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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           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*This discussion paper was discussed at the February 2007 meeting. It is one of a series of papers prepared to aid the Council in its decisions about policy options in organ procurement, transplantation, and allocation. Each paper in the series is designed to facilitate and inform Council discussions and does not represent the official views of the Council or of the U.S. government.*
Increasing the Supply of Human Organs: Three Policy ProposalsStaff Discussion Paper 
**By Sam Crowe, PhD, Eric Cohen, and Alan Rubenstein**
As of January 18 th , 2007, there were 94,664 Americans on the OPTN transplant waiting list. Patients needing kidneys make up the largest group, accounting for roughly two-thirds of the list. By most projections, their numbers are likely to increase significantly in the next few decades. As Dr. Neil Powe explained to the Council during the June 2006 meeting, we are seeing only the proverbial "tip of the iceberg" of chronic kidney disease: those Americans who have kidney failure make up only a very small percentage of those who have chronic kidney disease. But the large numbers of Americans who are today creeping toward kidney failure are only a part of the picture: during the next few decades the baby boomers will become elderly and thus more susceptible to kidney failure; public health experts are predicting a surge in diabetes, which is one of the main causes of kidney disease; and American minority populations, which tend to have higher rates of kidney disease than whites, are expected to increase substantially. If Dr. Powe's analysis is correct, America is on the verge of a massive increase in the demand for transplantable kidneys.

Some have argued that the best way to address organ failure is not by seeking to increase the supply of organs from deceased or living donors, but rather through other means, that is, by exploiting the potential of preventive medicine and regenerative medicine. The first would aim at improving the health of the population, and would thus shrink the number of individuals needing kidneys (or other organs) in the future, while the second would provide alternative treatments for organ failure, such as regenerating organs using stem cells. If these methods were to achieve the results envisioned by their advocates, we could look forward to an eventual end of the organ shortage-and of the burdens of morbidity that fuel it.

There is good reason, however, to doubt that these approaches will produce the desired results. As for regenerative medicine, despite the progress that has been made, for example, in generating structurally integrated bladder cells, this solution is for now more theory than reality and will not constitute an effective response to organ failure in the near future.

As for preventive medicine, if there were a well-established national program with considerable support from-and participation by-the American public, it could inhibit the growth in the need or demand for organs, but it, too, faces serious limitations. Although some causes of kidney disease are probably preventable through healthy practices such as a good diet, exercise, and sufficient sleep, preventive medicine cannot ultimately forestall the natural aging of the body. As human beings age, their kidneys lose the ability to function properly, so much so that if a person does not die by other causes that person will die from organ failure. With a graying America , this complication cannot be overlooked. Also, as every nutritionist and yoga instructor knows, being healthy is difficult. Many Americans will not follow the strict regimen of diet and exercise necessary to get and stay healthy, and even for those who change their ways, the disease processes set in motion by years and decades of sub-optimal health habits are often not readily reversible. In light of these constraints, we can expect only so much from preventive medicine. If our aim is to satisfy the current as well as future demand for replacement organs, we have no choice but to look, first and foremost, to ways of increasing the organ supply.

This essay will describe three policy proposals that aim at increasing the supply of organs. Arguments for and against each proposal are given. Each proposal stands on its own and should be considered independently rather than in tandem with the other two. The first proposal concerns paired donation and list donation. The second proposal concerns donation after controlled cardiac death. The third proposal concerns cash payment for organs. As the Council considers each proposal, it is important to keep this crucial point in mind: expanding the organ supply is not the only aim of public policy in this area, important as it is, or the only standard by which potential reforms should be judged. Other ends and purposes, such as the health and well-being of potential donors, care for the dying and the newly dead, and the dignity of the medical vocation, must also be kept in mind.
**I. Paired Donation and List Donation**
Paired donation and list donation are creative forms of organ giving, allowing living donors who are biologically incompatible with their intended recipients to work together with one another, or in conjunction with the public waiting list, to make donation possible in cases when otherwise it would not be. In paired donation, two biologically incompatible, living donor-recipient pairs-pair A and pair B-can surmount the biological barriers to donation in this way: donor A gives a kidney to biologically compatible recipient B and donor B gives a kidney to biologically compatible recipient A. Paired donations can occur between and among multiple pairs of donors and recipients. With list donation, a living donor who wishes to give a kidney to a biologically incompatible recipient donates the organ, instead, to the first individual in line on the waiting list for kidneys; in exchange, the living donor's intended recipient receives the next available compatible kidney or a higher place on the waiting list.

