Organ Donations and the Limits of Altruism

by Reihan Salam

Last night, I had a brief conversation on CNN’s OutFront on organ donations, prompted by the case, prompted by the case of Sarah Murnaghan, the 10-year-old girl who successfully secured a lung donation after her family pressed for her to get on the list for an adult rather than a pediatric lung. The central problem is that the supply of organs available for donation is limited, as individuals have to “opt-in” to a donor registry. One strategy for increasing the supply of donations is to shift to presumed consent, yet this strategy has met with considerable resistance in democratic societies — one assumes that people find the idea “creepy.” Another strategy, endorsed by Virginia Postrel, Sally Satel, and Josh Barro, among many others, is to allow some form of compensation. Many people find the idea of compensation discomfiting, as it raises the possibility of a free-for-all in which the poor and vulnerable sacrifice their bodily integrity in exchange for cash that can be used for immediate gratification. Two arguments immediately come to mind. The first is that compensation can be structured in many different ways. In 2006, Satel, who received a kidney from Postrel in March of that year, described various approaches, including:

1. A forward market for cadaver organs, as proposed by economist Lloyd Cohen — (a) receive a small amount of compensation for joining the current donor registry or (b) register now in return for a shot at more substantial compensation that will be paid to your estate in the event that your organs are harvested upon your death.

2. A centralized single compensator, in which a government agency would offer compensation in return for organs. Compensation could take the form of outright payment or (Satel suggests) a menu of options that would include tuition vouchers, retirement contributions, tax credits, charitable donations, long-term nursing care, and other forms of compensation that would not entail booze or strippers, thus defusing at least one objection to the idea of compensation.

3. And finally, private contracts between donors and recipients. Satel addresses the unfairness question in the following passage:

While private contracts may seem unfair because only those with means will be able to purchase directly, poor people who need kidneys would be no worse off—and, very likely, considerably better off—than under the current system. First, a stranger interested in selling a kidney is unlikely to give it away for free to the next person on the list (only 88 donors last year made such anonymous gifts); thus, few poor people would be deprived of kidneys they would otherwise have gotten voluntarily. Second, anyone who gets a kidney by contract is removed from the waiting list, and everyone behind him benefits by moving up. Third, private charities could offer to help subsidize the cost for a needy patient or pay outright.

Even under the most laissez-faire arrangement, the list of people in need of organ donations would shrink, thus benefiting others on the list. Squeamishness aside, I’m hard-pressed to see the downside, though of course squeamishness is nothing to sneeze at.

My argument is a bit different: opponents of compensation are operating under the assumption that one should only be motivated by altruism, or perhaps a desire for recognition. Yet we don’t ask that the surgeons who perform lung or kidney transplants abide by the same principle. A skilled surgeon has invested a great deal in her human capital, yet she also relies on an inherited endowment of traits and qualities that made her more “trainable” than the next person. We don’t ask that she provide her services for free. It’s thus not obvious to me that we should ask people to take on the risk — the negligible risk, but the risk all the same — that making an organ donation entails, or to bear the opportunity cost (three days in the hospital, etc.), without offering compensation in the same spirit. The argument is often couched in the language of protecting the bodily integrity of the poor. But I’m struck by the fact that we don’t apply the same standard to trained medical professionals. If surgeons can “profit” from transplants, why can’t people who don’t have the same skill set do they same if they also have something valuable to offer? A perfectly logical rejoinder, by the way, is that surgeons ought to be motivated only by altruism, and that compensation for performing transplanet surgeries should be put on the same footing as compensation for organ donations. But I think it’s pretty clear that the supply of people willing to perform organ donations would quickly collapse, and everyone knows it.