Running head: LIFE AFTER DEATH 1

Life After Death: An in Depth Analysis of the United States Organ Donation System

Reagan H. Tate

First Colonial High School

LIFE AFTER DEATH 2

Abstract

This paper explores the problems and potential solutions to the United States Organ Transplant

system. The paper starts with an analysis of laws presiding over the system and moves into

issues with the current system. In addition, an exploration of other countries systems such as

Iran, China, and other European nations. The paper then analyzes the effects of criminals on

organ donation and organ trafficking in the United States. The paper then concludes with

various proposals for the organ donation system.

Keywords: Organ Donation, Organ Transplants, United States

LIFE AFTER DEATH 3

“Life Goes On” An Analysis of the United States Organ Donation System

116,491 people are currently on the national transplant waiting list, but on average only

33,000 transplants are performed each year. As the waiting list continues to grow and transplant

rate does not, more and more people die while waiting. In the United States 95 percent of

citizens say they support the organ donation system, but only 54 percent actually sign up to

become donors ("Organ Donation Statistics," n.d.). Why is this? Anyone can sign up to be an

organ donor regardless of any existing conditions and infections because the organ transplant

team determines eligibility at the time of death. A common deterrent of signing up to be a donor

is that medics will not try and save your life when in fact this is untrue. First responders take an

oath to do any life saving methods possible until nothing can be done. No one can remove any

organs from a person's body legally until brain death is declared and is enforced by the Dead

Donor Rule. This rule states that organ donors must be dead before any procedure can begin,

and the organ donation process itself can not cause the death of the donor (Coons & Levin, n.d.).

Factors such as blood type, age, geographic location all factor into who receives the organ

donated ("Organ Donation Myths and Facts" 2017). The United Network for Organ Sharing

(UNOS) maintains a central computer network with all patients waiting and is staffed to respond

to new patients, changes in status, and placement of organs. In order to be on the waiting list,

people must be in end-stage organ failure and have been evaluated by a transplant physician

("United Network for Organ Sharing," 2017). The current United States Organ transplant system

is regulated by unrealistic laws that defund working transplant centers and prevent patients in

dire need of organs from receiving them.

Official Law for Organ Transplants

Medical Center Requirements

LIFE AFTER DEATH 4

42 U.S. Code § 488.61 states the special procedures for approval and re-approval of

organ transplant centers. Centers for Medicare and Medicaid Services is the organization that

creates the guidelines for clinical experience and outcome requirements and approves and

disapproves transplant centers. Each center must follow the guidelines and submit 95 percent of

their data to be reapproved.

Graft Survival Rates. “Graft Survival is an estimate of the probability of the transplant

functioning at a finite time after transplantation. If the patient dies and has not returned to long-

term dialysis, the date of the death is assumed to be the date of graft failure” ("Analysis of

Patient and Graft Survival," n.d.). Survival rates can vary depending on what organ is being

transplanted and how sick the patient is prior to the transplantation. Law 42 CFR 482.82 states

the condition of participation, data submission, clinical experience, and outcome requirements

for re-approval of transplant centers. The law states that the number of patient deaths and failures

minus the number of expected failures in a transplant center must be less than 3. The law also

states that transplant centers must provide 95 percent of their data. The rates of failed kidney

transplants allowable under the these regulations has dropped to 7.9 for every 100 transplants for

most centers (law.cornell).

Buying and Selling of Organs

42 U.S. Code section 274e states that “It shall be unlawful for any person to knowingly

acquire, receive, or otherwise transfer any human organ for valuable consideration for use in

human transplantation if the transfer affects interstate commerce” (Prohibition of Organ

Purchases, 2007). The first United States case dealing with organ trafficking was Levy Izhak

Rosenbaum vs. United States. Rosenbaum bought organs for as little as 10,000 dollars and sold

them for as much as 160,000 dollars. He served only less than 5 years in jail, confiscation of all
LIFE AFTER DEATH 5

profits based off the organs sold, and an additional fine of 50,000 dollars. Rosenbaum's ideas

were not entirely insane, but the price people paid to receive an organ was high, and he violated

the U.S code that states a person cannot sell or distribute organs for profit (United States vs.

Levy Izhak Rosenbaum).

