1

Lisanne van Wijngaarden 4058399

Organ Donation Have people who are registered as organ donor
more right to obtain an organ transplantation than people who are
not registered?

Introduction
Black markets can be found anywhere in the world, there exists a black market for every
product you can imagine. One of the worst black market that exists is the market for human
organ donors. People can sell their organs for money and in some horrible cases people get
robbed from their organs. In countries such as China and India a kidney can be sold for
$70,000 and a liver for even $120,000
1
. Therefor people are for instance willing to give up
one of their kidneys in order to pay back their loan
2
.
In the Netherlands there was quite some fuss about the programme The Grote Donorshow,
broadcasted in 2007. Organs were not sold, but just given away by a potential organ donor.
The potential donor candidate would choose among three people to whom she would donate
her organ. The choice was made during the programme based on the contestants history,
profile and conversations with their family and friends. The programme turned out to be a big
stunt in the end, but the message was clear: there is a big shortage of organ donors
3
.
Since the trade of organs is illegal in the Netherlands
4
, like in most countries, the focus of this
paper will be on the legal organ transplantation and especially the organ donation after death.
In the Netherlands the No-If system, also called approval system, is the current system for
organ donation. This means that organ donation after death only applies for those who are
registered as organ donor in the Donor register. If you are not registered then, by law, you are
no organ donor. However relatives can still decide after your death if your organs can be used
for transplantation, unless you have explicitly registered yourself as not willing to be an organ
donor. In 2013 the Organ Donation Act was amended. Before an organ can be transplanted,
doctors must carry out some preliminary donor research. In the past this was only done if the
patient was dying and registered as organ donor. Now the doctor can do this preliminary

1
Shimazonom,Y.; The state of the international organ trade: a provisional picture based on integration of
available information; World Health Organization, December 2007
2
BBC News; The Bangladesh poor selling organs to pay debts; October 2013
3
NOS; BNN Donorshow nep; July 2007; http://nos.nl/artikel/62473-bnn-donorshow-nep.html
4
Rijksoverheid; http://www.rijksoverheid.nl/onderwerpen/orgaandonatie/regels-orgaandonatie
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research with people who are dying, but are not necessarily registered as organ donor or are
registered and have left the decision about organ donation to their relatives
4
.
In the Netherland there are roughly 1100 people waiting for an organ transplantation at the
moment, varying from kidneys, livers and other organs to corneas and skin tissues
5
. To date
there are more than 5 million people registered in the Donor register. From those 5 million
people 3.5 million are willing to donate (part) of their organs, 1.5 million did not have given
permission and 0.7 million has given the choice to one of their relatives
6
.
Three and a half million people willing to donate an organ sounds like a lot, especially
compared to the 1100 people who are waiting for an organ transplantation. However, not
everyone is suited for an organ transplantation or a right match wasnt found in time. The
selection criteria for a right match are e.g. the blood type, length and age of donor, medical
urgency and waiting time. Also the conditions need to be right at the right moment, for
example the donor needs to pass away in the hospital. Therefore only a few hundred donor
organs are available per year.
In the Netherlands the only way to obtain more organ donations is more or less via the
goodwill of people. You are no organ donor unless you fill in the form yourself (the No-If
system). Therefore you need to take the initiative yourself to be registered as an organ donor,
or not, if you explicitly dont want to be an organ donor. Five million people are registered in
the Donor register, which means that eight million people are still not registered (considering
only people of 20 years and older)
7
. Since the urgency for new organ donors is high, it raises
the question why not everyone is registered yet. Are people too lazy to fill in the form or are
they all against organ donation and are they comfortably covered by the law? Is it fair to the
people who are registered as organ donor that they are willing to give up something that
others do not want to give up? A potential donor does not know in most cases to whom
his/hers organs are going, sometimes even to more than 1 person, and what if the receiver is
against organ donation? Would that be fair? In the Netherlands everyone is free to choose
what he/she wants (as long as it is in accordance with the law) and that is also the case with
being a donor or not. However, in this case, that choice could potentially save a life and
maybe even your own life. If someone chooses to save your life, wouldnt it be fair that you

