It is widely believed that if only we allowed a market in organs, supply would increase and shortages would disappear. However, there is considerable evidence that we have not wrung all the supply we can out of the donative system. This essay argues that shortages in organs are due to inadequate procurement effort rather than the inefficiency of appeals to donor altruism. The insufficiency of effort is ascribed to (1) ignorance of the regulatory authorities and the participants with respect to the nature of the production system in which they are engaged, (2) problems inherent in a production system that relies on exhorting donors, and (3) the wellknown limitations of the nonprofit organizations that are the key actors in this production system.

The principal regulatory instrument and the defining feature of organ procurement in the United States is a ban on markets. This study finds the average variable cost of procuring organ donations to have been $1,650 per organ in 1990. Virtually no difference is found between more and less successful procurement organizations in obtaining consent from next-of-kin; what distinguishes successful organizations is their ability to generate more and better quality referrals. These data suggest that procuring organs by donation may be cheap and that more procurement effort might yield more donations. The findings imply that it may be the obstacles to adequate effort, rather than the inefficiency of appeals to donor altruism, that are responsible for shortages.

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While transplantation of fetal tissues may alleviate a great deal of suffering, current policy bars federal funding of research using tissue from elective abortions. Using fetal tissue from spontaneous abortions would obviate the moral concerns. If existing studies of small samples are extrapolated to the US population, then each year about 750,000 fetuses are aborted spontaneously by week 28 (500,000 in the first trimester and 250,000 in the second trimester). The consensus among researchers is that spontaneously aborted fetuses are few in number, and inappropriate for transplantation because they are born dead or have defects. This intuition may not be supported by the evidence, and there is a compelling need to focus research on these issues.