410. "Values, not pay, provide best incentive to donate organs." USA Today (January 6, 2003) p. 113A.

New York's Department of Health could begin implementing as early as February some new rules approved last month for improving the care of liver donors. The guidelines, drawn up in response to the death of a donor at New York City's Mt. Sinai Medical Center last January, would set up "independent donor advocate teams," which would include doctors and social workers who could overrule a potential donor. The rules also would require increased and more experienced staffing. State officials hope the rules will serve as a national model.

New York's steps threaten to greatly limit in the short term organ donations from living persons. Those from deceased donors are far from sufficient. Indeed, thousands of Americans die each year because not enough organs have been donated. These facts have prompted some in the medical community, including the American Medical Association, to consider testing some form of financial incentive program. But before opening that tricky ethical box, we should do more to encourage voluntary donations. A group of doctors, writing in the June 20 issue of The New England Journal of Medicine, for example, suggests measures such as reimbursing funeral expenses and providing lifelong disability insurance for living donors. They call their proposals "ethical incentives -- not payment," as if cash is less green if called an "incentive."

Cash for donations

Two economists, Auburn University's David Kaserman and American University of Sharjah's A.H. Barnett, took the idea a step further: They favor giving each donor cash on the barrel. They figured that offering people $ 1,000 per donation would allow us to get all of the organs we need.

If the choice came down to paying for organs or allowing thousands to perish, the ethical judgment may lean toward a cash-and-carry system. And the shortage is very real: In the United States alone, about 6,000 people die each year while awaiting a transplant, and many more must lead a greatly diminished life.

That said, I see a danger in paying for doing things we ought to do out of moral commitment. Furthermore, when we turn organs into a commodity, we lose the sense of closeness people have when they act as family or friends rather than as traders.

Take a different approach

So a different experiment should be conducted: an encompassing drive to change the moral culture. Let's start by formulating a strong statement that declares that we, as a community, hold that giving our organs to another after our passing is a moral act of the highest order. It is an act all human beings should engage in, and the community appreciates those who choose to do what is right. This statement should be presented for endorsement to people every time they visit a doctor's office or hospital.

The names of all who make the noble commitment should be listed on a Web page, both to make it easy to establish that their organs are available when they die, as well as for others to see who did make the commitment. (The listing should be done, community by community, not simply alphabetically. And people would be listed only if they indicated, via a check-off box on their donation form, that they are willing for their donation to be publicly acknowledged.)

Next, the law must be changed so that commitments to donate will be recognized as binding. Currently, securing donations is difficult not only because hospital staff are reluctant to ask for organs from the family just before or after someone passes away, but also because even if the patient has left written instructions indicating a wish to donate organs, the legal status of such a will is not always sufficiently clear, especially if the family challenges it.

Economists also rush to point out that transplants reduce the costs to all of us. For instance, the health-care costs of someone who gets a liver, kidney or even heart transplant are much lower than those otherwise treated.

If we succeed in making it widely understood that donating organs is what a good person does, we will have all we need, even if only a majority of Americans sign on. Give a gift of life.

Amitai Etzioni is a university professor at George Washington University, author of The Moral Dimension and founder of The Communitarian Network.


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