United Network for Organ Sharing

The United Network for Organ Sharing is a private non-profit organization that under

contract of the federal government regulates and manages the organ transplant system. Congress

passed the National Organ Transplant Act in 1984 that called for a national network to

coordination the allocation of organs. The main goals for the organization are to increase the

number of transplants, provide equity of access to transplants, and to improve overall transplant

outcomes. UNOS matches patients to organs based on medical urgency, blood, tissue, size

match, time on the waiting list, and the proximity guide distribution. The waiting list is not in

chronological order and changes based on what organ is donated. The country is divided into 11

regions, the organ donated is offered to local patients in the region first then moves to the mass

list ("United Network for Organ Sharing," 2017).

Problems with the United States Organ Donation System.

Unrealistic Graft Survival Rates

Graft Survival Rates are the percentages of the graft survival divided by the total number

of transplants done within a center. Graft Survival is the functioning of an organ transplant

within a patient and is typically measured at the first, second, and fifth year mark ("Analysis of

Patient and Graft Survival," n.d.). In 2014 alone there were permitted 4.6 deaths for every 100

transplants in order to maintain compliance with the CMS(Centers for Medicare and Medicaid

Services) standards whose risk approximates with the national average. In some cases they allow
LIFE AFTER DEATH 6

up to 9.7 deaths, but only after further investigation. Graft survival rates are regulated by CMS,

backed by federal law and enforced by federal funding of transplant centers. Without funding,

an organization simply cannot function. In order to stay in operation, transplant centers such as

Duke and Johns Hopkins deny patients who have a survival rate as high as 80 percent. Ilene

Herman of Weston Florida needed a lung transplant in 2010 because of scarring from

scleroderma. She first attempted to go to Duke Medical Center to receive a transplant but was

denied because she was too “high risk.” She was then deferred to University of Pittsburgh

Medical Center and had to leave her family and job behind to travel and receive care. UMPC is

considered a dumping ground for other centers because of how large their program is. Their

overall stats are not as high as other medical centers but high enough to not be cited. UMPC is

able to take patients such as Ilene Herman because of how large their program is. This skews the

system of organ donation overall in the United States (Hawryluk, 2014). Not only are patients

being denied, but according to the Survey and Certification Group, the transplant programs

could be avoiding the use of viable organs that “potentially affect the outcome statistics.” In

2015 3,159 adult kidneys recovered were not used for transplantation (Survey & Certification

Group, 2016). The United States already lacks organs due to a low percentage of donors, and

throwing away viable organs further limits the amount of patients who receive an organ in their

lifetime.

Over Expensive Procedure

Receiving an organ entails more than just hospital bills and transportation fees. Costs

include insurance deductibles, anti-rejection drugs and other fees. Paying for a transplant is

costly enough. Additional bills make transplants almost impossible for those with low income.

The average cost for a liver in 2011 was 577,100 dollars. This cost included pretransplant and
LIFE AFTER DEATH 7

post transplant procedures, anti-rejection drugs, the surgery itself, and cost of physicians and

other doctors. This cost did not include travel fees and lost wages that people may suffer from

("Financing A Transplant | Costs," n.d.). According to the Milliman Research Report, by August

2017, the total costs for receiving a liver transplant and everything it entails was 812,500 dollars

(Bentley & Phillips, 2017).

Lack of Organs

In the past year the United States had only 15,000 donors and around 115,000 on the

waiting list. With 323 million people currently in the United States, why are there not enough

organs? The current United States system operates under an opt-in approach where each citizen

must say they they wish to be an organ donor in order to become one. Of those 323 million

about 95 percent say they support the organ donation system but only 54 percent are actually

signed up. ("United Network for Organ Sharing," 2017) What is stopping people? Much of the

reason is surrounded by the mistrust of the medical field and a lack of understanding of what

organ donation entails. Many citizens don't know that according to the Dead Donor Rule, organ

donors must be brain dead before organ donation procedure can begin and the organ donation

process itself cannot cause the death of the donor (Coons & Levin, n.d.). Religion can also

prevent many people from becoming an organ donor. But these misconceptions are not the only

reason for the lack of organs in the United States. Many hospitals and transplant centers began

throwing away perfectly good organs because they could have caused a possible failure and thus

a drop in the centers’ overall graft survival rate. It's imperative that transplant centers keep up

their survival rates to prevent being shut down. Due to these high rates, many organs are being

tossed and going unused (Wen, 2014).

