As a society, we presume that organ donation is an unambiguous good and that individual decisions to donate are desired because organ donation "saves lives."¹ In fact we suppress awareness of a legitimate opposing view. It is, at best, an ambiguous good for reasons often ignored in appeals for donations. Organ donation does not always save lives; some organ transplant recipients suffer tremendously, and some die more quickly than they would have without a transplant.² Furthermore, donating organs entails a hidden and questionable choice about allocating scarce resources. It commits millions of dollars from the relatively fixed budgets of insurance companies in an attempt to prolong a handful of lives. Potential donors must therefore weigh the desire to help those in need against the desire to avoid complicity in a potentially unjust health care allocation system.

From the standpoint of religious morality, the decision to donate is even more complex and takes on a tragic dimension. Allen Verhey's exposition of the tragedy of contemporary medicine elucidates the fundamental problem. Strain on financial resources makes contemporary medicine a theater of tragedies of a Sophoclean sort, in which "goods collide and evils gather." Verhey contends: "When the goods or services to be allocated are goods or services on which life or health may depend and when the unbounded love of God for each one requires that we regard each life as of equal value, then the necessary allocation decision is necessarily tragic."³ We can never choose against the good and in favor of an evil, but sometimes even wise choices will result in a gathering of evils.

This is the tragic bind that potential organ donors face. The act of donating organs signifies love for an identified and imperiled life, but it may distract our attention and our resources from other religious imperatives, such as the need to work toward a just society. The act of not donating will harm some on the transplant waiting list, but it can also signify a commitment to the greater number of people who lack access to basic health care. Both decisions can constitute a loving action because both take seriously the value of individuals whom we do not know. If we fully acknowledge these competing goods, the individual decision whether to donate one's own or a loved one's organs will be a morally difficult one, painful to make. Once made, it should leave traces of regret regardless of the decision.

Religious language and metaphors are often used in discussions of organ donation. William F. May first made the case for the importance of religious sentiments and symbols in public moral reflection about transplantation. He argues that, if "discipline[d] and prun[ed]," religious symbols can "keep us alive to suffering." They also transcend the "private world of feeling" and engage us as communities.⁴ The transcendence of the purely private is necessary for transplantation because the very practice currently requires a gift of organs and because communities share the financial burdens of the therapy. In addition, individuals often consider mortality and the meaning of death in religious communities.

Christian and Jewish ethicists often address organ donation in ways that understate the complexity of the competing demands of love and justice in their own traditions. One possible explanation for this is the way these ethicists conceptualize the decision. It is possible to see organ donation either as an individual gift to strangers or as a public declaration of one's priorities related to the allocation of shared resources. The latter turns our attention away from suffering individuals and towards the long-term implications for the American population as a whole. Religious ethicists have said much about donation conceived in the first way and perhaps too little about the second conception. Both conceptions are valid and need to be considered, although the recommendations we draw from them will often conflict. Yet religious ethicists may have special skills to help us define our responsibilities in the face of that potentially intractable conflict. In addition to addressing the current moral dilemma inherent in organ donation, religious communities can help us live with the difficult choices caused by the need to balance limited financial resources with the virtually unlimited possibilities of biotechnological advances, such as xenotransplantation and artificial organs.

In approaching organ donation as an issue of individual giving, religious ethicists have attended to two questions. Is donation allowable according to religious conceptions of the body and the afterlife? Should organ donation be encouraged by religious communities as a response to the bodily needs of strangers? Although there are exceptions, most religious writers, particularly those from mainstream Christian and Jewish traditions, have answered both of these questions affirmatively.

The general Christian response is that individuals don't need their bodies in heaven, that donation may imitate Christ's gift of his body and blood, and that the gift of one's body is good stewardship of a divine gift. Christian writers also stress that the decision whether to donate should be made in the context of the church community, where issues of mortality and responsibility are often addressed.

