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.