The demand for transplants has outstripped the supply of hearts, livers and kidneys by so much that doctors have to single out candidates they think will benefit most and who have the best chance of long-term survival. Patient selection can be based on utilitarian criteria, especially estimations of social worth or then on ethical criteria: lottery, queuing or "first-come, first-served" among medically suitable candidates. In 1998, the American government declared that organs must go to the sickest patients first, and not to those who live closest to the donor.
In the West, there are only about 25 potential liver donors per million inhabitants, because the donor must be brain-dead and the liver must be removed within a few minutes after the heart has stopped beating. Only 15 to 20 of the 25 potential donated livers actually are used, as sometimes the organs are unsuitable or relatives oppose the donation.
The roughly 20,000 transplants performed annually in the USA are no more than a quarter of those that would occur if enough healthy organs were available. It is a felony to sell organs for transplantation in the USA. Only 15% of the American who need organ transplants to survive and are on waiting lists will get them in 1993. Donations of eggs by newly dead women are being considered for infertile women in the UK.
The world-wide shortage of organs for transplantation has encouraged medical exploitation of the poor, especially in developing countries. Prisoners in the Philippines have been granted freedom by volunteering as kidney donors. In Brazil, it is reported that bodies are washed up on the beach with their kidneys removed.
In China, the scheduling and method of criminal execution is partly determined by the organ recipient's needs and his ability to pay for the surgery in foreign currency. Mainly kidneys and corneas of 2000 to 10,000 executed criminals are supplied to patients requiring transplants. In China, 65 offenses, including bicycle theft, embezzlement and political dissent qualify perpetrators for the death sentence, and China is considering expanding the set of capital crimes. In 1998, two Chinese government officials were arrested in the USA for apparently trying to sell kidneys, corneas, pancreases, livers and non-smokers' lungs and skin from executed political prisoners.
In India, the sale of organs for transplantation is legal, but there are no laws controlling the market. There are numerous reports of people being taken into hospital under false pretenses and having an organ stolen by doctors during surgery. Others report being paid as little as $160 for a kidney, so far less than $1100, the usual market value. Operations cost less in India than in many other countries, and so wealthy foreigners go there on purpose to undergo organ transplantation. This exacerbates local organ trafficking.
In countries such as Japan, kidneys have been accepted as payments to loan sharks. Lack of kidneys for transplantation is so great in the UK that pigs are being considered as alternative donors. Pigs are suggested because their organs are comparable in weight and size to human ones. Hence the colourful portrayal of pigs as "horizontal men".
While the techniques of heart surgery improve continually, the number of organs available for transplant is nowhere near the number of people needing them. Medical workers pour their efforts into trying to keep people with serious heart disease alive until an appropriate donor appears, but this effort is often wasted, because patients expire before donors appear. People do not like to think about their own death, let alone consider dividing their body up to share with strangers. This has led to the continuous development in many countries of procedures and systems to increase supply. But supply has never yet satisfied demand.