May's response, arguably the most influential, looks to Christ's life and Christian liturgy to support organ donation. Christ lived a life of "self-expending love," and Christians are called to perform "concrete service to the bodily needs of others" in their imitation of Christ.⁵ May believes Christian liturgy speaks even more directly to organ donation. "Liturgically, Christ shares, under the form of bread and wine, his body and blood with his disciples. He invites and bids his followers to share in this life of service. What more fitting and direct sign of this sacrifice than the believer's sharing of a portion of his body and blood?"⁶

Margaret Mohrmann (among some others) finds that the "appropriate conceptual category" for organ donation is not self-donative love but stewardship. She writes, "The call to stewardship is a call to recognize a basic fact of our existence: all that we are, all that we have, all that we can do is ours—is under our authority—by virtue of God's creation."⁷ Mohrmann argues that stewardship entails good use of God's gifts. This includes working to enhance our talents and using them to help others "by cultivating [our gifts]…by study and effort, but also by using them to teach, heal, feed, clothe, shelter, and be present with those who need what we have to give."⁸ Mohrmann feels that it is appropriate to the spirit of Matthew's parable of the talents to interpret organ donation as an example of good stewardship. She makes the parallels explicit: "'I was hungry and you gave me food.'…My heart was failing and you let me have the strong heart of your child who was brain dead after an auto accident."⁹ Like funerals, which express "our continuity and connections with each other,"¹⁰ organ donation "is an affirmation of the intrinsic goodness of living and of the desire that human life continue."¹¹

The Jewish response to transplantation is even more positive than the Christian response, as it describes organ donation as a religious duty rather than a supererogatory action. According to Jewish law, the obligation to save life takes precedence over all other rules except those prohibiting murder, idolatry, and illicit sex. Elliot Dorff writes, "If…one were to need to violate the Sabbath laws or steal something to save a life, then one is not only permitted but commanded to violate the laws in question to save a life."¹² This interpretation of Jewish law in relation to organ donation is consistent through Orthodox, Conservative, and Reform Judaism.¹³ To underscore the appropriateness of Jews donating their organs, Dorff also appeals to the traditions of honoring the dead—in that it is an honor to use a dead body to save life—and helping those in need.¹⁴

Although May and Mohrmann cast the donation decision as reflecting a particular view of community, all of these religious arguments actually envision the "gift" as an exchange between one individual and one or several strangers. The financial costs of transplantation borne by the larger community are not explicitly considered in individual decision-making.¹⁵ A decision to donate is seen as praiseworthy because it may save or extend the lives of one or more strangers and because it expresses solidarity with and care for others. A decision not to donate organs is usually understood to express squeamishness about the dissection of the body or dubious conceptions of the afterlife. Not donating is seen as grudgingly allowable because we need to respect people's religious beliefs or life trajectories, but it is also often seen as morally deficient. Put another way, these writers think the decision not to donate is wrong, but that trying to compel donation or overriding someone's wishes is worse. The result of refusing to donate is that several people will not receive potentially life-saving organs, which may cause them to wait for a long time for other organs or die while waiting. In addition, the transplant waiting list will continue to grow.

These positive Christian and Jewish responses to organ donation are at least partially dependent on an insufficient reckoning of what is entailed with a gift of a body. There are two major ethical factors that these religious writers and nearly all other bioethicists ignore. First, organ transplantation provides ambiguous goods for organ recipients. Transplantation is never a simple cure for organ failure. For a small number of recipients, transplant surgery is the beginning of a series of disasters. Deaths in the operating room are rare but possible. Some patients survive surgery but never regain normal function; some suffer irreversible strokes during surgery; and others receive new organs that never work or that are acutely rejected. Some recipients spend a year or more in the intensive care unit, never well enough to leave the hospital.

