Certain proposals designed to increase the supply of cadaveric organs suitable for donation, (e.g. confiscation of organs, an opt-out system, and various methods of compensation), are controversial in large part because many see cadaveric donation as a supererogatory act. The view that people are not obligated to make their organs available after death is based on Kantian respect for autonomy and a notion of rights derived from social contract theory. I look to both Kant and contractarian-informed views of free-riding to argue instead that making one’s own organs available for donation after death is in fact a moral duty. According to a Kantian conception of a duty of mutual aid , we have a duty to respond to the true needs of rational beings when fulfilling such needs places little burden on us. And a refusal to donate organs entails the kind of indifference to interdependency that characterizes morally problematic free-riding . Accepting that cadaveric explantation is morally obligatory lends justificatory support to the proposals mentioned above, though I do not endorse any of them here.

If the supply of suitable donated organs was sufficient to meet the need, arguing for a duty to make organs available would perhaps not be a wise allocation of philosophical capital. One might argue that although resolving the organ shortage would surely be a good thing, many other public health priorities are far more pressing. Still, the supply is woefully inadequate at present. This costly state of affairs has consequences that extend beyond aggregate suffering and loss of life, and raise concerns about justice and nonmaleficence .

According to the United Network for Organ Sharing (UNOS), as of January 8, 2010, there are 105,359 people registered on the waiting list for donated organs in the U.S. alone. More than 68 % of these candidates have been on the list for 1 year or more; more than 13 % have been waiting for more than 5 years. Yet each year for the last 10 years, the number of organ donors (both deceased and living) has hovered between 10,000 and 15,000, and decreased since 2006. The yearly number of transplants performed hovers between 21,000 and 28,000. Over 6000 patients die each year while awaiting transplants, an average of 18 patients each day.¹ The shortage of organs has additional costs: psychological harms to patients and loved ones, resources expended to provide continued care while patients wait, and resources expended on marketing campaigns to encourage more people to donate.

Recent years have seen an increase in the percentage of transplants performed with organs from living donors, due to both the shortage of cadaveric donations and advances in transplant medicine. In 1988, 14 % of transplanted organs came from living donors, while in 2008, 22 % came from living donors. Though exhaustive data on the outcomes is lacking, risks of morbidity and mortality are, of course, present for live donors. For example, a 2002 survey found that between January 1999 and July 2001, at least three kidney donors died and one was left in a persistent vegetative state as a direct result of their nephrectomies.²

The prospect of performing surgery on a healthy person, even in the most economically privileged of contexts, gives many of us pause for thought. But we cannot confine discussion of the organ shortage to its manifestations in the developed world. It is not surprising that some patients of means have not been content to languish on waiting lists, and have purchased organs on a burgeoning international black market , or through the ethically dubious Chinese system that harvests organs from executed prisoners.³ These cases raise justice concerns insofar as they present an unfair advantage to the wealthy and exploit some of the world’s most vulnerable citizens. They also raise nonmaleficence concerns, in that some of these donors are undoubtedly harmed (e.g. deceived, defrauded, coerced, or given inadequate follow-up care).⁴ To perform transplants with the suspicion that the organs being transplanted may have been procured through shadowy networks that do not properly care for donors (who are also patients), or to provide follow-up care to patients who have procured their organs through these means, undermines the integrity of physicians, who, in addition to being charged with helping patients (under a duty of beneficence), are also to refrain from inflicting harm (a duty of nonmaleficence).⁵

My argument has some precedent in the literature on a duty to participate as a subject in biomedical research . Arthur Caplan draws on a Rawlsian view of fair play, in which “[t]he members of a cooperative group can legitimately expect each group member to accept the burdens and risks of participation” (Caplan 1984, p. 3). Rosamond Rhodes makes a more comprehensive argument with three parts. The first, the argument from justice, acknowledges that the medical innovations, from which we all might benefit, require sacrifice of “our flesh, our privacy, our safety , our comfort, and our time,” as human subjects (Rhodes 2008, pp. 12–13). The argument from beneficence grounds our obligation in the Golden Rule and the interdependent reality of the human condition. Finally, the argument from self-development claims that it is essential to the exercise of our autonomy that we acknowledge our fragility, will that we be able to “fend off disease and disability,” and will the necessary means to achieve it, i.e., a robust system of biomedical research (Rhodes 2008, pp. 12–13).

In ethical terms, organ transplantation differs from biomedical research in two important ways. First, principles of justice and self-development elegantly accommodate the case of biomedical research—from which we all benefit whenever we purchase over the counter painkillers. But it is less obvious that the system of organ donation and transplantation is a cooperative group that benefits all or even most of us. Second, the patient who languishes on a waiting list for an organ is a clear case of someone in need of direct assistance from another person; a general public group/class that hopes to benefit from biomedical research broadly is more difficult to cast in such a role. Still, there are similarities between the argument for a duty to participate in research and the argument I present in the following sections.