Intended for healthcare professionals

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Public to be asked its views on ethics of incentives for organ donation

BMJ 2010; 340 doi: (Published 20 April 2010) Cite this as: BMJ 2010;340:c2182

Rapid Response:

Symbolic Organs and Extended Self: Expanding our Understanding of Motivation to Donate Organs

Although transplantation surgeries are relatively successful
processes, and donation of organs saves lives and improves the quality of
lives of many people, only few are willing to donate organs for
transplantation. While the number of willing donors has not risen
significantly over the years, the number of people waiting for such
surgeries has been significantly increased. This causes a serious health
policy problem that policy-makers, scholars, physicians and other experts
are trying to resolve for more than two decades.

One of the major reasons for unsuccessfully resolving this problem
lies in the fact that not enough serious research has been done to
indicate exactly what are the causes and factors inhibiting and
encouraging motivation for organ donation. Do ethical, religious or social
considerations prevent the public from donating organs or is it the lack
of financial, emotional or other incentives to donate? Alternatively,
should refusal to donate organs be explained by failure to convey the
importance of donation? Or is it the result of specific and contingent
legal mechanisms to allow for the extraction of organs from the dead, say
by opting in or opting out procedures [1] or statutory mechanisms to
sufficiently acknowledge the concept of brain-death [2]?

The legal and ethical debates on organ donation are usually not
concerned with the reasons for willingness or unwillingness to donate
organs. Instead, these debates focus on two major concerns. The first,
emphasizing the benefits of donation (especially to the recipient) and
seeking to encourage the feeling of solidarity and altruism amongst people
in the society and to increase people’s volunteer identity [3]. The other
area of concern involves the creation of some incentive, usually
financial, but also in the form of granting priority for a medical service
eg transplant or fertility treatment to the donor, thereby increasing the
motivation to donate organs for transplantation or reproduction. [4]

However, both areas of concern are limited in their effect. Empirical
studies show that motivation to donate organs is influenced more by the
negative attitudes of people who oppose donation than by the positive
beliefs donors have in regards to donation [5]. It follows from these
studies that the contribution of imposing values such as altruism or
solidarity to the motivation to donate organs is relatively insignificant
and that a better way to deal with refusal to donate organs is to refute
myths and false beliefs concerning donation and the circumstances
surrounding it.

The debate relating to financial incentives to donors or their family
members is also limited in its effect. Such a debate raises serious moral
objections and evokes weighty sentimental responses: How can one sell his
or her liver or heart? Do financial incentives not lead to exploitation of
the poor who will sell their organs in order to survive? Will these
incentives not result in broadening the social gaps in society and
increase injustice and inequality in access to health? In addition,
advocating for financial incentives to donors may not be practical within
legal systems already prohibiting commerce in organs making this action
criminal although some coexistence between such allegedly contrasting
systems may still exist as it is indicated eg by the awkward position of
the new Israeli law on organ transplantation [6].

In another paper, I argueed that our understanding of the motives for
and motivation to donate or not donate organs should be a precondition to
any public debate on organ donation. Drawing on the social science
literature, it was suggested to look into new factors which may affect
motivation or lack of motivation to donate organs. One such area concerns
the symbolic meaning of the act of donation, the specific organ to be
donated and the relationship between the donor and the recipient [7]. This
suggestion was supported by reference to Margaret Radin’s theory of
property from personhood and its application to the question of whether
people retain a proprietary interest in their bodies, Russell Belk’s
thesis of the extended self and an idea which I developed elsewhere
regarding the symbolic existence of human beings, also reflected in the
act of donation [8]. Recent empirical work carried out in four European
countries provides substantial support for such a suggestion [9]. It is
hoped that the new initiative launched by the Nuffield Council on
Bioethics to examine the attitudes regarding the incentives for organ
donation will also take into consideration this new direction pointing to
some further empirical data on the complex relationship between potential
donors and potential recipients and the symbolic meaning of the act of
organ donation to all parties involved.

1. Johnson EJ and Goldstein DG. 2003. Do Defaults Save Lives? Science
302: 1338-1339
2. Sperling D. 2009. Israel’s New Brain-Respiratory Death Act: One Step
Forward or Two Steps Backward? Reviews in the Neurosciences; 20(3-4): 299-

3. Gargano Gary et al. 2004. Identity and Motivation Predict Behavior
and Intention of Organ Donation. American Journal of Health Studies;
19(4): 241-245

4. Anderson MF. 1995. The Future of Organ Transplantation: From Where
Will New Donors Come, To Whom Will Their Organs Go? Health Matrix; 5: 249-
5. Brug J. et al. 2000. Predictors of Willingness to Register as an Organ
Donor Among Dutch Adolescents. Psychology and Health; 15: 357-368

6. Meranda. A. Knesset Approves Organ Donation Law (25 March 2008),
available at:,7340,L-3523461,00.html

7. Sperling D. 2008. Me or Mine? On Property from Personhood,
Symbolic Existence and Motivation to Donate Organs. in W. Weimar, M.A.
Bos, J.J. van Busschbach eds, Organ Transplantation: Ethical, Legal and
Psychological Aspects – Towards a Common European Policy (Lengerich: PABST
Science Publishers) 463-470

8. Sperling D. 2008. Posthumous Interests: Legal and Ethical
Perspectives Cambridge: Cambridge University Press

9. Schweda M. and Schicktanz,S. 2009. The 'Spare Parts Person'?
Conceptions of the Human Body and their Implications for Public Attitudes
towards Organ Donation and Organ Sale. Philosophy, Ethics and Humanities
in Medicine doi:10.1186/1747-5341-4-4

Competing interests:
None declared

Competing interests: No competing interests

23 April 2010
Daniel Sperling
Senior lecturer in biomedical ethics and law, The Hebrew University of Jerusalem
Braun School of Public Health,The Hebrew University of Jerusale, POB 12272 Jerusalem 91120 Israel