On December 23, 1954, the dream of transplant surgery became reality when a 23-year-old donated a kidney to his identical twin brother.[1] Subsequent to that first “living” donor success, in 1963, a kidney retrieved from a person declared dead by whole brain criteria would follow.[2] These two nascent steps, accompanied by further medical and surgical refinements, eventuated in the transplantation of single and double organs, with livers, hearts, and lungs initially retrieved solely from dead donors.[3] Unfortunately, as Charles Dickens once penned, the initial “spring of hope” for countless patients, each one straddling a precarious boundary between life and death, quickly reached a “winter of despair”—a scarcity of available organs. In the realm of deceased organ donation, only a bare minimum of individuals who die—one estimate is 1.5 percent—qualify as donors.[4] As a consequence, living donors would be required to fill the void. However, it has been estimated that living donors contribute merely one-sixth of all organs transplanted.[5]
For years now, the preceding description of transplant history, and its accompanying statistics, has also served as its own ethical frame. Recipients in dire need, an egregious organ supply side shortfall, and a potential donor pool lacking altruism represent a collective ostensibly incomplete without donor incentives. Unfortunately, in contemporary parlance, optimal incentivization equals the commodification of human organs. It is therefore time to revise and reframe ongoing ethical dialogue. Fundamental issues have been ignored within what has become a constricted and partisan cultural perspective. Should an increase in organ donation take precedence over myriad other ethical concerns in transplantation?
Therein lies the rub as well as the contingent challenge confronting the Christian community. After expanding the ethical issues surrounding financial incentives in general, their most recent iteration, tax refunds for organs, will be specifically debated. The pros and cons of a successful “altruistic” living donation model in Israel will be critiqued. Are there ethical pitfalls inherent in the command to save a life through organ donation? Is the good of altruism outweighed by risks to the donor? Finally, a “how should we then live” summary regarding solid organ transplantation will be presented.
The critical ethical boundary for incentivizing living organ donations in the United States was established by the National Organ Transplant Act (NOTA) of 1984.[6] NOTA has prohibited any person to knowingly acquire, receive, or otherwise transfer a human organ for purchase or sale. The Act recognized transplantable organs as gifts, bestowed by altruistic people or their families, establishing a red line in the gift-market dispute. The European Union has likewise established rules to exclude any financial exchange in organ donation.[7]
A seminal publication reviewed organ donation incentives.[8] This article was written by recognized experts in the field of transplantation ethics. A comprehensive list of organ donation incentives, financial or otherwise, was evaluated. Most importantly, in a medical journal recognized as a gold standard for medical research, best practices, and impact factor, financial incentives warranted prohibition.[9] Three incentives, however, were endorsed, and at first glance, may appear to be monetary exchanges. They were: (1) reimbursement for dead donor funeral expenses, (2) paid medical leave for live donor recovery after surgery, and (3) life/disability insurance for donation-related illness. This author agrees with the categorization as appropriate.