Improper Allocation of Organs

LIFE AFTER DEATH 8

The passage of National Organ Transplant Act made the organ transplant system a

federally mandated system rather than local. But overall the geographical problems have not

lessened because the nation still views geography as the most effective way of allocating organs.

The most heavily weighted factor in kidney allocation is waiting time. This means that the value

of receiving an organ is diminished by the years waiting in dialysis and fewer quality years are

received after getting an organ. It also means transplanting organs to an older generation. The

council recommended that factors such as age, long term benefit, and age relationship of donor

and recipient be also considered as factors. As terrible as it might sound, our current system

needs to adjust by allocating a scarce resource based on who will benefit the most, not waiting

time (Egendorf, ed., 2006).

The United States System Compared to Others

The Iranian Model

Worldwide there is a high demand for organs and the gap between those who need organs

and donors continues to grow. There have been various proposals of financial compensation and

other compensation for donation to encourage citizens to sign up. Iran developed a plan in 1997

that compensated living unrelated donors and also developed the 2000 Organ Transplant Act

which allows organ removal once a person is declared dead in the brain or a patient's heart stops

beating. Statistics showed that before the implementation of the compensation, 30 percent of

patients on the waiting list for transplantation would actually receive a kidney. After the LUR

(Living Unrelated Donor) act was implemented, the waiting list for kidneys was eliminated in

1999. The Charity Foundation of Special Diseases is a nongovernmental organization that is

responsible for providing the compensation to donors. The LUR donor receives 10 million rials

which is equivalent to 295 US dollars. The donors must go through a screening process that
LIFE AFTER DEATH 9

includes checking for diseases, a psychosocial evaluation, and tissue matching. The transplant is

performed by public university hospitals and costs are paid for by the government. A person

also must be an Iranian citizen to undergo a transplant through this program. The Council of

Europe’s “Convention on Human Rights and Biomedicine” prohibits financial gain but

compensates donors for expenses and lost income. In the United States, Pennsylvania has an

initiative to pay 300 dollars to deceased organ donors’ families for funeral expenses. The

purpose of compensation is to recognize the good act of the donor, not to gain financial status.

By compensating the living unrelated donor for lost time it avoids human parts becoming

products in the black market. The Iranian model prevents trade in organs. They have various

control measures, and prevention in organ trafficking. The Iranian rule that the organ donor and

recipient must be the same nationality prevents the country from being an organ trafficking site.

The kidney must also have an identifiable origin. The model provides that donors are not paid

for their organs but paid as a social gift for their time. Recipients also do not have to pay for the

organ. The downfall of the program is that it does not eliminate the possibility of kidney sales or

sales through private transactions, and it also brings up the idea to sell organs to solve financial

problems. The second downfall of the program provides that it will decrease donations within

families because they will not receive the benefits of the Living Unrelated Program. More

problems that the Iranian model brings up is the probability of recipients paying the donors more

money as they want to receive an organ faster, and transplants may be performed without the

correct safety precautions since there are no reports of results submitted. The process also

decreases the need for citizens to sign up to be organ donors after brain death. Arguments

against the Iranian model conclude that by focusing on living donors, it decreases the focus on
LIFE AFTER DEATH 10

brain death donors which leads to a shortage of other organs that cannot be transplanted by the

living (Bagheri, 2006).

European Nations

The general approach to organ donation systems in most European countries is the opt-

out or presumed consent approach. Presumed consent implies that all adults are signed up for

organ donation unless they opt out of the system. According to Wales, for every 160 transplants

39 transplants were due to this system change. Wales also reported that only 6 percent of the

population opts out, and it is less of a burden on the health staff ("Wales Organ Donations

'encouraging' in Year after Consent Law," 2016). The Spanish model is noted for its widespread

success in an increase of 25 donors per million people, which is currently the world's highest,

through the “ONT” model. The ONT model is the “Organización Nacional de Transplantes”

which relies on the promotion and facilitation of donation from their health care professionals.

