Is Rationing of Health Care Ethical?

A recent New York Times article entitled “New Kidney Transplant Policy Would Favor Younger Patients” references a proposal being considered by the nation’s organ transplant network to allocate organs in an alternative manner than the present first-come-first-served system. The article indicates it is intended to provide better matches between the life expectancies of recipients and the functional life of donated kidneys.

The proposal was first reported in the Washington Post. A 30-member Kidney Transplantation Committee, chaired by Kenneth Andreoni, MD an associate professor of surgery at Ohio State University, offered the proposal as part of its review of the system for the United Network for Organ Sharing (UNOS), a Richmond-based private nonprofit group contracted by the federal government to coordinate organ allocation. “It’s an effort to get the most out of a scarce resource,” Andreoni said.

The current organ allocation system, which dates to 1986, was initially based on giving kidneys to the patients who matched the organs best, but in its present form takes a first-come, first-served approach giving priority to patients who have waited the longest.

At issue in this current proposal is the dilemma that elderly recipients can get organs from much younger donors whose kidneys could have provided far more years of healthy life to younger, healthier patients. By the same token, younger patients could receive older or less-healthy organs that might be more likely to wear out sooner, forcing them back onto the transplant list in a few years.

According to some ethicists, this approach, if adopted, could have implications for other decisions about how to allocate scarce medical resources, such as expensive cancer drugs and ventilators during hurricanes and other emergencies.

The idea brings to mind the time when kidney dialysis first emerged as a treatment option for patients with kidney failure. Since, at the time, there were insufficient devices to provide the treatment for all patients; panels were organized to determine which patients would receive the new therapy. These panels became known as “death panels” as they made decisions that in effect decided who lived and who died.

Any time there is a limited resource that is insufficient to meet the demand, some form of rationing is inevitable. The ethical dilemma then becomes who decides what criteria will be employed to make the life or death determination. No matter how the system is defined, there will be those who believe the solution is unfair. The problem is as much ideological as it is ethical.

In a free market system, supply and demand determine how goods and services are rationed. A market price for the good or service is established and fluctuates based on the supply and demand variables. Those who have the ability to pay the market price, are able to acquire the good or service. When it comes to the matter of one’s health, the notion of “fairness” intercedes because ideologically, good health is often perceived as a “right” for all rather than a benefit of the wealthy.

So again, it becomes the debate over the so-called “haves” and “have-nots.” It is not a debate over whether rationing is occurring, since it most certainly is occurring. Instead, the debate is over the criteria that are proposed for deciding the allocation of the organs, and how that will impact the decisions regarding the rationing of other aspects of health care.

In the case of this particular issue, you have until April 1 to comment on the idea, which the committee said would make the kidney system more similar to those used to allocate livers, hearts and lungs. The committee will take those comments into account before formally proposing the specific changes, which will be open to public comment again before going to the UNOS board of directors. The board could approve final changes by June 2012.

About Larry

In 1986, Lawrence “Larry” R. Coutts recognized the need for physicians to learn the principles of running a successful practice and with his wife and business partner, Linda L. Coutts, co-founded Nephrology News & Issues, Inc., a Pennsylvania corporation, to publish a monthly news journal, Nephrology News & Issues, for the “business of nephrology.” This company later became NN&I, Inc., an Arizona corporation and a wholly-owned subsidiary of Medical News & Issues, Inc., another Arizona corporation which the Coutts’ established. Their stated mission was “to provide the best professional resources for the exchange of news and ideas in health care.” In November 2001, that mission was expanded into hematology and oncology with the establishment of HON&I, Inc., to publish the business news journal, Hematology & Oncology News & Issues. IN 2002, with the support of corporate sponsors and partners, the Initiative for HOPE (Hematology and Oncology Practice Excellence) was launched to help recognize community-based cancer clinics that exhibited standards of practice excellence. In 2008, the two publications were sold as Coutts decided to devote his energies and the resources of Medical News & Issues, Inc. to addressing the problems facing his generation of health care consumers. He has a BS from Carroll University in Waukesha, Wisconsin, and an MBA from the University of Wisconsin-Milwaukee. He has served on the Patients Advocacy Task Force of the American Kidney Fund, and served on the Publisher’s Advisory Council of BPA International, Inc., an independent circulation audit bureau for publishers. He has been invited frequently to speak at regional and national conferences on his favorite healthcare topics.
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One Response to Is Rationing of Health Care Ethical?

