The Golden Rule of Organ Donation

Here is Joseph Roth, president and CEO of New Jersey Organ and Tissue Sharing Network:

Caseworkers from our organization recently went to the hospital to visit the family of a woman who suffered a stroke. The woman was dead, but machines continued to keep her organs functioning. She was an ideal candidate to be an organ donor. Her husband, it turns out, was on the waiting list to receive a heart.

Our caseworkers asked the husband if he would allow his wife’s organs to be donated. The husband, to the shock of our caseworkers, said no. He simply refused. Here was a man willing to accept an organ to save his own life, but who refused to allow a family member to give the gift of life to another person.

…Cases like this are rare, thankfully, but are nonetheless troublesome.

Roth continues:

Our proposal — we call it the Golden Rule proposal — would permit health insurers in New Jersey to limit transplant coverage for people who decline to register as organ donors. It would be the first such law in the nation. No one would be denied an organ. But under the proposal, insurers could limit reimbursement for the hospital and medical costs associated with transplants of the kidney, pancreas, liver, heart, intestines and lungs.

I am not in favor of messing with the insurance system for this purpose but have argued for a more direct approach. Under what I call a “no-give, no-take” rule if you are not willing to sign your organ donor card you go to the bottom of the list should you one day need an organ. Israel recently introduced a version of no-give, no take which gives those who previously signed their organ donor cards points pushing them up the list should they need an organ transplant–as a result, tens of thousands of people rushed to sign their organ donor cards.

Hat tip to David Undis whose excellent group Lifesharers (I am an adviser) is implementing a private version of no-give, no take in the United States.

Here is my piece on Life Saving Incentives and here are previous MR posts on organ donation.


In some countries such laws would be, in effect, racist. Since in the modern state, devoted to secular religions, there is no worse crime than racism, what then?

How is it racist?

Because (or so I am told) there are "communities" whose members happily accept organs but won't donate them.

dearieme is 100% correct.

But this all matters very little. Within 20 years, the US Federal Government will be deciding who gets a transplant and who does not. If you are not making donations to whatever party is in power when you need an organ, God help you.

It matters very little but not for the reasons Other Jim specified. We are not far off from efficiently growing replacement organs in a lab from ones' own stem cells. This method is ideal because there is no risk of organ rejection, and benefits from non zero-sum economics. We're already doing this for simple organs like individual valves, bladders, skin, cartilage, etc. Complex organs like hearts, the pancreas, or liver, are not a long way off, most likely within 20 years.

American black's tend to be highly unlikely to provide donated organs.

Lucky you...lesser chance you might receive one.

False. Blacks are much more likely to be in need of a transplant. They are not significantly less likely to donate. In fact, relative to their share of population, Blacks and Hispanics are more likely to donate than Whites.

"The donation rates by minority populations are now in proportion to their population distribution in the U.S. census (Table 2-4). However, there is an increased need for trans-plants, particularly kidney transplants, in minority populations because of the higher incidence rates of end-stage renal disease among the members of these populations (USRDS, 2005). In addition, there is still room for improvement in the rates of consent to organ donation among all ethnic groups."

Or, in other words, "highly unlikely" my ass.

Other numbers, showing the same thing here:

"Minority groups also suffer from disparities in deceased and living donation. African-Americans comprise 12.9% of the population and 34% of the kidney transplant waiting list but only 13.8% of deceased donors. Barriers to minority deceased donation include: decreased awareness of transplantation, religious or cultural distrust of the medical community, fear of medical abandonment and fear of racism. Furthermore, African-Americans comprise only 11.8% of living donors."

But we wouldn't want to deprive dearieme, The Other Jim, and JWatts of their unfounded, bullshit opinions. That would be reverse-racist PC policing. Or something.

God, this is so disgusting... pick any topic and MR commenters find a way to divert the conversation towards their uncited, unfounded BS racist ideas while bitterly smirking at the oh-so-powerful anti-racists out there. Yeah, guys, its soooo hard being an educated white man in America these days. I just wish I could be black so I could face the sneering and discrimination of people like you every day! That would be so fun!