Why are these three incentives, with apparent financial valuations attached, considered acceptable when other payments are not? Funeral expense reimbursement has been “intentionally small”—$300 was the initial recommendation—to reflect an appreciation for organ donors and their immediate family, not primarily as a payment for organs.[10] Paid medical leave to support postoperative recovery for donation of an organ was not deemed a financial enrichment. Living donors assume an average cost of $3,650 for the donation process and subsequent recovery.[11] In fact, 15% of donors incur expenses of more than $7,500.[12] Regarding life/disability insurance, a minority of kidney donors progress to renal failure.[13] Other medical problems may ensue. The altruism of these individuals should be recognized, and medical care required as a direct consequence of their lifesaving donation reimbursed. Presently, people who have donated a kidney and later require a transplant themselves are given waiting list priority and “boosted” upward.[14] This incentive is obviously not financial. However, essential to the ethics of this discussion: is tax compensation for organ donation an unethical incentive? A quote capturing the critical difference between symbolism and financial enrichment may serve as a preamble to the answer:
Why draw a line between incentives, such as reimbursement for funeral expenses or life and disability insurance and actual payments, such as . . . regulated organ sales? . . . some people may view the differences as symbolic but . . . the symbolism is very important. Symbols . . . are representations of core social values. Despite the encroachment of market forces into Medicine . . . The symbol of altruism in organ donation continues to represent powerful notions about the use of human body parts . . . values that should not have a monetary price.[15]
In the United States, a recent Bill, H.R. 6171 (2023), approved a tax benefit of $5,000 for the living donor of a non-directed organ—that is, an organ donated to an unidentified stranger at the top of the waiting list without donor stipulations as to recipient characteristics such as race or religion. Consideration of tax relief as an incentive for organ donation, however, has a relevant history preceding 2023. A 2012 peer-reviewed publication reported that fifteen states, between 2004 and 2008, passed various tax credits to increase organ donations, with $10,000 representing the largest amount of relief.[16] This study found that tax remuneration had no significant effect on donation rates. In 2015, another peer-reviewed publication investigated all 50 U.S. states and their incentive policies for organ donors.[17] Among multiple endeavors, unsuccessful overall, tax refunds did not increase organ donation. In fact, an 8 percent increase in the contributions of organs retrieved from donors declared dead by whole brain criteria was observed. Drug overdoses, consequent to the opioid crisis, have increased the number of dead organ donors from 514 in 2013 to 1,313 in 2018.[18]
A lack of efficacy is not the primary reason H.R. 6171 and other tax benefits are problematic. The refunds themselves are clearly a direct payment. An argument in their defense has suggested that they are equivalent to tax deductions for charitable donations. However, a charitable donation is a monetary gift, not a human organ. Furthermore, immediately on the heels of H.R. 6171 comes the End Kidney Deaths Act (EKDA) currently under consideration in Congress.[19] EKDA proposes organ donation tax benefits of $10,000 per year for five years, totaling $50,000.
The remuneration of H.R. 6171 may have been the first step on a slippery slope. Might escalating popular pressure push an agenda for more robust tax incentives in the future? A web-based survey in Canada asked questions regarding the acceptability of measures to stimulate organ supply.[20] The survey revealed that of the respondents who supported tax incentives, 50 percent chose $10,000 to $50,000 as sufficient reimbursement. However, a greater number of those polled overall, including individuals who initially did not support tax refunds for donations, said they would be willing to donate an organ for $100,000 reimbursement. Despite NOTA, H.R. 6171 began with a one-time $10,000 stipend. EKDA has already suggested raising that monetary value to $50,000 over 5 years. Incremental increases in tax remunerations reflect a market supply/demand strategy. NOTA’s red line will become transplantation’s Rubicon.
If financial incentives are rejected, are there ethical, altruistic models that can stimulate donation? Solid organ transplantation in Israel should be reviewed as a potential example.[21] In 1968, one year after the first heart transplant in South Africa, a heart was successfully transplanted in Israel. An uproar ensued because consent for that organ was not obtained from the donor’s family. Israeli ethics, religion, and transplant practice were intimately connected from the outset. Israel’s citizens and the Rabbinate were also suspicious of whole-brain criteria for death. Their concerns regarding brain death have persisted—among multiple nations and religions—throughout transplantation’s history.[22] As a result, dead donors were limited. Transplant tourism and markets for organs attracted desperate people who possessed the financial wherewithal. To stop market intrusions, in 2008, two laws were passed by the Knesset.[23] Strict criteria for determining brain death were initiated, transplant tourism was banned, and organ donations incentivized by donor priority (boosting) in waitlist positioning.
