision making capacity) 
-  willing to donate 
-  free from coercion 
-  medically and psychosocially suitable 
-  fully informed of the risks and benefits as a donor 
-  fully informed of the risks, benefits, and alternative treatment            available to the recipient. 

**Recommendation 2**: That each institution that performs        living donor transplantation provide an independent donor advocate to        ensure that the informed consent standards and ethical principles        described above are applied to the practice of all live organ donor        transplantation.      

**Recommendation 3**: That a database of health outcomes        for all live donors be established and funded through and under the        auspices of the U.S. Department of Health and Human Services.      

**Recommendation 4**: That serious consideration be given        to the establishment of a separate resource center for living donors        and their families.      

**Recommendation 5**: That the present preference in OPTN        allocation policy-given to prior living organ donors who subsequently        need a kidney-be extended so that any living organ donor would be given        preference as a candidate for any organ transplant, should one become        needed.      

**Recommendation 7**: That a process be established that        would verify the qualifications of a center to perform living donor        liver or lung transplantation.      

**Recommendation 9**: That research be conducted into the        causes of existing disparities in organ transplant rates and outcomes,        with the goal of eliminating those disparities.      

**Recommendation 10**:� That legislative strategies be        adopted that will encourage medical examiners and coroners not to        withhold life-saving organs and tissues from qualified organ        procurement organizations.      

**Recommendation 11**:� That the secretary of HHS, in        concert with the Secretary of Education, should recommend to states        that organ and tissue donation be included in core curriculum standards        for public education as well as in the curricula of professional        schools, including schools of education, schools of medicine, schools        of nursing, schools of law, schools of public health, schools of social        work, and pharmacy schools.      

**Recommendation 15**:� That the following measure be        added to the CMS conditions of participation: hospitals shall notify        organ procurement organizations prior to the withdrawal of life support        to a patient, so as to determine that patient's potential for organ        donation.� If it is determined that the patient is a potential donor,        the OPO shall reimburse the hospital for appropriate costs related to        maintaining that patient as a potential donor.      

**Recommendation 19**:� That the primary principle in        organ donation be honoring the donor's wishes and fulfilling the        donor's intent.� This principle is known as donor designation.      

**Recommendation 20**:� That updated provisions of the        Uniform Anatomical Gift Act with respect to donor rights be fully        implemented in all states where the UAGA has been adopted, and that        those or substantially similar provisions be enacted in all other        states.      

        ACOT specifically recommends that every OPO and hospital in a state        that has enacted the UAGA, as amended, should be educated in the        implications and enforcement of the UAGA.� ACOT further recommends that        OPOs and hospitals in states that have not adopted the amendments to        the UAGA, or substantially similar provisions, should work with their        state legislatures to enact laws that enforce the donor designation        model.      

        ACOT recommends that a comprehensive review and updating of the laws        governing anatomical gifts take place in each state and that all states        be encouraged to adopt laws intended to uphold the intent of donors.      

**Recommendation 22**:� That the use of split livers be        encouraged as a matter of national policy.      

**Recommendation 26**:� That Section 105 of Senator        Frist's bill (S. 573) be endorsed, so as to make clear that the term        "valuable consideration," in the National Organ Transplant Act of 1984,        does not include familial, emotional, psychological, or physical        benefit to an organ donor or recipient.      

**Recommendation 29**:� HHS should fund necessary research        initiatives, and convene a national consensus conference, updating the        criteria involved in end of life issues related to the determination of        death in the context of organ donation and transplantation.� The three        specific areas for review would be brain death, cardiac death, and        imminent death.      

**Recommendation 30**:� HHS should review the results of        the research conducted and national consensus conference convened in        response to Recommendation 29 and seek to resolve the many        reimbursement issues related to the determination of death in the        context of organ donation and transplantation.� These deal with        determination of brain death, cardiac death, and imminent death,        particularly with regard to ECD organs.� CMS and other appropriate HHS        agencies should also review their procedures with regard to living        donors to ensure that living donors are fully reimbursed, and further        that living donors are not disadvantaged with respect to their other        insurance needs.      

**Recommendation 36:**� The Advisory Committee on Organ        Transplantation (ACOT) recommends that the Secretary of Health and        Human Services (HHS) seek authority to identify and exclude certain        practices from the definition of "valuable consideration" in section        301(a) of the National Organ Transplant Act, as amended.      

        The Secretary's authority should be limited to legitimate and        beneficial practices that are intended to increase the supply of human        organs, without creating a commercial market for the purchase or sale        of human organs or posing a risk of coercion of a potential donor or        donor family.� In addition, the Secretary should be required to obtain        an appropriate independent ethical evaluation before excluding any        practice from the prohibition on valuable consideration.      

        ACOT has concluded that a process to limit the scope of "valuable        consideration" would encourage the development of ethical practices to        increase the supply of human organs and provide certainty to the        transplant community about the scope of permissible activities.�        Regulatory authority is both more flexible and more responsive to        innovation than an expanded statutory list of practices that are not        included in the term "valuable consideration."� The notice and comment        period will provide an opportunity for public and professional input        into any proposed regulation.      

        ACOT, therefore, recommends that Section 301 of the National Organ        Transplant Act be amended in its entirety to read as follows:      

            (a) Prohibition        

            It shall be unlawful for any person to knowingly acquire, receive, or            otherwise transfer any human organ for valuable consideration for use            in human transplantation if the transfer affects interstate commerce.        

            (b) Penalties        

            Any person who violates subsection (a) of this section shall be fined            not more than $50,000 or imprisoned not more than five years, or both.        

            (c) Definitions        

            For purposes of subsection (a) of this section:        

 The term "human organ" means the human (including fetal) kidney, liver,            heart, lung, pancreas, bone marrow, cornea, eye, bone, and skin or any            subpart thereof and any other human organ (or any subpart thereof,            including that derived from a fetus) specified by the Secretary of            Health and Human Services by regulation. 

 The term "valuable consideration" does not include the reasonable            payments associated with the removal, transportation, implantation,            processing, preservation, quality control, and storage of a human            organ, the expenses of travel, housing, and lost wages incurred by the            donor of a human organ in connection with the donation of the organ, *or such other practices that the Secretary of Health and Human            Services shall designate by regulation pursuant to subsection (d) of            this section.*

 The term "interstate commerce" has the meaning prescribed for it by            section 321(b) of Title 21.

 (d) T*he Secretary of Health and Human Services shall propose and            promulgate regulations to ensure that interpretations of subsection            (c)(2) do not impede legitimate and beneficial practices that are            intended to increase the supply of human organs available for            transplantation, provided, however, that any practice that poses a risk            of coercion in connection with the donation of a human organ or of the            creation of a commercial market for the purchase or sale of human            organs is not a legitimate or beneficial practice within the meaning of            this subsection (d). In considering legitimate and beneficial practices            that will be excluded from the prohibition on valuable consideration            set forth in subsection (c)(2), the Secretary shall seek an ethical            evaluation from an appropriate entity, including without limitation the            Institute of Medicine and the President's Council on Bioethics, or such            similar or successor entity.*

**Recommendation 37:**� The ACOT recommends that the        Secretary of HHS encourage states to undertake demonstration projects        to test the feasibility of adopting a model of presumed consent to        organ donation.      

**Recommendation 41:�** The ACOT recommends that the        Secretary of HHS direct the OPTN to develop allocation policy        pertaining to nondirected, living-donor organs.      

**Recommendation 42:**� ACOT recommends to the Secretary        that the OPTN be asked to expeditiously consider all issues associated        with the development of a registry for matching living donors and        recipients, paying particular attention to informed consent and the        monitoring of long-term outcomes of the donors.      

*C. United Network for Organ Sharing (UNOS) Policy        Recommendations*

        Unlike some of the federal bills and certainly quite a few of the ACOT        recommendations, recent UNOS proposals are relatively modest.� Since        the beginning of the year, UNOS committees have recommended ten policy        changes.� Most of these policy recommendations would involve subtle        alterations to current policy.� A couple proposals would require        somewhat more significant transformations.� Here we describe the two        most significant recommendations.28�      

        Proposal 1 (2/27/06): Currently a few regions have a system of        paybacks, where the region that receives a liver from another region        must "payback" the giving region with a liver.� The payback system        supposedly promotes the regional sharing of livers.� This proposal        argues that such a system is outdated by new protocols and it        recommends the disbanding of the payback system.      

        Proposal 2 (5/19/06): This proposal recommends that transplant centers        report organ function failure of living donors and living donor deaths        within 72 hours of awareness of the event.� Currently the collection of        this information occurs six months and one year after the        transplantation.� The committee members desire that the information be        made available in a more timely fashion.      

        **      

        The federal bills, ACOT recommendations, and UNOS proposals described        above provide some insight into the general direction of U.S. policy        reform.� The federal bills primarily aim to support living donation,        perhaps as a means to increase the organ supply.� The Living Organ        Donor Job Security Act and the Living Organ Donor Tax Credit Act        propose to remove some of the disincentives that might discourage or at        least increase the difficulty of living donation.� The Gift of Life        Congressional Medal Act proposes to provide an incentive to donate by        appealing to the potential donor's sense of honor.� The Living Kidney        Organ Donation Clarification Act proposes to exclude paired donation        and list donation from the meaning of valuable consideration.� These        bills aim at making living donation less costly, more rewarding, and        easier.�      

        But Congress is not committed to every imaginable way of increasing the        organ supply. House Resolution 794 states that certain practices of        providing more organs are inappropriate by calling for the Chinese        government to "ensure that its organ donor programs proceed only on a        purely transparent, voluntary, and non-commercial basis."� Thus        prohibiting the conscription and the purchase of organs trumps        Congress' desire to increase the organ supply.      