Back door market?

This makes sense if the price you have to pay is the price of the organ itself.

Are you talking about the illicit second-hand sphincter trade?

I don't have a problem with a specific organ donor saying that he/she will only donate an organ to a fellow donor, but I have a major problem with any systemic or legal enforcement of the rule across society.

Fundamentally, this always comes down to one person's opinion that everyone else should be forced to adhere to their own personal moral principles, and that is basically a rejection of the whole philosophy of freedom.

Simply ask yourself, would you treat philanthropy the same way? Would you favor some sort of rule that only allowed people to receive charitable donations if they themselves also contributed to charity? Are you in favor of only telling the truth to other people who are honest?

I mean, think about it.

Here's the problem I see with it. What if I want to give my organs to my own network. Some of the real free-riders are the people who monopolize the rents on the network toll bridges.

What if you think of it as membership to a club albeit a very large one? Maybe not legal solutions but what's wrong about insurers or donor waiting lists mandating a "membership" requirement?

And if you object to the "in kind" transfers, fine, let an alternative "membership" option be a million dollar fee.

Like I say, I don't really have an opinion on the individual decisions people come to, but I think there are ethical problems with "eye-for-an-eye" organ donation. The thrust of my reasoning is that nobody treats any other ethical decision the same way. You'd never teach your child to only do nice things to other kids who are nice to him/her.

If altruism is supposed to be a moral precept, then this kind of bargain fails the altruism test. If individualism or enlightened-self-interest are the way to go, then this fails the freedom of choice test. Just MHO though!

I disagree, many people do indeed treat other ethical decisions a similar way. Most doctors and nurses and the like do not work for free, if they did, health care funding would not be such a political issue.

As for "teach your child to only do nice things to other kids who are nice to him/her", well obviously it makes sense for a child, or anyone, to start off a relationship by doing a nice thing, rather than always waiting for the first person to go. But if a child was always doing nice things for someone who never reciprocated, I'd really question whether that other person was their friend.

"what’s wrong about insurers or donor waiting lists mandating a “membership” requirement? "

Because what if I want to create my own club? In my club you could charge money for your organs.

Oh, yeah. I'd be arrested and thrown in prison.

That is true, but the person is still donating his organ. It is the administrator of the donation system that makes the rule for not donating the same to a non-donor or at least relegating the non-donor to the bottom of the list. I don't think the donor's morality is affected.


I think the problem is you are assuming altruism to be the sole mechanism through which organ donations ought to work. In many other sectors charity is only a second-order solution that kicks in when a primary system does not work. e.g. Most people buy groceries but for those who cannot there are food-banks.

We could do the same for organs; the altruistic organ-donation system could serve as a safety net. Being "nice" or kindness are more fundamental precepts.

Maybe I wouldn't teach a child that, but I don't think that's is a relevant comparison. Would you be happy to teach a child this:

If you have the chance to do one person some good, then choose a giving, fair and reasonable person over a grasping and selfish one.

It's not like anyone is seriously suggesting you burn the organs rather than give them to those who haven't signed organ donor cards, just that we make non-donors last on the waiting list. In that sense the term 'no-give no-take' is a bit misleading.

I'm fine with waiting lists giving preference to donors.

Insurance policies, on the other hand: I'm paying premiums to insure against unexpected events, that's a contract between me and the company. There is no good reason for the company to step in and say they won't cover a procedure that I've paid premiums for unless I also offer up my organs. That sounds like a contract violation to me and is terribly coercive.

I would be OK with offering reduced premiums for organ donors. But changing policies to require you to be an organ donor in order to get compensated for a procedure you're paying premiums to insure against? No, beyond the pale.

What if they put the clause in all new policies? It isn't a violation of contractual clauses then. In any case, I suspect all existing policies are subject to periodic re-negotiation provided sufficient notice etc. is given.

I don't think insurance companies would voluntarily rush to do that.