A unique model of altruistic living donations was added. As a result, Israel has become an international leader in living donations. A distinct number of donors are from the religious community of Orthodox Jewish believers. The impetus to donate is the mitzvah, or commandment, to save a life:
Probably the most important . . . reason for the success of the program is the religious . . . importance that the kidney donors place on . . . saving another person’s life. This is epitomized . . . by the Talmudic passage in the . . . Tractate “Sanhedrin” . . . “He who saves one life is as if he has saved the entire world.”[24]
At first glance, the commitment of a religious community to saving lives via organ donation might be applauded. However, further ethical evaluation of the Israeli model is necessary. In this regard, there are three issues that warrant consideration. First, the donations can be construed, at least to some degree, as partially directed. With the Israeli model, donors can choose preference categories for potential recipients without specifically choosing that recipient.[25] In that way, the recipient may not be a total “stranger” so to speak and may have important similarities shared with the donor, including nationality and religion. Second, some ethicists posit that the organ donations may not be free of religious coercion.[26] Is it possible that Orthodox Jewish persons feel compelled to donate under pressure from religious leaders and members of their faith community? The answer to that question is unavailable, but plausible and salient ethically. Finally, statistics suggest that women of childbearing age may be at greater risk of morbidity after a living donation.[27] Later pregnancies may be complicated by a higher risk of preterm births, fetal loss, gestational hypertension, and preeclampsia. This demographic should avoid living kidney donation, at least during childbearing years. Protection of donor dignity in this regard is essential.
In the United States, similar altruistic donors are called “Good Samaritans.”[28] The U.S. initial experience encountered obstacles.[29] At one time, 39 percent of U.S. transplant programs refused to perform organ retrieval from Good Samaritan donors.[30] The concern over possible donor coercion, donor psychological stability, and other factors, including the risk of kidney disease following donation, were responsible.[31] However, after an expected learning curve, donations in the U.S. have increased from 18 total living Good Samaritan donations in 2000 to 256 in 2016.[32] The caveats directed at the Israeli altruistic donation program Matnat Chaim apply to the United States Good Samaritan donations as well.
There is a tinge of the inhuman in the humanitarianism of those who believe that the perception of social need overrides all other considerations.[33] Reducing the focus of transplantation ethics exclusively to the needs of recipients is unjust. The dignity of donors, criteria for the determination of death, and the threat of commodification must be integral to the discussion. A more expansive ethical conversation may provide red, yellow, and green lights to any decision to donate a solid organ.
A red light has been proposed for any financial incentivization of organ donation. In the form of transplant tourism or markets for organs, vulnerable people and their organs are unethically commodified. This commentary has likewise opposed other financial incentives, including recent proposals suggesting tax incentives. Tax incentivization is not only a direct payment for a human organ, but also, in its contemporary guises, a step onto a slippery slope. If recipient need is the summum bonum, market forces will determine the monetary value of human organs. Within that cultural matrix human dignity would be devalued.
Addressing the contemporary frame for transplantation, Gilbert Meilaender has criticized the cultural presumption that organ donation is an absolute good, especially without questioning the whys and wherefores of this reigning paradigm.[34]
We know a person only in his or her embodied presence. In and through that body the person is a living whole. For certain purposes we may try to “reduce” the embodied simply to a collection of parts, thinking of that person simply as a sum of these parts.[35]
This author agrees. It is critical to establish that “embodied person” is an essential characteristic of donor and recipient. There are risks with donation, less so over time with kidneys, but substantive with living livers and lungs.[36]
Living liver donors have twice the all-cause mortality of matched healthy controls.[37] A peer reviewed paper reported on 393 living liver donors, of whom 82 had one and 66 had two or more complications after donation.[38] The same paper reported that potential life-threatening complications occurred in 103 living liver donors and led to death in three. Living lung donors bear a similar burden of serious complications.[39]
As a result, one must also inquire as to how this donor-centric ethic evolved. Where has an emphasis on donor morbidity and mortality gone? As the transplant enterprise has refined its technique, its cultural milieu—both medical and lay public—has undergone a disconcerting shift. Jeffrey Bishop has lent valuable insight into the philosophical underpinnings of transplantation’s contemporary ethos. Patients have been reduced from subjects to objects. They are holistic, embodied individuals no longer, but machines in need of repair. In Bishop’s own words, “metaphysical knowledge—knowledge concerned with final causes pertaining to the telos of life—becomes dismissed as irrelevant to medicine.”[40] He proceeds further,
The technologies of medicine are geared not to purposes . . .but to functionality; the . . . discourses of medicine are geared not toward . . . meaning but toward some notion of social function. . . . As such, medicine becomes forgetful of the living and embodied telos of this particular body that has called to it for help.[41]
Not only donors and recipients, but the entirety of medicine and the humanity it serves, will be depreciated by this ethos. The door to the commodification of human organs has been opened by a culture that no longer perceives individuals as embodied persons, but rather as a collection of saleable parts. With transplants thereby reduced to transaction, human telos and meaning are discarded in lieu of yet another business model.
