Ethical Constraints of Organ Rationing

Director Robert Truog writes in Harvard Health Policy Review

Center Director Robert Truog in the Harvard Health Policy Review on "Options for Increasing the Supply of Transplantable Organs."







Society’s need for transplantable organs dwarfs its supply. Every day 22 Americans die while waiting for an organ to become available for transplantation. 1 The scarcity of organs requires rationing, but merely because a strategy would improve organ availability does not mean it is ethically justified. In this article, we highlight options for increasing the supply of transplantable organs, and explore ethical constraints such as respect for autonomy, avoiding harm, and limitations related to the necessity for rationing.


Organ procurement is bound by the principle of autonomy. Under the principle of autonomy all competent persons have the authority to refuse unwanted bodily intrusion, and removing vital organs from a living patient without consent is uniformly condemned.

But do the same rules apply after the person has died? Some ethicists support “organ conscription,” or mandatory cadaveric organ donation.2 Despite its utilitarian appeal, our society ascribes value to posthumous wishes, including those relinquishing corporal remains. Forgoing all such wishes would be seen by many as subversive to dignity. Accordingly, strategies to expand transplantation must respect the voluntary decision to not donate organs, even after death.

The field of behavioral economics has given us the concept of the “nudge,” which respects freedom of choice while at the same time deliberately framing choices in ways that make people more likely to choose options that are seen as objectively good for that individual or for society.3 Along these lines, several countries have adopted an “opt-out” standard for donor consent — everyone is assumed to consent to organ donation by default — thereby increasing the activation energy for non-donation. Especially compared to organ conscription, this nudge respects the principle of autonomy because it allows people to act according to their preferences.

While opt-out countries must still ration organs, changing the United States to an opt-out system could help mitigate scarcity, especially if combined with other nudges. Israel, already an opt-out country, recently amended its organ allocating process to grant waitlisted transplant candidates priority when their family members are organ donors. Essentially, the nudge incentivizes reciprocity among families of transplant candidates — though arguably not to the extent that it is coercive. It also significantly increased the nation’s rate of organ donation.4 If new forms of nudging can similarly function in combination, they might help reduce organ scarcity without disrespecting the principle of autonomy.

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