In 2013, over 94,000 people were on the waiting list for an organ; however, only 26,500 transplants were performed (Radcliffe-Richards).  Out of the 26,500 transplants, 19,500 came from deceased donors and only 7,000 were living donors.  These low donation numbers create long wait times; for example, the average time spent on a waiting list for a kidney is approximately 3.6 years (National Institute of Health).  The extensive wait time, poor public policy, and differing laws and standards around the world has allowed a thriving illicit organ market. The most effective way to end the organ deficit, and the illegal market, is a multipronged solution coupling a revamping of the altruism system with an education and awareness campaign, and an investment in stem cell research to ultimately end donation dependency.

Approximately 4,400 people in the United States are added to the organ waiting list each month but only 30,000 transplants are performed each year (Haken 21).  A significant organ deficit is thus created, with about 12 people dying each day because they did not receive a transplant (Lim 00:01:36).  This deficit results in a thriving black market organ trade.  It is estimated that the illicit liver and kidney market alone is valued to range from $500 million to $1.2 billion per year (Haken 22).  Sellers of organs tend to come from poverty ridden countries including China, India, Pakistan, Turkey, Brazil, Bolivia, and Peru while buyers usually live in the United States, Canada, Japan, and Australia (Haken 22; Purkayastha).  While a robust organ market may seem like it would benefit these struggling third world economies, it does little, if anything, because each deal is done under the table to avoid government detections as well as taxes (Haken 23).  The risks involved in the illegal removal and transplantation compared to the legal removal and transplantation are much greater. In illegal situations, surgery often takes place in areas where there is not sufficient food or clean water, making the patient more prone to complications, such as infection and tuberculosis, and increasing the recovery period (Harken 24).  These risks often result in the patient being permanently disabled or dying. 

Although they are not completely effective, there are policies in place to stop and prevent organ selling.  Organ trafficking originally was differentiated from human trafficking, resulting in a different treatment of victims than expected.  Instead of being handled as victims, subjects of illegal organ harvesting were viewed as criminals (Purkayastha).  In 1991, the World Health Organization (WHO) created boundaries to make an ethical framework regarding organ transplantation (Purkayastha). This was then further expounded on in 2010, declaring the exploitation of individuals for organs and the purchase of body parts illegal and immoral (Purkayastha).  The wording of the 2010 “Guiding Principle” grouped organ trafficking with human trafficking, changing the way that victims of organ trafficking were helped and viewed.  The Declaration of Istanbul, in 2008, clarified exactly what qualifies as organ trafficking and defined transplant commercialism as a practice that treated organs as commodities that could be bought and sold (Purkayastha).  Despite numerous guidelines, it is still difficult to determine what is organ trafficking because victims can be uninformed donors, individuals who had no choice but to submit, or individuals who are declared dead when they are still living.  The coercion of organ trafficking victims is rarely physical, making it a hard case to prosecute.  The perpetrators of these crimes are well respected surgeons.  The releases of the WHO and UN are only recommendations for what countries should do, rendering them essentially ineffective.  For example, The United States enacted the National Organ Transplant Act of 1984, but very few cases of organ trafficking appearing after 1984 have been actively pursued (Purkayastha).  A common denominator of these policies is that they all focus on a single perpetrator and their victims rather than the cause of organ selling. 

If the current ban of organs is not effective in curbing the number of illegal organ transactions, then why not create a legal, regulated system to sell organs? Creating a legal market for organs would require a construction of a future shares market, which involved complications.  In a future shares market, the commodity is purchased and the rights to sell the commodity in the future is sold (“Organ Donation: Opportunities for Action” 304).  Ideal conditions for a future shares market would be essential to keep it running smoothly.  Dr. Lewis Burrows outlines the following conditions necessary for a successful legal organ selling environment:  the patient must come from an area where sufficient aftercare is available, the entire process of purchasing organs should be overseen by medical professionals and not brokers or third “party individuals, an evaluation must be performed on the donor, and no bidding wars for organs are allowed.  In a donor-recipient situation, both parties should proceed if they freely accept and understand the risks involved, each party benefits in some fashion, the risks on both sides remain minimal, and the system will create a fair and equal distribution of organs.  These conditions are somewhat idealistic, and would be incredibly difficult to achieve. 

The organization of an organ futures market is also complicated.  In an organ futures market, the person selling their organs would receive a payment for contingent organ rights while they are still living.  The person paying the organ seller, an organ broker, or a hopeful recipient, now has a vested financial interest in the organ seller.  Could this possibly result in a substandard level of end of life care? Additionally, if the selling of organs is made as an end of life decision, would the choices regarding end of life treatment made by family members be scrutinized and viewed as hasty?  For organs to be harvestable death must occur in certain circumstances and it is highly likely that the seller will die in an undesirable way (“Organ Donation: Opportunities for Action” 305).  The death of the seller may occur far into the future.  These risks devalue the organs (“Organ Donation: Opportunities for Action” 305).  These factors indicate the uncertainty in terms of the time required and possible revenue for a future organ shares market.

The moral quandaries of selling organs also presents an obstacle to create a functional organ market.  By having market of brokers and sellers selling to the highest bidder, the lower socioeconomic class is excluded.  This goes against the basic philosophy held in the medical community that all patients are equal (Bramstedt).  The lower socioeconomic patients will almost inevitably lose a battle for an organ if they go against wealthy patients.  A price on life is created that only the wealthy can afford.  The altruism of man will deteriorate until no donations are made and the poor are left with only dialysis then death.  Additionally, the illicit organ trade would not decrease if a legal market was created.  In Iran, where selling organs is legal, there is a thriving black market for organs where respected doctors coerce patients to donate organs or remove organs, usually kidneys, without the patient’s knowledge (Purkayastha). The legal organ market enables the illicit organ market because it provides easier access to the equipment required, thus creating more opportunities to illegally harvest organs.  Instead of creating an organ market, a revamping of the altruistic system should take place.

