Prioritising existing donors to receive organs would boost donation from ethnic minorities

Prioritising existing donors is clearly an interesting and controversial proposal with the potential to increase organ donation rates. It represents a shift beyond the currently assumed primarily altruistic motivations for donation towards more self-interested motivations, which will inevitably present a challenge to organ donation’s highly altruistic self-image. Whether it is better to have a slightly less altruistic donation system with higher rates of organ donation, or a more altruistic donation system with lower rates of organ donation is a complex question, but the consistent number of people dying while waiting for a transplant suggests that something has to change. A similar proposal has proved reasonably effective in Israel, and beyond the effectiveness in terms of promoting donation, such a system may have advantages with regards to the general fairness of allocation.

There is, for me, one possible problem with systems that prioritise existing donors, and this is to do with part of their fundamental justification of reciprocity. There appears to be an assumption that it is inconsistent to be unwilling to donate, yet willing to accept a transplant (Sharif describes this as being “dissonant”). While this looks superficially appealing, some unpicking will show that it is not obviously true in all circumstances. For those who think all organ donation is wrong, it may be inconsistent to accept a transplant. As Sharif correctly points out, transplantation cannot exist without donation. I think, however, that if one considers the perceived personal cost of organ donation, the situation may be more nuanced. Take, for instance, someone who personally thinks that organ donation is a good thing, but is aware that donating will cause significant distress to her family, and reputational harm to both her and her family. The perceived cost of donating in this situation may be high, so this person may choose to not be a donor. Similarly, someone who considers it particularly important that their body remains intact after death may perceive the cost of donation as being unreasonably high for them, but not consider the cost of donation to be unreasonable for those for whom post-mortem bodily integrity is unimportant. It seems to me that one could reasonably take the moral position that people ought to donate their organs, but not at any cost (indeed, I suspect that most of us do take this position). Given that the perceived and actual costs of donation may differ significantly from person to person, one may consider one’s personal situation to render the costs of donation excessive, yet still think it right that other people (with lower costs) ought to donate. A personal unwillingness to donate does not necessarily reflect an opposition to organ donation more generally.

This is not necessarily hugely problematic for reciprocity-based donation/transplantation systems, as such systems would have to be sufficiently nuanced anyway. People would presumably not have to agree to donate their organs at any cost in order to receive priority if they need a transplant –otherwise a John Harris style survival lottery may quickly ensue. A system based upon reciprocity may have to consider the varying costs of what people are required to contribute in order to receive priority: although in some sense it is equal because everyone is expected (in principle) to contribute the same thing -their organs - this does not mean that the cost of donating is the same for everybody.