        ACOT shares Congress' desire to continue to ban the purchase of        organs.� But its recommendations also focus on a few other important        donation issues, namely improving the process of living donation,        increasing public awareness about the need to donate, and promoting        experimentation with presumed consent laws.� Recommendations 1, 2, 3,        and 42 very clearly express ACOT's concern for living donors.�        Recommendation 1 calls for improving informed consent standards for        living donors; Recommendation 2 proposes that transplant centers have        living donor advocates to protect the rights and represent the        interests of the donors; Recommendation 3 argues for the creation of a        database of living donors; and Recommendation 42 calls for the OPTN to        consider how to create a registry that would match living donors and        recipients.� These recommendations respect the need for more organs,        but they also seek to protect the health and well-being of those who        donate.��      

        ACOT also understands the need for an informed public.� In        Recommendation 11 it proposes that the HHS Secretary and the Secretary        of Education suggest to the states that they include a section on organ        donation in their public school curriculum.� Better education certainly        equals more informed citizens, but hopefully also more willingness to        donate organs.�      

        In Recommendation 37, ACOT introduces the only policy proposal that        would clearly lead to a significant change in the guiding principles        and governing framework of the current system.� It states that the HHS        Secretary should urge states to test the feasibility of "presumed        consent" laws.� As mentioned in Part I, most states have "first person        consent" laws.� A few states give the family members of a deceased        person some legal authority to determine if they would like to donate        their dead family member's organs.� Both kinds of laws are "opt-in"        policies, in which donation occurs only by request and only with the        explicit permission to donate. (There is a partial exception to this        general rule in some state laws.� This exception is explained more        fully below; see footnote 42.)� Presuming that the lack of declaration        means that the deceased person intends to donate would be a radical        alteration of the current practice by transforming the "opt-in"        policies to "opt-out" policies.� Such a policy shift would alter the        current policy by removing some of the responsibility of the individual        or the family to choose to donate and placing that power in the hands        of the government.�      

        It is also worth noting that Recommendation 37 involves a process        typically left to the states.� But it is not the only recommendation to        do so.� ACOT's recommendations cover public education, first person        consent laws, donor rights, and the determination of death.� All of        these issues are integral parts of the process of donation.� While ACOT        never explicitly says that the national government should address these        issues instead of the states, its status as an HHS advisory body        suggests a possible expanded scope for national governance and        oversight of the transplantation process.�      

        Perhaps the most difficult ACOT proposal to evaluate is Recommendation        36, which calls for an amendment to the federal law prohibiting the        sale of an organ for "valuable consideration."� On the one hand, this        recommendation seems to affirm the existing ban on the buying and        selling of human organs.� Yet it also seems interested in making room        for incentives that would boost the organ supply without creating a        "commercial" organ market.� The scope of this suggested change would        thus depend upon how the term "commercial" is interpreted.      

        Like ACOT, UNOS is also concerned about the health of living donors, as        Proposal 2 from May 19, 2006, demonstrates.� In this proposal, UNOS        calls for better monitoring of instances when a living donor's health        fails.� UNOS recognizes that living donors compose a significant part        of the donor pool and that the needs of these donors should be more        formally considered through established rules.�      

        In general, these proposals would not radically alter the current organ        transplantation policy.� Yet especially with the ACOT recommendations        on presumed consent and valuable consideration, they might plant the        seeds for more significant changes in current practice.� In Part IV, we        will consider a much wider range of potential policy reforms. Before        doing so, we consider in Part III a few organ transplantation policies        in other countries that differ significantly from our own policies.��

**III. Alternative Policies in Other Countries**
        Before discussing a sample of countries with alternative organ        policies, it is worth noting that the United States policy on organ        transplantation is fairly similar to that of most other democracies in        which organ transplantations occur.� The precise laws of these        countries are of course different from U.S. law, but they share many of        the same guidelines.� Most countries' laws reflect a belief that organ        donation is a public good that should be supported and increased.� Many        countries have some form of first person consent laws, where individual        citizens freely decide if they would like to be living donors and        freely determine the fate of their organs after death.� Many countries'        laws respect the wishes of the families of the deceased and request the        family's consent if a family member who died did not declare a clear        desire to donate or not donate.� Many countries do not permit or        support the buying or the selling of organs.� And many countries        protect their citizens from coercion to donate.29������������      

        Nevertheless, a few countries have vastly different policies on organ        transplantation than the United States, and these policies imply a        different set of guidelines. Considering a few of these approaches will        provide a broader perspective from which to evaluate United States        policy.� This section briefly describes Spain's presumed consent law,        Sweden's mandatory choice law, Iran's organ market, and China's policy        of organ conscription.30

*A. Presumed Consent in Spain*

        Spain is widely perceived in the transplant community as having one of        the best organ donation programs in the world,31 and many analysts believe that its presumed        consent law accounts for part of its success.� As mentioned above,        presumed consent in the organ donation context means that the        government and procurement organizations may assume that citizens are        willing to donate their organs at death if they do not state        otherwise.� There are two main kinds of presumed consent laws: "Strong"        presumed consent laws rely solely on the individual citizen to declare        himself or herself a non-donor. "Weak" presumed consent laws allow the        family members of a decedent to opt-out if they desire to do so.� Spain        has a weak presumed consent law, where hospital staff members always        approach the surviving family members-not to request permission to        procure organs, but to see if they would prefer not to allow        procurement to proceed as it normally would.32

*B. Sweden's Law of Mandatory Choice*

        In the spring of 1996 the Swedish health authority, Socialstyrelsen,        distributed enough pamphlets about organ donation to reach Sweden's        entire population.� The pamphlets specifically requested to know        whether or not each individual would like to donate his or her organs        at death.� In the summer of that year Sweden began implementing a law        that required each citizen to decide whether or not they wish to        donate, and what was a request in the spring became a command in the        summer.� This statute is commonly referred to as Sweden's "mandatory        choice" law.33� We cannot        say what the precise effect of this law has been, but we do know that        Sweden ranks relatively low in donation rates compared to other Western        countries.34����������      

*C. Iran's Organ Market*

        Iran's transplant program is one of the most active in the Middle        East.� Unlike most other countries in the world, the vast majority of        organs come from non-related living donors.35� And unlike in most other countries, many of        these donors receive payment for their body parts-typically        kidneys-which are legally bought and sold.� In Iran, donors are        actually vendors. The Charity Association for the Support of Kidney        Patients and the Charity Foundation for Special Diseases are the two        nongovernmental organizations that organize and monitor the organ        trade.� They match donors to recipients, and provide the donors with a        specific sum of money for the donation.36� Without this source of kidneys from living        donors, the organ supply would probably drastically diminish, in part        because of significant disagreement among Islamic scholars over the        guidelines for cadaveric donation.37

*D. Organ Conscription in China*

        In July 2006, China banned the buying and selling of human organs.38� Presumably this ban        might affect the Chinese policy of routinely harvesting organs from        prisoners, or at least those organs that the government is selling.�        The policy of organ conscription has its roots in the 1983 "Strike        Hard" campaign, which announced that China would begin executing common        criminals.� With this new supply of decedents, China then created the        "Rules Concerning the Utilization of Corpses or Organs from Corpses        from Executed Criminals" law the following year.� This law claims that        the government can use a prisoner's organs if that prisoner consents to        donate.39� In November        2005, at a World Health Organization meeting, the vice minister of        China's Ministry of Health disclosed that 95% of organs transplanted in        hospitals in China come from executed criminals, with the other 5%        coming from living donors.40� The first percentage is shockingly high, and given China's        human rights record one might rightly doubt that most prisoners who        surrender their organs freely consent to donation.� This doubt explains        why many organ transplantation scholars refer to the Chinese system as        organ conscription.      

        **      

        While the accounts of the practices of these four nations are very        brief, they highlight a few major differences from the U.S. system, and        in doing so help define more clearly the boundaries of our national        organ policies, most especially concerning the role of the government        in questions involving organ donation.� In the United States, the        choice to donate is left to the individual person or to that person's        family, and the decision that the person or the family makes is to        opt-in to the donation system, not to opt-out.� These guidelines        severely limit the government's power in determining who will donate.�        In systems that conscript donors (like China) or presume that donors        consent when they do not declare otherwise (like Spain), the government        plays a much larger role in the determination process.� The same can be        said for mandatory choice laws (as in Sweden): a government that        sponsors this type of law forces its citizens to make a decision,        whereas in the U.S. system the government offers every citizen the        choice to declare themselves potential donors but does not require an        explicit declaration of one's intentions.      

        As for the limits concerning the giving of an organ, the U.S.        distinguishes between "gifting" and "selling."� By not permitting the        buying and selling of organs, the U.S. system declares that gifting is        the only way organs can be procured.� Thus, unlike the case of consent,        the U.S. government is arguably more involved than some other nations        by legally prohibiting organ commerce.� A more libertarian system would        permit both forms of organ exchange-giving and vending-and leave        individuals free to decide for themselves, without government        interference, whether selling a body part made personal sense.      

        Clearly the U.S. government's role in the organ transplantation process        is fairly complex, but it is not arbitrary.� Our laws reflect our        liberal democratic principles, though not simply in a libertarian way.�        These guiding principles aim to protect personal autonomy, respect the        needs of the family, recognize the equality of American citizens,        defend the inherent worth of human life, and promote the pursuit of        health.� But it is also worth remembering that the current system        reflects certain judgments about the relevant meaning of and proper        balance among these principles.� Those who seek to modify current        policy, whether in a limited or a dramatic way, would alter how we        understand and how we balance the human goods that govern the system.�        We turn now to the range of potential policy reforms.�����

**IV. Potential Policy Reforms**
        As the preceding overview should make clear, organ donation,        procurement, allocation, and transplantation is a complex matter, both        at the level of clinical practice and of public policy.� This section        aims to provide an analytical survey of a range of possible policy        reforms.� It focuses primarily (though not exclusively) on reforms at        the level of public policy, not clinical practice, and in particular        (though again, not exclusively) on those policy reforms that would        require changes in state or federal law.� Some important areas of        reform are specifically not addressed-including changes in organ        allocation policy aimed at reducing organ waste and promoting equitable        distribution (addressed in Working Paper #3), new protections for        living donors to ensure that all procedures meet an acceptable level of        safety (addressed in Working Paper #1), and efforts to expand the pool        of deceased donors by establishing protocols for donation after        uncontrolled cardiac death (addressed in Working Paper #2).� In        addition to changes at the policy level, this section will explore,        albeit all too briefly, various scientific and medical efforts to        develop clinical alternatives to transplantation.      

