Because the surgical transfer of organs strikes us as unmistakably wondrous, it has produced an ever-growing need for new surgical techniques, pharmaceuticals, and clinical subspecialties that then further perfect the medical ability to sustain life in this way. The intense desire to prolong life and cure disease has spawned as well an ever-increasing national list of patients for whom transplantation is deemed a basic medical right. Today the national list is an urgent topic of debate: heated discussions are spurred on by fears associated with the assumed shortage of transplantable organs and, thus, the dire need to increase the supply of willing donors. For more than a decade I have watched how proposals designed to enhance donation have shifted from casual, what-if scenarios to a pronounced level of alarm and even desperation. Thus, although concerns over supply and demand have always pervaded transplantation, the intensity of organ scarcity anxiety is new.
Significantly, much attention is given to the growing number of patients in need, set against either an assumed leveling or, at most, a sluggish climb in the annual number of donors. The urgency expressed in a recent story from the Boston Globe typifies current phrasing (the data and wording nearly always supplied by UNOS):
The waiting list for organs, now at about 82,000 people, keeps growing, and nothing has succeeded in significantly increasing the number of donations. Almost 60 percent of those on the list are expected to die waiting…. The transplant community has tried various initiatives…. But the gap keeps growing. Overall, the waiting list has been increasing by about 12 percent a year, while the number of brain-dead donors has been rising by under 3 percent, to about 6,000 a year. A recent study estimated that the number of potential donors each year is about 17,000. (Goldberg 2003)
The UNOS Web page has at times displayed a clock alongside an up-to-date report on the number of candidates on the national waiting list, recorded to the minute, stressing, too, that “for each person who receives a transplant, two more are added to that list.”10 As these examples illustrate, scarcity anxiety is focused squarely on the short supply of organs as transplant's great dilemma. In contrast, little is said about the responsibility the transplant industry bears in generating its own patients, a process that in turn increases the national demand for organs. Transplantation is in essence the capitalist's dream because the supply can never answer the pressing and ever-increasing social desire for these coveted goods.
When I first entered this field of research in 1991, innovative proposals designed to stave off the organ shortage were generally dismissed because they defied dominant assertions that linked bodily integrity to a respect for the dead. In short, professionals collectively expressed open disgust for blatant forms of body commodification, a stance guided in large part by the medical imperative to do no harm. Today, all involved parties embrace the need for ever more diligent public education campaigns; nevertheless, within the last five years financial incentives have surfaced as the most popularly proposed solutions. The momentum of this approach is evident in recent policy statements issued by the American Medical Association (AMA), which, in partnership with UNOS, now advocates investigating the viability of financial reward programs. Proposals include offering to donor kin a maximum ten-thousand-dollar tax credit, a funeral expense supplement, a charitable donation credit, direct payment, or a donor family medal of honor.11 A dominant assumption today, then, is that Americans will respond more quickly to monetary rewards than to more basic requests of altruism. Such proposals nevertheless require delicate semantic massaging (Richardson 1996) for fear that financial incentives will be interpreted as offering direct payment for human organs.
A decade later, these proposals have advanced to an entirely new level of understanding and debate, illustrated by recent testimony delivered by the AMA before the House Energy and Commerce Subcommittee (AMA 2003). Some of these new policy initiatives have moved to the pilot phase of experimentation. The state of Pennsylvania (which houses several of the nation's most prestigious transplant centers) provides a case in point. Its State Act 102, which became effective in March 1995, was initiated under the late governor Robert Casey, who himself was a liver and heart recipient. This legislation offers a comprehensive approach to public outreach and donor motivation, strategies that other states and federal agencies have duplicated. An earlier and controversial component proposed offering partial financial assistance to donor kin for funeral costs (Nathan 2000). Although this section of the act failed to win full support in the legislature, it evolved at one point into a proposal for a three-year pilot project designed to test the effectiveness of three thousand dollars in funeral assistance to donor kin.12 This sort of cash payment remains a highly experimental strategy (and one that to date has failed to evolve into official practice); this proposed component of Act 102 nevertheless marks an important watershed in policy responses to organ scarcity anxiety. More recently, Wisconsin passed legislation that reimburses living donors for travel expenses and lost wages, an example other states are certain to follow.
States have tried a variety of other approaches to increase organ donation within their own borders. Many currently use donor card campaigns as a means to raise donor awareness; the most common strategy entails offering this card when residents register for or renew a driver's license. This approach targets especially the nation's youth, thus capturing the attention of the very segment of the population that defines the ideal donor category. More specifically, these are young people whose organs are free from diseases associated with advanced age, and for whom the incidence of deaths from automobile, motorcycle, and bicycle accidents is particularly high (such accidents often result in head traumas and, thus, potentially, brain death).13 What most Americans fail to realize, however, is that the donor card has long served merely as a reflection of a desire, not the promise, to donate, for it is surviving kin who ultimately decide whether or not a loved one's organs will be offered for transplantation. In response, recently many states have also passed legislation that transforms the donor card into an advanced directive so that procurement staff can legally override the desires of surviving kin. Also, nearly all states have long-established laws that require hospital personnel to report all cases of potential brain death to their local procurement offices (but enforcing these laws is another matter entirely). In such instances, health care workers may fail to comply because they are unaware of the law, they do not embrace the definition of brain death, or they are too deeply disturbed by the idea of shifting their attention from keeping a patient alive to monitoring the physiological status of a brain dead donor.
In response to these sorts of limitations, some reformers now advocate for presumed consent laws: such legislation means that unless one has registered one's opposition to organ donation, one can be categorized automatically by hospital personnel as a donor, thus bypassing the objections of kin (AMA Council on Ethical and Judicial Affairs 1994; C. Cohen 1992). As evidence of the great potential of presumed consent, advocates point to Spain, where this approach is believed to have altered radically the size of the nation's donor pool.14 As the foregoing discussion makes clear, however, the United States presents significant barriers to such reforms, perhaps the most significant being that, unlike a country with socialized medical care, each of the fifty states passes its own legislation relevant to donor registration and brain death criteria. Thus, one can become an organ donor more rapidly in Pennsylvania (which houses several of the nation's largest transplant centers and among the most active organ procurement organizations [OPOs]) than in, say, Idaho (a predominantly rural state far less involved in organ transfer).15
A more mundane approach—mundane because it has required no specific legislation to bring it into effect—involves a loosening of medical criteria that allow a larger pool of dying hospitalized patients to qualify for donor status. In the context of my own research I have watched how procurement staff have shifted various medicalized boundaries so that those who might have been excluded ten years ago are now considered viable candidates for donation. For instance, in the early 1990s brain dead patients greater than seventy years of age were categorized as too old to donate, their organs considered too spent for safe reuse.16 A commonsense approach dictated, too, that it would be unfair to transplant into an already chronically ill person an old and thus inferior organ. By 1995, however, procurement professionals had begun to take aged donors more seriously, the argument being that an old organ was better than none