It's very different from other forms of charity. Normally, in a charitable situation, the donor has an ability to give which the receiver does not. Asking for a quid-pro-quo does not make sense when only one party has the power to live up to it. It does make sense when they both do.

(Actually, do people needing organ donations actually have organs worth donating? I'd guess usually they don't.)

Maybe they don't at the point that they need a transplant, but what about years earlier, when they sign a donor card, or refuse to?

What do the following have in common:

No give, No take.

Insurance reimbursement denial for those who do not sign organ donation, in effect fining them if they do not.

Obamacare mandate for health insurance, and fine if there is no insurance to reimburse costs of unfunded care.

They all seem to be solutions to solve a market failure by changing incentives for those to participate and fine those who are free riders.

It's not a market.

As in, the solution to your kind of market failures is...a market.

It is a market to use insurance companies. It's just that pooling and adverse selection risks are overcome by mandatory participation.

That's not it. Mandatory pre-payment is used to overcome the mandated service. And it's ironic because it's insurance. The government could rather run a loan market rather than pre-payment. Although they are piss-poor at that too.

The government creates a faux public good by making something that is excludable illegal to be excludable. Then you guys stumble upon the scene and say "hey, look a public good and a market failure."

Andrew, By the "you guys", you mean Mitt Romney?

Yes. You, Mitt, Obama.

Another way of looking at it, however, is that markets exist for people, not the other way around. If people decide that they want a particular outcome, and that outcome does not occur, then it is reasonable for them to decide that the market failed.

Maybe, but not in these cases.

You forbid exclusion in a non-public good, you cannot claim that causes the market failure of free riding.

That is a government failure.a

Why can't we as a country decide that we don't want forbid exclusion in a particular non-public good?

It would be far more palatable to give extra points to those willing to donate than to penalize those who are unwilling even if the effect would be the same.

The two are functionaly equivalent. Those willing to donate would get extra points, move up in the queue while those unwilling to donate would be bypassed again and again.

Functionally equivalent =/= politically equivalent.

Which is Jeff's point I believe.

Why not simply allow organ donors to opt-in/out of "no give, no take?" Eliminates direct govt involvment and allows the donor "market" to determine the "right" policy.

It's about who is in control.

I am confused by the organ donation discussion. A vast majority appears to believe that it's acceptable to use force to take my money (that I can and will use given an opportunity). and give it to other people to improve their life. There is also a vast majority that appears to believe that it's not acceptable to take my organs after my death to save other people's lives unless I explicitly agree.
I don't understand how those two opinions can be compatible.

Well it's very simple really. "Your" money is a social creation, the product of certain rules of the market -- rules which were invented by humans. Taxes are part of that same system of rules. Without the system of taxes used to enforce property rights, there would be no property rights; thus no money would be "yours." Basically, you can consider the entire tax/property system as a whole; you cannot sever its parts.

Your organs, on the other hand, are yours in a truly biological, non-socially-constructed way.

So if some taxation (to protect property rights) makes sense, other taxation(to improve other people's lives) makes sense? I don't quite see the logic in that.

My organs are a part of me biologically, but there is nothing biological in other people being forbidden to remove them from me, especially after I die. That's a pure social construct.

Taxation to improve people's lives also serves to protect private property. It serves to protect the survival of the state in general. A state which protects property, but offers no concessions to the masses who own no property, will be overthrown by revolution. Just as King John could not have saved his own head without signing the Magna Carta, the unpropertied majority will not respect an institution of property which leaves them as destitute as laissez-faire.

However, ultimately you are right that the sanctity of the body is as socially constructed as the institution of property. My point really is only that these social constructs -- viz. (a) the sanctity of the human body, and (b) the institution of property -- are _separate_ constructs, which need not be, and are not, consistent with one another.

Sometimes the medical staff seems more interested in preserving the organs than in saving the life of the patient.

