Organ Grinders

The federal government's idea of "fairness" may exacerbate an already deadly organ shortage.

James V. DeLong from the November 1998 issue

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More mercenary considerations are also at stake. If priority is given to local use, then the industry will be characterized by a multitude of local programs, each performing a limited number of transplants. It will be difficult for national centers to develop because such entities cannot be supported by donations in a single city.

Sixty percent of the people on the waiting list for the University of Pittsburgh's liver transplant program are from outside the area, for example, even as the number of procedures performed there has declined. The local centers fear that HHS wants to move toward a system of major national transplant facilities.

The centers argue that HHS's "sickest first" policy serves the interests of their big competitors. As the director of the Wisconsin Donor Network put it: "The redistribution of organs away from Wisconsin so as to ostensibly benefit the `sickest' patients can be perceived to satisfy the business agenda of a few transplant centers which have encouraged unlimited growth in their waiting lists till they have outstripped the capacity of their community to meet their organ needs. This situation is exacerbated when these lists are heavily populated with out-of-area patients, many of whom could be transplanted quicker and with better outcomes in their home community."

The participants in this debate agree on a few points. One is that donors and their families should have no say in who receives organs. Doctors and bureaucrats regard this as so obvious that they never bother to justify it. In fact, it is far from obvious. Quite the reverse--given the intimacy of the gift, the donor should have a say.

One reason for HHS or the medical establishment to eschew criteria of moral worthiness in allocating organs is that such standards are highly subjective. Fine. Let multiple criteria be used, reflecting the views of multiple donors.

HHS is also making a moral judgment by establishing a standard of "sickest first." It is deciding that a small chance of a couple extra years for a cirrhotic senator is more important than a good shot at 40 years for a young person who contracted a rare liver disease while serving in the Peace Corps.

One can see why Congress would regard this as a reasonable set of priorities, but others are entitled to skepticism. "Sickest first" also means that more repeat transplants will be required and more recipients will die.

Every wasted organ means that someone else who might have lived won't make it. HHS's avoidance of considering "life years" or "quality of life" (instead of just "life") is ethical cowardice. To force patients to reach the brink of death before receiving a transplant out of fear that someone, somewhere might be willing to exercise moral responsibility lends new meaning to the term "dead hand of bureaucracy."

A donor might also be disturbed by the financial requirements for a transplant. He might decide to earmark an organ for a less-favored class of people on the condition that other players in the system cut their fees to make the operation affordable. If my liver were in shape to be useful to anyone, I would deem small-business operators and other poorly insured people at least as worthy as well-covered bureaucrats.

Another point so well accepted that it's rarely mentioned is the assumption that organ donors should not be paid. Even though everyone agrees that donation rates need to be raised, few are willing to consider how financial incentives might serve that cause. A lively debate on the issue is heating up in the academic literature, including the pages of the prestigious British medical journal Lancet, and is beginning to spill over into popular discussion.

The idea that it's offensive to discuss transplants in financial terms is droll, since the system is awash in economic calculations by medical centers, surgeons, health insurers--everyone except the donors.

In a current working paper, Julia Mahoney, an associate professor of law at the University of Virginia, notes that "given our current institutional arrangements, avoidance of market language is misleading and...even damaging," making it difficult "to comprehend what benefits are available and how they are distributed."

By trying to establish a single national distribution system, the federal government is moving in precisely the wrong direction. We don't trust central planning to deliver potato chips. Why should we trust it to deliver life-saving organs?