Spare Parts

On June 6, 1995, Mickey Mantle's doctor said the Baseball Hall of Famer, whose liver had been severely damaged by hepatitis, cancer, and decades of heavy drinking, would need a transplant. Two days later, he got one.

Since the median wait for a liver transplant ranges from four months to a year (depending on blood type), many people thought Mantle's expedited operation smacked of favoritism. But the staff at Baylor University Medical Center insisted that the 63-year-old former Yankee had received a liver quickly not because he was so famous but because he was so sick.

So sick, in fact, that he was dead two months later. In retrospect, it was not a very wise use of a scarce resource, which might instead have saved one of the 804 patients who died waiting for liver transplants that year.

Now the Clinton administration wants to impose the policy that favored Mantle on the whole country. The Department of Health and Human Services says organs should go to the "neediest" patients, without regard to how they got that way or where they live.

The new policy has been put on hold because of objections from local organ procurers and transplant centers. Five states have approved legislation aimed at preserving the current system, which favors local patients and allows consideration of factors other than proximity to death.

Because of geographical preferences, waiting times vary dramatically from one part of the country to another. To HHS and its supporters, this situation is manifestly irrational; The New York Times calls it "misguided chauvinism" and "dangerous parochialism."

But the people who obtain organs, which requires broaching a delicate question with anguished relatives, think it's only fair for their towns and states to have first dibs. Then, too, the sense that organs will help people nearby arguably makes hospital personnel more likely to ask for donations and families more likely to say yes.

The "sickest first" approach favored by HHS has problems of its own. As Mantle's case illustrates, the most desperate patients are also the least likely to survive a transplant and the most likely to require a second operation. Even if the transplant is a success, they tend not to live as long as patients who were healthier to begin with.

The upshot is that "sickest first" saves fewer lives and provides fewer additional years than a policy that incorporates other criteria, such as age and chances of survival. Hence it's not clear that the federal plan is more efficient than the current arrangement.

Nor is it necessarily superior in moral terms. As James V. DeLong noted in the November issue of Reason magazine, HHS "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."

Of course, there are all sorts of moral criteria that could be applied to organ transplants. After Mantle's operation, a medical ethicist told The New York Times that, ordinarily, "alcoholics should go to the bottom of the transplant list." But he said he'd make an exception for Mantle, "a real American hero."

It seems unlikely that we will ever reach a national consensus about such matters. But do we really need to?

Experts estimate that 10,000 to 15,000 Americans die each year in circumstances that could produce usable organs, but organs are obtained in just one-third of these cases. Meanwhile, more than 60,000 Americans are on transplant waiting lists, and about 4,000 die each year before an organ becomes available.

Something is amiss here. On the one hand, people are eager to buy a commodity and able (through insurance) to pay for it. On the other hand, potential suppliers are holding back.

The problem seems clear: Federal law bans the sale of human organs. Consequently, everyone involved in a transplant gets paid except for the people who actually provide the organ. Unlike the surgeons, the hospitals, and the procurement organizations, they are supposed to be motivated exclusively by altruism.

Defenders of this policy, which seems designed to create a shortage, express a vague sense of unease about allowing a trade in human body parts. But since the ban they support predictably results in about 10 avoidable deaths every day, they need to do better than that.