The United Network for Organ Sharing (UNOS), the national organisation responsible for transplantable organ distribution in the United States, recently condemned the direct solicitation of organs in situations “where no personal bond exists between the patient and the donor or donor family”.¹ UNOS worries that “such appeals, although well-intentioned, compromise the principle of fairness” or worse, “may divert organs from patients with critical need to those who are less ill.”¹

Despite UNOS objections, it is difficult to pinpoint who is harmed by unpaid solicitation of organs. Those on transplant waiting lists have few grounds for complaint, as the organs obtained from direct solicitation would not have been available otherwise. In such cases, the incremental increase in organ supply occurs after direct engagement with donors. At no point is an organ “taken away” from a transplant candidate, as there is no time in which the organ enters the wider UNOS distribution pool.

Moreover, presuming that all transplantable organs should be relegated to UNOS belies the established practice of directed donation, explicit in the Uniform Anatomical Gift Act,² whereby an organ is obtained from a donor known personally by the recipient.³ The existence of this mutual, prior relationship solely distinguishes directed donation from direct solicitation. Encouraging the former but not the latter hangs a good deal of moral weight on this criterion, which seems unsupportable given the life or death outcomes under consideration.

UNOS also recognises that it takes money to promote one’s cause, so wealthier individuals will inevitably—and unfairly—enjoy greater success in contacting prospective donors.⁴

Unfortunately, this line of reasoning fails to explain why wealthier individuals should rationally forgo pursuit of life improving options they can afford but which others cannot. It is especially incongruous with today’s “ability to pay” medical system. Recourse to these exclusionary costs selectively ignores identical problems plaguing the rest of US healthcare.

Reflexive deference to the status quo is ultimately undesirable. If indeed no one is harmed by direct organ solicitation, then its recent success should be reassuring to members of the transplantation community. It should also be a wake up call to UNOS, which apparently has ample room to improve its own procurement initiatives.

Incorporation of more intimate strategies beyond rote rehearsal of depressing statistics is probably a good first step and the likely comparative advantage—and appeal—of direct solicitation.