5
Nederlandse Transplantatie Stichting; http://www.transplantatiestichting.nl/cijfers/actuele-cijfers-organen
6
Donorregister, Ministerie van Volksgezondheid, Welzijn en Sport;
www.donorregister.nl/organisatie/cijfers/registraties/default.aspx
7
Centraal Bureau Statistiek; Bevolking Kerncijfers; 2013
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should do the same? Or has the right to be saved more value than the right of being saved?
Many questions are raised from this topic and therefore the question that will be analysed in
this paper is:
Have people who are registered as organ donor more right to receive an organ
transplantation than people who are not registered?
This answer will be analysed from the Dutch perspective (law, statics etc.). In this case donor
registered will be considered as willing to donate (part of) your organs and not donor
registered that you give no permission to donate your organs or have not filled in the organ
donation form (unknown if you are willing or not). In moral analysis the current law and
proposed laws of organ donation, different reasons to be organ donor registered or not and
different ethical issues will be discussed.
Moral Analysis
I know a case in which a person desperately needed a lung transplantation and was put on the
waiting list for receiving one. He and his wife are religious and believe that their bodies need
to be whole after their death. They therefore refused to be registered as an organ donor,
because after a potential organ transplantation their bodies wouldnt be whole. With the
current state of the law and the procedure of the waiting list he did receive a lung
transplantation in the end, with which he has lived some years longer. His wife is still not
willing to be registered as an organ donor, despite her own experience of saving or extending
someones live
8
.
The above described case is a good example of the different aspects of the main question
asked. Someone who is not donor registered because of religion, receives an organ and even
than he and the close relative, who is also experiencing the urgency of requiring an organ, are
not willing to become an organ donor. It sounds wrong to me, but can you force people to do
something that is against their religious background in this case? Would it have been more
right to give the lung transplantation to someone who is donor registered? Or is that a form of
discrimination? Different aspects are playing a role in the decision of being registered as an
organ donor or not. With these aspects the law, peoples religious backgrounds and ignorance
on the subject could all play a role. In the next part the law will be elaborated on further, what
right do people have according to healthcare and what are the legal issues around organ
donation and what are they compared to other countries? In order to get a better view on the

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Own experience
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papers question the facts of the choice of not becoming an organ donor will be analysed
further and also the ethical issues of organ donation will be analysed.
Law
In the introduction the current state of the law according to organ donation is elaborated. The
No-If system is the current system in the Netherlands. One of the parties in the Dutch
Parliament introduced a new initiative to change the No-If system to a Yes-If system in 2012.
The Yes-If system is currently applied in Spain, Austria, Belgium, France, Italia and Sweden.
The Yes-If system implies that everyone from the age of 18 is automatically donor registered
and you need to take action if you dont want to be an organ donor. The Yes-If system is thus
exactly the opposite of the If-No system, with the big advantage that the lazy people are now
automatically registered as organ donor instead. This new system is not (yet) active in the
Netherlands
9
.
Besides the Organ Donation Act also the Law of Equality is important in this topic. In the
Dutch law system distinction in society is illegal when it comes to offering services in the
healthcare sector
10
. This also implies that it is not allowed to make a distinction in order to
offer someone an organ transplantation or not even when the receiving person himself is not a
donor. So it is not possible to deny a person an organ transplantation, but would it be possible
to adjust the order of the waiting list? Would it be legally possible to put a group of people on
top of the waiting list, in this case that would be the group who are registered as donor?
According to the Dutch law this is not possible. In Article 18.3 of the Organ Donation Act the
designation of an organ to a patient may only consider the following aspects: blood- and
tissue correspondence, medical urgency of the receiver. In case that these aspects give no
decisive answer the waiting time on the list will be the decisive factor.
Although the law is pretty clear about the rights of receiving an organ transplantation, it
remains a debatable issue. Therefore other aspects will be considered and elaborated further in
the paper.
Why not register as organ donor?
People can have different reasons for not registering as potential organ donor. The lazy
people are already mentioned, the people who just have not registered yet for no reason. Other