The model prioritizes considering donation from any patient regardless of cause of death.

According to Beatriz Dominguez “Professionals attending to these patients in our country

consider that, in caring for patients at the end of their lives, it is their duty to systematically

explore their wishes with regards to donating organs upon their death.” The model’s success is

credited to the opt-out approach and to always discuss with patients about organ donation. This

increases awareness in citizens so they feel more informed and are more likely to become organ

donors (Matesanz R, et al., 2016).

The Chinese Model

The ethics of the Chinese organ transplanted model have been disputed for decades due

to abnormal reports from many transplant centers. Recently Chinese authorities have been

attempting to control unethical harvesting of organs, but it continues to be a prevalent problem in

LIFE AFTER DEATH 11

the prison system especially. According to the China Organ Transplant Response System, all

transplants and donations since 2013 must have been registered, but figures given don't match up

with the number of transplants performed versus how many donations were accounted for. The

Tianjin First Central Hospital transplant center reported that their hospital bed utilization was

131 percent. Beds were wedged in and excess patients put in nearby hospitals. Many hospitals

also reported that at least 15,500 transplants are performed each year in China up to 2006. After

the passage of the first Chinese legiston in 2007, death row prisoners were viewed as a never

ending source for organ donation. Even though the number of death row prisoners has greatly

declined, the number of transplants in China has not declined and even grown in trajectory.

Many ethical groups have proven that the true source of the growing transplant numbers are

“prisoners of conscience,” or people who are imprisoned in China for holding views not tolerated

by the Chinese government. The organization Freedom House reported that in the early 2000’s

many prisons had suspicious activities such as the blood testing of the Uyghur prisoners and

mysterious death of Tibetans and Falun Gong detainees. These prisoners are considered to be a

part of those “evil religions” and are detained by the government (Robertson & Lavee, 2017).

DAFOH, an organization of medical doctors against forced organ harvesting, has advocated

against the Chinese organ transplant system for years and battled its government to stop the

harvesting the organs of prisoners of conscience specifically. According to DAFOH the Chinese

communist party continues to ignore protests against the mass killing of prisoners of conscience

and continues to increase trajectories of transplants in the years to come. China claimed that

organ harvesting from executed prisoners would end by January 2015, and the system would be

converted to a traditional source of organ donation. Many organization in the global transplant
LIFE AFTER DEATH 12

community question how a new organ donation system could already have more than 7,000

reported organ donations a year (DAFOH, 2017).

Organ Trafficking in the United States

The first case of organ trafficking in the United States was United States vs. Levy Izhak

Rosenblum in 2012. Levy Izhak Rosenbaum was found guilty and convicted of violating U.S.

Code 42 Section 274e that prohibits the buying and selling of organs. Rosenbaum was buying

organs for as little as 10,000 dollars through an ad in the paper written in Hebrew. He would then

match people with similar blood types and bodies to create matches in organs and send them to

hospitals. Rosenbaum would charge recipients up to 160,000 dollars for a single organ.

Rosenbaum was exploiting vulnerable people on both sides of the spectrum but only served 5

years of jail time, a confiscation of all profits, and an additional fine of 50,000 (United States vs.

Levy Izhak Rosenbaum, 2012). Although the United States has laws against organ trafficking,

many other countries take no action against con artists such as Rosenbaum. Even with strict

laws, organ trafficking can go undetected. In 2006 USA Today found that over 16,800 families

looked into lawsuits that involved the selling of their loved ones body parts and had a net

estimate of 6 million dollars in value. In 2013, a Georgia student was found dead inside of a mat

in school, and the death was initially ruled an accident, but according to a second autopsy it

revealed that his internal organs, brains, lungs, liver were missing and filled with newspaper.

This case was left unsolved and not further investigated. In 2014 a Georgia actor was found

dead in Death Valley, California with multiple organs missing. Investigators ruled it may have

been an animal attack, but the rest of the body remained intact. Many suspicious cases like these

pop up across the United States. Although these cases were never directly linked to organ

trafficking, they raised questions for many authorities in the area (Small-Jordan, 2016).
LIFE AFTER DEATH 13

Criminals and Organ Donation

Christian Longo was one of the first convicted criminals to appeal to give life after death.

