The Human and Economic Dimensions of Altruism
By Richard A. Epsteini
Abstract
This short paper analyzes issues critical to understanding the chronic
shortage of organs in two parts. The first defends the various devices
that seek to take advantage of lower search costs in order to expand
the supply of organs: directed donations, matchingdonors.com,
donor-recipient pairs, and LifeSharers. The second part develops a
simple economic model of altruism that helps explain how markets with
altruistic participants operate in ways similar to ordinary economic
markets, but produce an equilibrium position in which more organs are
transferred at lower cash prices.
Make no mistake about it, altruism is a scarce commodity.
I choose these words carefully because I want to stress the biological
and economic origins of the principle. The strongest and most powerful
urges that all human beings have are those of self-preservation, which
lead them to rate their own well-being far higher than the well-being
of others. To this principle there is one giant qualification that does
not rise to the level of an exception: Individuals are bound to their
families by natural affection and genetic connections, so that some
degree of sharing within that environment is the norm and not the
exception. In this context, it is an open question whether donations
within families count as altruism. But toward strangers, altruism is,
I repeat, a scarce commodity.
Just how do we know this? The evidence is everywhere. Far
afield, the original advertisement campaign for the New York State
Lottery, I recall, stressed the way in which the funds would help
education. When that fizzled, the newer, and lasting, campaign
stressed the large pots of winnings that were at the end of the
rainbow. Altruism is also in short supply on matters that relate to
individual sacrifice in the cause of medical advancement. In a soon to
be published book on clinical trials, Patients at Risk,
Jerry Menikoff (both doctor and lawyer) and Edward Richards
(both public health specialist and lawyer) stress that the dominant
motivation of people who enter into clinical trials is improvement of
their own health, pure and simple. Menikoff treats altruism as a
"myth," and rejects the view that it ever counts as a dominant
motivation for human behavior. And still closer to the point, we have,
by any reckoning, exhausted the gains that can be achieved from
altruism in the market-if only there were one-for organs. The misnamed
United Network for Organ Sharing (UNOS) (sorry, you can't share
kidneys, even if you can transplant half a liver, but only to one
donee) gives living proof of that on its web page.1 Current waiting list candidates: 91,532;
transplants for 2005: 28,110; donors for 2005: 14,492.2 It is now well known that every day,
many people on the waiting list, about 17 per day, die for want of a
transplant. It is equally well known that many persons in need of
kidney transplants (66,085, as of March 29, 2006)3 survive on dialysis. If altruism were a
strong motivation, we would have shorter queues and more donations.
Yet note the qualification. I said that altruism was a
scarce commodity. Scarce is not the same as nonexistent. And there is
evidence of that as well. It may well be that most individuals who are
desperate for a cure are concentrated on their own well-being. But it
is equally clear that under the current rules we do have altruistic
transfers. The most visible case in my experience is one in which
Virginia Postrel recently gave a kidney to Sally Satel.4 Both are libertarians, which should
caution against any easy inferences of personal behavior from political
philosophy: to recognize the forces of self-interest is not to be
selfish.
Yet, for these purposes, it seems clear that one reason why
the Satel/Postrel transaction is so notable is that it is so rare.
There are literally millions of individuals who could make these
transfers at minimal risk to their own lives and health, yet there are
only a handful that make them outside close family connections. The
reason is all too clear: the price that people have to pay in the
risks and inconvenience that they still bear is not offset in its
entirety by the indirect benefits that they receive from doing good.
The question for this session is what we can learn from these
transactions.
I think that there are two ways in which to look at this
problem. The first of these is to examine the ways in which private
parties have sought to overcome the inability to offer payment in cash
or kind to potential organ donors. There are several such programs
that are worthy of some discussion: directed donations,
matchingdonors.com., four party transactions, and LifeSharers. All of
these devices rely on a mixture of altruism and self-interest to expand
the supply of organs and thus have drawn the ire of those who defend
the current system of UNOS allocations on equitable and ethical
grounds. The extent of altruism is uncertain in these models, and one
constant theme is that any introduction of payment is likely to
undermine that system. I believe that this claim is false, and that
the errors are best understood by a simple model of altruism that
stresses the continuity between altruism and self-interested
transactions, and that works regardless of how large or small the
influence of altruism in human affairs.