9
NOS; D66: Iedereen automatisch donor; August 2012
10
Nederlandse Overheid; Wet- en Regelgeving Artikel 7 Overige bepalingen op sociaaleconomisch terrein,
2014;
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people might have however a clear reason to not be a donor. Different reasons will therefore
be elaborated, in order to get a better view on why people might choose not becoming a
donor.
Ignorance
People are unaware what organ donation is about and are frightened, or just find it an
unpleasant idea, by the fact that their organs are donated after their death. This could be a well
thought decision, but it could also be a response to lack of information (ignorance). Ignorance
could be taken away with more awareness and maybe the Yes-If system would help to force
people to get better informed about organ donation.
Religion
Some people are restricted by their religion. Numbers show that in general religious people
are less willing to become a donor than not-religious people
11
. But is it true that (some)
religions are against organ donor and believe that the human body must remain intact even
after death? Since there are many practiced religions, only the largest religious groups in the
Netherlands will be elaborated.
The Catholic Church is relatively positive towards organ donation. They see it as an act of
good and free will from altruism (unselfishness). Protestantism is a bit reserved, it encourages
organ donation, but also respects the fact that the body needs to be kept intact. The Islam has
taken a positive attitude towards organ donation under some stated conditions. But since those
conditions (high urgency, no financial gain and with great care) are not different from the
already existing conditions in the Dutch law, organ donation is fully approved according to
the Islam. The Jewish believe is divided into the liberal and orthodox divisions. The liberal
side is stating that the care for someone else has more value than the honour of an intact body.
The orthodox division states the opposite, the body needs to be kept intact
12
.
In general it can be said that different religions have reconsidered their opinion towards organ
donation. From the original perspective the religions are proclaiming that the human body
needs to be kept intact, even after death, but the fact of the high urgency for organ donors and
the act of saving lives has turned the tide for most religions. Most of them are now
encouraging organ donation. it should be noted that the source of the opinions of the different

11
Centraal Bureau Statistiek; Houding ten aanzien van orgaandonatie en orgaanontvangst; 2012
12
Nederlandse Transplantatie Stichting; Donatie en Religie; http://www.transplantatiestichting.nl/vraag-en-
antwoord?f[0]=field_category%3A3
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religions are originating from the official Dutch Transplantation Foundation, so it might be
that the opinions are somewhat more positive toward organ donation than they might be in
reality.
These opinions of the different religious backgrounds are just recommendations, so still
quite an amount of people believe in the fact that the human body needs to be kept intact after
death. But what if that person himself does need an organ transplantation (like the case
described at the beginning of this section)? Besides the main question of this paper another
question could then be asked: Is the human body still intact after receiving an organ
transplantation and if so, is it fair to accept that someone elses body is not intact anymore?
Apparently people think so, which could be seen as selfish.
Ethical analysis
Many ethical issues are combined with the main question. In the paper already some ethical
statements are mentioned. The Deserted-Based Principle, a dimension of the Distributive
Justice, is stating that the distribution of goods or economic benefits should be in such a way
that the distribution should be based on the amount of input. In this way a person who is
willing to be a donor should have more right to obtain an organ transplantation, than a person
who is not willing to donate. The person who is willing to donate his/her organs is so to say
putting in more effort to help people than the person who is not willing to donate
13
. However
another dimension of the Distributive Justice is the Strict Egalitarianism, which states that
every person should have the same level of material goods and services. In that point of view,
every person has the same right to have an organ transplantation
13
.
Collective Responsibility is stating that the group that is not donor registered could all be seen
as blameworthy. Since the Collective Responsibility system is not looking at the individual
but rather to the whole group, there is no distinction within the group and the whole group is
responsible for their actions that may have done harm to the world. That would in this case be
the fact that a certain group is not donor registered (action) and that they therefore do not
contribute to the urgency of having more donors (harm). Are they then therefore also all
accountable to have less right to receive an organ transplantation? They all share the same

