An Economic Analysis of Organ Donation Law

Dylan Thakker*

The central issue surrounding organ donation is one of supply and demand. Across the world, the demand for organ transplantation is increasing in accordance with the prevalence of relevant diseases and advances in technology.[1] The supply of donated organs is consistently failing to meet this demand. For instance, the number of living donors in the UK remained generally stagnant at 1066 (2017-2018), 1047 (2018-2019) and 1057 (2019-2020) prior to the COVID pandemic.[2]  Likewise, the numbers of ‘brain dead donors’ per year were 955, 959 and 946 respectively.[3] The result has been extremely large and often understated waiting lists.[4] In the UK alone there were 7000 people waiting for transplants in 2021[5] despite 90% of the UK’s population claiming to support organ donation.[6] This evidences the assertion that ‘the willingness to express a positive attitude toward a socially approved activity is not the same as the willingness to take concrete action’[7] and represents each individual’s hesitation to deviate from their preferences. Most appear unwilling to take the altruistic action of donating one’s organ for the sole benefit of a nameless stranger. Statistics on the consequential loss of life are certainly sobering. In the USA, 17 people die everyday while waiting for an organ transplant.[8] That is over 6000 people per year. But how is the law responding and is the criterion of efficiency being met? With the law’s response being to ban organ markets, in direct contravention to the clear dictates of supply and demand, one can foresee the creation of black markets[9] and the perverse incentive for medical professionals to kill patients for their organs[10] or terminate their patients’ lives prior to their true deaths.[11] Fortunately, this has not happened on a large scale, although singular instances of abuse have occurred.[12] To meet the needs for both a greater supply of donated organs and the prevention of unlawful means of acquiring organs, a critical analysis of organ donation law and its efficiency is necessary.

In this article, economic analysis will be applied predominantly to the English and Welsh laws of organ procurement to critically assess the economic efficiency of presumed consent regimes. First, the current presumed consent regime in England and Wales will be set out. Second, the methodological individualist approach to economic analysis will be introduced and applied. Third, traditional English property, medical, and contract law principles will be employed to reveal the difficulties with the notion of presumed consent. Fourth, the discussion will turn to the criticism that alternative legal regimes rely extensively on altruism. Fifth, methods of increasing organ procedurement such as the imposition of compensation schemes and the legalisation of organ markets will be addressed as economically worthy enhancements. Finally, the past religious exceptions to Singapore’s presumed consent regime will be discussed, highlighting further difficulties with a presumed consent regime unique to another jurisdiction. What becomes clear from this varied discussion is that the current presumed consent regime in England and Wales does not lead to an efficient outcome. It is imperative that we consider how the law can change to reach greater efficiency. Thus, positive, policy-based, and normative economic analyses[13] will be employed to ultimately advocate for change in the law – the legalisation of organ markets.

The Current Legal Landscape

In the UK, it is possible to donate organs either as a live donor or as a deceased (cadaveric) donor. England and Wales have implemented a soft opt-out presumed consent regime. This means that where the deceased has not opted out then, unless there is evidence from someone close to the deceased that would lead a reasonable person to believe that the deceased would not have consented, it is lawful for medical professionals to procure the deceased’s organs. The statutory particulars are briefly explained here. The Human Tissue Act 2014 (HTA) initially required that ‘appropriate consent’[14] be provided by the donor themselves or, if deceased, someone in a close ‘qualifying relationship’[15] with the deceased. Following the implementation of deemed consent legislation in Wales,[16] England introduced The Organ Donation (Deemed Consent) Act 2019. Section 1 amended the HTA by inserting section 3(6B) which was a provision that equated ‘deemed consent’ with ‘appropriate consent’. Hence, in England and Wales, presumed consent is the current policy.