Expanding Supply Within the Current System
Directed Donations. The first of these goes to the
question of directed donations, which I take is a subject that is now
under review at UNOS. The law on the subject today is that these
donations are allowed, so that individuals who wish can match up in the
same fashion as Sally Satel and Virginia Postrel. Yet there is some
unhappiness about this result, for apparent reasons of equity. Right
now the UNOS system works with rigorous queues that are set by a range
of objective tests that have this virtue: they remove (in most cases
at least) the subjective element from the system, and thus tend to
counteract the perception that the decisions of public bodies are
skewed toward the rich, famous, and influential. But at the same time,
the system does not give any indication of the relative value of the
organ to persons on the list, whether measured in quality-of-life years
or in terms of net social value contributed, as measured by income or
some other more complex social indication. If the organs tend to go to
people who have been on the list for a long time, then the current
system suffers from the regrettable defect that our principles of organ
"sharing" do not do all that they could to reduce the total level of
human suffering. In light of the averages the actual recipient will
gain fewer quality-years of life than some person further down on the
list.
The use of directed donations within this context has been
attacked as a reprehensible form of queue jumping, but in my view this
amounts to a short-sighted and misanthropic view of the subject.
Implying that every donor should give a kidney to the first person on
the list only casts doubt on the high purpose that someone like
Virginia Postrel has in making the donation. But this proposition is
fantasy. The only way to nourish altruism is to praise individual acts
of altruism, not to condemn them. After all, the kidney transfer is
more important than a refined discussion of whether this transfer is
selfish (because of the adulation) or altruistic. Let directed
donations be banned, and no one else will get that kidney. Allow it,
and the queue for organs will be shortened by one person. It is a
situation in which everyone gains and no one loses. It is a case in
which if many other people followed the Postrel example, the queue
would disappear altogether.
The moral here seems clear. The use of directed donations should not
be regarded as some dubious loophole that eager regulators should
plug.5 It should be
encouraged by all the means that we have at our disposal. Right now
there is visible dissatisfaction with individuals who mount
advertisement campaigns to secure themselves organs. Frank L.
Delmonico, President of UNOS has voiced an uneasy acceptance of
directed donations to specific persons: "I don't think we can
legislate or regulate how people get to know each other. Once that
occurs and someone decides they want to save another person, I
don't think we ought to stop that as long as they are medically
suitable, are not violating the law and are fully informed."6 Arthur Caplan, a
University of Pennsylvania bioethicist, voices outright opposition to
them: "It undercuts the ability of the system to get organs to
those most in need and who have the best chance to survive. It's
not fair because it gives priority to people who can get
attention."7 (I pass by the point that the persons who
receive organs on the list are too sick to count as the ones with the
best chance to survive.) And Zink and his colleagues urge a misguided
loyalty to the UNOS guidelines on the assumption that the supply of
organs is fixed so that directed donations only allow privileged
individuals to jump the queue. "[T]here is no proof that a family who
donates to an organ solicitor donated only because of the
solicitation. It is equally likely that someone who makes the decision
to donate to a relative stranger would make the decision to donate to
any person on the wait list who is also in extreme medical need."8
Unfortunately, this skepticism about directed donations misses the
positive effects of this program on supply. The solicitation clearly
has effects on the overall supply. Taking Zink literally, each two
organs solicited result in an increase in one organ. Indeed, it seems
more likely that very few live organ donors who receive no compensation
would give unless they had the choice in the selection of donees. No
organ donation in the absence of solicitation seems to be the far more
likely result. Far from denouncing these personal campaigns, UNOS
should imitate them, by running stories on the personal relationships
that made all this possible. I would hope that they would do that in
connection with Virginia Postrel and Sally Satel. There was nothing
about their relationship on the UNOS site. Indeed the UNOS website
failed to thank by name any of the individuals who gave organs,
or who gave their consent to the transfer of their loved ones' organs.
