The Failure of U.S. Organ Procurement Policy:"how many deaths will it take 'til we know that too manypeople have died?".

As anyone even vaguely familiar with the organ transplantation industry is keenly aware, there is a severe and longstanding shortage of human organs made available for transplant in both the United States d abroad. Every year for at least the last years, the number of patients in need of organ transplants--primarily

kidneys, hearts, livers, and lungs--has exceeded the number of deceased organ donors by a considerable margin. As a result, transplant waiting lists have continued to expand monotonically and expected waiting times have grown apace. The principal (and predictable) upshot of the ongoing shortage is an increasing number of deaths of patients who, because of an insufficient supply of deceased donors, fail to receive the needed organs in time.

Meanwhile, transplant professionals and academic observers have been engaged in a prolonged and often heated debate regarding potential policy actions that might be adopted to resolve the shortage. There has been a series of largely ineffective policy responses ranging From increased educational spending, to donor cards, to the latest strategy involving diffusion of so-called "best practice" procurement techniques. Notably absent from this parade of remedies is the one policy that is likely to end the organ shortage: the adoption of financial incentives for cadaveric organ donors.

While proposals for the use of such incentives have been advanced for almost as long as the shortage has existed, opposition to this option has remained both highly vocal and adamant. Such opposition is ostensibly based upon a set of ethical concerns, although no one has yet articulated a sensible, ethical reason for why we should continue to allow thousands of patients to die each year instead of paying surviving families a few thousand dollars to motivate an increased rate of consent for organ removal.

In this article, we calculate how many lives will be lost if the United States continues in its current policy course. We do this to motivate policymakers to stop implementing one ineffectual policy action after another and attack the organ shortage with more effective weaponry in the Form of financial incentives.

THE ORGAN SHORTAGE

The first successful human organ transplant in the United States was performed on December 23, 1954. On that date, a kidney was transplanted from a living donor who was an identical twin of the recipient. The body's immune system will attack what it perceives to be a foreign organism and, in the early days of organ transplantation, there were no advanced immunosuppressive drugs that would prevent the rejection of "foreign" organs. As a result, the only organ for which transplantation was feasible was the kidney and the only donors who were technologically suitable were living, closely related biological relatives of the recipient. As a direct consequence of that technological constraint, there were no transplant waiting lists and no obvious organ shortage in the late 1950s and early 1960s. In effect, organ transplant candidates brought the necessary donor with them when they checked into the hospital for the transplant operation. If there was no acceptable (and willing) donor, no transplant could be performed.