Not as Simple as Civic Duty: A Response to Andrew Michael Flescher’s Argument to Increase Living Kidney Donations

Abstract

In The Organ Shortage Crisis in America: Incentives, Civic Duty, and Closing the Gap (2018), Andrew Michael Flescher analyzes and critiques proposed ways to solve the kidney shortage in the United States. He advocates removing disincentives to living donation and emphasizes types of nonmonetary compensation, eventually establishing “a gift exchange powered by civic engagement,” (p. 16) where the relational aspect of the exchange between donor and recipient is of primary importance. Unfortunately, the project fails. A reliance and emphasis on civic duty as the primary driver of living organ donation is unrealistic and potentially harmful. Without making structural changes to the current recruitment and distribution system to account for institutional biases within the healthcare system, there is no hope for a just solution to the organ shortage crisis. Relying on “civic virtue” requires a trustworthy healthcare system that uses a fair method to distribute organs. Empirical evidence demonstrates that we do not have either of those in the U.S. Policymakers could construe arguments that frame civic virtue as the most important missing ingredient in solving the organ shortage crisis as arguments that justify the current prejudicial framework. The U.S. should remove disincentives that deter donations, but that will be only a partial solution. Alternatives that can move the U.S. closer to an ethical solution include increasing access to primary and preventive care, to reduce the need for donor kidneys in the first place, and expanding the eligible donor pool.