Paired donation and list donation can be combined and used together in a "chain exchange." Chain exchanges, in their simplest form, entail two pairs (A and B) that do not qualify for paired donation, meaning that both donors do not match the recipients of the opposite pair. Instead, only the donor of pair A matches the recipient of pair B. In a chain exchange, the donor of pair A gives a kidney to the intended recipient of pair B, and the donor of pair B in turn gives a kidney to the general kidney list. The intended recipient of pair A then moves up the waiting list for kidneys.**1**

Paired donation and list donation are not new, untried ideas. Transplant surgeons in some centers have been matching donors and recipients and performing transplants in these ways for the past few years. In fact, there have been an estimated 62 list donations and 149 transplants using paired donations carried out in the United States.**2**Nevertheless, the legal status of these forms of donation remains in question, and in February 2006 the "Living Kidney Organ Donation Clarification Act" was introduced in the Senate. The aim of this bill is to clarify that paired donation and list donation do not fall under the prohibition against "valuable consideration."

Beyond clarifying the legality of these practices, there are two main ways that a policy promoting paired and list donation could be implemented. First, the OPTN could establish protocols for paired and list donation in a similar fashion as it has for the more conventional forms of donation. The OPTN would most likely create a national paired donation registry and clear rules to ensure that list donations do not unfairly disadvantage those who are already at the top of the waiting list, especially those with rare blood types. This approach would presumably bring many potential donors to the registry, and would unify the registry policy and living organ donation policy more generally.**3**

The second approach would consist of providing federal assistance to improve the science and application of regionally-based paired donation and list donation programs.  The federal assistance would be offered primarily to existing programs to subsidize patient registries, transplant coordinator salaries, education programs, and research and development.  By offering assistance primarily to existing programs, this approach utilizes the expertise that the regionally-based paired and list donation programs already possess. In this way, federal funds are not wasted creating new programs when well-managed programs already exist.**4**

If the Council wishes to lend its support to these forms of donation it could recommend passage by Congress of the Living Kidney Organ Donation Clarification Act or a similar bill, and encourage the creation of expanded and ethically responsible national/local protocols for paired donation and list donation. Passage of the Act would facilitate this creative form of donation, allowing generous potential donors to become actual donors. Through these measures, the bonds of community could be both widened and deepened, binding individuals to one another through mutual acts of generosity.

Yet these forms of donation raise some ethical questions. First, some argue that paired donation and list donation involve the giving of organs for valuable consideration, which is forbidden by current law. By way of proof, consider one of the main arguments in support of paired and list donation. Supporters claim that these forms of donation would increase the organ supply by encouraging those who would not normally donate to give an organ. What encourages these donors, or perhaps entices them, is that once they give an organ their loved one will gain a corresponding advantage by receiving either a transplanted organ or a higher place on the organ waiting list. Without this enticement, many of these donors would probably not even consider giving. Donation in these instances involves more than freely offering an organ with no expectation of gaining any advantage from the gift. Paired and list donation are, some might argue, forms of organ trading. They thus corrupt the morally preferable practice of pure gifting.