        The potential policy reforms surveyed here are broken down into eight        thematic categories: (1) the expansion of education programs; (2) the        removal of disincentives for living donation; (3) the use of expanded        criteria donors; (4) the promotion of organ exchanges; (5) the        alteration of donor consent laws; (6) the legal and clinical        redefinition of death; (7) the creation of new rewards or incentives        for donation; and (8) the promotion of medical alternatives to        transplantation.� Each policy reform is described in terms of its        larger aims and its effect on existing policies and regulations.� Then,        briefly, the strengths and weaknesses of each proposed reform are        evaluated.      

*A. The Expansion of Education Programs*

        For the past few decades, education and outreach about the benefits of        organ donation-the "gift of life," as it is regularly called-have been        promoted, supported, or undertaken by the federal government, state        governments, and myriad private organizations.� These efforts could be        significantly expanded.� National campaigns might take the form of an        "organ donor awareness day," where the President and Congress issue        proclamations or commemoratives explaining the need for and virtues of        organ donation.� Congress might promote an extensive publicity program        that targets communities throughout the country that have low donation        rates.� States might have similar programs, and they might further        expand their education efforts at their DMVs, public schools, and        driver's education courses.� Local communities might also sponsor donor        awareness events, such as parades or carnivals.� One might even make        the education campaign more aggressive-by declaring organ donation a        national duty, or shaming those who do not register as organ donors as        "wasting the gift of life."      

        The strength of this policy option is that it recognizes the need for        more organs and the current ignorance of this need by many American        citizens, yet it does not require vast changes in the practical        workings and ethical guidelines of the current system.� The weakness of        this policy is that it is seen by many as an inadequate means of        significantly boosting the organ supply.� Numerous education programs        are already in place, and while surely useful and valuable, it seems        unlikely to many observers that more education alone will drastically        change donation behavior.      

*B. Remove Disincentives for Living Donation*

        Disincentives are the financial costs a potential organ donor might        incur during the process of living donation.� Some of the most        significant disincentives are: lost pay and forgone advancement due to        missed work; the costs of transportation, from the initial visit to        determine eligibility for donation to the final trip home after        transplantation and recovery; lodging and perhaps food during these        trips; and any other financial costs directly related to the donation        process.�      

        Already, the federal government and a few states have laws that aim to        ease the economic burden of being a living donor.� These laws mainly        apply to government employees and typically only reduce a portion of        the donation costs.� A more comprehensive policy would cover most, if        not all, of the financial costs incurred during the donation process.�        It might do so by providing expanded benefits for government employees,        tax credits to private employers who offer organ donor benefits to        their employees, or direct grants or tax credits to the donors        themselves.� The federal government explicitly excludes such forms of        reimbursement from the meaning of "valuable consideration," so policy        reforms in this area would not encroach on forbidden practices.      

        This policy presupposes that living organ donation is a public good, or        at least a useful means of supplying organs to those who need them.� It        aims to use public funds and public law to help altruistic individuals        help others in need, yet it does so without undermining the system and        spirit of organ "gifting."� It recognizes that giving an organ involves        a grave personal sacrifice, and that we should not make donation to a        loved one impossible for those who could not bear the burden of lost        pay or the extra out-of-pocket expenses.      

        The potential weakness of this policy is that the line between removing        disincentives and creating new incentives might become murky.� In the        name of reducing the burden of organ gifting, such a policy introduces        money and payment into the mix; donors get paid for being donors, even        if they are not paid for the organs themselves.� To remove a        disincentive is to create an incentive to donate, albeit a very small        one.� Moreover, covering such costs through the public purse would add        to the overall expense of organ transplantation to taxpayers, and there        might be better ways to invest public funds even if the goal is to        promote more organ donation.      

*C. The Use of Expanded Criteria Donors*

        One way to expand the potential pool of organ donors is to loosen the        health criteria for being a donor at death.� Already, as discussed in        greater detail in Working Paper #3 on organ allocation, we use both        "standard donors" who meet the strictest standards of eligibility and        "expanded criteria donors" who meet a looser, more discretionary        standard.� The UNOS Board of Directors defines the eligible dead donor        as an individual who is 70 years or younger and meets a very extensive        list of health requirements.41 There are two main ways of expanding this definition.� First,        the age limit might be increased to 75 or 80.� Second, some of the        health requirements imposed on potential donors might be reduced.�        Serious diseases such as AIDS would still disqualify the use of organs,        but less severe conditions might not.�      

        Expanding the criteria would require specific changes in the rules        governing organ transplantation.� UNOS would need to change its        definition of eligible death, but given that the current definition is        not federal regulation or law, Congress and the Department of Health        and Human Services would not need to change any of their policies.�        There might, however, need to be some updates of the informed consent        policies, letting recipients of older, less healthy organs know of the        increased risks of receiving such organs.� In addition, the rules of        allocation might need to be altered to accommodate this new tier of        organs.      

        Such a policy is rooted in the principle that in some cases the risks        of an imperfect organ are preferable to waiting for a higher quality        organ.� Such a policy would potentially make transplantation available        to individuals who would likely never receive an organ otherwise.�        Given that these organs would be less desirable than standard criteria        organs, those at the top of the waiting list might reject them,        believing that a slightly longer wait time will lead to a longer        lasting/better performing organ.� If this scenario in fact happens,        transplant centers might give these less healthy organs to the elderly,        including those whose other health problems make them marginal        candidates for transplantation.�      

        The major weakness of this policy is that by increasing the age and        loosening the health requirements of potential donors, we risk harming        those whom we desire to help.� We also risk introducing new layers        confusion into the allocation system, with doctors and patients forced        to decide, under pressure, whether to take a less healthy organ now or        hope for a better organ later.� For some, even considering such an        expanded criteria proposal demonstrates the need to consider more        aggressive ways of expanding the pool of healthy donors.      

*D. The Promotion of Organ Exchanges*

        One possible way to expand the donor pool is to promote and facilitate        organ exchanges. In some cases, an individual wishes to act as a living        donor for a loved one, but cannot do so because he or she is not        biologically compatible with the intended recipient.� An organ exchange        would permit the living donor to give his or her organ to someone else        in exchange for the intended recipient receiving an organ from another        source.� There are two main forms of such exchanges: list donations and        paired exchanges.

        1. List Donation      
        A list donation occurs when Donor A desires to give a kidney to        Recipient A, but the two individuals are not biologically compatible.�        Instead, Donor A gives a kidney to someone on the general kidney list,        and in exchange Recipient A receives a compatible kidney from the        list.� Depending on how such a policy is enacted, Recipient A could        receive a certain number points to improve his or her list ranking,        meaning he or she would get a kidney earlier but not immediately.� Or        the intended recipient could be moved up to the top of the list,        meaning that he or she would get the next publicly available kidney.      

        Some transplant hospitals across the country currently practice list        donation, but its legal status is somewhat ambiguous.� While the law is        presently silent on list donation, competing interpretations exist.�        Some believe that list donation might be considered a form of "valuable        consideration," because the donor receives a "reward" for donating        (i.e., the donor's desired recipient moves up the waiting list).�        Others believe that this form of exchange is a type of dual gifting, a        creative form of altruism that does not involve "valuable        consideration" as defined by the law.� The Living Kidney Organ Donation        Clarification Act, mentioned above, would clarify that list donation        does not involve valuable consideration and does not violate existing        law in any way.      

        The promotion of list donation might involve not simply ensuring its        protection under the law, but establishing protocols to encourage this        practice by making potential donors aware of this alternative means of        helping a loved one.� The case for list donation is that it allows two        patients to be helped instead of one; it adds a donor to the donor pool        who would not donate otherwise-a donor whose only motivation to give is        helping a *particular* person in need.� It is a way to strengthen        community, by binding individuals to one another in overlapping acts of        altruism      

        The argument against list donation is that it gives an unfair advantage        to those who have willing donors-though, of course, this situation is        always the case, given that those with compatible living donors do not        need to wait on the list.� The specific difference here is that the        desired recipient gets an organ from the public list, and it is        possible, in certain cases, that this form of exchange would        disadvantage those at the top of the list who are not potential        recipients of Donor A's organ but who are potential recipients of the        organ that might end up going to Recipient A.� In addition, some might        see list donation as a form of trading, no different than commerce even        if money is not involved.� This practice would mean reducing the body        and its parts to *objects* of trade; as such, the meaning of        gifting is blurred or ultimately lost.      

        2. Paired Exchanges

        A paired exchange is similar to list donation, but it involves two        living donors instead of one living donor and a kidney from the list.�        In other words: Donor A gives to Intended Recipient B, and Donor B        gives to Intended Recipient A.� Paired exchanges can also occur among        multiple pairs of donors and recipients.� For example: the donor from        pair A has a kidney that matches the recipient of pair B.� The donor of        pair B has a kidney that matches the recipient of pair C.� And the        donor of pair C has a kidney that matches the recipient of pair A.�        Each donor can then offer a kidney to a compatible recipient, allowing        three donations to occur instead of (in some cases) none at all.      

        The legal implications of paired donation are very similar to those of        list donation.� Many transplant centers throughout the nation are        currently practicing paired donation, but confusion still exists on        whether or not paired donation involves the transfer of organs for        "valuable consideration."� The moral arguments are also similar: to        some, this is a form of creative altruism that allows many individuals        to benefit; to others, it transforms gifting into exchange and body        parts into objects of trade.� With paired exchanges, however, there is        not even the possibility of disadvantaging anyone on the waiting list,        given that no publicly available organs are used.� Moreover, the fact        that all the donors are living makes it possible for them to know one        another, and thus to see one another as engaged in interconnected acts        of generosity.      

*E. The Alteration of Consent Laws*

        This category includes a range of policy options that would modify or        fundamentally alter the ways of consenting to organ donation.� While        any typology is an oversimplification, there seem to be five main kinds        of consent laws: (1) first person consent, which is when one becomes an        organ donor only by explicit personal consent; (2) family consent,        which is when the surviving family members give explicit permission for        a deceased loved one to be an organ donor; (3) mandatory choice, which        is when the government requires every adult citizen to use his or her        right to consent by declaring himself or herself either a donor or a        non-donor; (4) presumed consent, which is when the government assumes        that organs can be procured from the deceased unless the individual or        the family expresses the explicit desire to "opt out"; and (5) organ        conscription, which is when the government procures organs, from the        dead or even the living, without the individual having any real choice        to opt out.� In the United States, as we have seen, current policy        centers on first person consent, with surviving families almost always        consulted, both when the deceased person's wishes are unknown and even        when the decedent's desire to be a donor is clear.42� In what follows, we survey each of        these policies, beginning with where we are and then exploring the        range of possible reforms.

