Commentary

Some will view the emerging phenomenon of public solicitation of organ donors (whether via the Internet, classified ads, or billboards) as an effort by patients to take positive steps to increase organ donation and to improve their health. Alternatively, it may represent a new vigilantism—just the tip of the proverbial iceberg of what patients will do, in desperation, to improve their lot—everyone else be damned. In any event, this new activism underscores the critical shortage of donor organs for transplantation in this country.

Currently, there are more than 88,000 people on the waiting list for organ transplantation in the United States (United Network for Organ Sharing, http://www.unos.org), about 70 percent of whom need a kidney. To the extent that public solicitation puts a human face on the need for transplantable organs, it has tremendous power to motivate potential donors in a way that abstract data never can. Furthermore, we must acknowledge that for almost anyone with end stage renal disease, transplants offer better survival rates than continued dialysis, not to mention improved quality of life. Thus the earnest desire of individual patients to secure a transplant is entirely understandable, particularly when it is within the constraints of the law. There is certainly nothing prohibiting public solicitation; moreover, the "Organ Donation and Recovery Improvement Act" allows for reimbursement of travel and subsistence expenses incurred by living donors.

So, if it is legal and potentially beneficial, what is the problem with this "bring-your-own-donor" approach to transplants? Living organ donation can be justifiable only when the expected benefits to the recipient far outweigh the projected risks to a well-informed donor with autonomous decisionmaking capacity. Historically, living donors have shared some genetic or emotional relationship with their intended beneficiaries. While there may be a fine line between motivation and coercion in such relationships, nevertheless there is a moral context in which the donor's willingness to assume personal risk for another's benefit makes sense. Relationships born solely of the quest to establish a donor-recipient "transaction" raise concerns regarding the exchange of "valuable consideration," or at the very least, the potential for tyrannical expectations of reward in some form. Absent a morally compelling relationship, we ought to be legitimately concerned about subtly coercive influences on the potential donor, transplant candidate, and even the transplant center stemming from the lack of knowledge, information, and context for such a magnanimous gift.

Some will no doubt argue that living organ donation is essentially a private matter, requiring only that the principles of informed consent and sound medical practice be observed. Yet organ donation is a gift unlike any other. The intent of the gift cannot be realized in private; it necessarily involves a broader community: physicians, nurses, the pharmaceutical industry, and ultimately those who pay for the health care, to name just a few. Therefore, community values matter. While encouraging potential living donors is a laudable goal, society also has an interest in where those organs land.

Public solicitation changes, in a fundamental way, the principles governing access to transplants. The transplant community has gone to great lengths to develop an equitable system that relies on clinically relevant considerations in organ allocation. The new paradigm of public solicitation threatens to evolve into a marketing showcase or a popularity contest, benefiting those who can write clever or compelling ad copy. Wittingly or not, it also favors those with the financial resources not only to launch an effective media campaign but also to reimburse their donor's expenses. End stage organ failure may not be an equal opportunity destroyer, but access to transplants should exist on as level a playing field as can be achieved. And no, we are not there yet.