The second criticism applies only to list donation. As a quick reminder, list donation occurs when a donor gives a kidney to the transplant waiting list and the donor's intended recipient then in turn either receives the next available biologically compatible kidney or gains a higher place on the waiting list. Generally, those who are waiting for a blood-type O kidney face the longest wait of the different blood-types on the list because of the scarcity of O organs. An ethical dilemma arises when a person who is waiting for a blood-type O kidney has a biologically incompatible donor who is willing to donate a kidney to the general waitlist in return for seeing his or her loved one receive the next available O kidney or move up the O waitlist. Those who do not have a willing list donor must then wait even longer for a relatively scarce O kidney in an already slow moving line.**5** By this argument, fairness requires prohibiting list donation, or at least list donations involving an intended recipient with O blood-type, even if permitting this practice means that more patients get organs because more organs are available.

The third criticism also applies only to list donation. As noted previously, with list donation, the intended recipient of a donor who gives a kidney to the general kidney list receives a deceased donor kidney. Deceased donor kidneys have a shorter average lifespan than living donor kidneys. The ethical dilemma raised in this criticism is whether or not it is just for an intended recipient to receive a kidney that will not last as long as the kidney that the intended recipient's donor is donating to the general kidney list.**6**

The fourth criticism is of list donation's impact on paired donation. It is estimated that for a realistic maximum conversion rate using paired donation there must be around 250 incompatible pairs registered. With 250 pairs, roughly 50 percent of the recipients of these pairs would receive a kidney. To reach a 55 percent conversion rate, the registry would need 5,000 incompatible pairs.**7**Currently, most paired donation registries are aiming at 250 pairs, but even this relatively modest number of pairs is difficult generate. List donation only exacerbates this problem. When programs permit list donation, the number of incompatible pairs on the paired donation registry usually drops because these pairs are turning to list donation. When these pairs leave the paired donation registry, it becomes more difficult for paired donation programs to achieve the realistic maximum conversion rate. **8**

Finally, some argue that paired donation and list donation will not substantially affect the supply of transplantable organs. Between the two of them, they have accounted for slightly more than 200 additional transplants over the six years they have been used. With nearly seventy-thousand Americans waiting for kidneys, some see these options as welcome but wholly inadequate. 

**II. Donation after Controlled Cardiac Death****

In certain, well-defined clinical circumstances, doctors and family members may decide that continued life-sustaining treatment no longer benefits the life a given patient still has. In some cases, these dying patients are potential organ donors, whose organs can be removed once death is declared according to cardiac criteria. The practice of so-called "organ donation after controlled cardiac death" has been gradually increasing in recent years: in 1994 there were only 11 such donations, whereas in 2004 there were 366. Those 366 deceased donations produced 689 kidneys, 233 livers, 47 pancreata, and 10 lungs.**9**Advocates of the practice argue that it has as yet unrealized potential in the struggle to increase the supply of organs because some transplant centers and hospitals still do not have donation after controlled cardiac death protocols. 

Donation after controlled cardiac death should be practiced only within the framework of an explicit hospital policy articulating clear moral and clinical criteria. A morally sound hospital policy would include the following six criteria. First, the decision to withdraw interventions must be made independently of the decision to donate. Second, donors must receive the same end-of-life palliative care as non-donors. Third, the hospital should provide the potential donor's family with the option of being present when life support is withdrawn and, in general, take every measure to permit family and friends to say goodbye in a dignified way. In addition, families should not incur any additional costs related to donation. Fourth, procurement teams must wait the recommended amount of time (two to five minutes) after the permanent cessation of heart function before beginning the removal of the organs. Fifth, the medical staff overseeing withdrawal of interventions must not hasten the patient's death, even if the organs might become un-transplantable. Sixth, if patients do not die quickly enough to become donors, a procedure should be in place to move these patients to a location where they can die more peacefully.**10**In general, the desire to expand the practice of donation after controlled cardiac death should not encourage hospitals to proceed without transparent policies in place that ensure consistent and ethical practice. 

Several arguments can be marshaled in support of an expansion of the practice of donation after controlled cardiac death. First, it would increase the organ supply in a way that is consistent with current ethical standards: donors and/or families freely consent to donation; the patients are dead before becoming donors; and every possible effort can be made to respect the needs and wishes of the donor's family in the last moment of life and first moments of mourning. Second, it would provide the opportunity for individuals and families to donate in situations which now commonly do not lead to donation. And third, establishing clear protocols for donation after controlled cardiac death would help to ensure that a bright line is maintained between those patients who are already dead by neurological criteria and those who are still alive, although severely neurologically compromised. 