Bingo! What does the doctor mean when he says "she's dead"? If so why is she on life support? Maybe the husband disagrees. At some point this comes down to a question regarding ethics, philosopy, or religion. After all we still don't agree when life even begins. His decision may be either rational or irrational, but; it should be his to make.

If politicians want to increase organ donations then they should make a law that allows for a market for organs. Whether that means pricing and selling them, or; just trading them. As it stands the husband has very little in the way of incentives to donate his wifes organs, and a huge emotional disincentive not to do so.

No silly. Vaccines are a free lunch and half a million dollar paydays have no affect on hospital incentives.

That's all very much beside the point. Eventually she will be taken off life support and be unable to maintain her own life, what happens then? That the husband doesn't want to donate her organs now makes him something of a selfish douche, but has nothing to do with the larger argument, with which I happen to agree, that Alex routinely makes in these types of posts.

So you want to deliberately create an incentive for the husband to kill the wife? Are you nuts?

In the example, the husband is refusing to allow his wife's organs to be donated -- not his own. We are told nothing about his organ-donor status. He might have reasons for refusing of which we are unaware: his wife's wishes, for example. He might disagree with her philosophy (or theology) on this point, and yet respect it enough not to violate it.

On the other hand, let's suppose that his wife has expressed no wish -- that he is simply making a choice under the pain and stress of his wife's passing. The psychological evidence is clear that we make poor decisions under stress. His wife's death, possibly sudden (the stroke), might weigh on him sufficiently that he is not thinking clearly. This is not the best moment to consider him hypocritical or morally blameworthy. That is why the organ donor decision, either way, should be made at leisure, upon reflection, rather than at the moment of emergency.

Very well thought out. Excellent post.

Regarding your first argument I think the question is how far should one humor an irrational wish of a (dead) individual especially when it harms larger social interests. Is harm by inaction less culpable than harm by action?

Well courts enforce wills with all sorts of farcically irrational provisions in them -- giving hundreds of thousands of dollars to ensure the dog lives a life of luxury; large trusts set up to ensure the deceased gets a gaudy and well-maintained tomb. Would you be comfortable with a court who said "look this will is stupid. I'm just going to ignore it and give all the money to the Red Cross."

Oh, I wasn't arguing the courts ought to step in or anything. I was merely speculating what the husband ought to have done, which I suppose is a far laxer standard than a legal one. Think of it as a "reasonableness" argument.

I see. That is a much closer issue.

This was my first thought - the example simply doesn't match up with the "problem" that Alex has identified.

In other words, his wife, knowing he needs a transplant, refused to agree to allow her organs to be donated because it might benefit her husband. Sees like his treatment of his wife justifies not providing him with a transplant.

However, in most States, once a person is dead, their wishes on their remains are no longer more than suggestions. She might have checked organ donor but once dead, her husband now has the final say.

Legislatures are hesitant to deny relatives the right to override a person's wish, in part because some people fear doctors are going declare people dead just to get their organs, so they want families to agree they are dead first, by agreeing to organ harvest.

If we instituted mandatory default donor status with an explicit action opt-out option what percent of people would opt out?

Isn't that a more effective solution?

Another organ donation post! This issue must be very close to Alex's heart.

... which he seems eager to get rid of when he's done using it, by the way.

Too bad more aren't eager to get rid of their organs when they are done with them.

Pay them and they would be.

But even this isn't a sustainable solution. We are already past the point where people outlive the odd organ and there aren't enough helmetless motorcycle riders to fill the gap.

We are going to need anti-aging research to keep up with the tissue engineering and tissue engineering research to keep up with the anti-aging technologies.

In 2009 there were approximately 120,000 deaths due to "unintentional injury" and 35,000 suicides. Total dead-donor transplants in the US were about 22,000.

I am not sure how many of those suicides and accidents result in medically salvageable organs but I suspect your time-point of "people outliving organs" is not quite yet here (nor will be for the next decade or so).

Not sure if this is a true story, but it might explain why some family members refuse organ donation:

"‘Brain dead’ Quebec woman wakes up after family refuses organ donation"

Nooo, that simply cannot happen...if you apply more pressure.