        1. First Person Consent

        Most states, as we have seen, have first person consent laws.� Simply        put, these laws stipulate that the individual person has the sole        authority to choose whether or not to donate his or her organs.�        Legally, neither the family nor the state can trump the person's        decision to donate or not donate.� But sometimes there is a difference        between law and practice.� In the case of a living individual who        wishes to donate a "non-essential" organ,43 the legality of first person consent is        typically upheld, so long as the consenting individual is deemed to        understand the risks and benefits of donation and is deemed medically        eligible to donate.� In the case of donation after death, however, the        situation is somewhat more complicated from the perspective of        consent.� When a declared donor dies, most procurement teams still        consult the surviving family members and do not procure the decedent's        organs if the family objects.� In those cases in which the deceased        person is not a declared donor, surrogates must decide on his or her        behalf-whether by seeking to discern what they believe the deceased        person would have wanted, or by doing what they believe themselves to        be right.� The most complicated cases involve situations in which it is        unclear who speaks for the deceased, or when there seem to be no family        members or surrogates at all to speak for the deceased.� In the latter        case, some states will not procure organs without explicit family        consent; other states have the option to proceed with procurement after        making a reasonable effort to get consent.      

        First person consent is described here as a policy "option" in the        United States precisely because it is not always strictly enforced.� To        strictly enforce such a policy in the context of deceased donation        would not change the law or governing principles of the current system,        but it would alter prevailing practice: specifically, in those rare        cases when the deceased person wished to donate but the surviving        family does not, it would mandate that the family's objections be        overridden and the decedent's organs be procured.� It would strengthen        even further the respect for personal autonomy that is so central to        the current system, at the possible expense of violating the wishes of        those in mourning. (Such a strict first person consent policy, one        should note, might also invite the creation of a "non-donor registry,"        so that individuals who wish not to have their organs procured at death        can make their desires legally clear.)      

        One might argue that the strength of a first person consent policy is        that organ donation is treated always as a personal        *choice*-freely embraced as a good by the one who gives, without        explicit coercion by others.� It enshrines the principle that        individuals do not belong to others, and that neither the state nor        anyone else can take one's body parts without the individual willingly        seeking to give them and explicitly authorizing their being taken.�        First person consent laws solidify the individual person's rights over        his or her own body even after death, by respecting the person's        autonomous wishes about the handling of his or her mortal remains.�      

        One might argue that the weakness of first person consent laws is that        they push the principle of autonomy too far, neglect the needs of        others, and forget the larger context in which individual persons        live.� This context consists of family, friends, and fellow        citizens-family and friends who need to accept the death of the one who        has died, and fellow citizens whose very lives sometimes hang in the        balance as they wait for transplantable organs.� Only by balancing the        autonomy of individual persons and the needs of others can family and        community be preserved.��

        2. Family Consent
        As just explored, the surviving family plays a central role-arguably        the central role-in actually deciding whether a deceased loved one's        organs are donated.� To enshrine what is standard practice into an        explicit, legally sanctioned policy would give family members the final        say about whether organs are procured, even in those cases in which the        deceased person is a registered organ donor.� Such a law would, in a        sense, make registering as an organ donor a signal of one's desires        rather than a binding legal contract. In those rare cases when an        individual's wishes and a family's wishes come into conflict, the will        of the living family members would prevail.      

        Given that most states have first person consent laws, strict family        consent laws would alter one of the fundamental guidelines of current        policy, though such a legal reform may not actually change what        presently happens at the bedside after death.� Moreover, like first        person consent laws, organs could only be removed with explicit        permission.� The body is given by the family; it does not belong to the        community or the state.      

        One might argue that the strength of such a policy is that it would        respect the role of family members in speaking for those who can no        longer speak for themselves.� It would respect the needs of the family        during the grieving process, and acknowledge that the deceased cannot        foresee in life the exact circumstances of their death, and that there        might be times when doing what the deceased person claimed to want is        not what is best for those who must remember him or her.������      

        One might argue that the core weakness of this policy is that it        weakens autonomy unnecessarily, and authorizes family members to        violate the explicit wishes of the person whose mortal remains they        were instructed to oversee in a particular way.� By ceding so much        authority to the family, some individuals may be denied the right to be        donors, and thus the right to have their death redeemed by giving life        to those whose organs are failing.� Families do not always have the        best interests of the individual members in mind, and this conflict of        interests is one reason why the individual person currently has        principal rights over his or her body.� And families in grief are not        always the most rational decision-makers, whereas a registered donor        has made a deliberate decision rather than an emotional decision in        crisis.

        3. Mandatory Choice
        A mandatory choice law would dictate that citizens must explicitly        choose whether or not they are willing to donate their organs.� By law,        individuals would be required to assume the status of donors or        non-donors, or else to declare explicitly that they wish their        surrogates to decide on their behalf at the time of their death.� In a        system that has "opt-in" consent policies, like the United States, the        person who does not declare an intention leaves the ultimate decision,        by default, in the hands of his or her surrogates at death. In a system        that has an "opt-out" policy, like Spain, the person who does not        declare an intention is presumed to acquiesce.� A mandatory choice law        would forbid this lack of explicit decision making.� It would force        people to speak autonomously for themselves, yet it would do so by        imposing a novel legal obligation upon individuals backed by the force        of the state.�      

        Mandatory choice laws would alter the U.S. system by removing the        option not to choose.� With every citizen required to make a        determination whether or not to donate, the family in all likelihood        would no longer play as central a role, except in those cases when        individuals remain silent in violation of the law, or when they        explicitly choose to put decision making authority in the hands of        others.      

        The strongest argument for such a law is that by forcing citizens to        choose, more citizens will agree to donate.� Combined with public        education, mandatory choice will awaken people to the good of organ        donation, and engage them in deeper reflection about how they wish to        have their bodies cared for after death.� In addition, mandatory choice        laws respect the right of the individual person to choose, and simply        require that the individual person use that capacity.� Such laws seem        to rest on the belief that the decision to donate is more justified if        made by individuals themselves rather than left to surrogates by        default, who can never fully know what the deceased person would have        wanted.      

        The strongest case against mandatory choice laws is that they would        undermine the very end they seek to achieve: instead of expanding the        number of donors, they would create a new class of explicit        non-donors.� Such laws would unduly impose upon the individual's        freedom not to decide, and would expect a decision about donation when        many citizens lack adequate understanding of what being a donor really        means.� Rationally or irrationally, some people fear that being a        designated organ donor will affect the quality of their care either in        crisis circumstances (like a heart attack) or at the end of life.�        These fears might lead many individuals to opt out of the donation        system, whereas their surrogates might have allowed donation after        death to occur for those who presently have no legally stated        intentions.

        4. Presumed Consent
        Presumed consent means that the government assumes that citizens agree        to donate their organs at death unless the individual or the family        explicitly declares otherwise.� Such policies vary based upon *how        easy* it is to "opt out" and based on who has the *authority*        to opt out: a hard presumed consent law might permit only the        individual, before death, to opt out, meaning that surviving family        members would have no authority to prevent organ procurement if their        deceased loved one had remained silent.� A softer presumed consent law        might authorize surviving family members to opt out, but only if they        take the initiative to intervene; or, such a law could require organ        procurement agencies to inform family members that organs are being        taken, giving them an explicit opportunity to opt out.      

        Presumed consent in any of these forms would alter the current U.S.        system.� Instead of *asking* the families of deceased individuals        who are not registered donors for permission to procure organs, OPOs        would *inform* them of the intention to do so.� It would change        our "opt in" system to an "opt out" system.� It would thus give the        government more authority over citizens' bodies, by presuming that all        individuals wish to surrender their bodies for public use after death.�        As William May has written, it would require those families who do not        wish to donate to reclaim their loved one's body at the very moment        when they must engage in the final acts of saying goodbye.      

        That said, the U.S. system does already have a limited form of presumed        consent.44� Section 4 of        the 1987 Uniform Anatomical Gift Act asserts that under certain        circumstances specific medical personnel may allow OPOs to remove        organs from the deceased if they are not able to find an available        surrogate to give consent.� Nearly half of all U.S. states have        codified the 1987 Act.� This policy clearly conflicts not only with the        earlier sections of the 1987 Act on first person consent and family        consent, but also with the general consent guidelines for organ        transplantation policy.� ��

        Presumed consent laws aim at increasing the organ supply, and they        assume that ordinary citizens are willing to give up their organs when        they die even if they do not explicitly declare an intention to do so.�        Unlike conscription, such laws aim to be rooted in a notion of        consent-not that the government owns everyone's body at death, but that        the government can presume that people wish to have their bodies used        to benefit others. Such a law aims to balance the rights of individuals        with the good of the community; it preserves the possibility of not        giving for reasons of conscience, while presuming that giving one's        organs is a civic good in which everyone should desire to participate.�        Another argument in favor of presumed consent is that it would allow        organ procurement to proceed without burdening the family with such        matters in the first moments of their mourning.      

        The case against presumed consent is that such a policy transfers too        much authority to the state.� Consent needs to be *given* by        individuals, not presumed.� Consent requires being informed, whereas        many individuals do not understand all that is entailed in being a        donor.� Rather than presuming every individual's consent, it is better        to allow family members or surrogates to decide on behalf of those who        never made their intentions known, and to do so in light of an informed        conversation with a designated requester. Such laws would place a        special burden on those families who do not wish to donate, by forcing        them, as said above, to reclaim the loved one's body in order to say        goodbye.