There are currently a few organizations that are attempting to further establish ethically sound donation after controlled cardiac death protocols. One of these groups is the Organ Donation Breakthrough Collaborative. The Collaborative began in the spring of 2003 when the Department of Health and Human Services paired up with key figures from the transplant community to spread "best practices" that aim at increasing access to transplantable organs. Education and training of medical and other health professional staff-in hospitals, organ procurement organizations, and transplant centers-are central to the initiative. The Collaborative also supports research to improve surgical techniques, organ preservation, and matching with potential recipients. **11**

The efforts of the Collaborative are in sync with actions being taken by OPTN and other groups to provide incentives to and requirements for hospitals to expand the practice of donation after controlled cardiac death. OPTN adopted a resolution in August 2005 to include in its bylaws a requirement that all participating organizations have a donation after cardiac death protocol in place by January 1, 2007. The organizations subject to this requirement include all OPOs and all transplant hospitals in which procurements occur. The requirement would not require hospitals without transplant centers to have protocols because the OPTN has no jurisdiction over these centers. A requirement to develop donation after controlled cardiac death protocols in every hospital is currently being considered by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).**12**The Council could lend its weight to these efforts by endorsing the practice of ethically responsible donation after controlled cardiac death. 

Concerns expressed by critics of donation after controlled cardiac death fall into a few general classes. The most significant of these is the concern that, even with explicit ethical guidelines in place, dying patients will come to be seen primarily as future donors, undermining the quality of their end-of-life care and unduly influencing the decision about when or whether to terminate life-sustaining treatment. If this is the case, there could then be the danger that the patient's death might be subtly hastened when the viability of the organs is in question. Moreover, some worry that managing the death of potential donors, which by necessity requires having them die in the surgical suite, hooked up to machines, with doctors hovering over them waiting to act the very moment death is declared, conflicts with the very human desire to die relatively peacefully in the company of family. 

Critics also feel that there will be an unavoidable conflict of interest with regard to the decision to withdraw treatment. Decision makers-whether they be the families of an unconscious patient or the conscious life-support dependent patient him or herself-will be forced to factor in the possibility of "doing a good deed" by allowing death to come. Health care providers, as well, will have this extrinsic factor to consider in helping the patient or family decide on a course of action. This will be all the more true as the practice becomes more commonplace. 

Another concern involves the persistent question of whether the two to five minute waiting period after cessation of heart function is sufficient to declare the patient dead, given that resuscitation by medical personnel could, technically, still be successful. Supporters of donation after controlled cardiac death maintain that the absence of any chance of auto *-*resuscitation is sufficient to maintain that death has occurred. Most sources agree that five minutes is an ample waiting for this purpose, though many call for more studies on this question. 

This form of donation also has a practical limitation: while it will probably increase the organ supply in a minimal way, it will not ameliorate the organ shortage because the pool of healthy candidates for donation after controlled cardiac death is limited. Many would argue that donation after controlled cardiac death, like paired and list donation, is worth encouraging, but that more significant reforms-such as cash payment for organs-are necessary to address the organ shortage. 
**III. Cash Payment for Organs****
One of the most discussed and controversial proposals for increasing the organ supply is to amend the 1984 National Organ Transplantation Act to legalize cash payments for organs-a proposal that could take any one of a variety of forms. In light of its prominence in recent debates and in Council discussions, this proposal merits a somewhat extended discussion. 

In any system in which payments are offered for organs there would be at least two principal actors, the organ "vendor" and the organ recipient. Three types or categories of organ vendors are possible. The first category includes living donors who agree to sell their organs in the present. These vendors, for reasons of safety, would be limited to offering a kidney, a segment of liver, or perhaps a lung lobe. The second category includes potential donors who sell the future rights to their organs, which would be available after death, if they should happen to die in a way that makes them suitable donors. The vendors in this category would participate in what is commonly referred to as a "futures market." The third category would consist of deceased donors, whose appointed surrogates would be paid at the time of organ procurement. The surrogates might include family members, friends, or perhaps even a favorite institution, such as a charity. The organs of the deceased would be, in effect, given to the surrogate who would then sell them. 