No private charitable organization would be so oblivious to the small
things that help spark private generosity. But UNOS just lacks the
personal touch. The momentum to stop directed donations has nothing to
do with helping make the lives of others better. It has a lot to do
with the preservation of state-sanctioned monopolies in areas where
some private initiative should be most welcome. UNOS, even though it
is a nonprofit organization, fits this description. The federal
government has granted it a monopoly over organ procurement under a
contract that has been renewed four times over the past sixteen
years.9 The
nonprofit/profit line has little significance in this area because the
desire for aggrandizement is equally present in both settings. It is
not the first time that high ethical rhetoric has been used to preserve
a state monopoly: State agricultural boards are also nonprofit
organizations.
Matchingdonors.com. A second effort to expand the supply
of available organs within the current legal framework is an
organization called Matchingdonors.com.10 The "dotcom" in the title is no accident,
for this on-line organization could not exist without the easy
communications afforded by the web. By its own formulation,
"MatchingDonors.com is a venue where patients and potential donors can
meet and communicate, and hopefully expedite a donor agreeing to give a
patient a much needed organ." The overall strategy recognizes that no
financial transfers are allowable, so the site operates on the
principle that if it can narrow down the potential matches for any
prospective donor, it can increase the odds that there will be a
directed donation. The basic intuition is again that people, whatever
their dispositions, will find it easier to give to someone whom they
like rather than someone they do not.
I believe that the use of modern technology to expand the potential
supply of donations is an unqualified good. But the reaction from UNOS
officials has been far more muted. UNOS has in fact criticized the
operation of the program because it requires a fee for participation,
which is said to "exploit vulnerable populations."11 Why this should be true in this context
but none other is difficult, however, to determine. In addition, UNOS
protests that the program favors those with the best "media skills,"
which again ignores the increase in supply that these advertisements
bring about. Here there are no precise data, but the number is
certainly not zero. An organizer of a similar web-based donor-matching
program said of the program's success, "We're drawing a lot of people
to donate who wouldn't otherwise. We're saving lives."12
Donor-Recipient Pairs A third way to increase the supply
of organs is through a system of barter involving donor-recipient
pairs. In most economic markets, barter has a limited role to play
because it requires a precise matching of the needs of one person with
those of another, especially if no cash can be added in to balance the
transaction. Your horse must be worth my cow, and each of us has to
gain from the exchange. In unregulated situations, we tend to see
barter only with respect to low price goods of roughly equal value,
where it is easier to work an exchange than to set prices for two
goods. In regulated situations, barter may be used to reduce the level
of taxes or the risk of illegality. In these settings, the parties are
willing to suffer some level of market inefficiency in order to improve
their individual positions against third persons.
It is this last element that explains the rise of barter in the form of
donor-recipient transactions. Thus a pilot program proposed (but not
executed) at the University of Chicago contemplated this sort of
transaction with donor-recipient pairs.13 The proposal suggests how it might be
possible to incorporate gains from trade through a system of barter:
if donor A is not compatible with his or her family member, and donor B
is not compatible with his or her family member, then the kidney center
would offer to broker an exchange so that donor A gave to recipient B,
and donor B gave to recipient A. The double pairings in effect were
done without the use of a price mechanism. The simple mechanism has
value because the barter sets a unique price that eliminates bargaining
complications, and does so in a setting where the gains to both
donor-recipient pairs are large enough to propel the situation
forward. Owing to the want of specific performance of organ donation
arrangements, the two transfers have to take place simultaneously, as
there is no other means of assurance that the second donation will take
place once the first is completed.
The effectiveness of this pairing-program depends in part on the
asymmetrical position of persons with blood types O, A, and B. O-type
individuals are universal donors, but not recipients. Persons of blood
type A can receive O or A blood, but not B; similarly, persons of blood
type B can receive O or A blood, but not B. In this model, therefore,
there are limited opportunities for barter given that most individuals
are type O, so that in principle no cross-group pairing is needed for a
type O donor to make a donation to a family member. But barter could
expand the potential donations in two situations that have somewhat
different consequences.