In England and Wales, payments for human organs or tissues are strictly prohibited.[17] However, payment can be made to living organ donors insofar as they compensate ‘any expenses or loss of earnings incurred by [the donor] as reasonably and directly attributable to [the donor] supplying the material from his body.’[18] 

Introducing Economic Analysis

Economic analysis assumes that everyone is rational. A rational person is defined as someone who will follow their preferences, as subjective as they may be, to maximise their utility.[19] This idea of quantifying, comparing, and maximising the utility which flows from our decisions derives from traditional utilitarian theory.[20] Economic analysis perceives preferences as fixed. Rules are perceived as changeable and, therefore, an appropriate means by which to regulate or influence human behaviour. The interactions between rational individuals and the pattern within their behaviour is what informs an aggregate group’s collective decisions which are relevant for economic analysis. This is the methodological individualist approach.[21] This approach, as applied to organ donation law, is unique because it is otherwise a subject fraught with emotionally, morally, and ethically charged debates. An economic perspective may bring new insights as we question how much inefficiency the ethics may have led to. Thus, ethical considerations are not weighed into the present economic analysis or conclusions, though it is acknowledged that certain moral positions may need to be preliminarily taken to enable the economic analysis to proceed.

Organs, as a scarce resource, signify a weak natural scarcity in the present case. They are called this in economic theory because efforts can be made to increase their supply.[22] If everyone chose to donate their organs post-mortem the demand would almost certainly be satiated. So, while economics generally assumes that supplies are scarce and so rational individuals face difficult decisions, the relevant decisions here concern whether or not to contribute to the scarce supply of resources itself. This problem is necessarily independent of the government, though the law ought to be a tool for persuasion.

The benefits and costs for each actor involved should be considered next. Benefits and costs in economic analysis are broadly construed and need not be monetary in nature.[23] First, the sole benefit for donors is usually private feelings of altruism. In the minority of cases, the donor knows the recipient, who may be important to them due to the existence of intimate bond(s) or affection. In those cases, the recipient’s survival is the principal benefit of donating. Meanwhile, the costs for all donors can include the time taken to donate organs (for live donation), the consequential loss of earnings, pain from the surgical procedure, any risks to their long-term health or life expectancy, and any psychological impact that follows from the need to address the issue of organ donation with their families. There is currently a lack of incentive for individuals to donate.[24] In the majority of cases, a rational person is unlikely to be so altruistic as to donate their organs voluntarily without reward. There are clearly those who are willing to donate, to accept these costs with altruistic motivations, but they are logically the exception considering the inadequate supply of donated organs. The law must provide sufficient incentives or minimal transaction costs where necessary in order to encourage organ donations.

The main interest of an economic analysis is to evaluate the law against the criterion of efficiency. The common method of measuring efficiency is called Pareto efficiency. This refers to an economic condition where no further allocation of resources can be made without making other individuals worse-off.[25] Coase theorem is also relevant, despite conventionally being brought up in the context of property. The theorem dictates that the law minimises transaction costs to encourage rational individuals to reach an economically efficient outcome. Applied to the present subject matter, the efficient outcome is the donation of one’s organs and thus the maximisation of the scarce resource. This means more organs can be distributed, benefitting the recipients. The law seeks to internalise the externality (the need to donate) by presuming consent. This will be considered further.