        5. Organ Conscription      
        An organ conscription policy would mandate that all available organs be        removed from the deceased, regardless of the wishes of individuals or        families.� Such a law is not at present being seriously contemplated in        the United States, but it is worth noting here to show what might be        embraced by those who take the pursuit of health as their only or most        important guide to organ policy.� A conscription policy would maximize        the number of available organs from deceased donors, and it would        eliminate the added complexity of creating donor registries and seeking        permission from surviving family members.� It would treat organs as a        societal resource that the needy have a right to acquire.� Just as we        might conscript individuals to act as soldiers in wartime, we might        conscript the newly dead to act as sources of spare parts in the        struggle to save or improve the lives of those suffering from organ        failure.� It would take something that the dead will never need again        to give it to the living who desperately need it.�      

        One might also contemplate the conscription of kidneys from living        donors-for example, by giving every 25-year old a lottery number,        subjecting them to basic medical screening, and working one's way down        the list of healthy conscripts until everyone who needs an organ has        received one.� This would, in effect, shift resources from those who        have more than they need (two functioning kidneys) to those who have        less than what they need (no functioning kidneys).� From a utilitarian        perspective, it might maximize national health.� It would focus on the        needs of those who suffer most.      

        Yet most people find such the prospect of organ conscription ethically        indefensible or even abhorrent, because it violates both individual        freedom and human dignity.� It turns individuals and their bodies into        resources of the state; it transforms organ donation from a generous        act of altruism into a mandatory act of surrender; it violates the        conscience of those who wish not to be donors; and in the case of        conscription from living donors, it would force healthy individuals to        put themselves at risk and coerce doctors to perform surgery on        healthy, unwilling persons.      

*F. The Legal and Clinical Redefinition of Death*

        The definition of death and its relationship to organ procurement        practices is explored at great length in Working Paper #2, so it will        be dealt with only briefly here, merely for the sake of completeness.�        At present, nearly every state sanctions two standards for declaring        someone dead: a neurological standard (death of the whole brain,        including the whole brain stem) and a cardiopulmonary standard        (permanent cessation of heart and lung functions).� Critics of current        practice come from many different directions, but there seem to be four        basic alternatives that one might consider as policy options:      

*1. Cardiopulmonary Definition*: Some argue that even those who        meet the standard for whole brain death are not dead, or they argue        that the condition of brain-dead individuals is too ambiguous to make a        confident declaration of death.� They propose, therefore, that all        declaration of death be made according to cardiopulmonary criteria        alone.      

*2. Higher Brain Definition*: Some argue that those who have lost        the higher brain functions, even if they retain some autonomic brain        function, are already dead, because they have lost all those qualities        that are necessary for a distinctly human life.� They propose,        therefore, permitting the declaration of death by a more lenient        higher-brain standard, meaning that some individuals now considered        alive would be considered dead and thus potentially deceased donors.      

*3. The Self-Definition of Death*: Some argue that because        defining death is such a biologically and morally ambiguous matter,        individuals should be permitted to declare, by means of a living will,        which reasonable definition of death should apply to them-ranging from        the strictest cardiopulmonary standard to the whole brain-death        standard to the higher brain-death standard.      

*4. Criteria for Dying Donors*: Some argue that we should        disentangle the question of defining death from the question of who is        an eligible donor.� This would mean developing clinical and legal        criteria for permitting organ removal from the severely debilitated        and/or the nearly dead-that is, that class of patients whose medical        condition is defined as futile and/or for whom death is imminent.�        Rather than debating interminably the best definition of death, they        argue that we should establish protocols for using dying donors.      

        The moral arguments and practical implications of these different        possible reforms are explored in great length, as noted, in Working        Paper #2.� The first three policy reforms-cardiopulmonary definition,        higher brain definition, and the self-definition of death-would require        explicit changes in state law, specifically in the version of the        Uniform Determination of Death Act adopted state by state.� The final        option-developing criteria for dying donors-would seem to necessitate        granting legal authority to surrogates to declare dying individuals as        eligible donors or legal authority to individuals to declare in their        living wills the medical conditions in which they desire to be donors.�        It would also seem to require the creation of eligibility standards at        the level of clinical practice-that is to say, a determination of how        sick, how disabled, or how close to death a patient must be for        physicians to licitly remove a person's organs, vital organs included.      

*G. New Rewards or Incentives for Organ Donation*

        One range of policy options involves creating new incentives or        offering new rewards for being an organ donor.� While disincentives are        the costs that originate with the act of donation, incentives are the        rewards offered to those who donate.� These potential incentives vary        significantly in type, and include: (1) public honors or medals for        organ donors and/or their families; (2) gifts to charity in the name of        the donor; (3) preferred status as a potential donor recipient; (4)        health insurance coverage for living donors or insurance premium        reductions for those who agree to donate their organs after death; (5)        life and disability insurance for living donors; (6) payment of a        deceased donor's funeral expenses; (7) cash payment for organs, with        either fixed prices set and paid by the government or a true organ        market with prices set by the laws of supply and demand.� We will        consider each of these options briefly in turn.

        1. Public Honors
        Public recognition of organ donors might take a variety of forms: a        medal or plaque that the federal or state governments present to the        living donor or the deceased donor's family; a memorial for organ        donors with each donor's name inscribed; an annual day of recognition,        with each new donor's name read aloud at a public ceremony.� Honoring        donors in this way would elevate them in the eyes of their fellow        citizens; it would pay tribute to their generous act of gifting.      

        Currently, only a few states provide honors to organ donors.� In        Kentucky, the Governor conducts an annual ceremony honoring organ        donors.� In Maine, the Governor publicly recognizes one donor,        recipient, or listed person per year during the Organ Donor Awareness        Day celebration, and presents five donors with the "Gift of Life"        award.� In New York, a donor is awarded the "New York State Gift of        Life Medal of Honor."� And in Ohio, local and statewide programs        recognize families of deceased donors.�      

        The federal government also recognizes donors.� The last few presidents        have published proclamations celebrating organ donors and donations.�        Currently both chambers of Congress are deliberating over the Gift of        Life Congressional Medal Act of 2006, which would provide donors and        their families with a commemorative medal.�      

        Such programs could be expanded without altering existing law or        policy, so long as such honors are not interpreted as a form of        "valuable consideration."� The strength of such an initiative is that        it elevates public awareness of the good of organ donation and rewards        those who donate without turning organs into commodities or undermining        the principle of "gifting."� It recognizes the virtue of citizens        freely choosing to assist one another, and thus helps stave off the        individualism that liberal democracies sometimes foster.� The argument        against such a policy is that it is an inadequate incentive for        increasing the number of organ donors, or (alternatively) that it        elevates the good of organ donation too much, transforming a private        choice into a civic duty.      

        2. Gifts to Charity
        Another way to honor organ donors and potentially create new incentives        for organ donation is to make a charitable donation in the donor's        name.� The donor or donor's family could pick a charity of their        choice, and the federal government, state governments, or private        philanthropies could make a contribution as a way to honor or remember        the donor's altruistic act.� Such a policy might achieve multiple goods        at once: spurring more people to donate, providing a way to remember        donors who have passed away, and expanding the nation's philanthropy in        general.      

        Yet some might argue that, especially for living donors, the prospect        of such a charitable gift might become the reason, or a reason, to        donate.� It would introduce cash payment into the mix in a novel        way-not to cover the costs of donating, but as a reward for donating.�        Moreover, in order to really act as an incentive, such gifts would need        to be more than mere token contributions, and if funded by federal or        state governments, such a program would be a considerable public        expense.� Some might also worry about which charities donor's would        choose, and what criteria, if any, should be established for eligible        recipients of these charitable gifts.

        3. Preferred Status      
        One way to honor or reward living donors would be to give them        preferred status as organ recipients were they ever to suffer organ        failure themselves.� As discussed at much greater length in Working        Paper #3, this is already, to some degree, standard practice: living        kidney, liver, and lung donors are given extra priority points as        potential kidney recipients; because they donated organs, they in        effect move up the waiting list to receive organs.� This policy could        be expanded-both by moving living donors even higher up the kidney list        and by expanding the policy to include liver, lung, heart or other        types of organs that a past donor might need in the future.      

        Defenders of such a policy see it as a form of reciprocity or even        care: that is, those who potentially put their health at risk by giving        up one of their organs to help another should be helped first if and        when they need an organ themselves.� In particular, those who suffer        kidney failure later in life after having given a kidney seem to        deserve first priority as kidney recipients.� This is not an incentive        to donate so much as a way to care for willing donors.      

        Yet those who oppose preferred status argue that one's status as a        prior donor is not a relevant criteria in determining whose need for an        organ, in the present, is most medically urgent.� This is especially        the case for those organs-like livers-for which there is no alternative        to donation in urgent cases, and thus where medical need alone is the        only sensible criteria for allocating a scarce resource.� Furthermore,        some argue that being an organ donor does not necessarily give one a        special claim on available organs; everyone in need should be treated        equally.� They argue that one's previous actions, for good or bad,        should not advantage or disadvantage one's claim to medical care, which        should be allocated according to medical criteria alone.      

        4. Health Insurance      
        Some argue that living donors should be provided extended or lifelong        healthcare coverage in return for being donors.� Rather than seeing        this as an incentive to donate or a reward for being a donor, it might        be defended as the only responsible way to care for donors, who require        follow-up visits and whose long-term health may be compromised by their        gift.� Just as organ donors do a public good by helping or saving the        life of another, ensuring the physical well-being of living donors        through healthcare access is a public responsibility.� This is        especially the case for lower income donors, who might not get the        short-term and long-term follow-up care they need because they lack the        resources to pay for it.      

        Yet some argue that guaranteed healthcare, in a country with so many        uninsured persons and with the costs of healthcare continuing to rise,        would become for many persons a reason to donate.� This would create a        situation in which people put their health at risk in order to ensure        access to healthcare-a perverse situation, in the eyes of many,        especially in an affluent country.� In order to avoid this moral        hazard, one could restrict such healthcare benefits only to those who        donate an organ to a family member, to ensure that receiving health        insurance is not itself the motivation for gifting.� Some believe,        however, that offering health insurance in exchange for organs is a        morally legitimate and even morally praiseworthy incentive, especially        for the poor.� Those without health insurance might be healthier over        the long-term with one less kidney if they have access to the best        doctors and hospitals for life.� Such a system might, in fact, benefit        the health of both donor and recipient alike.      

        Such a program would of course add a new public expense.� And it might        also create a perverse incentive: at present, healthcare coverage is an        incentive to work; with coverage guaranteed for life, that incentive        might disappear.      