Thus far the author seems to have solely placed red lights in front of potential organ donors. However, he is a supporter of solid organ donation within appropriate ethical boundaries, some of which have been engaged in this commentary. As a former nephrologist, his perspective and experience support a yellow, and not a red light, for the “Gift of Life” if the aforementioned proscriptions are heeded. There is still a place for Christian altruism cognizant of human dignity. Yellow or green lights, depending on circumstances (donor health risks, the exertion of undue pressure on the donor, avoidance of financial reward), may be given to living kidney donations. Kidney donor chains permit living donors to simultaneously benefit a relative or friend as well as a stranger.[42] Living lung and liver donations are a difficult category based on significant donor complications. The author respects Christians who believe that death by whole brain criteria is not a valid determination of death and therefore do not donate. But for those who donate organs of brain-dead donors, I offer my sincere gratitude on behalf of the many recipients who have benefitted.
Transplantation presents critical ethical dilemmas to Christians, some clearly outside the pale of approval, but many others worthy of prayerful consideration.
[1] Marc A. Shampo and Robert A. Kyle, “Joseph E. Murray—Nobel Prize for Organ Transplantation,” Mayo Clinic Proceedings 76, no. 3 (2001): 240, https://doi.org/10.4065/76.3.240.
[2] Eelco F. M. Wijdicks, “The First Organ Transplant from a Brain-Dead Donor,” Neurology 66, no. 3 (2006): 460–61, https://doi.org/10.1212/01.wnl.0000209204.87339.ef.
[3] Kenneth W. Kizer, Rebecca A. English, and Meredith Hackmann, ed., Realizing the Promise of Equity in the Organ Transplantation System (The National Academies Press, 2022), https://doi.org/10.17226/26364.
[4] Corinne Berzon, “Israel’s 2008 Organ Transplant Law: Continued Ethical Challenges to the Priority Patients Model,” Israel Journal of Health Policy Research 1, no. 11 (2018): 11, https://doi.org/10.1186/s13584-018-0203-6.
[5] Lisa Milot, “The Case Against Tax Incentives for Organ Transfers,” Willamette Law Review 45 (2008): 67–90, https://digitalcommons.law.uga.edu/fac_artchop/788.
[6] National Organ Transplant Act, Pub. L. No. 98-507, 3 USC g301.
[7] Nicole Scholz, “Organ Donation and Transplantation: Facts, Figures, and European Union Action,” European Parliament, April 3, 2020, https://www.europarl.europa.eu/thinktank/en/document/EPRS_BRI(2020)649363.
[8] Francis L. Delmonico, Robert Arnold, Nancy Scheper-Hughes, Laura A Siminoff, Jeffrey Kahn, and Stuart J. Youngner, “Ethical Incentives—Not Payment—for Organ Donation,” The New England Journal of Medicine 346, no. 25 (2002): 2002–5, https://doi.org/10.1056/nejmsb013216.
