Much has been said about the ways we expect our oncoming fleet of driverless cars to change the way we live—remaking us all into passengers, rewiring our economy, retooling our views of ownership, and reshaping our cities and roads.
They will also change the way we die. As technology takes the wheel, road deaths due to driver error will begin to diminish. It’s a transformative advancement, but one that comes with consequences in an unexpected place: organ donation.
Since the first successful recorded kidney transplant in 1954, organ transplant centers have been facing critical shortages. Roughly 6,500 Americans die waiting for an organ transplant each year, and another 4,000 are removed from the waiting list because they are deemed too sick for a transplant. Since 1999, the waiting list has nearly doubled from 65,313 to more than 123,000. Liver and kidney disease kill more people than breast cancer or prostate cancer, and the Centers for Disease Control and Prevention expects the incidence of these chronic diseases to rise along with the need for more organs.
It’s morbid, but the truth is that due to limitations on who can contribute transplants, among the most reliable sources for healthy organs and tissues are the more than 35,000 people killed each year on American roads (a number that, after years of falling mortality rates, has recently been trending upward). Currently, 1 in 5 organ donations comes from the victim of a vehicular accident. That’s why departments of motor vehicles ask drivers whether they want to be donors.
It’s not difficult to do the math on how driverless cars could change the equation. An estimated 94 percent of motor-vehicle accidents involve some kind of a driver error. As the number of vehicles with human operators falls, so too will the preventable fatalities. In June, Christopher A. Hart, the chairman of the National Transportation Safety Board, said, “Driverless cars could save many if not most of the 32,000 lives that are lost every year on our streets and highways.” Even if self-driving cars only realize a fraction of their projected safety benefits, a decline in the number of available organs could begin as soon as the first wave of autonomous and semiautonomous vehicles hits the road—threatening to compound our nation’s already serious shortages.
We’re all for saving lives—we aren’t saying that we should stop self-driving cars so we can preserve a source of organ donation. But we also need to start thinking now about how to address this coming problem.
Because they’re following the trajectory of transportation revolution, these further shortages won’t arrive all at once. We’re only starting the cautious rollout of the first wave of semiautonomous cars, which still require occasional operator input and, as we saw recently in San Francisco, further technical development. Sophisticated sensors and collision-avoidance systems will help reduce accidents, but the real change will come with well-engineered fully autonomous vehicles. The federal government has fast-tracked their adoption and sees them as a key part of a goal to get the nation to zero highway deaths in the next 30 years. Barring a monumental medical breakthrough in the field of organ replication, that means we need a national solution for our donation shortages—fast.
The most straightforward fix would be to amend a federal law that prohibits the sale of most organs, which could allow for development of a limited organ market. Organ sales have been banned in the United States since 1984, when Congress passed the National Organ Transplant Act after a spike in demand (thanks to the introduction of the immunosuppressant cyclosporine, which improved transplant survival rates from 20–30 percent to 60–70 percent) raised concerns that people’s vital appendages might be “treated like fenders in an auto junkyard.” Others feared an organ market would exploit minorities and those living in poverty. But the ban hasn’t completely protected those populations, either. The current system hasn’t stopped organ harvesting—the illegal removal of organs from the recently deceased without the consent of the person or family—either in the United States or abroad. It is estimated that, worldwide, as many as 10,000 black market medical operations are performed each year that involve illegally purchased organs.
Though advocates may be concerned about the inequities organ markets may create, it bears noting that our current donation system already disproportionately favors the wealthy. For one, shortages have created incentives to game waiting lists. A wealthier liver-transplant candidate, for example, can afford to undergo analysis at numerous liver centers and, in doing so, get put on multiple transplant lists. Richer patients can also afford to travel to countries with more prevalent black markets for organs (which, unregulated, may have meant darker outcomes for their original owners).
What’s more, chronic diseases—especially those like kidney disease—disproportionality affect minority communities. According to the CDC, these disparities occur as a result of disparate environmental and social conditions, as well as limited access to health care. As a result, more than half of those on the national organ waiting list are minorities. While it isn’t unreasonable to surmise that some in these communities might have strong monetary incentives to sell their organs, they’re likely making more organs available to those from similar disadvantaged backgrounds.
There’s also the question of whether we have inconsistent ideas about what parts of the human body we find acceptable to commoditize. We’ve already legalized paid medical trials and paid donations of blood plasma, sperm, and eggs. Egg donation is an invasive process that, like kidney donation, includes a small risk of health complications. But according to a national 2007 survey of clinics, egg donors are compensated an average of $4,217 for their contributions.
So what would an ethical fix to our organ transplant shortage look like? To start, while there’s certainly a place for organ donation markets in the United States, implementation will be understandably slow. There are, however, small steps that can get us closer to a just system. For one, the country could consider introducing a “presumed consent” rule. This would change state organ donation registries from affirmative opt-in systems (checking that box at the DMV that yes, you do want to be an organ donor) to an affirmative opt-out system where, unless you state otherwise, you’re presumed to consent to be on the list. Researchers comparing liver and kidney donation rates in 48 nations found that countries with opt-out systems had higher transplant rates of both organs than those with opt-in systems. Of course, whether drivers opt in or opt out will become less relevant as autonomous vehicles make driving safer.
There’s also evidence that both monetary and nonmonetary compensation offer strong incentives for donation. In 2008, for example, Israel instituted a benefit package for living donors that included full wage reimbursement for 40 days and up to five years of paid expenses for a variety of services, including health and life insurance. The country also amended its organ transplant law again in 2010 to allow a patient to gain priority allocation on a transplant list if a member of his or her family demonstrated willingness to donate an organ. The number of living organ donors increased by 67 percent between 2011 and 2013 compared with the previous three-year period.
Setting up and regulating a paid donation system inevitably would be far more complex. But it’s useful to remember that, while autonomous vehicles are on the near horizon, they are not quite at the door. Widespread deployment of high-level autonomous vehicles is likely more than a decade away. In that time, as lower-level autonomous vehicles are deployed, policymakers could develop and refine legal protections for organ donors, with state-by-state standards to accommodate different levels of comfort. To address the potential for coercion, policymakers could institute a cooling-off period between when a donor agrees to sell an organ and when he or she goes through with the donation. To alleviate concerns associated with commercialization, compensation could be limited to fixed payments or to benefit packages that include insurance, tax deductions for travel, lodging and lost wages, or paid donor leave.
We’ve come a long way since that first kidney transplant more than 50 years ago. Like today’s autonomous vehicles, organ donation was a powerful scientific breakthrough with great potential to save lives. But to get the human benefits, it all comes down to implementation. Lifting barriers for potential organ donors isn’t just a matter of personal freedom. It will soon be a dire need. We don’t want to reduce preventable fatalities on the road only to preventively increase them for those waiting on the transplant list.