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Spring 1-1-2017
Revamping the United States Organ Donation
System: An Ethical Justifcation for Compensated
Live Organ Donation
Jordan Poter
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Recommended Citation
Poter, J. (2017). Revamping the United States Organ Donation System: An Ethical Justifcation for Compensated Live Organ
Donation (Doctoral dissertation, Duquesne University). Retrieved from htps://dsc.duq.edu/etd/144
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REVAMPING THE UNITED STATES ORGAN DONATION SYSTEM: AN ETHICAL
JUSTIFICATION FOR COMPENSATED LIVE ORGAN DONATION
A Dissertation
Submitted to the McAnulty College and Graduate School of Liberal Arts
Duquesne University
In partial fulfillment of the requirements for
the degree of Doctor of Philosophy
By
Jordan G. Potter, M.A .
May 2017
Copyright by
Jordan G. Potter, M.A.
2017
REVAMPING THE UNITED STATES ORGAN DONATION SYSTEM: AN ETHICAL
JUSTIFICATION FOR COMPENSATED LIVE ORGAN DONATION
By
Jordan G. Potter, M.A .
Approved March 28, 2017
________________________ ________________________
Gerard Magill, PhD Henk ten Have, MD, PhD
Vernon F. Gallagher Chair Director, Center for Healthcare Ethic s
Professor, Center for Healthcare Ethics Professor, Center for Healthcare Ethics
(Dissertation Chair) (Committee Member)
________________________ ________________________
Joris Gielen, PhD Henk ten Have, MD, PhD
Assistant Professor Director, Center for Healthcare Ethics
Center for Healthcare Ethics Professor, Center for Healthcare Ethics
(Committee Member) (Center Director)
________________________
James Swindal, PhD
Professor and Dean, McAnulty College
and Graduate School of Liberal Arts
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ABSTRACT
REVAMPING THE UNITED STATES ORGAN DONATION SYSTEM: AN ETHICAL
JUSTIFICATION FOR COMPENSATED LIVE ORGAN DONATION
By
Jordan G. Potter, M.A .
May 2017
Dissertation supervised by Professor GerardM agill
With over 100,000 Americans currentlyo n organ waiting lists in the United States, the
mass shortage of viable organs for transplantation is one of the most pressing healthcare issues
that we face as a country today. Thousands of these individualosn organ waiting lists will
ultimately die waiting on an organ transplant that will never come. Many differing proposals
have been discussed with the aim of increasing organ donation rates and the raw number of
organs available for transplant, including cahnging our default consent status for cadaveric organ
donation and the option of incentivizing organ donation by compensating live donors with
financial incentives. Iran is the only nation in the world that currently has a legally regulated
system of compensated live organ donation (CLOD), specifically for kindeys, and it has been
successful since its implementation, even eradicating its kidney waiting list, which no other
nation in the world canc laim. However, even with thisp ractical success, CLOD has ben a very
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controversial concept in the professional bioethics literature, and it has been labeled as unethical
and illegal in many Western countries, including the United States.
This dissertation utilizes arguments and principles from applied ethics, political
philosophy, and behavioral economics to ethically and practically analyze the need for
revamping the entire United States organ donation system, including both live and cadaveric
organ donation. The primary focus of this dissertation will be on justifying the ethical basis of
CLOD in the United States, and a practical model of CLOD will be proposed that also includes
significant changes to the cadaveric organ donation system.
The dissertation proceeds as follows. Chapter one gives a brief overview of the issues and
debate surrounding CLOD. Chapter two provides the necessary background context for
establishing the practical need and feasibility of a system of CLOD in the United States,
including examining past, present, and future systems of organ donation and situating the
medical, moral, and political bases of a potential system of CLOD in the United States. Chapters
three and four examine the major ethical components and arguments for and against CLOD,
including but not limited to the ethical principles of principlism and the objections from
exploitation and commodification. Chapter five ethically analyzes the differing types of
cadaveric organ donation and examines several other potential proposals for procuring organs.
And finally, chapter six amalgamates the previous arguments and develops them into a complete
proposal for a practical model to revamp the current United States organ donation system to
create a more efficient and ethical system of organ donation, procurement, and transplantation.
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DEDICATION
To my wife, Kim, and our children, Jackson and Addison:
thank you for enduring me during this trying time.