Here in most US states, one can sign up as an organ donor while getting a drivers license.
While filling out the form, our local DMV quickly marks the sections that need to be filled. They never mark the organ donor section (as per my experience).
So not only its not "opt-out", they are nudging folks to not fill that section of the form.

There is this rule for blood donation in India. If any someone is in hospital and needs blood, then the hospital blood bank provides blood on the condition that a relative of the patient replenishes that blood through donation. Without this certificate from the blood bank, the patient is not discharged. Well, organ donation is a different thing, but I thought the underlying principle was similar.

My daughter is a pathologist, and she was appalled at family donation routines, in particular, family members giving blood to other family members.


Because family members who are called upon to donate by a relative may have a disease and would be reluctant to disclose it to other family members by their refusal or inability to donate.

A voluntary system has some elements of self-screening. What you want to avoid is social pressure which causes someone to act in a way that may injure others.

I think the reason for this rule in India (and it is pretty new one, may be 10 years or so) is that people were buying blood from blood banks and not donating enough, with the result that there was severe shortage of blood. On top of that, most of blood donors were professional blood donors, that is selling blood was often their sole source of income. Quite understandably, many of these professional blood donors were also drug addicts and had diseases with the result that their blood would get rejected often. Overall, a severe demand supply mismatch with blood being sold in the black market. This regulation was aimed to narrow this demand supply gap. Now about your questions on what if a family member refuses. This is kind of solved in the Indian context where most have large extended families and there is always someone healthy and willing to donate. For example, once my mother in law needed blood, and my husband was on a dose of anti-biotic, so I donated instead. Then, once my father needed blood, and for some reason, my blood count was below acceptable limit, so my husband donated. No big deal, really. And anyway, if someone does have any disease, and donates blood, knowingly or unknowingly, his/her family members would not really know, because tests are done only after donation and patients are released whether or not blood donated by the relative was of acceptable quality. Now suppose that the donor was carrying some disease and it was detected during tests after donation. The blood bank will call the donor and tell him/her that look, we found such and such thing in your blood and therefore throwing it away, can you get yourself tested again and consult a doctor? This would be done in confidence.

What's to prevent a person that signed their card and one day benefits from receiving an organ from then reneging on their agreement to do so?

Inertia and laziness.

Which are fairly reliable.

How 'bout an eye for an eye and a tooth for a tooth?

If you introduce rules re organ domning it is only a matter of time and political logic before a points system comes in.
Could start that if you want to have an operation you cannot afford then a kidney 'donation' would solve the problem.
Or there could be a lifetime ration of major operations. So only one hip replacement unless you have a good liver to donate later.

Badly named policy. They clearly don't understand the meaning of The Golden Rule.

A better solution is to reward recruiting organ donors by bringing in the names of registered organ donors, with instructions on how to get someone registered as an organ donor.

Doctors and hospitals are certified to make entries in vital records in most States without any review, so the same people could update the vital records on organ donation, just as the DMV does. The medical staff would provide a lot more information on donations than the DMV staff if asked.

Organ donor checkoffs on drivers licenses are nice in theory, but in practice, I worry about the incentives. The random hospital where I lay unconscious stands to make a million dollars, give or take, selling my organs (with installation!) to others.

Are hospital administrators, as a class, more selfless than the rest of us?

One thing to also consider is that not all organ donation cards are legally binding. Simply signing the card might not mean anything. It is also common practice for hospitals to still ask next of kin for consent regardless of intent of the donator.

I think that donating organ is a difficult problem because it is related to ethics. Regulation about it is necessary. We should prevent donating organ from being exploited. Hospital and doctor should be certified and the condition is pblic.

I propose that all organs belong to the State at birth, and as such we should argue over a plan on how to regulate their distribution...
Oh, wait, I forgot I believed in personal property rights.
People own their organs, and if they want to sell them to hungry dingos on their death they should be allowed.

The world as a Monty Python movie.

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