  1. Larry says:

    The following comment was reported on the University of Michigan Health System news site:

    Survival matching should be used to allocate donated kidneys to transplant recipients

    Ann Arbor, MI (March 16, 2011) — Providing kidney transplants to patients with the best probability of longer survival would reduce repeat transplant operations and improve life span after kidney transplant, said a U-M researcher in a commentary published in the New England Journal of Medicine March 16.
    Alan B. Leichtman, M.D., professor of Internal Medicine at U-M and his co-authors endorsed new concepts designed to improve kidney allocation. These concepts were circulated in February by the Organ Procurement and Transplantation Network (OPTN). The OPTN is the federal contract that oversees solid organ recovery and allocation in the United States.
    “We strongly support the concept of rank ordering donated kidneys based upon their potential post-transplant survival, and matching that survival to that of waitlisted kidney transplant candidates,” said Leichtman, the commentary’s lead author.
    “The current deceased donor kidney allocation system allows distribution of kidneys with very short potential survival to candidates with long expected survival. Candidates with long potential lifetimes that received kidneys with short expected survival have twice the repeated transplantation rate than similar recipients who received organs with a longer expected survival rate.”
    The current U.S. deceased donor kidney allocation system relies primarily upon how long a candidate has been waiting for an organ. However, systems for liver and heart transplantation allocation are based upon candidate medical urgency. The lung allocation system allocates organs based upon a mixture of medical urgency and expected one-year post-transplant survival.
    The Organ Procurement and Transplantation Network has released for public comment three proposed concepts for deceased donor kidney allocation.
    1. Using a Kidney Donor Profile Index to rank deceased donor kidneys according to the length of time that the kidney would be expected to function in an average kidney transplant recipient.
    2. Allocating the 20% highest quality kidneys to the 20% of candidates with the longest expected post-transplant survival.
    3. Allocating the remaining 80% of kidneys such that candidates who are within 15 years (older or younger) of the donor’s age have highest priority.
    Because of the current system and the aging of the candidate pool, post-transplant life span following kidney transplantation in the United States has declined on average by 18 months since 1995, Leichtman said.
    The authors said that computer simulations based on the current donor pool suggest that more than 35,000 years of post-transplant survival are lost each year under the current system. Additionally, more than 10,000 years of incremental post-transplant survival — extra years of life that would not have been achieved without the benefit of transplant – also are lost each year.
    “We are wasting hundreds of thousands of potential years of life,” Leichtman said. “The proposal for survival matching as described in the concept document has the potential to reclaim many of these lost years of life, and therefore warrants serious consideration.”
    The authors also support using the proposed Kidney Donor Profile Index. The new index provides a more granular and accurate survival estimate for organs.
    “We suspect that utilization rates of shorter-lived kidneys will increase with accurate information about their survival potential and reduced opportunity for potentially short-lived candidates to be allocated kidneys with long estimated post-transplant survival,” the authors wrote.
    About 80,000 people are listed nationwide for a kidney transplant. Demand continues to increase, some of it driven by an unnecessarily high rate of repeat transplantations because kidneys and recipients weren’t well matched, according to Leichtman.
    Kidney transplants are the most common transplants done at the University of Michigan Transplant Center and nationwide. But more than half of those who get wait-listed for a kidney transplant in the U.S. never receive a transplant.
    “The lost potential life years, and the increase in the waiting list resulting from an unnecessarily high rate of repeat transplantation are intolerable consequences of the current kidney transplant allocation system,” Leichtman said. “There likely are further opportunities for improvements to the proposed system, but the core proposals presented in the concept document, adoption of the KDPI and survival matching, warrant the strongest endorsement and the earliest possible implementation by the kidney transplant community.”
    Public comment is open until April 1 on the proposed concepts. Comments can be e-mailed to
    Journal citation: 10.1056/NEJMp1102728
    Additional authors: Robert A. Wolfe, Ph.D., professor emeritus in the University of Michigan School of Public Health and Keith P. McCullough. M.S. Both Dr. Wolfe and Mr. McCullough are investigators at the Arbor Research Collaborative for Health in Ann Arbor, Mich.

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