Those who have relatively successful surgeries nevertheless begin a lifelong balancing act with their physicians to regulate the body's immune responses with immunosuppressive medications. Transplant recipients need to suppress their immune system enough or the new organ will be attacked and rejected; too much suppression of the immune system, however, leaves the body vulnerable to potentially deadly infections. Many transplant recipients experience prolonged generalized fatigue and weakness, and face possibilities of very serious complications, including diabetes, atherosclerosis, bone density problems leading to hip and other bone fractures, cataracts, and cancer.¹⁶ Many patients also have psychiatric problems after transplantation; 80 percent suffer depression after transplant. They often have problems reentering the work force due to physical debility or psychological issues.¹⁷ The length of survival after a transplant varies, depending on the organ transplanted. Currently lung recipients have the lowest survival rates. Three out of four can expect to live through the first year, and less than half will live five years.¹⁸ Of course, there is the real possibility of ameliorating many of these problems over time, but that should not stop us from considering the probable fate of those who receive organs now.

Recognizing the potential complications and adverse outcomes of transplantation forces us to acknowledge the potential disparity between our intentions and the actual result of the "gift" of organ donation. Donating organs is always benevolent; that is, the intention is always to help someone else. However, organ donation is not always beneficent; it does not always accomplish its benevolent goal. Dorff's assertion that those who donate organs "are doing nothing less than saving lives" is simplistic in light of these facts.¹⁹

The second main problem of these Christian and Jewish accounts of the gift of the body is that this "gift" costs individuals, hospitals, insurance companies, and government agencies a great deal of money. An individual act of organ donation may prolong the lives of six individuals on the transplant waiting list. The first year costs for the hospital charges, physician fees, and medication are approximately $253,000 for the heart, $314,000 for the liver, $271,000 for each lung, and $116,000 for each kidney. Neither the donor nor his or her family is likely to pay any of these expenses. The donor commits others to spend well over $1 million in short-term surgical and medical costs and $130,000 in follow-up costs each succeeding year, barring complications.²⁰

The actual payer of these costs varies depending on the insurance coverage of the recipients. Usually those who make it onto transplant waiting lists have relatively good private insurance, although these plans often set an upper limit on the amount of money they will reimburse physicians and hospitals. Sometimes these limits cover a lifetime of medical care or are treatment specific. If a transplant recipient has not reached his or her lifetime or transplant maximum by the time an organ becomes available, insurance will cover most of the initial transplant expenses. There are, however, very costly long-term follow-up expenses. For recipients with Medicaid and Medicare coverage, federal and state governments pay for transplantation and some of the follow-up costs. Whether the patient is privately insured or not, transplantation usually causes severe economic strain on the families who receive organs as well as on the shared resources of insurance companies and government agencies. It is rare that an individual or family can give a gift that costs others so much.

The risks and benefits of transplantation extend far beyond individual donors and recipients. Thus, rather than considering donation an individual act of giving, it may be more appropriate to consider the decision to donate as a vote on the allocation of public resources. This would require that we consider donation in the context of the current American health care system. In the United States, health care currently consumes 13.5 percent of our Gross Domestic Product.²¹ Within that health care budget, we spend a disproportionate amount of money on acute care health costs, more and more of which is used to extend the lives of those in their 60s and beyond.²² We spend relatively little on preventive medicine or long-term care for chronic illnesses. Organ transplantation serves as a good example of these priorities, although it is certainly not responsible for them. With an alleged severe organ shortage, we currently spend approximately $4 billion on the practice of organ transplantation annually.²³ An increase in organ availability would substantially increase this amount.²⁴

How might we approach the organ donation decision as an allocation decision on the public policy level, in which we focus on the broader and longer-term implications of organ donation and the practice of transplantation? A decision to donate organs represents approval of the practice of transplantation and, by extension, of the high priority for curing life-threatening disease in our modern health care system. Further, an act of donation materially cooperates with the practice, "investing" one's unique biological material in pursuit of these benefits. In an immediate and direct way, substantial resources are mobilized after a successful donation and could affect funding decisions within insurance companies and government agencies. For instance, if several people in an insurance plan receive transplants each year costing several million dollars, the insurance company must either raise premiums or provide fewer services for other beneficiaries. The same is true for federally- or state-funded transplants. In an environment of absolute scarcity of organs, contributing one's own organs makes a real difference both to people waiting (a fact continuously underscored by organ donation advocates) and to the allocation of resources. If it is wrong to divert scarce resources away from basic needs, like access to basic medical care, housing and shelter, then transplant practices are morally suspect for contributing to these diversions. By extension, individuals who donate organs are to some extent complicitous in that wrongdoing.