        Another incentive plan would offer registered organ donors (i.e., those        who agree to give their organs at death) reduced health insurance        premiums.� Such a program would reward those who agree to be a benefit        to the healthcare system as a whole with a healthcare related benefit        for themselves.� Yet, at least in the private market, it is unclear how        much of a cash value could be placed on agreeing to be a donor at        death, since most individuals do not die in such a way that organ        procurement is possible.� Unless subsidized by government in the form        of a rebate, such a policy would offer a very small premium reduction        and thus a limited incentive-though it may be that even a token        reduction is enough to motivate people to declare themselves organ        donors.� Moreover, unlike providing health coverage to living donors,        which can be defended as a form of care, giving potential donors a        premium reduction is simply a cash benefit, raising the moral questions        explored more fully below in the context of direct cash for organs.      

        5. Life and Disability Insurance      
        Some argue that living donors should be given a life and disability        insurance benefit to protect their families in those rare cases when        living donors die or become permanently disabled as a direct or        indirect result of giving an organ or part of an organ.� As with health        insurance, this can be defended as a form of *care* for living        donors, not payment for being a living donor.� After all, living donors        would prefer *not* to receive such a benefit, since it comes only        at the cost of their own death or disability.� Moreover, such a benefit        would be one way of ameliorating some of the risk of being a living        donor-i.e., the risk of leaving one's family uncared for in the        unlikely event that donation leads to death or disability.� One might        even define such a benefit as a way of removing disincentives rather        than creating novel incentives for donation.      

        Some argue that, as with health insurance, life insurance is still a        cash benefit that could become a reason, if not the reason, to donate.        (As with a health insurance benefit, a life and disability benefit        could be limited to interfamily donation only.)� More deeply, some        argue that the need for such a benefit points to a deeper problem with        living donation itself: the fact that donors put not only themselves,        but also their families, at risk by being living donors.� Of course,        they often do so in the name of another family member.� The question,        also raised in Working Paper #1, is whether some kinds of inter-family        donation are more ethically sound than others-for example, husband        giving to wife or sister giving to brother, as opposed to daughter        giving to father or parent giving to grandparent.      

        6. Funeral Expenses
        Another way of rewarding or honoring organ donation is to pay for some        portion of a donor's funeral expenses.� Such a policy could work in        multiple ways: providing a cash benefit or tax credit to the families        of deceased donors; providing rebates to funeral homes that offer        reduced prices to donors; or putting money every year in a special        account for everyone who maintains themselves in a donor registry.�        Such policies could also vary in the size of the benefit-from a token        payment, as a way to honor the memory of the donor, to full coverage of        all funeral expenses, as a way to increase the donor pool by making        donation financially appealing to individuals and families.� Such a        policy would reward those who do a public good with a public honor, and        it would ameliorate the economic burden some families face in providing        a proper burial and proper remembrance for their loved one.� Moreover,        it would create an additional reason to be a donor without putting a        cash value on particular organs or treating the body as alienable        property.      

        Critics of such a proposal believe that paying a death benefit of this        sort might deform the care of individuals in their final days, or        create divisions at death among family members who disagree about        whether to take money in exchange for a loved one's organs, even in the        limited form of reimbursement for funeral expenses.� In general, they        worry about opening the door to payment for organs, or making        compensation a reason or the reason to donate.� On a practical level,        some argue that incentives for deceased donors will have only a limited        effect on boosting the organ supply, given that for most individuals        and families, the willingness or unwillingness to donate at death turns        on moral and psychological considerations; the prospect of        reimbursement is not likely to turn non-donors into donors, or family        members who say no into family members who say yes to donation.� Where        incentives can have the largest impact-for better or worse, depending        on one's perspective-is in the rate of living donation, by giving        healthy individuals a reason to sell their organs to strangers.� There,        not funeral expenses, is where the action is.      

        7. Cash Payment for Organs      
        One of the most discussed proposals for increasing the organ supply is        to allow individuals to sell their organs.� The idea of monetary        incentives takes a variety of forms, and given its prominence in recent        debates, it merits a somewhat more extended discussion.� Such a system        of payment could involve *living donors* who agree to sell their        organs in the present, *deceased donors* whose appointed        surrogates are paid at the time of organ procurement, or *potential        donors* who sell the future rights to their organs if and when they        become available at death.� Some believe cash payment should only be        permitted for deceased donors, where the possibility for harm is more        limited.� Others believe that cash payment would have the greatest        impact, by far, in increasing the supply of organs from living donors        turned vendors, by giving them a monetary reason to supply their organs        that would not exist otherwise.      

        One specific proposal is for the federal government or state        governments to pay organ vendors directly.� This could involve either        paying a fixed price for each individual organ (most relevant to living        donors, who might sell a kidney, part of a liver, or part of a lung) or        paying a fixed price for the right to procure all available organs        (relevant only to deceased donors).� Defenders of "fixed price, public        payer" compensation proposals seek to distinguish them from true organ        markets: they argue that the compensation would be public, not private,        and thus would represent the appreciation of the entire community        rather than a private contract between parties.� Moreover, a public        compensation system for increasing organ procurement could be kept        separate from the system of organ allocation so as not to endanger the        equity of organ allocation, whereas the right to sell one's organs        in the open market would likely give special advantages to wealthy        prospective buyer-recipients.� Of course, the government could also set        prices for organs without being the payer; or it could create hybrid        arrangements, such as giving private insurance companies rebates and        tax incentives for buying organs on behalf of their clients.      

        A different proposal would permit and promote the buying and selling of        organs in the open market, with prices and practices set by supply and        demand, just as with other valuable commodities.� Most likely, such a        system would give rise to organ brokers who act as middle-men, matching        prospective buyers with potential sellers, and matching both suppliers        and recipients with a medical facility that can perform the procurement        and transplantation.� It would likely include both "spot markets,"        where living individuals or relatives of the deceased could sell their        organs now; and "futures markets," where living individuals could sell        the rights to their organs if and when they die in a manner that makes        organ recovery possible.� The highest prices would likely be paid for        living organs from healthy donors, who provide not a potential future        commodity but an actual present commodity.� The future rights to one's        organs would likely command a far lower market price because most        people do not die in such a way that organ retrieval is actually        possible. There already exists a black market for living organ donors,        suggesting that the most likely organ sellers would be the very poor at        home and especially abroad, who see their organs as a valuable economic        asset, and who judge that selling them is a way to improve their        quality of life.      

        A truly free market in organs would affect not only organ procurement        but organ allocation: the wealthiest individuals would have readiest        access not only to the most organs but to the best organs.� Most        likely, a two-tier system would evolve, with the wealthy securing their        organs from living donors in the private market and the less affluent        joining the public waiting list for organs from the deceased that are        donated rather than sold.� Some seek to develop a system that would        permit organ selling in the free market while preserving a system of        organ allocation that is dictated by moral and medical criteria rather        than market criteria.� But others believe that such a division between        procurement and allocation is problematic, since it would prohibit the        creation of a motivated buyer pool (i.e., those who need organs for        themselves or their loved ones) and thus would prevent supply and        demand from setting prices.      

        The argument for financial incentives is rooted primarily in the desire        to increase the organ supply and thus ameliorate the current suffering        and potential death of those on organ waiting lists.� Advocates argue        that organs should be treated like any other commodity, where the free        market effectively brings supply and demand into balance, and that we        already permit the buying and selling of blood, sperm, and human        oocytes. They see concerns about the "commodification of the body" as        vague and unconvincing, especially when they stand in the way of the        concrete good of saving lives by potentially expanding the organ        supply, and especially when there are wealthy people desperate to buy        organs and poor people desperate to sell them, an exchange that        mutually benefits both parties.      

        A second, related argument for permitting organ selling is the desire        to expand the scope of human freedom.� Advocates argue that free choice        should dictate the provision of organs; that those individuals who        believe selling a "redundant organ" could improve the quality of their        life should be permitted to do so; and that it is condescending to        protect the poor (or anyone else) against the rational choices they        might make for themselves, including the decision to sell part of their        body.� They note, quite correctly, that everyone else involved in the        organ transplantation business-the doctors, the health insurance        companies, those working for organ procurement organizations, and so        on-profits in some way from the practice of organ transplantation,        except for those who supply the most valuable asset: the organs        themselves.� They further argue that permitting individuals to sell        their organs would not prevent anyone from giving their organs; vending        and gifting could co-exist, allowing everyone to act on the values they        hold dear.      

        The most common objection to payment for organs is that such monetary        incentives would exploit the poor, who would bring harm to themselves        motivated only by money. Of course, to defenders of organ markets, the        freedom to sell their organs extends opportunity to the poor, who stand        to benefit the most from this new freedom and expanded ownership over        their own bodies.� They would not be coerced to sell their organs; they        would merely be given the option to do what many poor people want to do        anyway (and in some cases are doing already); and they would be lifted        up from the dangerous underground market, where the health of the donor        is a low priority, to a regulated system of compensation, in which all        exchanges are legal and provide adequate safeguards for donor health.�        Yet critics of organ selling believe that in a wealthy society like our        own, we do not really benefit the poor by encouraging them to believe        that the only way or best way to make ends meet is to sell their body        parts-that is, to sell "assets" that require no work, no skills, and no        possibility for long-term self-improvement.� They argue that, in fact,        we consign the poor to hopelessness if the only hope we extend them is        the one-time sale of a kidney.� And while it is true that everyone else        in the business of organ transplantation is paid for their services,        they are paid because of their professional skills, not for selling        their bodies.      

        When it comes to deceased donors, critics of cash payment fear that        adding money into the mix would only disrupt the already difficult        period of mourning.� It could lead to new tensions among surviving        family members who disagree about the propriety of taking money for        organs; it could tempt surrogates to alter the course of care in order        to get paid; it could (in the case of "futures markets") give a third        party a commercial claim on the body that trumps the interests of the        surviving family, whose wishes and needs as mourners might violate the        business arrangement entered into years ago by the deceased.      