The benefits for recipients of donated organs first include the significant improvement to the quality of their lives and money-savings because organ transplants are generally cost-effective. Despite early representations that organ transplantation can be ‘among the most costly of medical treatments,’[26] transplants are cost effective for both the recipient and the NHS. For example, the approximate cost of a kidney transplant per patient is £17,000 as well as £5,000 for any immune-suppression or required follow-up treatments.[27] Meanwhile, a patient who cannot receive an organ transplant will require constant treatments for the rest of their lives which is both restrictive and expensive. For instance, dialysis (the procedure a patient will likely take if there is no replacement kidney available) is £17,500 per patient for every year of treatment. Otherwise, should the patient require hospital haemodialysis, the costs are £35,000 yearly.[28] Thus, the average cost for a patient of dialysis per annum is estimated to be £30,800.[29] Considering the significant difference in price between the one-time organ transplant procedure and the constant medical interventions otherwise required, a rational decision maker would likely choose the former. Moreover, by increasing transplants, it reduces the need for the NHS to provide alternative long-term treatments like dialysis or chemotherapy. This is cost effective for the NHS. For example, each living-donor kidney donation saves the NHS up to £25,800 per year for each year that the patient has a functioning transplanted kidney when compared to dialysis.[30] Likewise, a 25% increase in the number of donors could save the NHS almost £9.2 million every year.[31] Thus, the rational individual’s investment decision to have a transplant is to be expected. Reflecting on this, it is clear that we are far from a Pareto efficient state. Available resources and consequential benefits to recipients have not been maximised. It is also worth mentioning that the Kaldor Hicks criterion (which identifies efficiency where gains to the winners outweighs the losses of the losers[32]) would also likely encourage the maximisation of organ donations. The donors’ loss of utility (by donating organs they do not require to survive) is negligible in comparison to the recipients’ gain in utility.[33] So, although the two measurements of efficiency can differ with the Kaldor-Hicks criterion being less stringent,[34] on this matter the conceptions conceivably agree that efficiency dictates the increase of organ donation rates. A final means by which to justify the sharing of organs for the optimal maximisation of utility is by considering diminishing marginal utility under Bentham’s utilitarianism.[35] If the addition of each consecutive unit of happiness offers less utility, then one does not logically benefit from the second as much as they do from the first. Equally, one doesn’t benefit from their second kidney as much as they do from their first. Thus, the maximisation of utility would justify donating one’s second kidney given that they don’t require it and it could bring another individual much more utility. Whether we consider pareto optimality, the Kaldor-Hicks criterion or diminishing marginal utility, the maximisation of donation rates is encouraged.

Insights from Property, Medical and Contract Law - Analysing Presumed Consent

The default position in English common law is that there are no property rights over the human body.[36] This is indeed inspired by religious, social, and cultural values which predate modern advances in medical procedures.[37] However, the many ways that the law protects our bodies and allows us bodily autonomy is comparable to its treatment of property. A property right is by no means a unitary one. It is a collection or ‘bundle or rights’ associated with something, whether it is a right to use it, to exclude others from it or to make a profit from it.[38] The law grants us corresponding rights regarding our bodies. We are protected from unwanted touching (battery), our consent is required prior to any surgical procedure,[39] we can acquire damages for physical harms and loss of amenity suffered through the law of tort,[40] we cannot be falsely imprisoned and so forth. Property rights are also not absolute. We cannot commit crimes with our bodies, we cannot trespass, we may need to use our bodies where required to do so by the law. On this basis, when one is alive, their organs are arguably treated and protected akin to property. Furthermore, as a profound departure from the default position, it was recently held that sperm cells constituted property.[41] Canadian law has also come to the same finding.[42] It is interesting, then, that upon extracting cells from our body, it can be found to constitute property. On this basis, one may reasonably question the currency of the default position. Furthermore, once deceased, it is questionable whether our bodies continue to be treated akin to property. In the absence of settled law, theoretical analysis follows.

Presumed consent runs contrary to the laws of property and contract. English contract law recognises the bilateral nature of contracts, prioritises the sanctity of contract,[43] secures the reasonable expectations or intentions of parties[44] and fundamentally aims to protect parties’ consent to undertake contractual obligations.[45] But in this case, where the individual is deciding whether they will donate organs upon their death, the legal agreement to do so is unique: first, because it involves a decision as to whether they may exercise property rights over their deceased body and second, because their agreement to donate is presumed - almost as though a contract has been signed for them.

