In the U.S., every 90 minutes a patient awaiting an organ transplant dies, while over 100,000 patients continue costly treatments such as dialysis, burdening Medicare with expenditures exceeding $30 billion annually1. Despite this critical shortage, only 42% of eligible deceased donors’ families consent to donation, severely limiting the available organ supply2. Notably, current policies paradoxically allow reimbursement for funeral expenses for whole-body donors but explicitly prohibit similar compensation for deceased organ donors. We propose extending funeral expense reimbursement to deceased organ donors, aligning ethical imperatives with practical health policy to address this persistent crisis.

The Uniform Anatomical Gift Act (UAGA), enacted in 1968 to standardize organ donation processes, still exhibits substantial state-level variability, creating challenges for uniform implementation of national organ donation strategies. Whole-body donations, typically managed by private institutions for medical research or education, regularly provide reimbursement for funeral costs. However, these programs lack uniform regulatory oversight, sometimes resulting in misuse and public mistrust. By contrast, organ donation is strictly regulated by the Organ Procurement and Transplantation Network (OPTN) and Health Resources and Services Administration (HRSA) but explicitly excludes financial support for donor families.

These historical hesitations underscore the importance of addressing both ethical concerns and empirical uncertainties through carefully designed and rigorously tested policy frameworks. As early as 1993, the Payment Subcommittee of the Ethics Committee of the OPTN examined funeral reimbursement but rejected it due to concerns about insufficient supportive evidence and potential negative impacts on altruistic motivations. Similar reservations were expressed in the National Academies’ 2006 report, which questioned whether financial incentives would meaningfully increase organ supply. In 2011, the UK’s Nuffield Council on Bioethics endorsed funeral reimbursement, sparking brief public debate without resulting policy changes. OPTN and UNOS revisited this issue in a 2017 white paper, ultimately calling for further empirical research. More recently, the AMA’s 2022 Council on Ethical and Judicial Affairs echoed previous hesitations, emphasizing uncertainty about whether benefits outweigh potential harms.

Recognizing these longstanding concerns, a reconsideration of funeral reimbursement today necessitates explicit ethical boundaries and regulatory clarity. Reimbursing funeral expenses differs fundamentally from direct payments for organs, and it neither commodifies the human body nor diminishes altruistic intent. It is not a precondition for a dignified funeral, but rather an expression of societal gratitude and respectful financial support for the altruistic decision of donation, offered during a period of emotional and economic vulnerability for donor families. This approach seeks to honor the donor’s gift, not to create a transactional requirement that could add stress to grieving families. By capping reimbursement to reflect median funeral costs ($6000–$8000)3, policymakers can mitigate concerns about undue inducement or coercion, preserving human dignity and familial autonomy in donation decisions. This clearly distinguishes funeral reimbursement from outright financial compensation for organs, thereby preserving dignity and protecting families from undue financial pressures at a vulnerable time.

Public attitudes toward incentives for organ donation have been mixed but shifting. A 2006 survey revealed moderate/mixed support, with 63% of African Americans and 47% of White Americans endorsing funeral expense reimbursement4. Such support underscores significant cultural and demographic variations in perceptions of financial incentives. Updated empirical research capturing contemporary public attitudes indicates robust support for compensation for organ donation broadly5. Nonetheless, given the racial disparities in organ transplantation—particularly affecting African Americans, who experience higher incidences of end-stage renal disease and prolonged wait times—targeted reimbursement strategies may promote equity in transplantation access and outcomes.

Ethical considerations of fairness are paramount. Concerns that funeral expense reimbursement might disproportionately influence economically disadvantaged families, thereby shifting the burden of donation, must be addressed head-on. Reports of organ procurement coordinators being perceived as overly forceful underscore a risk of undue influence, which has become especially salient with the expansion of donation after circulatory death6. These concerns interact with end-of-life planning disparities that impact donation consent rates among socioeconomically disadvantaged families and across racial groups7. Furthermore, high funeral costs associated with burial or cremation and a viewing contribute to “funeral poverty” leaving some low-income households unable to afford services8. As a result, the addition of funeral reimbursement must be met with safeguards to monitor and improve organ procurement practices. This includes improved practice guidelines and monitoring for procurement coordinators already under consideration to ensure that they do not influence the consent decision, regardless of potential funeral reimbursement9. These efforts would reduce the risk of undue influence and help protect public trust.