        Yet perhaps the strongest objection to organ selling is that some        people believe it would invite us to see the body as a mere thing, like        any other commodity or natural resource. The market works efficiently        by making things generic and therefore interchangeable; the price        system is effective because it can put a price on anything, with little        regard for what the thing *is*.� In many cases, this reduction of        things to comparable quantities is desirable, since it allows different        commodities to be traded, and thus allows a multitude of different        producers and consumers to obtain what they need and dispose of the        valuable things they wish to sell.� But in some cases, as with the        human body, the market's blindness to what a thing is arguably debases        those who trade in it.� The very efficiency that would come from        depersonalizing the source of organs-by treating them as mere        resources, not as parts of this embodied person-makes the whole        enterprise, in the eyes of some, morally compromised.� Even if a market        in dead bodies were to increase the organ supply-which many opponents        of organ sales readily admit-they believe that the cost of putting so        explicit, so impersonal a price on the body is too high for society as        a whole.      

        These worries about commodification are especially significant, some        people believe, when we consider buying organs from living (and        probably mostly poor) donors.� Living donors necessarily expose        themselves to some harm, an exposure that makes greatest moral sense        when done to benefit a family member or friend as an act of love.� It        makes less moral sense, they argue, as an act of commerce.� True, the        motive to sell one's organs might still be love: namely, the desire to        benefit one's family with the proceeds of one's sale.� And the poor,        merely by being poor, are no doubt already exposed to a variety of        risks comparable to or greater than the risks associated with giving up        a kidney. But even if this is so, some argue, it does not justify the        act of organ removal by physicians, whose willingness to put a healthy        donor at risk is rooted in the direct connection between the donor's        sacrifice and the donor's desire to see a *particular* person        benefit from the organ he has given.

*H. Promote Medical Alternatives to Transplantation*

        Most of the policy reforms considered above are animated by the desire        to increase the organ supply and thus come to the aid of those now        waiting for transplantable organs. Other policy proposals involve        ensuring that donors, both living and deceased, are treated with        dignity and never exposed to undue risk or insufficient respect.�        Another approach-not incompatible with current policy or with the        reforms considered above-is to look for ways to decrease the        *need* for organs by preventing organ decline or repairing organ        failure without requiring human organs.� All we can do here is        highlight three notable strategies, each of them worthy of much greater        consideration and analysis: (1) preventative medicine; (2)        xenotransplantation; and (3) regenerative medicine.

        1. Preventative Medicine
        Preventative medicine means exactly what its name suggests: keeping        people healthy so they do not get sick.� Some of the more common        preventative measures include eating a healthy diet, exercising,        getting enough rest, not smoking, not drinking to excess, and taking        preventative medications that halt or slow down bodily decline.� By        living more responsibly early in life, one might not need a        transplantable organ later in life.�      

        Nearly everyone would applaud and support such measures.� Yet        preventative medicine necessarily has limits.� First, it does not help        those who already suffer or are destined to suffer from organ failure.�        Second, even if preventive measures delay bodily decline, deterioration        is inevitable.� And third, some people enjoy their vices, and perhaps        are even willing to pay the cost later in life.� It may be that        preventative medicine will change the prevailing causes of death, such        that the body shuts down as a whole rather than certain parts needing        replacement.� In this sense, it might ameliorate one of the miseries of        organ failure: knowing that an extended quality of life is possible if        only an organ were available.� And preventative medicine might surely        allow individuals to be healthier longer, unburdened by renal failure        or heart troubles.� But in the end, we will almost certainly continue        to look for alternative ways to treat organ failure, in addition to        ways that aim to prevent it.

        2. Xenotransplantation      
        Xenotransplantation involves transplanting organs from non-human        species into human patients.� At present, xenotransplantation is a        theory, not a possibility.� Grave obstacles remain-from the uncertain        biological compatibility of non-human organs with the human body, to        worries about introducing deadly animal diseases into human        circulation, to worries about the long-term viability of animal        organs.� But there is interesting research, albeit speculative,        underway in this area.� If it were possible and safe,        xenotransplantation might solve a crucial problem: most people believe        it would be morally licit to harvest animals as sources of life-saving        organs and to kill animals in order to procure their life-saving        organs.� The supply would thus more than meet the demand, and it would        do so in a way that might be less morally hazardous than other        potential routes of boosting the human organ supply.      

        3. Regenerative Medicine and Artificial Organs
        Another alternative to human organs would be the possibility of        repairing existing organs or building new ones from scratch.� Such a        prospect, at present, is wholly speculative. But exciting work in        fields like nanotechnology, stem cells, and the creation of artificial        organs might, in the future, offer us a solution to our problems.� Some        of these methods, of course, introduce their own novel moral problems.�        And, as with preventative medicine and xenotransplantation, they offer        little help to those now waiting for organs or those who will need them        in the years just ahead.      

        **      
        This section has attempted to lay out a range of possible policy        reforms for the Council's consideration.� As it deliberates, the        Council would do well to keep in mind the human goods at stake in our        organ policy-health, freedom, and dignity central among them-as well as        the moral and practical arguments for preserving crucial elements of        the current system.� In an area as complex as organ transplantation,        the pursuit of some goods always risks compromising others, and the        preservation of even the most important goods may leave us to endure a        heavy weight-including the weight of those who suffer and often die        waiting for organs that never come.      

