Who should wait for organ transplants?

The shortage of organs for transplantation results in some people having to be at the end of the line. For some, this will result in their dying for lack of an organ. In response, some people have discussed whether people who have destroyed their organs or have unhealthy lifestyles should get lower priority. They might have destroyed their organs via the use of alcohol, drugs or cigarettes.

Among the organs that are successfully transplanted are heart, intestine, kidney, liver, lungs, pancreas and thymus. There are also transplanted tissues such as bones, corneas, heart valves, nerves, skin, tendons, and veins. A single donor can save eight lives, for example, by giving a heart, liver, pancreas, etc. The donors can be living or dead. On some accounts, they are alive if the donor is merely brain dead.

The Department of Health and Human Services reports that in 2016, 116,000 people were on the waiting list for an organ and the list is getting longer. Each year, 7,300 people die waiting for an organ — roughly 20 a day.

The group that oversees organ distribution, United Network for Organ Sharing, recommends that organ transplants be distributed based on who most needs the organ, who would most benefit from it, and who has been waiting the longest to receive it.

The organization’s criteria are mistaken. First, by not allowing the donor or his family to sell or otherwise determine who gets the organ, the recommendation tramples on people’s property rights. The National Organ Transplant Act of 1984 made it illegal for dying people or their families to sell human organs and bone marrow. Unsurprisingly, the act did not make it illegal for doctors to sell transplant-related services. Perhaps the congressional delegation that passed the act was brain dead.

Second, by not solely focusing on who would benefit the most from receiving an organ, the criteria fail to be efficient. Such a focus would put people in the line based on the number and quality of years they would get from a new organ. Instead, the system favors fairness over people’s rights and doing the most good.

Philosophers John Harris and Benjamin Smart separately discuss whether those with unhealthy lifestyles should go to the end of the line. The fairness argument is that people who destroyed their organs have reduced the number of organs available to the public. As a result, they should go to the back of the line. In other words, because the unhealthy have lessened the public’s supply of organs, they should get lower priority when it comes to tapping into the supply.

One problem with this is that organs are not communal goods. It is not as if organs are like coal on government land that the government owns and may distribute as it sees fit. If the concern is about depletion of resources, then it is unclear why the penalty for depletion of resources should be limited to those who have depleted the supply of organs. Criminals and welfare recipients deplete people’s resources. It is unclear why they shouldn’t go to the end of the line because they depleted the pool of medical and other resources just as the unhealthy depleted the pool of organs. More than one in five Americans (and one in three New Yorkers) is on medical welfare (Medicaid and CHIP). The welfare recipients likely don’t pay their fair share of their children’s education costs or the cost of fire, military, and police protection, the cost of the roads, and so on. If people who deplete resources should go to the end of the line, then criminals and welfare recipients should join them.

A second problem with sending the unhealthy to the end of line is that harm is imposed by individuals, not groups. If we are going to put unhealthy individuals at the end of the line, we should allow them to buy their way out of it, perhaps by purchasing organs from the third world or, perhaps, merely paying for people’s transplant surgeries.

If we are going to put groups, rather than individuals, at the end of the line for depleting the supply of transplant organs, we should also do so for groups who don’t give their fair share to the organ pool. In the U.S., African Americans are 29 percent of the transplant-organ waiting list, but donate only 16 percent of the organs (by deceased donors). Asians are 8 percent of the waiting list, but donate only 3 percent of organs. If we’re prioritizing people by how their group depletes resources, blacks and Asians should join the unhealthy, criminals, and welfare recipients at the back of the line.

Also, as philosopher Stephen Wilkinson points out, some people with unhealthy lifestyles sometimes benefit others by increasing the supply of transplant organs or increasing the overall amount of all medical resources. The former might include people who engage in dangerous sports (for example, motor sports) and whose organs are donated after an accident. The latter might include smokers. As a group, they save the government money by dying before they require expensive medical treatment that accompanies old age.

If the pool of organs were increased by allowing people to sell them, there would be less of a need to prioritize people. The best way to do this is to create a market in organs. This would ensure that many more people would donate organs, especially families of people who died or who are brain-dead. This would also be more respectful because people own their organs and thus have a right to sell them just as people who own cars have a right to sell them.

Putting the unhealthy at the end of the line depends on there being a communal pool of organs. There’s no such pool. If there were, criminals, welfare recipients, and some minorities should join the unhealthy at the back of the line.

Stephen Kershnar is a philosophy professor at the State University of New York at Fredonia. Send comments to