Thus, assume that the first donor/recipient pair is type A/type B, and
that the second is type B/type A. This is, in fact, a low probability
pairing because of the relative infrequency of A and B types in the
population. But if it does occur, and the organs are of equal quality,
then both pairs gain because the swap increases the supply of usable
kidneys in this subpopulation from zero to two. Ross calls these
"balanced transactions." Lawyers capture the same notion by indicating
that the program has no disparate impact. Since all the gains are
fixed, there is no need for any side cash payment. The second situation
arises when the first donor-recipient pair has a type O/type A, while
the second pair has a type A donor and a type O recipient. The first
pair does not need the second to complete the transfer. But both
transfers can take place if the first donor supplies to the second
recipient and the second donor supplies to the first recipient. In this
case, the increase in available organs is one because the ineligible A
donor/O recipient pair is replaced by an eligible A donor/A recipient
pair. Ross calls these transactions "imbalanced" because all the gains
are enjoyed by the separate couple, and elsewhere has argued that the
risks of coercion should block this transaction, even though it is more
likely to occur than the first scenario.14
There is no question that this program does suffer from an intuitive
unfairness, which I believe can be given a precise account, namely,
that in voluntary exchanges we would like to see proportionate gains to
the parties. In addition, it seems as if these the unbalanced
transactions are unlikely to take place precisely because there is no
gain to the first pair, given that it faces higher transaction costs
with no benefit (except perhaps when it receives a better organ for an
inferior one). Yet, rather than abandon the potential gain in the name
of coercion, a cash transfer payment would allow us to expand the
supply of organs. It is just at this point that the intersection
between economics and law enters the picture. The use of these barter
transactions between unrelated families looks as though it violates the
standard terms of the National Organ Transplant Act, which prohibits
the use of "valuable consideration" in payment for organ donations.15 The willingness of UNOS
to allow them to pass muster seems to stem from the fact that there is
no bargaining space in a straight organ-for-organ transaction, even
though each organ could easily be regarded as valuable consideration
for the receipt of the other. But the imbalanced transactions, which
promise smaller gain at higher cost, do require a cash supplement in
order to make it mutually attractive, and thus open up the question,
just how much should be allowed? Hence, these transactions are
illegal.
It is easily possible to imagine other situations where gains from
trade could be increased if cash supplements were allowed. Thus,
assume the first donor recipient pair is type A/type O, the second is
type O/type B, and the third is type B/type A. The middle pair is
self-sufficient, but without its participation, there is no sensible
exchange between the first and third pairs, because only the third pair
can gain, as the type B/type O transaction cannot take place. So we
have a mix of the balanced and unbalanced transaction, and, in light of
the inability to arrange for a cash payment, two more lives are likely
to be lost.
LifeSharers. A somewhat different effort to reduce the
chronic shortages under the current system is through an organization
known as LifeSharers,16 whose founder is the tireless David Undis. Unwilling to wait for
action that unclogs the legislative logjam, Undis has put forward a
program of preferential donations, whereby each program participant (I
am one) gets preferential rights over non-participants to receive a
suitable organ from other program participants.17 The program clearly seeks to work on mixed
motivations: some self-interest and some altruism in uncertain
proportions. Needless to say, the program attacks the strong criticism
of those like Zink and her colleagues who think that all efforts to
expand supply should be treated as efforts to disrupt the current UNOS
structure.18
I do not think that there has yet been a successful transplant that
has taken place through LifeSharers. Indeed, there are good reasons to
expect this outcome. The dominant force in human affairs, as noted
above, is self-interest. The prediction, therefore, is that there will
be a fundamental imbalance between a nonexistent supply and high
demand. Put otherwise, the individuals who are most likely to sign up
are those who will need an organ, not those who are in a condition to
give. In addition, the small base of members (under 5000) makes it
unlikely that any match would occur, even if a greater proportion of
program participants were suitable donors. Finally, there is some
question as to whether the current UNOS rules permitting directed
donations to specific individuals also permit donations to anonymous
members of a class-a point on which the Delmonico quotation is somewhat
evasive.19 But still the
program has an important role to play because it urges people to find
some way within the law to challenge the hegemonic authority of the
UNOS program. Neither Undis nor anyone else whom to my knowledge is
familiar with LifeSharers thinks that it is cure-all. But other
proposals to use voluntary reciprocal altruism on a national scale try
to seize a similar impulse, simply by first asking individuals if they
would like to have an organ transplant to save their lives, and then to
ask them, gently, if they are prepared on death to consent to organ
donation.20 The same
difficulties with strategic behavior remain, but it is yet another
effort to expand the supply within the current framework.