[9] “About NEJM,” The New England Journal of Medicine, accessed April 27, 2025, https://www.nejm.org/about-nejm/about-nejm.
[10] Delmonico et al., “Ethical Incentives.”
[11] Paula Chatterjee, Atheendar S. Venkataramani, Anitha Vijayan, Jason R Wellen, and Erika G. Martin, “The Effect of State Policies on Organ Donation and Transplantation in the United Staes,” JAMA Internal Medicine 175, no. 8 (2015): 1323–29, https://doi.org/10.1001/jamainternmed.2015.2194.
[12] A. S. Venkataramani, E. G. Martin, A. Vijayan, and J. R. Wellen, “The Impact of Tax Policies on Living Organ Donations in the United States,” American Journal of Transplantation 12, no. 8 (2012): 2133–40, https://doi.org/10.1111/j.1600-6143.2012.04044.x.
[13] Arthur J. Matas and Andrew D. Rule, “Risk of Kidney Disease After Living Donation,” Nature Reviews Nephrology 17, no. 8 (2021): 509, https://doi.org/10.1038/s41581-021-00407-5.
[14] Jennifer L. Wainright, David K. Klassen, Anna Y. Kucheryavaya, and Darren E. Stewart, “Delays in Prior Living Kidney Donor Receiving Priority on Transplant Waiting List,” Clinical Journal of the American Society of Nephrology 11, no. 11 (2016): 2047–52, https://doi.org/10.2215/cjn.01360216.
[15] Delmonico et al., “Ethical Incentives.”
[16] Venkataramani et al. “The Impact of Tax Policies.”
[17] Chatterjee et al., “The Effect of State Policies.”
[18] Kizer, English, and Hackmann, Realizing the Promise of Equity.
[19] “Malliotakis Introduces Bipartisan End Kidney Deaths Act,” Nicole Malliotakis, August 12, 2024, https://malliotakis.house.gov/media/press-releases/malliotakis-introduces-bipartisan-end-kidney-deaths-act.
[20] Lianne Barnieh, Scott Klarenbach, John S Gill, Tim Caulfield, and Braden Manns, “Attitudes Toward Strategies to Increase Organ Donation: Views of the General Public and Health Professionals,” Clinical Journal of the American Society Nephrology 7, no. 12 (2012): 1956–63, https://doi.org/10.2215/cjn.04100412.
[21] J. Cohen, T. Ashkenazi, E. Katvan, and P. Singer, “Brain Death Determination in Israel: The First Two Years’ Experience Following Changes to the Brain Death Law,” American Journal of Transplantation 12, no. 9 (2012): 2514–18, https://doi.org/10.1111/j.1600-6143.2012.04089.x; Berzon, “Israel’s 2008 Organ Transplant Law.”
[22] Farr Curlin, “Brain Death: New Questions and Fresh Perspectives,” Theoretical Medicine and Bioethics 40, no. 5 (2019): 355–58, https://doi.org/10.1007/s11017-019-09507-7; Ari R. Joffe, Gurpreet Khaira, and Allan R. de Caen, “The Intractable Problems with Brain Death and Possible Solutions,” Philosophy, Ethics, and Humanities in Medicine 16, no. 11 (2021): https://doi.org/10.1186/s13010-021-00107-9.
[23] Hagai Boas, “How Did Organ Donation in Israel Become a Club Membership Model? From Civic to Communal Solidarity in Organ Sharing,” Monash Bioethics Review 41, Suppl. 1 (2023): 49–65, https://doi.org/10.1007/s40592-023-00179-7.
[24] Walter G Wasser, Geoffrey Boner, Meni Koslowsky, and Adi Lazar, “Emergence of an Israel Faith-Based Community Organization Facilitating Live Donor Kidney Transplantation,” BMC Nephrology 19, no. 1 (2018): 128–35, https://doi.org/10.1186/s12882-018-0923-4.