When one is dead, there is the suggestion that their body is only their property if they actively take steps to secure themselves that right by opting out. The current legal regime is therefore one best described as voluntarism where the living donor or the deceased donor’s family possesses proprietary rights over the organs so long as they affirmatively claim them.[46] Again, these rights are not absolute because the organ can be donated but cannot be sold as a commodity. Hence, the current law of presumed consent is shifting the transaction cost onto those registered donors who wish to opt-out. They bear the transaction cost of having to actively deregister their organs. They must claim property rights over the body, contrary to the previous regime of informed consent where the property rights are assumed. The fact that consent is presumed by default legal rule is the law’s way of recommending donation as the socially desirable decision. Inversely, the law minimises any transaction cost for the medical institution to acquire donated organs. The burden to opt out is on the individual. Where individuals are inactive, whether intentionally or not, they are assumed to have consented to donate their organs. The organs themselves then appear to essentially become public property by default, assigned instead to the NHS or relevant medical agency.[47] It is conceivable that in many instances, organs will be procured irrespective of that person’s objective consent or bodily autonomy (these being two important concepts in English medical[48] and contract law[49]). Where mistakes (as to individuals’ true consent) are made in a presumed consent regime, the consequential breach is grave because organs can be removed from their corpse. On the contrary, if mistakes as to consent were made in an opt-in regime (because an individual actually intended to donate their organs and failed to actively opt in) the result would have merely been no removal of organs. Though this is wasteful, it is not as grave a violation as those within the presumed consent regime. By choosing law which allows for the possibility of unwilling removal in place of wasteful non-removal, this demonstrates the extent to which legislators are trying to develop a social inclination towards donating organs. Given that, logically, mistaken non-removals are more costly than mistaken removals (in terms of utility), the presumed consent regime is a more efficient legal position. Yet, reflecting on present UK law, requiring affirmative action to exit an agreement to donate is certainly contrary to standard English medical and contract law. By extension, it is also noteworthy that families can have a say over our bodies once we are dead. Does this mean that our respective family members share a property right over our corpse or is this simply a rare instance of relational autonomy represented through law?[50]

A variety of issues have been discussed here. One can see that, through presumed consent, the law is internalising an externality: the donation of our organs for the benefit of others. Presumed consent has been beneficial by increasing the supply of organs.[51] Countries with opt out systems have up to 30% higher donation rates in comparison to opt-in countries.[52] Having said this, the supply still does not meet the demand in each country with a presumed consent regime.[53] A likely reason is that they are soft opt-out systems which allow family members to veto presumed consent. The law therefore fails to maximise the supply of donated organs and remains inefficient.

Problems with Relying on Altruism

Countries with informed consent or opt-in regimes insist upon altruistic donations only. This was the case for England and Wales until the recent changes. The benefit of relying on altruism is the minimal financial costs needed to implement such a system. Unfortunately, it yields short-term benefits and insufficient donations. As previously discussed, there are issues as to whether solely altruistic motivations with no further external benefit can provide enough utility for rational individuals to donate. Altruistic behaviour is possible so long as the act of donation is of sufficiently high ethical value to the particular individual[54] and unfortunately, this is not likely to be the case for enough people. Few share a bias for this level of altruism or, given that altruism can depend on social context rather than individual behaviour,[55] individuals may feel pressured by others to act a certain way – hence the current shortage of organs and inability to reach a Pareto efficient state.[56]

Compensation Schemes

Currently, the UK allows donors to receive compensation for only certain expenses.[57] This law is effectively a means of reducing the costs of donors. Nonetheless, as has been made clear, the issue for individual decision-makers is not one of costs but rather the lack of benefits and incentives that individuals have to donate. It is mentioned in passing that monies paid to the donor under the above law are likely strictly regulated. Otherwise, excessive or generous sums could simply amount to a reward for donation in itself.