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ACKNOWLEDGEMENT
“I hold it to be the inalienable right of anybody to go to hell in his own way.” – Robert Frost
Though I have undoubtedly been aided by numerous individuals during this journey, several
individuals deserve special acknowledgement and thanks:
My wife, Kim, who has been a lasting source of support during this stressful time – from
picking up and moving across the country for this doctoral program to taking care of our
children during the many long hours I put into research and writing;
My children, Jackson and Addison, who have loved me unconditionally, even though
work and research has at times not allowed me to spend as much time with them as I
would prefer;
My parents, Dean and Karol, who have always pushed me to achieve more than I thought
was possible;
Glory Smith, who has always been an advocate in my corner and a sour ce of timely
advice;
Dr. Gerard Magill, who has always been a n ardent advocate of my work and a personal
supporter of me as a person and a professional;
Dr. Joris Gielen, who has always given me excellent advice and helped bring out my
inner libertarian, even if that was never his aim;
And finally, Dr. Henk ten Have, who has always challenged me and forced me to think in
new ways outside of my own perspective.
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TABLE OF CONTENTS
Page
Abstract iv
Dedication vi
Acknowledgement vii
List of Abbreviations x
Chapter 1 - Introduction 1
1.1 Practical Need for Compensated Live Organ Donation 2
1.2 Autonomy, Justice, and Exploitation 16
1.3 Beneficence, Non-Maleficence, and Commodification 33
1.4 Cadaveric, Imminent Death, and Other Organ Donation Proposals 47
1.5 A New Model for the United States Organ Donation System 58
Chapter 2 - Practical Need for Compensated Live Organ Donation 80
2.1 Present and Past Systems: Efficiency 81
2.1.1 Non-Compensated Systems of Cadaveric Donation 81
2.1.2 Compensated Systems of Live Donation 85
2.2 Potential Future Options 98
2.2.1 Stem Cells and Regenerative Medicine 98
2.2.2 Cell-Based and Genetic Therapies 104
2.2.3 Tissue Engineering 106
2.2.4 Xenotransplantation 109
2.3 The Medical, Political, and Moral Context of Living Organ Donation 114
2.3.1 The Medical Context 114
2.3.2 The Political and Moral Context 115
Chapter 3 - Autonomy, Justice, and Exploitation 124
3.1 Autonomy and Justice 125
3.1.1 The Principle of Respect for Autonomy 125
3.1.2 The Principle of Justice 128
3.2 The Exploitation Objection 132
3.2.1 The Background and Context of Exploitation 132
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3.2.2 CLOD and Exploitation 140
3.2.3 Claim One - Exploitation from Autonomy-Undermining Choices 144
3.2.4 Claim Two - Exploitation from Constrained Choice Sets 154
Chapter 4 - Beneficence, Non-Maleficence, and Commodification 164
4.1 Beneficence and Non-Maleficence 165
4.1.1 The Principle of Beneficence 165
4.1.2 The Principle of Non-Maleficence 169
4.2 The Commodification Objection 174
4.2.1 The Background and Context of Commodification 174
4.2.2 Rebuttal One - Mill’s Harm Principle 178
4.2.3 Rebuttal Two - Arbitrariness and Inconsistency 183
4.2.4 Rebuttal Three - Missing Distinctions and False Analogies 189
Chapter 5 - Cadaveric, Imminent Death, and Other Organ Donation Proposals 207
5.1 Present and Past Cadaveric Systems: Ethicality 208
5.1.1 Opt-In, Explicit Consent 208
5.1.2 Opt-Out, Presumed Consent 210
5.1.3 Mandated Choice 212
5.2 Imminent Death Organ Donation and Other Proposals 215
5.2.1 Imminent Death Organ Donation 215
5.2.2 Other Proposals 231
Chapter 6 - A New Model for the United States Organ Donation System 243
6.1 Compensated Live Organ Donation: Tax Benefits 244
6.1.1 Tax Benefits 244
6.1.2 Funding and Other Proposals 251
6.2 Mandated Choice, Opt-Out Cadaveric Organ Donation 256
6.2.1 Libertarian Paternalism and “Nudges” 256
6.2.2 “Nudges,” Mandated Choice, and Organ Donation 259
Chapter 7 - Conclusion 270
Bibliography 276
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