There are three basic ways of organizing the system in which the selling of organs could take place: a relatively free market, a regulated market, and a government-controlled program. In a relatively free market, prices would be set by the laws of supply and demand, just as with other valuable commodities. More likely than not, such a system would give rise to organ brokers, who would act as middlemen, matching prospective buyers with potential sellers, and matching both suppliers and recipients with a medical facility for procurement and transplantation purposes. The highest prices would likely be paid for living organs from healthy donors, who provide not a potential future commodity in the event of death 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. 

A relatively free market in organs would govern not only organ procurement but also 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 advocates of organ markets seek to develop a system that would permit organ selling in the free market while preserving a system of organ allocation determined by moral and medical criteria rather than market criteria. Others believe that such a division between procurement and allocation is problematic, because 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 the laws of supply and demand from setting prices. 

As Dr. Benjamin Hippen argued during the June 2006 Council meeting, a properly regulated market in organs would be distinguishable from a free market by its four side constraints. First, the market must be safe for the vendor and the recipient. Safety, here, would be determined by current medical knowledge and practice. Second, the processes of donation and transplantation must be transparent, meaning that the risks of the surgeries and the potential outcomes must be clear to the vendor and the recipient. Third, there must be institutional integrity. Each institution involved in organ transplantation (hospitals, transplant centers, and even transplant physicians) must establish policies that explain the institution's moral commitments regarding organ vending, namely whether or not the institution will support it. And fourth, the organ market must operate under the rule of law. The law would provide the boundaries of the market (i.e., what can and cannot be done while buying and selling) and would provide a means to settle contractual disputes, which naturally arise in any market setting.**13**

A government controlled payment system for organs would primarily involve the federal or state governments paying vendors for their organs, more than likely through Medicare or a similarly functioning program. This approach could involve either paying a fixed price for each individual organ (which would be most relevant to living donors, who might sell a kidney, part of a liver, or a lung lobe) or paying a fixed price for the right to procure all available organs (which would be relevant only to deceased donors). Defenders of the government controlled payment system distinguish it from other organ markets by arguing 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. **14**

There are variations to this model of government control. For instance, the government could simply 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. The common feature of these different approaches, however, is the intimate involvement of the government in the payment process. 

Regardless of how a system of payment for organs is established, this proposal has putative strengths worthy of consideration. Perhaps the greatest strength is that it would, more than likely, generate substantial increases in the supply of organs and would thus ameliorate the suffering of many people who are now on organ waiting lists. With more than ninety-thousand Americans on the organ waiting list and with thousands of those on the list dying each year while waiting for an organ, significantly reducing the list by procuring more organs would be a great good. Proponents of this position view 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. These advocates argue that organs should be treated like any other commodity, where the market effectively brings supply and demand into balance. We already permit the buying and selling of human blood, sperm, and eggs, so why should we not permit the selling of organs, which would save many American lives? 

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 and paternalistic to protect the poor (or anyone else) against the rational choices they might make for themselves, including the decision to sell parts of their bodies. They note, quite correctly, that everyone involved in the organ transplantation business-the doctors, the health insurance companies, those working for OPOs, 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 donating their organs; vending and gifting could co-exist, allowing everyone to act on the values that they hold dear. In sum, the government should not dictate morals in a pluralistic society, but should rather allow each individual to determine for him or herself what is right as long as these decisions do not harm others. Selling organs will not harm others; in fact, it will help many of them. 

Yet embracing a system of cash payment for organs raises many ethical concerns, which is why this practice is, at present, impermissible as a matter of public policy. **15**One of the most common objections to payments for organs is that such monetary incentives would exploit the poor, who would expose themselves to potential physical harm because of their dire need. 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). They would be protected from the dangers of black markets, in which the health of the donor is a low priority, and benefit from a sanctioned 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 his or her services, these payments are for professional knowledge and skill-not for selling spare body parts. 