He has become a lifetime advocate for the right to donate post-execution as he waits on death

row. He was denied the appeal on the grounds that the interests of the public and condemned

inmates was best served. The debate of whether to allow death row inmates to donate has been

going on for years. According to the National Transplant Act of 1984, death row prisoners

should theoretically be allowed to donate because they will not be receiving shorter sentences.

Death row inmates would also provide for a reduction of the ever growing organ transplant list.

Although not all death row inmates would be eligible to donate, at least 30 of every 1,500 death

row inmates would be able to provide healthy usable organs and save as many as eight lives

each. Many non-death row inmates have been allowed to donate before this issue was brought

up, and individuals with past criminal records have been permitted. But how would the

government be able to ensure the right of “Voluntary consent” is not compromised in the prison

environment? Capital punishment is an ongoing debate in politics whether it is ethical and

moral. Many prisoners are vulnerable to direct and implied coercion and could be forced into

agreeing and becoming a donor. The government would have to provide a safe and secure

location for the procedure to happen and keep the ethics of the death penalty. In China many

death row inmates are killed by the removing of their organs as a way of execution. This process

is painful and unethical in the standards of the United States system (Lin, Rich, Pal, & Sade,

2012). Non-Death row prisoners can run into problems with donation as well. Anthony

Dickerson, the father of a 2 year old boy born without kidneys, was scheduled to make a

donation to his son in October of 2017. This donation would have been lifesaving and given A.J,

his son, a chance to not have to be on the kidney transplant waiting list. But a week before the
LIFE AFTER DEATH 14

scheduled donation, Dickerson was arrested for a parole violation and charged with possession of

a firearm. Emory Hospital said if Dickerson could be escorted to the hospital, then the transplant

could go as scheduled, but it was ruled that he would be reevaluated in January of 2018 when he

is released (Abdulahi, 2017).

Reform Proposals

Brodsky’s Proposal

A New York assemblyman, Richard Brodsky, scripted a proposal that was two parts: one

that prevented the families of deceased registered donors from overruling the decision, and two,

an opt-out or or presumed consent system. This proposal also included a provision of giving

living donors a 1,000 dollar tax credit. Presumed consent, also known as an opt-out policy,

states that each deceased citizen will be assumed to be an organ donor unless stated otherwise.

Presumed consent is the opposite system of what the United States currently has which is an opt-

in. Since over 90 percent of Americans say they support organ donation but it is not represented

by those who actually sign up, presumed consent would provide for a great increase in organ

donors. The only concern with presumed consent is the infringement upon body rights and thus

providing a backlash against organ donation in general. The second piece of the proposal would

be to deny requests of living family members to overrule the decision to donate. This would

allow for many registered donors to go through with their donation commitment. Between 2010

and 2015 over 1,200 people did not get the chance to donate because family members objected.

These organs could have accounted for over 7,000 people on transplant waiting lists.

California Bills

In California a Bill was proposed to create a living donor registry for kidneys. Since

many kidney transplant patients are often from family or friends, what happens when there is no
LIFE AFTER DEATH 15

match? A living donor registry would allow for random willing kidney donors to be matched

with someone who needs a transplant. Another California proposal suggested that instead of just

a box to check when they receive a license they will be verbally asked whether or not they would

like to become a donor. This proposal was expected to increase the amount of donors (Park,

2010).

Conclusion

The solution to the ongoing debate over the United States organ transplant system is

indefinite and cannot be solved in days, months, or even a couple of years. The main focus of

the United States organ donation system needs to be increasing the amount of donors. Whether

that means moving to an opt-out system or increasing awareness, any efforts count. Encouraging

medical professionals to discuss with patients before death about their donation could greatly

increase the number of donors. At the rate the waiting list currently is at, it will continue to grow

rapidly as the number of transplants done every year remains roughly the same. Socioeconomic

status should no longer determine your eligibility to receive an organ and transplant centers

should no longer worry about their success rates dropping to below 90 percent. The United

States must lower the graft survival rates enough to allow for more transplantation and a chance

for life for higher risk patients.

LIFE AFTER DEATH 16

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want-to-donate-their-organs/382297/