[25] Miran Epstein, “Living Kidney Donors and Masked Nationalism in Israel,” Indian Journal of Medical Ethics 2, no. 2 (2017): 121–24, https://doi.org/10.20529/ijme.2017.028.
[26] Aviad Rabinowich and Alan Jotkowitz, “Altruism and Religion: A New Paradigm for Organ Donation,” Journal of Religion and Health 57, no. (1): 360–65, https://doi.org/10.1007/s10943-017-0488-8.
[27] Rabinowich and Jotkowitz, “Altruism and Religion.”
[28] Katrina A. Bramstedt, “What’s Mine Is Yours: Long-Term Experiences of Good Samaritan Organ Donors,” Journal of Patient Experience 5, no. 1 (2017): 16–20, https://doi.org/10.1177/2374373517718146.
[29] Kudirat Busari and Abigail Garba, “Altruistic Kidney Donation: Overview and Ethical Considerations,” in Current Challenges and Advances in Organ Donation and Transplantation, ed. Georgios Tsoulfas (IntechOpen, 2023), https://www.intechopen.com/chapters/83831.
[30] Busari and Garba, “Altruistic Kidney Donation.”
[31] Busari and Garba, “Altruistic Kidney Donation.”
[32] Jan MY., Yaqub MS., Adebig OO., Taber TE., Anderson MD., Mishler DP., Burney HM., Ly Y., Xiachun Li, and Sharfuddin AA. Non-Directed Living Kidney Donation—Recipient Outcomes in the U.S. A 20-year review. Kid Int Rep 2022; 7:1289.
[33] May WF. Religious justifications for donation of body parts. Hastings Center Report 1985; 15:38-42.
[34] Gilbert Meilaender, “‘Strip-Mining’ the Dead,” The Human Life Review 26, no. 1 (2000): 105–8.
[35] Gilbert Meilaender, “Gifts of the Body,” The New Atlantis (Summer 2006): 25–35, https://www.thenewatlantis.com/publications/gifts-of-the-body.
[36] Gregory Rutecki, “The ‘Gift of Life?’ A Perspective on Adult Partial Liver Donation,” Ethics and Medicine 20, no. 3 (2004): 167–78.
[37] Jin Yong Choi, Jae Heon Kim, Jong Man Kim, Hyun Jung Kim, Hyeong Sik Ahn, and Jae-Won Joh, “Outcomes of Living Liver Donors Are Worse Than Those of Matched Healthy Controls,” Journal of Hepatology 76, no. 3 (2022): 628–38, https://doi.org/10.1016/j.jhep.2021.10.031.
[38] R. D. Yusen et al., “Morbidity and Mortality of Live Lung Donation: Results from the RELIVE Study,” American Journal of Transplantation 14, no. 8 (2014): 1846–52, https://doi.org/10.1111/ajt.12771.
[39] Muhammad Y. Jan et al., “Nondirected Living Kidney Donation—Recipient Outcomes in the United States: A 20-Year Review,” Kidney International Reports 7, no. 6 (2022): 1289, https://doi.org/10.1016/j.ekir.2022.03.012.
[40] Harold Braswell, “Review: Jeffrey P. Bishop, The Anticipatory Corpse,” Foucault Studies 14 (2012): 196–200, https://doi.org/10.22439/fs.v0i14.3899.
[41] Jeffrey P. Bishop, The Anticipatory Corpse: Medicine, Power, and the Care of the Dying (University of Notre Dame Press, 2011), 299.
[42] Rpbert A. Montgomery et al., “Domino Paired Kidney Donation: A Strategy to Make Best Use of Live Non-Directed Donation,” The Lancet 368, no. 9533 (2006): 419–21, https://doi.org/10.1016/s0140-6736(06)69115-0.
Gregory Rutecki, "Preserving Dignity in Solid Organ Transplantation," Dignitas 31, no. 3-4 (2024): 15–18, www.cbhd.org/dignitas-articles/preserving-dignity-in-solid-organ-transplantation.