This policy is not designed to be a solution to poverty but an acknowledgment of a family’s generous act. The proposed framework, with reimbursements capped at a modest amount and managed through a transparent federal regulatory body like OPTN/HRSA, ensures the incentive does not become coercive. This cap is a critical safeguard against undue burden, as it limits the financial value to a level that supports rather than persuades, ensuring the choice is not unduly influenced by financial need. The focus remains on removing a financial barrier that some families may face in honoring their loved one’s wish to donate, rather than creating a system where donation becomes an economic necessity. Such a regulated approach is crucial to ensure that the decision to donate remains a voluntary and altruistic choice for all, regardless of their socioeconomic status.

The United States Renal Data System reports annual hemodialysis costs of roughly $100,000 per patient10. As a result, even a modest 5%–10% increase in the organ donation consent rate would lower US spending on dialysis alone by $200–800 million (1–3% of the current $27 billion cost)10. There is an estimated one million dollars in cost-savings per kidney transplant over a recipient’s lifetime. In Fig. 1, we demonstrate that funeral expense reimbursement results in dramatic overall financial savings even for modest increases in donation consent rates. The policy would achieve financial break-even with just 135 additional kidney donors, less than a 1% increase in the current authorization rate2. Meanwhile, based on their direct experience with donor families, organ procurement professionals project a potential increase in consent rates of 5–10%, figures that far surpass the break-even threshold. While these are necessarily projections, they represent the informed judgment of experts working within the current system and provide a credible basis for anticipating the policy’s impact, validating its potential benefits.

Fig. 1: Estimated increase in total organ transplants and associated cost savings resulting from varying modest increases (5-10%) in donor consent rates under a funeral reimbursement policy.
figure 1

Transplant projections based on average organ yield per donor from the 2022 OPTN/UNOS Annual Report. Cost savings calculated using kidney transplantation savings from Held et al.10, adjusted to 2023 dollars.”

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Past research estimates that an additional deceased donor can save more than 30 life-years by donating multiple organs, including two kidneys, one liver, one heart, two lungs, and other tissues11. This policy could increase annual transplants by 3494–13,977 (9–35% above the current 39,797 transplants), potentially saving an additional 105,000–419,000 life-years while generating substantial financial savings. As a result, the policy is a life-saving measure that would also drastically reduce federal spending on dialysis and increase cost-savings for the entire US healthcare system.

Recent policy developments provide a conducive environment for revisiting this reimbursement issue. Bipartisan initiatives such as the “Securing the U.S. Organ Procurement and Transplantation Network Act” and the “Advancing American Kidney Health” executive order reflect widespread political acknowledgment of the urgency to enhance the organ donation system. Building on this progress and alongside other proposals to improve organ recovery and utilization1, while aligning funeral reimbursement policies under federal oversight through amendments to the National Organ Transplant Act and managed via OPTN and HRSA, the new policy is timely, life-saving, and ethical.

The comparison to whole-body donation, where funeral expense reimbursement is common, is instructive but also reveals important distinctions. Currently, private entities manage reimbursements for whole-body donations, often without standardized federal oversight. This lack of regulation has, in some cases, led to ethically concerning abuses and a commodification of human tissue that has undermined public confidence. Our proposal explicitly avoids this weakness. By integrating funeral reimbursement for organ donors within the stringent, federally regulated framework of the Organ Procurement and Transplantation Network (OPTN) and HRSA, the system would ensure accountability, transparency, and public trust. This key difference—placing the policy under a robust, pre-existing regulatory authority—directly addresses the ethical pitfalls observed in some whole-body donation programs and is central to our recommendation.

In summary, despite longstanding ethical debates and empirical uncertainties surrounding financial incentives in organ donation5, a carefully structured policy of funeral reimbursement addresses many historical objections. The proposal neither commodifies organs nor undermines altruism; rather, it supports families in critical moments, potentially boosting organ supply and reducing healthcare disparities. To ensure ethical integrity and policy effectiveness, immediate next steps must include pilot programs and rigorous empirical evaluations to confirm the beneficial outcomes anticipated and address any residual ethical concerns definitively. Such evidence, combined with thoughtful policy design and robust oversight, could significantly enhance donation rates, reduce healthcare expenditures, and save countless lives.