Should All Living Donors Receive Equal Priority in Organ Allocation? An Equality of Opportunity Perspective

Priority rules in organ allocation confer preferential access to organs for individuals who have previously donated or pledged to do so. Several countries extend such rules to living donors. Yet existing systems do not distinguish between different kinds of living donation. This paper examines whether all living donors should receive equal priority or whether distinctions are justified, using John Roemer's conception of equality of opportunity as the analytical framework. The paper develops a typology of living donation along two axes: interest-based versus altruistic motivation and directed versus non-directed allocation. Interest-based directed donation occurs when someone gives directly to a loved one; interest-based non-directed donation when they donate through paired or pooled exchange. Altruistic directed donation involves giving to a specified stranger, often following a media appeal, while altruistic non-directed donation involves donating to an unspecified recipient, sometimes initiating a donor chain. Holding circumstances constant, equality of opportunity appears to favour greater recognition for altruistic non-directed donation, as it involves the least offset effort. However, closer attention to circumstances-such as awareness of donation pathways, illness within a personal network, and exposure to media campaigns-suggests that differences between donor types cannot be attributed to effort alone. Moreover, many altruistic non-directed donors report a sense of moral duty and psychological relief, indicating that their effort is also partially offset by personal benefit. The analysis concludes that priority rules might recognise all living donors but any additional recognition for particular donor types should be modest and sensitive to circumstance and motivation.