If the law were to provide compensation to donors (or their families in the case of a cadaveric donation) it could potentially incentivise greater organ donation. For example, a study located in Chile found that ‘monetary incentives of US$12,000 save US$38,000 to [the] health care system per donor and up to US$169,871 when we consider the gains in quality of life of receiving an organ.’[58] Meanwhile, an incentive need not be monetary in nature.[59] Examples of alternative forms of compensation include coverage for the burial expenses of cadaveric donors[60] or reimbursement of hospital fees.[61] These can be viewed as not (at least directly) monetary in nature and can represent an expression of appreciation for the donor or their family members.[62] Compensation can certainly incentivise organ donation and, should an organ market not be legalised, this alternative ought to be sought.

Legalising a Market for Organs

How can the law grapple with strictly prohibiting commercial transactions and yet simultaneously encouraging organ donations? By banning a market for organs, the law puts in place an artificial restriction on donations by prohibiting economic incentives for rational individuals to donate. The legislator’s restriction runs counter to the dictates of supply and demand and thus it is not surprising to see the development of black markets and organ trafficking schemes.[63] It is argued that, by legalising the sale and trade of organs, sufficient economic incentives are introduced and this will hugely improve the supply to the extent that demand is met and we are closer to a position of pareto-efficiency. It stands to reason that all rational individuals who currently wish to sell their organs (and there is ample evidence of individuals’ willingness to do so)[64] are denied the ability to donate at this moment by law. Rather, the best means by which to balance the gains received by recipients and the losses suffered by donors is for the former to pay the latter. Benefits to donating are thereby made mutual.

At this point, one may question why compensation is not a more efficient alternative to an organ market. For instance, if organs are overpriced, excessive rent is granted to a seller. Contrary to this argument, a market would be more efficient given that, while the compensation provided may be static and predetermined in quantity, organs in a market setting can be priced competitively based on the supply and demand at the time of purchase.

Further criticisms to the proposal hereby made are first, that the selling of organs could result in a higher proportion being sourced from low-income donors which could amount to exploitation of the poor and, second, this could therefore correlate positively with the sale of lower quality or diseased organs.[65] In response to the former, it is appreciated that any such exploitation would be unreservedly morally objectionable. However, the development of a lawful and legitimate organ market would provide the opportunity to establish regulations and protections for such individuals, unlike with black organ markets. In any case, the moral issue is set aside on the basis that it has no bearing on the gains to efficiency with which the economic analysis in this paper is concerned. In response to the latter criticism, it is contended that even if a correlation between income and organ quality were provable (which is unlikely given the scientific and technical limits as well as a lack of empirical studies available to support such a correlation), this does not mean that there will be more diseased organs actually transplanted.[66] An organ market is ripe for competition and where there is competition, suppliers are likely to seek reputable gain through the promise of the highest standards of organs. Suppliers would implement extensive screening and quality checks. The consequential quality of organs being transplanted, sourced through an organ market, could therefore be better than those which are donated altruistically at current. Moreover, as with other products, the organ quality may not be knowable to the recipient or consumer (such a product which cannot be measured for quality is known as a credence good[67]) in which case the demand for the organ remains unaffected.

In further support of the proposal, one may simply look at the countries where an organ market is permitted by law. In Iran, a compensated kidney donation system was introduced in 1988. By 1999, the waiting list for kidney transplants was empty and a state, at the very least, much closer to Pareto efficiency, had been reached.[68]

Economic Analysis of Singapore’s Religious Exception to Presumed Consent

The opportunity is taken here to deviate from the focus on English and Welsh law and consider presumed consent law that is comparatively seldom mentioned in academic literature and is equally, not without its economic flaws. The religious economical model derives from Religious Market Theory and seeks to evaluate religions by assessing the numbers of subscribers to the relevant faith, the decisions made by the religious, and whether those decisions maximise their utility.[69] Everyone is assumed to be rational, though biases and factors including emotional attachment, peer pressure and fear of divine justice, are acknowledged to impact individuals’ behaviour.[70] In Singapore, a 1995 Fatwa stated that trading bodily organs opposed Islamic views.[71] Recognising this, the law specified that Muslims were exempt from the deemed consent regime and would instead opt-in if they intended to donate their organs.[72] However, the law also stated that anyone who did not opt-in to pledge donation of their organs would not receive the exclusive benefit of being offered priority in the waiting list for organ donations.