_______________________ 
ENDNOTES
 1. The NCCUSL is a          non-profit association of commissioners from each state in the Union,          the District of Columbia, Puerto Rico, and the Virgin Islands.� The          association was founded in 1892 in response to a growing          interdependence between the states.� The NCCUSL was designed to          create uniform statute proposals on significant issues that each          state might adopt and declare law.� It is important to remember that          the NCCUSL does not create law, but rather recommends models that          might then become law.� For more information on the NCCUSL, see their          website, www.nccusl.org.�          
 2. www.nccusl.org          
 3. www.nccusl.org          
 4. This number is          according to the NCCUSL website.� The states that have adopted the          1987 Act are: Alabama, Arizona, Arkansas, California, Connecticut,          Hawaii, Idaho, Indiana, Iowa, Minnesota, Montana, Nevada, New          Hampshire, New Mexico, North Dakota, Oregon, Pennsylvania, Rhode          Island, Tennessee, Utah, Vermont, Virginia, Washington, and          Wisconsin. 
 5. For further details on          the breakdown of the organ donation laws among the states, see the          spreadsheet at the end of this essay.          
 6. The exceptions are          Massachusetts, Mississippi, and New York.          
 7. The exceptions are          Maryland, Mississippi, New Hampshire, South Carolina, and West          Virginia.          
 8. There is one main          exception.� New Jersey's law states: "the death of an individual          shall not be declared upon the basis of neurological criteria          pursuant to sections 3 and 4 of this act when the licensed physician          authorized to declare death, has reason to believe, on the basis of          information in the individual's available medical records, or          information provided by a member of the individual's family or          any other person knowledgeable about the individual's personal          religious beliefs that such a declaration would violate the personal          religious beliefs of the individual.� In these cases, death shall be          declared, and the time of death fixed, solely upon the basis of          cardio-respiratory criteria pursuant to section 2 of this act."          
 9. The NCCUSL promulgated          the Act in 1980 in order to help clarify the "medical determination          of biological death."� The Act states: "an individual who has          sustained either irreversible cessation of circulatory and          respiratory functions, or irreversible cessation of all functions of          the entire brain, including the brain stem, is dead.� A determination          of death must be made in accordance with accepted medical          standards."� It is worth noting that the NCCUSL left the Act          sufficiently vague to permit adjustments in determining death in two          ways.� First, the Act gives physicians the discretion to determine          the meaning of "irreversible."� Second, the Act states that death          must be determined by using "accepted medical standards."� This          clause allows physicians to use new forms of medical technology to          determine death, and thus to be more precise in their determination          as technology advances.� For more details on the Act, see the          NCCUSL's website, www.nccusl.org.�          
 10. There is one major          exception.� Roughly a third of the states have "hoarding laws," which          declare that organs procured within the state must first be offered          to a citizen of that state before they are offered to a citizen of          another state.� The states are permitted to have these laws because          the HHS has not officially regulated organ allocation.� The rules          governing allocation are simply UNOS rules, and the states are not          legally bound to obey them. 
 11. The few exceptions          reside in: Title 5 (Government Organization and Employees), Title 8          (Aliens and Nationality), Title 10 (Armed Forces), and Title 18          (Crimes and Criminal Procedure).          
 12. For those who are          interested in the laws not described here please see the following.�          8 USC Sec. 1611: Aliens who are not qualified aliens are ineligible          to receive organ transplantations using federal public health          benefits.� 8 USC Sec. 1621: Aliens who are not qualified aliens are          ineligible to receive organ transplantations using state and local          public health benefits.� 10 USC Sec. 1109: Establishes an organ and          tissue donor registry for the armed forces personnel.� 18 USC Sec.          2721: Prohibits the release of personal information from state motor          vehicle records with an exception of organ donation information.� 42          USC Sec. 274b: Lists the general provisions respecting grants and          contracts made by the federal government to OPOs.� 42 USC Sec. 274c:          The HHS Secretary must designate and maintain an administrative unit          that provides technical assistance to the groups involved in the          transplant process and that provides information to the public about          organ transplantation and about the national and state resources          available for transplantation.� 42 USC Sec. 274d: Every two years the          HHS Secretary must produce a report on the scientific and clinical          status of organ transplantation and submit it to Congress.� 42 USC          274f: The Comptroller General of the United States must report on the          efficiency and fairness of organ procurement and allocation by          January, 1992.� 42 USC Sec. 274g: Authorizes appropriations for          carrying out this part of the law on organ transplantation.� 42 USC          Sec. 1320b-8: Establishes the hospital protocols for participating in          the program.� 42 USC Sec. 1395rr: Explains the end stage renal          disease program of Medicare.���          
 13. For more          information, see the Registry website: /www.ustransplant.org/">www.ustransplant.org.          
 14. From Supplement III          of the 2000 edition (January 19, 2004) of the United States Code.          
 15. See Section 1138 of          the Social Security Act of 1986 and the Federal Register Notice for          the OPTN, October 20, 1999.          
 16. For those who are          interested in the regulations not described here please see the          following.� 42 CFR Sec. 121.1: Defines the applicability of 42 CFR          Sec. 121.� 42 CFR Sec. 121.2: Defines the terms used in this part.�          42 CFR Sec. 121.3: Explains the OPTN structure.� 42 CFR Sec. 121.9:          Lists the designated transplant program requirements.� 42 CFR Sec.          121.10: Describes how HHS conducts reviews, evaluations, and enforces          rules.� 42 CFR Sec. 405.2100: Gives definitions for the end-stage          renal disease (ESRD) program.� 42 CFR Sec. 441.35: Explains federal          funding for state projects.� 42 CFR Sec. 441.40: Discusses Medicare          and end-stage renal disease.� 42 CFR Sec. 482.45: Explains conditions          of participation for hospitals in Medicare and Medicaid.� 42 CFR Sec.          485.643: Explains conditions of participation for critical access          hospitals in Medicare and Medicaid.� 42 CFR 486.301: Explains basis          and scope of conditions for coverage of OPOs in Medicare and          Medicaid.� 42 CFR 486.302: Defines terms used in this subpart.� 42          CFR 486.304: Lists general requirements for designation as member of          Medicare and Medicaid.� 42 CFR 486.306: Explains qualifications for          designation as an OPO member of Medicare and Medicaid.�� 42 CFR          486.307: Defines OPO service area size designation and documentation          requirements.� 42 CFR Sec. 486.308: OPOs that are members of Medicare          and Medicaid must also be members of the OPTN.� 42 CFR Sec. 486.309:          Explains recertification requirements.� 42 CFR 486.310: OPOs that are          members of Medicare and Medicaid must adhere to certain performance          standards.�� 42 CFR Sec. 486.316: CMS designates only one OPO per          service area.� 42 CFR Sec. 486.318: Lists requirements for changes in          ownership or service area of an OPO that is a member of Medicare and          Medicaid.� 42 CFR Sec. 486.325: Lists kinds of termination of          agreement with CMS. 
 17. The information          provided in the next couple of pages can be found on the UNOS          website: www.unos.org.          
 18. For more information          on the allocation standards please see Part 3 of the UNOS policies.          
 19. See 1.07C of          Appendix C to the Bylaws of UNOS.          
 20. See 1.0 (Member          Rights and Obligations) of UNOS policies.          
 21. For more information          on the different requirements for membership, see Appendix B of the          UNOS Bylaws.�          
 22. Region          1-Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island,          Vermont; Region 2-Delaware, District of Columbia, Maryland, New          Jersey, Pennsylvania, Northern Virginia, West Virginia; Region          3-Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Puerto          Rico; Region 4-Oklahoma, Texas; Region 5-Arizona, California, Nevada,          New Mexico, Utah; Region 6-Alaska, Hawaii, Idaho, Montana, Oregon,          Washington; Region 7-Illinois, Minnesota, North Dakota, South Dakota,          Wisconsin; Region 8-Colorado, Iowa, Kansas, Missouri, Nebraska,          Wyoming; Region 9-New York; Region 10-Indiana, Michigan, Ohio; Region          11-Kentucky, North Carolina, South Carolina, Tennessee, Virginia. 
 23. The states certainly          serve as an important testing ground for policy innovation, and while          a comparison of state bills would be extremely useful to have in this          part of the essay, the vastness of this project precludes its          incorporation here.� If a Council member is interested in the organ          transplantation bills of any particular state, the information can be          provided. 
 24. For those who are          interested, here is a list of the bills and resolutions that will not          be described in this part of the essay.� 109th Congress,          1st Session-H. Con. Res. 124: Concurrent resolution          "expressing the sense of the Congress regarding the importance of          organ, tissue, bone marrow, and blood donation and supporting the          goals and ideals of National Donate Life Month"; H.R. 2051:          Comprehensive Immunosuppressive Drug Coverage for Transplant Patients          Act of 2005; H.R. 3633: Medicare Fairness for Organ Transplant          Recipients Act of 2005; S. 173: Comprehensive Immunosuppressive Drug          Coverage for Transplant Patients Act of 2005; 109th          Congress, 2nd Session- H.R. 5209: Safe Tissue Act; S.          2609: Safe Tissue Act. 
 25. ACOT Charter.          
 26. Please see /www.organdonor.gov/">www.organdonor.gov for a description          of the other recommendations.          
 27. The exception will          be Recommendation 36, which will include the complete recommendation          from the ACOT report.          
 28. To review the other          proposals, see the UNOS website, www.unos.org.          
 29. See A. Bagheri's          "Organ Transplantation Laws in Asian Countries: A Comparative Study" in *Transplantation Proceedings*, 2005, 37:4159-4162; Jose Osmar          Medina-Pestana and Valter Duro-Garcia's "Strategies for Establishing          Organ Transplant Programs in Developing Countries: The Latin America          and Caribbean Experience" in *Artificial Organs*, 2006,          30(7):498-500; Miriam Meijer's "World Attitudes Toward Organ          Donation" in worldtravelcenter.com's *Travel Health Newsletter*,          2000, Vol. 2, Issue 1; and pages 32-34 of the IOM's 2006 report *Organ Donation: Opportunities for Action*.�          
 30. These considerations          will be cursory.� A detailed account of the organ policy of each of          these countries is beyond the scope of this essay. 
 31. See Luskin's and          Delmonico's "Assessing Organ Donation from the Dead Should Not Be          Done by Reporting a Census of the Living" in *American Journal of          Transplantation*, 2003, 3:1185-1187; and pages 33-34 of the IOM's          2006 report *Organ Donation: Opportunities for Action*.          
 32. See Rafael          Matesanz's "Factors Influencing the Adaption of the Spanish Model of          Organ Donation" in *Transplant International*, 2003, 16:736-741;          B. Miranda's, J. Vilardell's, and J.M. Grinyo's "Optimizing Cadaveric          Organ Procurement: the Catalan and Spanish Experience" in the *American Journal of Transplantation*, 2003, 3: 1189-1196; and          Richard Luskin's and Francis Delmonico's "Assessing Organ Donation          from the Dead Should Not Be Done by Reporting a Census of the Living" in *American Journal of Transplantation*, 2003, 3: 1185-1187.          
 33. See Moussa Awuonda's          reports in *The Lancet*: "Swedish Organ-Donor Campaign Offends,"          May 4, 1996, Vol. 347, Issue 9010, pg. 1256; "Swedish Organ-Donation          Drive Set for Success," May 18, 1996, Vol. 347, Issue 9012, pg. 1401;          and "Swedish Organ-Donation Law Takes Effect," July 6, 1996, Vol.          348, Issue 9019, pg. 54. 
 34. See "Swedes Willing          to Donate Organs," in *Swedish Press*, March 2006, Vol. 77,          Issue 3, pg. 10; and pgs. 33-34 of the IOM's 2006 report *Organ Donation: Opportunities for Action*.          
 35. See Marwan A. Masri          et al. "Middle East Society for Organ Transplantation (MESOT)          Transplant Registry" in *Experimental and Clinical          Transplantation*, 2004, Vol. 2, No. 2, pgs. 217-220.          
 36. See Alireza          Bagheri's piece in *A Cross-Cultural Introduction to Bioethics*,          2005, pg. 165; Abraham McLaughlin et al. "What Is a Kidney Worth?" on *The Christian Science Monitor* website: www.csmonitor.com, June          9, 2004.          
 37. See Ghulam-Haider          Aasi's "Islamic Legal and Ethical Views on Organ Transplantation and          Donation" in *Zygon*, 2003, Vol. 38, No. 3, pgs. 725-734; Sahin          Aksoy's "A Critical Approach to the Current Understanding of Islamic          Scholars on Using Cadaver Organs Without Prior Permission" in *Bioethics*, 2001, Vol. 15, No. 5/6, pgs. 461-472; S.M. Akrami          et al. "Brain Death: Recent Ethical and Religious Considerations in          Iran," *Transplantation Proceedings*, 2004, 36, pgs. 2883-2887;          and Julie Corwin's "World: The Risks, Benefits of a Free Market in          Organs" on Radio Free Europe/Radio Liberty's website: www.rferl.org,          May 16, 2006. 
 38. See "China Bans          Human Organ Sales" in *United International Press*, July 2,          2006.          
 39. See Carl Becker's          "Money Talks, Money Kills-The Economics of Transplantation in Japan          and China" in *Bioethics*, 1999, Vol. 13, No. 3/4, 236-243.          
 40. See "Human Rights in          China" in *Congressional Quarterly*, April 19, 2006, and "A          Harvest of Horrors" in *Western Standard*, May 22, 2006.          
 41. See the Executive          Summary of the Minutes of the OPTN/UNOS Board of Directors Meeting,          March 22-23, 2006.          
 42. There is one major          exception to this rule.� Section 4 of the 1987 Uniform Anatomical          Gift Act declares that specific medical personnel may permit the          removal of organs from decedents without consent from the deceased or          from the family of the deceased.� It states: "(a) The [coroner]          [medical examiner] may release and permit the removal of a part from          a body within that official's custody, for transplantation or          therapy, if: (1) the official has received a request for the part          from a hospital, physician, surgeon, or procurement organization; (2)          the official has made a reasonable effort, taking into account the          useful life of the part, to locate and examine the decedent's          medical records and inform persons listed in Section 3(a) of their          option to make, or object to making, an anatomical gift; (3) the          official does not know of a refusal or contrary indication by the          decedent or objection by a person having priority to act as listed in          Section 3(a); (4) the removal will be by a physician, surgeon, or          technician; but in the case of eyes, by one of them or by an          enucleator; (5) the removal will not interfere with any autopsy or          investigation; (6) the removal will be in accordance with accepted          medical standards; and� (7) cosmetic restoration will be done, if          appropriate.� (b) If the body is not within the custody of the          [coroner] [medical examiner], the [local public health officer] may          release and permit the removal of any part from a body in the [local          public health officer's] custody for transplantation or therapy          if the requirements of subsection (a) are met.� (c) An official          releasing and permitting the removal of a part shall maintain a          permanent record of the name of the decedent, the person making the          request, the date and purpose of the request, the part requested, and          the person to whom it was released."� Nearly half of the states have          codified this Act. 
 43. A non-essential          organ here means an organ or a piece of an organ that the donor can          live without.
 44. Please see footnote          42 for further details.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           |