Seen from a public policy perspective, a refusal to donate keeps one from material cooperation with the practice when one is ambivalent about its ambiguous benefits to individuals and society. Although we clearly don't have control to redistribute funds not used because of our refusal, the refusal can signify a commitment to changing priorities in medicine by showing preference to preventive or chronic care. It symbolizes the commitment to save statistical lives over identified others dying of organ failure. This is, obviously, a rarely articulated view in the public rhetoric of transplantation which assumes that there really is no rational or compassionate reason to choose not to donate.

It is unclear how religious thinkers ought to counsel people were organ donation framed as a decision about the allocation of national resources. For example, tension is inherent in the metaphors chosen by May and Mohrmann. They see an attempt to increase organ donation as a way to call Christians and others to serve both the bodily and spiritual needs of love and community. However, religious counsel might be substantially more ambiguous if we apply the rich, noble images of feeding and community to a more nuanced understanding of the gift of organ donation in the context of our complex and troubled health care system. May's use of the image of sharing bread and wine and Mohrmann's use of the parable of the talents as an exhortation to "teach, heal, feed, clothe and shelter" might lead us first to consider stewardship as a resource allocation issue, with basic needs like food and shelter for the poor taking precedence over the probable extension of the lives of individuals with organ failure.

The moral problem created by allocating scarce fiscal resources to transplantation is not lost on the strong proponents of organ donation featured here. In The Patient's Ordeal, May states that "We should not sustain transplant policies driven by fear alone, supporting acute care medicine without limit, at the expense of preventive medicine and other human goods."²⁵ Other theological writers ask, "Does the notion of stewardship not apply to the numbers of people who could be helped or healed with an effort equivalent to one person's healing through transplantation?"²⁶ Dorff, although having made a very strong case for the duty of Jews to donate cadaver organs, goes on to assert that "preventive medicine and, for that matter, provision of food, clothing, and shelter to those lacking them may arguably take precedence over organ donation, if only because we can save more lives using those measures than we can through organ transplantation."²⁷

When we address both individual gifts to strangers and the more encompassing priorities of our health care system, the same religious values and beliefs can lead to conflicting conclusions. My contention is not that one of these conceptions is vastly superior to the other, but that both point us toward something true. If one purpose of using religious themes to analyze transplantation is to keep us alive to the suffering of others, then we should face squarely the suffering that could potentially be caused regardless of the choice we make regarding organ donation.

Those who consider themselves compassionate and responsive to the needs of strangers may find themselves in a tragic bind. They may disapprove of the priority given to acute care medicine in our society particularly in light of injustices in our health care system and, thus, generate a presumption against the practice of transplantation. This presumption signifies deep and compassionate care for strangers, including the millions of children who lack adequate health care, housing, and education. However, to say "no" to organ donation when we know there is a tangible opportunity to save lives seems selfish and uncaring, and to refuse because of financial reasons appears "cold" and overly calculating. Personally, I have yet to make a decision about organ donation. I have not declared myself a donor, and I don't know what to tell my family to do in the event of my death. Perhaps moral ambiguity at the time of my death would be a fitting end to a life that I perceive as being full of such ambiguity. I must admit to feeling a strange pleasure when I imagine my husband trying to explain my beliefs on the subject to an Organ Procurement Organization representative in the event of my premature death: "She really liked to help people, wouldn't step on an ant, but thought transplantation contributes to a misallocation of scarce national resources."