In this case, Muslims were provided an exception by the law. The exception was informed by religious beliefs at the time. This could have had one of two effects, the accuracy of which is unknowable given the lack of empirical research available. This, in some ways, accommodationist legal exception and martyrdom for Muslims, could have boosted their sense of faith, religious integrity and ‘perceived credibility’[73] (as can be characteristic of opposing state actions).[74] On the other hand, the more likely perception was that the law was plainly discriminating; it was at odds with Islam by creating an incentive for Muslims to deviate from the encouragement of religious leaders at the time. The deviation of opting in was encouraged by the law given the consequential reward (incentive) to be granted priority on organ waiting lists, a potentially lifesaving result for some. This could have been a concern at the time because Muslims had constituted 21% of the 600 Singaporeans who were waiting for an organ transplant, yet they represented only 2% of those who in fact received organ transplants.[75] The resolve of Muslims, in comparison to other religious believers, was challenged by the law. The religious competitiveness thereby encouraged by the law could have otherwise been seen as detrimental to the religion. Thus, Muslims were likely disadvantaged by the law.

Since then, the law in Singapore has changed to put all individuals who subscribe to a religion on a level playing field. Everyone’s consent is now presumed in Singaporean law.[76]

Conclusion

It has been contended that altruism and informed consent fail to produce sufficient levels of donated organs to meet the demand. Presumed consent represents a more efficient option than informed consent but also cannot produce a sufficient supply. The main concern is that rational decision-makers lack sufficient foreseeable gains to balance their losses when they contemplate donating organs. Earlier in this paper, it was stated that donated organs are a weak natural scarcity. On further inspection, organs are actually an artificial scarcity because their supply could be increased to meet the current demand so long as the government or legislature is willing to make the necessary changes to the law.[77] For instance, economic incentives provided by way of a legal organ market or lawful compensation schemes can persuade rational individuals to donate and can lead to greater efficiency.

Dylan Thakker is a current Bar Course student at City, University of London. He received Exhibition and Michael Hodge Scholarship Awards from the Inner Temple. He graduated in International Legal Studies at the University of Kent, having also read law at the University of Hong Kong.

References:

[1] J. G. O’Grady, ‘Clinical Economics Review: Liver Transplantation’ (1997) 11(1) Alimentary Pharmacology & Therapeutics 445

[2] NHSBT, Organ and Tissue Donation and Transplantation Activity Report 2022/23 (2023) 5 <https://www.odt.nhs.uk/statistics-and-reports/annual-activity-report/> accessed 10/11/2023

[3] ibid

[4] D. Barney and L. Reynolds, 'An Economic Analysis of Transplant Organs' (1989) 17(1) Atlantic Economic Journal 12, 12; B. Belb et al., ‘The Ethics of Testing and Research of Manufactured Organs on Brain-Dead/Recently Deceased Subjects’ (2020) 46 Journal of Medical Ethics 199, 199-201

[5] NHSBT, Organ and Tissue Donation and Transplantation Activity Report 2020/21 (2022) foreword <https://nhsbtdbe.blob.core.windows.net/umbraco-assets-corp/23461/activity-report-2020-2021.pdf> accessed 10/11/2023

[6] NHSBT, Consent and Authorisation (2022) <https://www.odt.nhs.uk/deceased-donation/best-practice-guidance/consent-and-authorisation/#:~:text=NICE)%20clinical%20guidance-,Increasing%20consent%20and%20authorisation%20rates,authorisation%20rate%20hovers%20around%2068%25.> accessed 10/11/2023

[7] J. M. Prottas, 'Encouraging Altruism' (1983) 61(2) Milbank Memorial Fund Quarterly Health and Society 278, 283

[8] LifeSource, “Fast Facts – March 2023” (LifeSource, 18/04/2023) <https://www.life-source.org/latest/fast-facts/> accessed 10/11/2023