In the United States, over 100,000 people are on the waiting list for an organ, with an estimated 4,400 more people added each month, but only approximately 30,000 transplants are performed each year (Haken 21).  A dozen people die each day because they do not receive an organ (Lim 00:01:36).  In 2004, 19,500 of the transplant organs came from deceased donors and 7,000 transplant organs came from living donors, many of which were kin to the recipient (Richards 296).  The current system of organ donation in place in the United States is commonly referred to as the “Opt In” system (Jarvis 200).  The “Opt In” program does not take into consideration people who want to make living donations, only donations made by people on their deathbed.  This system requires medical personnel asking if the patient, or the patient’s family in the case of cadaveric donation, would like to donate their organs.  Even if the patient has consented to organ donation, the patient’s kin can override the patient’s wishes (Burrows 251). Additionally, many families are not asked about the donor status of the patient because of ill timing.  Currently, only 40-60% of US families consent to cadaveric donation (Burrows 251).  

Other countries, including Spain, Belgium, Israel, and Austria, operate under the “Opt Out” system of presumed consent.  In this system, patients or kin of cadaveric donors must inform medical staff that they do not want to donate organs (Burrows 251).  The “Opt Out” system obtains approximately 40 donations per million (Burrows 251).  Although 40 per million may not seem like much, it is double what the “Opt In” system acquires (Burrows 251).  The United States could convert from the “Opt In” to the “Opt Out” system similar to how Israel did (Ravitsky).  Israel not only switched to presumed consent, but also gave registered organ donors and family members who consented to the donation of their kin’s organs priority on the organ waiting list (Ravitsky).  Changing to the “Opt Out” system aids the individuals who want to donate, but have not taken the steps to register as a donor or make their wish know postmortem.  Coupled with the new system was a multilingual and multimedia education program to inform the public about the importance of organ donation and how it does fit into the Jewish faith and culture (Ravitsky). Since the campaign, organ donation has increased steadily in Israel (Ravitsky).  The United States is a melting pot of culture and religion, so while explaining how donation fits into Christian values, it should create a multimedia and multilingual campaign to dispel the fears of organ donation and educate the public on why organ donation is essential for our society. 

The United States following Israel’s suit and changing to presumed consent would increase the amount of deathbed and cadaveric donations, but the issues surrounding living donation, primarily the financial aspects, remain. Removing financial disincentives is necessary to increase the number of donations because the range of individuals willing to donate will increase dramatically.  It is estimated that it costs on average $6,000 to donate an organ because of travel expenses and lost wages (Delmonico F. L. 1189). The latest economic recession caused a decrease in living donors because fewer people could afford to do so (Delmonico F. L. 1189). Financial reimbursement is recognized as ethical by the WHO in their Guiding Principles (Delmonico F. L. 1189), but this guideline is rarely taken note of.  There are programs in the United States that assist with the some of the financial loss carried by donors, but these programs are poorly advertised and most people do not qualify for their assistance.  The numerous fees add up to build a barrier between those who want to donate and the act of organ donation itself.  These costs include tests to determine compatibility of the organ, travel costs, surgery, aftercare, and lost wages.  Insurance, whether it be private or public, should cover these costs.  Any future complications that occur because of the donation should also be covered to ensure that no financial burden is placed on the donor.  Donors should be guaranteed health insurance for life, as well, to ensure that the fear of not being able to get insurance is dissipated.  In the long term, insurances would ultimately save money because the increased access to organs would reduce the number of patients on treatments such as dialysis as well as other necessary procedures and machines necessary for organ failure support and treatment (Capron). 

In addition to removing financial disincentives, research should be funded for stem cell research.  The medical field has progressed from transplanting entire organs as a form of therapy to injecting cells in affected areas (Lim 00:07:24). Stem cells do not have to come from embryos, they can come from bone marrow, skin, fat, and other organs.  These stem cells are mature so they are less flexible in what they can be engineered to do (Lim 00:08:52). In 2007, it was discovered that adult stem cells can be engineered to regress back to a similar state of embryonic cells (Lim 00:10:52).  These embryonic like cells can be programmed to other specialized cells, such as insulin producing pancreatic cells.  Dr. Lim is currently researching adipose stem cells with the purpose of treating, and possibly even curing, diseases such as diabetes or heart disease.  Funding adipose stem cell research is significantly less controversial than embryonic stem cells.  The United States should provide federal funding for adipose research as working solution to the organ shortage.  Stem cell therapy will eventually replace entire organ replacement therapy.  Stem cell therapy will be cheaper than transplanting an entire organ, and the wait time to obtain these cells will be shorter than searching for a compatible organ.  The United States could use stem cell research as a solution to decreased the dependency on the altruistic system of giving.

To decrease and ultimately end the organ deficit in the most effective and efficient manner, multiple solutions must be employed. The donation system must be revamped to create a system more conducive to organ selling, and financial disincentives must be removed to broaden the range of people able to donate organs.  An education and awareness campaign is essential to inform people of the dire need for organs, as well as how organ donation is acceptable within cultural and religious norms.  Finally, funding must be allocated to stem cell research regarding the development of organs.  Exploring the opportunities that stem cells provide can reduce the amount of organs needed, if not eliminate the need entirely.  