13
Stanford Encyclopedia of Philosophy; Distributive Justice; 2013; http://plato.stanford.edu/entries/justice-
distributive/#Desert
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burden, good reason or not
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. In case that they would share all the same burden, they would
not have the right to receive an organ transplantation, with no exceptions.
Paternalism is a system that would describe the asked ethical dilemma quite well. Paternalism
is the interference of a state or an individual with another person, against their will, and
defended or motivated by a claim that the person interfered with will be better off or protected
from harm. In our case the state (the Dutch law) states that people who are donor registered
have more rights in order to obtain an organ transplantation than people who are not donor
registered. The government is doing this to force people to become a donor, but it will be in
the best interest of everyone. Because more donors will result in a reduction of the donor
shortage
15
.
Since there is a shortage of donors, the preference could be in this case to have a Paternalism
system in society. In that way the No-If system can be changed to a Yes-If system, with the
knowledge that every person will be better off with that system in the end, even if it is against
their will. Implementing a Paternalism system would be less harsh than the Deserted-Based
Principle, which approves the main question and agrees upon the fact that people who are
donor registered have more right to obtain a donor transplantation than people who are not
registered. Paternalism is more likely to have more resistance in society than the Strict
Egalitarianism, which is in fact the same system we have now for donor transplantations, but
is more effective to reduce the shortage of donors.
Policy Advise
The chance is small that at the same time two people are equally suitable for the same organ
transplantation and a choice has to be made (based on the waiting list) between those two
people, it is however an important ethical issue when it happens if one of those persons is
registered as donor and the other is not. Therefore I return to the question of the paper:
Have people who are registered as organ donor more right to receive an organ
transplantation than people who are not registered?
It is a question that is impossible to answer with a straight yes or no. The question rather
raises more questions with the same content
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:

14
Stanford Encyclopedia of Philosophy; Collective Responsibility; 2010;
http://plato.stanford.edu/entries/collective-responsibility/#2
15
Stanford Encyclopedia of Philosophy; Paternalism; 2014; http://plato.stanford.edu/entries/paternalism/
16
Center for Bioethics; Ethics of Rogan Transplantation; University of Minnesota
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o Should someone who has received one organ transplant be given a second
transplant?
o Should people whose lifestyles choices (smoking, drinking, drug use, obesity etc.)
damaged their organs be given a chance at an organ transplant?
o Should people who have young children be given an organ transplant over a single
person?
o Etc.
It can be seen that an endless amount of ethical questions could be considered and that none
of them is easy to answer. The fact of having something scarce and something that is saving
lives is together something that brings many ethical issues.
The current law in the Netherlands gave already an clear answer to that question, the decision
of who gets an organ transplantation may only depend from blood- and tissue correspondence,
medical urgency of receiver or, when that is not decisive enough, the time on the waiting list.
Everything can be changed though, even the law. In order to answer the question from an
ethical perspective, both sides yes and no could be ethically approved. The main
conclusion however, is that there is no main answer and many other questions are raised in
order to answer this main question. It is an ethical issue that affects many aspects; religion,
ignorance, and many social issues. One thing is clear about organ donation, it should be
possible (and necessary) to register more people as potential organ donor, but it would never
be possible to register everyone, due to the current state of law and the different opinions and
religious backgrounds of people.
The policy advice of this paper would be to follow the Paternalism system. That would
indicate the change of the law from a No-If system to a Yes-If system. Hereby no one is
obligated to be a donor or denied to receive an organ transplantation, but a large amount of
the lazy people, of which it is believed that they are the largest group of the non-registered
people, will be automatically registered. The amount of donor registered people will therefore
increase. In the most positive case, the amount of organ donors in the Netherlands will be
sufficient to cover the current shortage and no ethical questions of who has more right to
obtain an organ transplantation are required anymore.