[9] J. S. Taylor, 'Black Markets, Transplant Kidneys and Interpersonal Coercion' (2006) 32(12) Journal of Medical Ethics 698

[10] J. J. Thompson, ‘Killing, Letting Die and the Trolley Problem’ (1976) 59(2) The Monist 204

[11] N. Barber, The Nasty Side of Organ Transplanting (3rd Edn, Pandora 2001) 11

[12] G. Morton, ‘Why Did Professor Dick Van Velzen Think Butchering Babies Was Right?’ The Independent (London 5/12/1999) <https://www.independent.co.uk/life-style/health-and-families/health-news/why-did-professor-dick-van-velzen-think-butchering-babies-was-right-738078.html> accessed 10/11/2023

[13] R. A. Posner, Economic Analysis of Law (9th Edn, Aspen Publishing 2014) §2.2

[14] HTA 2014, ss1-3

[15] HTA, s27

[16] The Human Transplantation (Wales) Act 2013, ss3(1)(b) and 4(2)

[17] HTA 2014, s32

[18] HTA 2014 s32(7)(c)

[19] E. Towfigh, ‘Chapter 2: The Economic Paradigm’ in E. V. Towfigh and N. Petersen, Economic Methods for Lawyers (Edward Elgar 2015) 20-22

[20] J. Bentham, Introduction to the Principles of Morals and Legislation (Clarendon Press 1876) 1-3

[21] Towfigh (n>19) 18-19

[22] F. Bilgel, The Law and Economics of Organ Procurement (Intersentia 2011) 5

[23] S. J. Spurr, Economic Foundations of Law (2nd Edn, Routledge 2010) 2-4

[24] K. M. Chow et al., ‘Introducing Incentives and Reducing Disincentives in Enhancing Deceased Organ Donation and Transplantation’ (2022) 42(4) Seminars in Nephrology 1

[25] Towfigh (n>19) 29-30

[26] J. M. Kress, ‘Xenotransplantation: Ethics and Economics’ (1998) 53(2) Food and Drug Law Journal 353, 357

[27] NHSBT, Factsheet 7: Cost Effectiveness of Transplantation (2009) <https://nhsbtmediaservices.blob.core.windows.net/organ-donation-assets/pdfs/Organ_Donation_Registry_Fact_Sheet_7_21337.pdf> accessed 10/11/2023

[28] ibid

[29] ibid

[30] Living Organ Donations, POST PN0641, 27 April 2021, 2 < https://post.parliament.uk/research-briefings/post-pn-0641/> accessed 10.11.2023

[31] NIHCE, Organ Donation for Transplantation (2011) <https://www.nice.org.uk/guidance/cg135/evidence/organ-donation-full-guideline-184994893> accessed 10/11/2023

[32] Towfigh (n>19) 30-31

[33] R. A. Epstein, ‘Organ Transplantation: Or Altruism Run Amuck’ (1993) University of Chicago Law Occasional Paper, Number 31, 9

[34] J. L. Coleman, ‘The Grounds of Welfare’ (2003) 112(6) Yale Law Journal 1511

[35] J. Bentham, ‘Pannomial Fragments,’ in J. Bowring, Works 3 (W.T 1843), 228-230

[36] Williams v Williams (1880) 20 Ch D. 659, 662-663; R v Bentham [2005] UKHL 18, [8]

[37] D. Barney and L. Reynolds (n>4) 14

[38] D. M. Wagner, ‘Property Rights in the Human Body: The Commercialisation of Organ Transplantation and Biotechnology’ (1995) 33(4) Duquesne Law Review 931, 933

[39] E. Shuster, ‘The Significance of the Nuremburg Code,’ (1997) 337 The New England Journal of Medicine 1436, Principle 1

[40] Wagner (n>38)