If this is a tragic bind, we could all benefit from creative responses from religious writers, who are accustomed to making sense of tragedy in this mortal world. One major religious theme that bears on this issue is the significance of death, and whether it is a door to something better or a final end or "defeat." Both May and Mohrmann argue that death is not final, and thus defeating it should not be our highest priority. May argues that we should confront death with "metaphysical nonchalance."²⁸ It is real, but not ultimate. Mohrmann argues that "none of us has the impossible task of preventing death. And all of us have the theological task of imparting hope—sometimes hope for an extension of earthly life, but always hope for life beyond death, in God."²⁹ Although Mohrmann knows that not all will be comforted by this hope, she feels it is a responsibility to refuse to "be part of the lie…of the denial of the fact of death" and "to remind each other…that Lazarus died again."³⁰ Death is thus seen as an acceptable and inevitable part of human life and represents a perceived—but not real—tragedy. Most people who take this view, including May and Mohrmann, have a strong theological justification for prioritizing justice in terms of access to care over funding for acute care medicine.

For those less confident about a continued life after death, deaths that might have been prevented will likely cause even more anxiety. A 1991 poll done by the Los Angeles Times showed that 67 percent of Christians and 30 percent of Jews report believing in life after death.³¹ Aside from what this may signal about willingness to donate organs because of a perceived future need for one's body, I find it significant because many people think that there is no heaven. If that is true, then May's metaphysical nonchalance will be hard to come by. There is nothing to convince those who doubt an afterlife that death should be welcomed, or that it is immoral or unfaithful to use technology to oppose it. That does not mean, however, that all life-saving efforts are acceptable when weighed against other goods. Fights against death may be unacceptable if they cause more people to suffer than can be saved, either by affecting health care specifically or by contributing to societal injustice in the allocation of other resources. Denying some individuals the chance to have their lives saved for this reason is a true tragedy; genuine goods conflict with each other.

I tend to favor the more tragic picture of the conflict inherent in organ donation and transplantation; talk of heaven would not comfort me were I faced with the death of a loved one. But even those who reject the notion that death is good in an ultimate sense are not logically bound to the claim that fighting death takes precedence over all other goods. The title of this essay, "Wading through Blood and Suffering," is taken from Paul Ramsey's Basic Christian Ethics.³² He argues that Christians have an infinite obligation to all, even though they must, by virtue of the professions for which they prepare, choose whom to serve. The fact that society can't serve all does not mean that it can abandon any single person with a restful conscience or clean hands. We must make choices, but we remain responsible for what we omit. If we look carefully enough, we will find that we are always wading through blood and suffering. This is a hard truth for those who strive to be good, but it is one we might do well to get used to.

Bringing Christian and Jewish metaphors and beliefs to both the personal and the public policy questions surrounding transplantation can help us sharpen our skill at facing difficult and potentially tragic allocation decisions compassionately and justly. Verhey argues that facing this conflict of goods is necessary to foster religious virtues of truthfulness and humility.³³ I agree that these are character traits we should all admire, but my aim is more practical. There are many policy decisions Americans will be asked to make about transplantation in the approaching decades, particularly as progress in xenotransplantation and artificial organs will move most decision-making away from individuals and into insurance companies and government agencies. Learning to make tough decisions and retain compassion in the face of the tragedies of individuals who might have been saved can serve as a kind of training ground for conscientious voters and policy-makers of the future. Although individual gifts may not always be a unique source of needed biological material, individuals will remain citizens, who should make known their preferences for funding expensive but marginally effective life-saving medical treatments.

ACKNOWLEDGEMENTS
I would like to thank Richard B. Miller, Ann Mongoven, and Mark W. Graham for their insightful comments on an earlier draft of this paper. I would also like to thank David H. Smith for his support and guidance throughout my dissertation project on transplantation when I first began to formulate these ideas.

NOTES
1. In this article I refer only to solid organ transplants, although most of the same issues pertain to bone marrow transplants as well.