Opportunities not taken: Successes and shortcomings in the Institute of Medicine's report on organ donation

The Institute of Medicine's recent report, Organ Donation: Opportunities for Action, studies the current problems facing organ donation in the USA, making suggestions for quality improvement and analyzing various proposals of incentivized donation and presumed consent (PC). Although the report deals with the donation of several solid organs, this mini review examines the findings from the perspective of kidney transplantation. The committee's recommendations to move from circulatory to neurologic criteria for cadaveric donation and to increase opportunities for donor decision making are prudent. We agree with the committee's arguments against providing incentives for donation because of the inherent distributional inequalities and imperfect information; the intrinsic difficulties in establishing market equilibrium for such heterogeneous and perishable goods; the implied commoditization of the human body; and the inadequate data regarding the long-term risks of living donation. However, we question the committee's firm opposition to PC, especially given recent data from 22 European countries showing a 25–30% increase in organ supply attributable to a PC policy. If this simple change in the default position on donation has the potential to increase organ supply, decrease the need for living donation, reduce the burden on grieving families, maintain familial authority over the deceased, and respect patient autonomy, at least a pilot program of PC seems warranted.