[41] Yearworth v North Bristol NHS Trust [2009] EWCA Civ 37

[42] J.C.M v A.N.A 2012 BCSC 584

[43] E. McKendrick, ‘English Contract Law: A Rich Past, An Uncertain Future’ (1997) 50(1) Current Legal Problems 25, 25-28

[44] First Energy (UK) Ltd. v Hungarian International Bank Ltd. [1993] BCLC 1409, 1410

[45] G. H. Treitel, The Law of Contract (10th Edn, Sweet & Maxwell 1999) 260

[46] D. Barney and L. Reynolds (n>4) 15

[47] E. D. Thorne, ‘Chapter 20: The Economics of Organ Transplantation’ in S. Kohm and J. M. Ythier, Handbook of the Economics of Giving, Altruism and Reciprocity (Elseiver 2006) 1351

[48] T. L. Beauchamp and J. F. Childress, Principles of Biomedical Ethics (OUP 2001) 57

[49] Treitel (n>45)

[50] C. Foster and R. Gilbar, ‘It’s Arrived! Relational Autonomy Comes to Court’ (2017) 26(1) Medical Law Review. 125

[51] E. J. Johnson and D. G. Goldstein, 'Defaults and Donation Decisions' (2004) 78(12) Transplantation 1713

[52] A. Abade and S. Gay, 'The Impact of Presumed Consent Legislation on Cadaveric Organ Donation' (2006) 25(4) Journal of Health Economics 599

[53] W. N. Gerson, 'Refining the Law of Organ Donation,' (1987) 19(1) Journal of International Law and politics 1013

[54] Towfigh (n>19) 22

[55] Bilgel (n>22) 6

[56] Kress (n>26) 360

[57] HTA 2014 s32(7)(c)

[58] M. Parada-Contzen and F. Vásquez-Lavín, 'An Analysis of Economic Incentives to Encourage Organ Donation: Evidence from Chile' (2019) 28(6) Latin American Economic Review 1

[59] Spurr (n>23)

[60] Kress (n>26) 359

[61] D. H. Howard, 'Producing Organ Donors' (2007) 21(3) Journal of Economic Perspectives 25

[62] Delmonico et. al., 'Ethical Incentives not payment for Organ Donation' (2002) 346(25) New England Journal of Medicine 2002

[63] Kress (n>26) 359

[64] F. S. Chapman, ‘The Life and Death Question of an Organ Market’ (1984) Fortune 108, 114

[65] A. H. Barnett, R. D. Blair and D. L. Kaserman, ‘A Market for Organs’ (1996) 33 Society 8, 15

[66] K. N. Hylton, ‘The Law and Economics of Organ Procurement’ (1990) 12(3) Law and Policy 197, 209

[67] U. Dulleck, R. Jerschbamer and M. Sutter, 'The Economics of Credence Goods' (2011) 101(2) American Economic Review 526, 526-527

[68] A. J. Ghods, ‘Organ Transplantation in Iran’ (2007) 18(4) Saudi Journal of Kidney Diseases and Transplantation 648

[69] J. Chen, The Law and Religious Market Theory: China, Taiwan and Hong Kong (CUP 2017) 13-15

[70] ibid

[71] C. Hayward and A. Madill, ‘The Meaning of Organ Donation: Muslims of Pakistani Origin and White English Nationals Living in North England’ (2003) 57 Social Science and Medicine 389

[72] Medical (Therapy Education and Research) Act 1972; Human Organ Transplant (Amendment Act) 2004

[73] Chen (n>69) 25

[74] L. Witham, Marketplace of the Gods: How Economics Explains Religion (OUP 2010) 61-65

[75] ‘Muslims Set to Become Willing Organ Donors’ Asia News (27/07/2007) <https://www.asianews.it/news-en/Muslims-set-to-become-willing-organ-donors-9939.html> accessed 10/11/2023

[76] Fatwa 2008 s2; Human Organ Transplant (Amendment) Act 2008

[77] Bilgel (n>22) 5