Economic Theory. Last, there is the question
of what kind of model we can make of the problems at hand. In this
particular context, it is often said that the narrow economic models of
self-interest cannot be used to capture what is going on in a world of
altruism. I quite agree that the psychology of altruism is complex and
delicate. But for these purposes, that is neither here nor there. The
question to ask is rather different: what are the fewest changes that
have to be made to the standard economic models of human behavior to
explain altruistic behavior? I believe that we need make only one such
change. Draw a new supply curve that intercepts the y-axis in
negative territory. Here is the set up. The explanation follows
below:
Line I, sloping upward and to the right, indicates the supply of
organs from nonaltruistic persons. It assumes that the total number of
organs offered is zero when the benefits received are zero; as benefits
increase, the number willing to donate will increase. The assumption
is made for reasons of simplicity. Typically the supply curve crosses
the y-axis at some positive point to reflect the positive costs of
goods. But this model just sets the cost of the good at zero. But for
these purposes that does not matter, for it does not alter the basic
qualitative analysis to increase the gap between Line I and
Line II. Indeed the formal analysis does not depend on the
vertical difference between Line I and Line II, which is
just an empirical measure of the degree of altruism within the system.
Indeed, this construction of Line II does not make any comment
on the motivations of individual altruists any more than Line I
makes assertions about the motivations of self-interested persons.
Both lines only assert the common relationship that as the amount paid
for any quantity of goods increases, so the supply will increase as
well.
All the action is in the lower line, Line II, which represents
the current world with altruistic donors. Insofar as it indicates that
there is some positive quantity supplied at negative cost, it rejects
the relentless model of self-interest that drives the traditional
economic model. But it does so parsimoniously because it continues to
hold to the older model that states that supply curves are positively
sloped. At this point it becomes possible to use the same analytical
framework that governs markets without any altruism at all, because it
indicates that there is a consistent supply response even when prices
are negative, which in this case, without loss of generality, is
modeled in linear fashion. Point A, at which Line II
touches the y-axis, marks the point at which the costs are so
high that all altruists decline to donate organs. But the upward slope
of Line II means the quantity supplied is positive as costs
decrease, even if no compensation is paid. If this model is correct, it
also follows that individuals who start on Line I in negative
territory remain on that line once positive compensation is offered.
There is no sharp discontinuity where the use of positive compensation
converts altruists into egoists whose supply behavior is governed by
Line I once the activity takes place above the x-axis.
Both altruists and egoists share yet another feature. Any increase in
payment that is needed to attract the marginal organ donor must, in the
absence of any system of effective price discrimination, be paid to
inframarginal organ donors as well. But those extra payments are not
social losses, but only transfer payments. The change in social
welfare, apart fro the distributional consequences come from the gains
associated with any reduction in organ shortage.
Now that these points are established, assume that with the limited
benefits that organ donors can receive-reimbursement for transportation
and expenses for example-under today's law, the quantity supplied is
point B, placed midway on the bottom line, between its y
and x intercepts. The conceptual question is whether we should
treat this as a sale or a gift. My contention is that the transaction
is properly regarded as a gift precisely because there is no prospect
of tangible gain to the organ transferor who by design is left
indifferent between donating and not donating.. Indeed, so long as the
total package of benefits and harm produces no net benefit, then all
transactions up to the x-axis should be regarded as gifts as
well, and therefore, one hopes, free of any and all complications under
NOTA, with its valuable consideration requirement.
