The Organ Shortage Crisis in America

Incentives, Civic Duty, and Closing the Gap

Andrew Michael Flescher

"An extraordinary exploration of what 'giving the gift of life' actually means to donors."
+ Add to Cart Preorder


Request Print Exam Copy

Request Digital Exam Copy

Nearly 120,000 people are in need of healthy organs in the United States. Every ten minutes a new name is added to the list, while on average twenty people die each day waiting for an organ to become available. Worse, our traditional reliance on cadaveric organ donation is becoming increasingly insufficient, and in recent years there has been a decline in the number of living donors as well as in the percentage of living donors relative to overall kidney donors. Some transplant surgeons and policy advocates have responded to this shortage by arguing for the legalization of the sale of organs among living donors. Andrew Flescher objects to this approach by going beyond concerns traditionally cited about social justice, commodification, and patient safety, and moving squarely onto the terrain of discussing what motivates major and costly acts of human selflessness.    

What is the most efficacious means of attracting prospective living kidney donors?  Flescher, drawing on literature in the fields of moral psychology and economics, as well as on scores of interviews with living donors, suggests that inculcating a sense of altruism and civic duty is a more effective means of increasing donor participation than the resort to financial incentives. He encourages individuals to spend time with patients on dialysis in order to become acquainted with their plight and, as an alternative to lump-sum payments, consider innovative solutions that positively impact living donor participation that do not undermine the spirit of the National Organ Transplant Act of 1984. This book not only re-examines the important debate over whether to allow the sale of organs; it is also the first volume in the field to take a close look at alternative solutions to the organ shortage crisis.

Table of Contents


Introduction: The Organ Shortage Crisis in America
Motivations for Giving, Especially of Precious Goods
Civic Duty
A Word about the Audience and Purpose of This Book

1. The Case for Legalizing the Sale of Organs
The Market as a Solution, If Not a Virtue
Costs and Equity
The "Tyranny of the Gift"
Financial Incentives, Libertarianism, and the Black Market
The Unique Case of Iran
A Legal, Regulated Market for Organ Trade

2. Ethical Concerns with Legalizing the Sale of Organs
The Utility of Utility
Selling Organs and the Impoverished
Selling Organs and Public Safety
Moving from Ethical to Pragmatic Considerations

3. Organ Donation, Financial Motivation, and Civic Duty
Paying It Forward
Wolfenschiessen, Switzerland
How Buying a Good Changes a Good
The Difference between Lump-Sum Incentives and Compensatory Measures
Civic Duty

4. Living Donors and the Confluence of Altruism and Self-Regard
Complex Human Motivations and the Myth of Unmotivated Altruism
Living Donors and Living Donor Advocacy
The Health Benefits of Living Donation
Reflections of a Living Donor Advocate

5. Making Altruism Practical
Reducing Disincentives and Opening Doors to Virtue
Paired Exchanges and Donor Chains
Creating Incentives to Opt In
Lost Wages and Travel Expenses
Publicly Acknowledging Living Donors
Nonmonetary Valuable, Comparable Goods
Helping Virtue Along

Conclusion: Two to Four Hours of Your Life


About the Author


"An excellent overview of the challenges the current organ donor system faces and the ethical issues that arise with potential system reforms . . . The author’s experience as a medical ethicist for a hospital’s organ donation council enables a nuanced and compelling exploration of many perspectives. . . . The text will be very useful for study of the issues associated with organ donation from a medical ethics perspective."—Choice

"An extraordinary exploration of what 'giving the gift of life' actually means to donors."—Chico Enterprise-Record

"A thoughtful approach to mobilizing interest in loving donation. . . . Engaging for a transplant professional while accessible to the general public."—American Journal of Transplantation

"Proposing market solutions to the massive problem of a shortage of organs for transplant is quite fashionable today. The transplant community needs a work challenging this approach, and Flescher provides it. The scholarship is generally superior. The work is subtle, thorough, and novel. The author is sophisticated and rich in his discussion of a complex topic. I expect this to become the definitive work rebutting advocates to market approaches to organ procurement. The author moves between academic and anecdotal style in a way that is quite effective. I was particularly impressed with the first chapter's fair and thorough representation of the position he will eventually attack. I learned a lot from the work."—Robert Veatch, Senior Research Scholar, Professor of Medical Ethics, Emeritus, The Kennedy Institute of Ethics


Supplemental Materials


About the Author

Andrew Michael Flescher is a member of the core faculty, program in public health; professor of Family, Population, and Preventive Medicine; and professor of English at the State University of New York, Stony Brook. A member of the United Network for Organ Sharing Ethics Committee, he is the author of several books, including Moral Evil and Heroes, Saints, and Ordinary Morality, both from Georgetown University Press.

188 pp., 6 x 9

ISBN: 978-1-62616-543-4
Mar 2018

188 pp., 6 x 9

ISBN: 978-1-62616-544-1
Mar 2018

188 pp.

ISBN: 978-1-62616-545-8
Mar 2018

Related Titles