When it comes to deceased donors, critics of cash payment fear that adding money into the mix would only disrupt the already difficult burden of caring well for the dying and the newly dead and the mourning of lost loved ones. 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; and 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-and thus the self-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, primarily because 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-the cost of putting so explicit and 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, many people argue, as an act of commerce. To be sure, 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 even 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 or she has given. 

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FOOTNOTES
 1. For more information on chain exchanges see Roth, Sonmez, Unver, Delmonico, and Saidman's "Utilizing List Exchange and Nondirected Donation through 'Chain' Paired Kidney Donations" in the *American Journal of Transplantation*, 2006, 6: 2694-2705. 

2. See the OPTN's data report entitled "Living Donor Transplants By Donor Relation." This report includes data from January 1, 1988, through October 31, 2006. 

 3. For more information on how such a program might work see the OPTN's Policy Proposal 1 from August 28, 2006, and the New England Program for Kidney Exchange website. 

 4. This approach is best articulated by Dr. Steve Woodle, Professor of Surgery and Director of the Division of Transplantation at the University of Cincinnati College of Medicine. Much of the substance of this approach is based on ideas described in personal correspondences with Dr. Woodle. It must be noted here that Dr. Woodle supports only paired donation programs. List donation programs are included in this paragraph for the purpose of this policy proposal, but are not advocated by Dr. Woodle, in part because of the objections to list donation mentioned below. 

 5. For more detailed accounts of this issue please see Gentry, Segev, and Montgomery's "A Comparison of Populations Served by Kidney Paired Donation and List Paired Donation" in the *American Journal of Transplantation*, 2005, 5: 1914-1921; and Ross and Zenios' "Practical and Ethical Challenges to Paired Exchange Programs" in the *American Journal of Transplantation*, 2004, 4: 1553-1554. 

6. See Gentry, Segev, and Montgomery 's "A Comparison of Populations Served by Kidney Paired Donation and List Paired Donation" in the *American Journal of Transplantation*, 2005, 5: 1914-1921. 

 7. See Mitka's " Efforts Under Way to Increase Number of Potential Kidney Transplant Donors " in the *Journal of the American Medical Association*, 2006, 295: 2588-2589. 

8. Personal correspondence with Dr. Steve Woodle. 

9. See pages 142-143 of the Institute of Medicine 's *Organ Donation: Opportunities for Action*. 

10. For more information on these points please see: DeVita and Snyder's "Development of the University of Pittsburgh Medical Center Policy for the Care of Terminally Ill Patients Who May Become Organ Donors After Death Following the Removal of Life Support" in the *Kennedy Institute of Ethics Journal*, 1993, 3(2): 131-143; the Institute of Medicine's *Non-Heart-Beating Organ Transplantation: Practice and Protocols*; and the Ethics Committee of the American College of Critical Care Medicine's "Recommendations for Nonheartbeating Organ Donation" in *Critical Care Medicine*, 2001, 29: 1826-1831. 

11. For more information see the Collaborative's website: www.organdonationnow.org. 

12. For more information see the OPTN's Policy Proposal 19 from August 28, 2006. 

13. For a more complete account of these side constraints please see Dr. Hippen's "The Case for Kidney Markets" in *The New Atlantis*, Fall 2006, and "In Defense of a Regulated Market in Kidneys from Living Vendors" in the *Journal of Medicine and Philosophy*, 2005, 30: 593-626. 

 14. See Matas' "The Case for Living Kidney Sales: Rationale, Objections and Concerns" in the *American Journal of Transplantation*, 2004, 4: 2007-2017. 

15. During the 1983 hearings before the Subcommittee on Investigations and Oversight of the Committee on Science and Technology of the House of Representatives, some of the ethical arguments presented in the following paragraphs were explored. These arguments played an important role in decision to ban the buying and selling of human organs. 

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