Thus far, I have talked about the conditions of supply. To make the
model complete, we have to look at the demand side as well. Here I
assume that the demand side is the same no matter whether we deal with
altruists or egoists on the supply side. Hence by the basic law of
demand, we observe the downward sloping demand curve represented by
Line III. It crosses the x-axis at point D, which
represents the demand for organs at zero cash price, which is the
situation we have today, where the demand is rightly huge. If we
assume a market of pure egoists, then we note that the observed supply
will also be zero, so that OD represents the observed shortage.
The level of donations is, of course, positive, so that the orthodox
model is wrong in picking Line I over Line II. I leave
to one side the unresolved philosophical debate over whether altruism
is possible, given that it is always possible that apparent altruists
receive some indirect benefit in the form of self-satisfaction or
social approval from doing a good deed. For these purposes, it is
sufficient to distinguish those who receive some tangible gain in cash
or in- kind in exchange, from those who do not. In this model, the key
question is, once we shift to Line II, what is the quantity that
is supplied in equilibrium, and what is the shortage? The demand
remains constant at OD for a zero price. But the supply
conditions will change for the better if we reduce the amount of
altruism that we demand from donors. If we can find some benefits that
cut the shortfall to potential organ donors from OA to
OB, then we can increase the supply of organs from zero to
OB, leaving only a shortage of BD. If we could move
further upward along Line II until we reached the x-axis,
then we could elicit a quantity OC, with a shortage of only
CD.
But is it possible to eliminate that shortage if we went to a
market? The answer here is yes. The key question is what counts as
the equilibrium position. There are many people who take the position
that once we introduce compensation, we alter the supply curve. No
longer is Line II the operative line. Rather it is Line I
that becomes operative in the analysis. I see no reason to accept that
assumption. The supply curve is continuous and positive sloping in the
area below the x-axis. What huge psychological transformation
requires the supply to approach zero once a single dollar is offered
for organs? The more sensible assumption is that the supply moves
upward. The only possible complication here is whether infra-marginal
altruists (i.e. those who would donate at negative prices) would
continue to do so. My guess is that many of them would. If so, then
the total transfer payments needed to secure payment at the equilibrium
point E would not be equal to quantity supplied times price. If
all altruists were generous, and all persons not altruistic demanded
the last pound of flesh, then in equilibrium, CE (on the
x-axis) would demand payment, while OC (on the
x-axis) would not. Yet, no matter which way it comes out, we
have an equilibrium in which altruism matters. We get more organs in
equilibrium than we do in a world of all egoists, where the quantity
consumed is only OF (on the x-axis) and the price paid is
OF (on the y-axis). But either way we get rid of the
queues. Nor does the use of a price system alter any other incentives,
including those to take care of one's self or to use medicines to avert
a kidney transplant.
Indeed, there is this irony. Once the model is fully understood, it
follows that there are no institutional adjustments that need to be
taken to respond to it. The explanation here is that altruists and
egotists are not distinct types of persons. Rather, there are some
individuals who are willing to accept benefits from a transaction that
are less than their costs. So long as they are able to self-identify,
there is no reason for the legal system to draw any hard-edged
distinction between types, or to encourage one and discourage the
other. There can be degrees of altruism reflected by the size of the
net loss that certain transferors are prepared to bear, which are
captured by the observed patterns of voluntary transactions. In the
end, the more the altruism, the lower the equilibrium price and the
larger the quantity. End of story.
In response, it will be argued of course that these markets, even with
limited altruism, are flawed by ignorance, opportunism, coercion and
worse. And so they are. But that situation is made worse in a world
in which voluntary sales are prohibited by the law, because it is hard
to develop responsible intermediaries who could respond to the usual
problems of mistake and sharp practice. And it is equally the case
that the current system that does not allow the market to reach
equilibrium is open to corruption and influence as well, as desperate
people, mostly egotists, seek to maneuver their way to the head of the
queue. The point of this little demonstration is that we do not have
to ignore simple economic principles to model altruism. Rather, we can
use those principles to explain how the market I imagine would work,
and why it would work better than any system of price controls, which
would create the permanent shortages that economic theory predicts.
Just those shortages came about with price limitations on gasoline In
the 1970s. It remains true for rent control in New York and other
cities today. And it is shamefully true with respect to the market for
organ transfers, which obeys the law on price controls and shortages to
a "T." Why it is moral to insist on an arrangement that results in
needless suffering and death escapes me. But let the philosophers
debate as they will, so long as the regulators open up the supply side
of the market. It will work better with altruists, few in number
though they are, than it does without them. And it will work far
better than the current misshapen system.
_______________________
FOOTNOTES
i. James
Parker Hall Distinguished Service Professor of Law, The University of
Chicago; Peter and Kirsten Bedford Senior Fellow, The Hoover
Institution. Lloyd Cohen, Harold Kyriazi, Jerry Menikoff, Mark Nadel,
Lainie Ross, David T. Rubin, Mark Siegler, Mary Simmerling, and Dave
Undis provided comments on earlier drafts. My thanks to David
Strandness, Stanford Law School Class of 2007 and Brian Perez-Daple
for their prompt, energetic and thoughtful research assistance.
_______________________
ENDNOTES
2. Waiting list
candidates 91,780 as of
03/29/2006
Transplants January - December 2005 28,110 as of
03/29/2006
Donors January - December 2005 14,492 as of 03/29/2006
Now these numbers are garbled because the figures for 2005 are
reported as of March 23, 2006. Just the kind of opening web page
presentation to build confidence!
4. For Virginia
Postrel's blog, see http://www.dynamist.com/weblog/index.html.
5. See
Memorandum Addresses Federal Register to Solicit Comments on OPTN
Oversight of Living Donor Guidelines,
www.optn.org/news/newsDetail.asp?id=526, January 23, 2006, which,
though confusingly worded, seems to point in that direction of
increased regulation of direct donations.
8. Sheldon
Zink, et al., Examining the Potential Exploitation of UNOS Policies,
5 Am. J. Bioethics No. 4 1, 3 (2005).
11. Snowbeck,
supra note 7 .
13. Lainie Ross
et al, Ethics of a Paired-Kidney Exchange Program, 336 New Eng. J.
Med. 1752 (1997).
14. See, Lainie
Friedman Ross & E. Steve Woodle, Ethical Issues in Increasing
Living Kidney Donations By Expanding Kidney Paired Exchange Programs,
69 Transplantation, 1539, 1542 (2000).
15. See,
National Organ Transplant Act, P.L. 58-507 (NOTA):
Prohibition "It shall be unlawful for any person to knowingly
acquire, receive, or otherwise transfer any human organ for valuable
consideration for use in human transplantation if the transfer
affects interstate commerce."
.Definitions (2) "The term 'valuable consideration' does not include
the reasonable payments associated with the removal, transportation,
implantation, processing, preservation, quality control, and storage
of a human organ or the expenses of travel, housing, and lost wages
incurred
17. See, also,
for a variation on LifeSavers that operates within the current
system, Mark Nadel & Carolina Nadel, Using Reciprocity to
Motivate Organ Donations, 5 Yale J. of Health Policy, Law, and Ethics
293, 312-23 (2005), which seeks to give additional points within the
UNOS framework to those who promise to donate organs. Once again, the
proposal raises the same risk that parties who are most likely to
commit are those who are likely to be organ recipients.
19. Raised in
Stein, supra note 12.
20. Donald W.
Landry, Voluntary Reciprocal Altruism: A Novel Strategy to Encourage
Deceased Organ Donation, 69 Kidney Int'l 957 (2006).
|