Should younger transplant patients receive higher priority for the best available kidneys? What are the unintended consequences of changing the rules, for example in altering incentives for transplants from living donors? My University of Chicago colleague Lainie Friedman Ross appeared (with others) on the terrific NPR program On Point. She was discussing how we should prioritize patients waiting on the kidney transplant list. Worth a listen, especially for the audience’s phoned-in questions.
The older I get, the more I believe that younger people should be privileged in the allocation of such scarce resources. I’ve already had the opportunity to complete my education, to have relationships, to marry and raise my children. My 12- or 18- or 25-year-old peers have not had the opportunity to experience these things.
Once again, kudos to Tom Ashbrook, one of the nation’s great radio journalists. Even greater kudos to Virginia Postrel and others who have provided one of life’s most precious gifts to others. I happen to disagree with Postrel’s politics. Some things are more important than politics.
Harold, I agree. I’m 65 and should I “need” a liver or kidney - well, then it’s time to go. The other issue is that I want to be allowed to choose when and how I go given such a situation - with as little fuss as possible. Your comments re: letting others, younger, have an opportunity are spot on.
65-year-olds certainly deserve kidneys and livers, too. Yet we’ll let the 25-year-olds get the first crack at the organs they won’t have to retransplant 10 years later…..
In some sense, allocation seems a second order problem with the first order problem being why is there such a shortage of kidneys? Moving froma system where you have to sign up to be a donor upon death, versus one where you have to sign up not to, might save many lives and also avoid the heartache of allocation decisions.
Where do donor preferences fit in here? I haven’t really thought about who should get my kidneys, and I’m not sure what I would conclude, but surely there ought to be room to take that into consideration.
Another issue, and a pet peeve of mine on the whole organ donation matter, is the attitude of religious groups. I personally believe that donating organs upon my death is a moral obligation. Why does this not draw more attention from religious leaders? (or maybe it does, and I’m unaware?)
“with the first order problem being why is there such a shortage of kidneys?”
Where’s the mystery? You pretty much always get a shortage of a good, if you refuse to pay for it.
In any event, given recent developments in tissue printing, the shortage shouldn’t last much longer.
Why should you even be able to sign up not to donate? When one is dead, one has no interests in what happens to one’s body. Are there people who will suffer while alive if they know that they might have an organ removed after they’re dead? These questions are not rhetorical.
Brett Bellmore: You pretty much always get a shortage of a good, if you refuse to pay for it.
I refuse to believe that Brett means rich people ought to get first dibs on kidneys. I prefer to believe that Brett is advocating the following: let some sort of organ bank pay donors for their kidneys — thus increasing the supply of kidneys — but continue to allocate the more abundant supply of kidneys based on medical/ethical criteria. This would allow people farther down the priority list to get kidney transplants. All we have to do is decide how to fund such a program.
-TP
There’s no point in allocating transplant organs outside of medical criteria, a mismatched kidney is pointless to pay for. If rich people can get higher priority for organs that actually match them, OTOH, what’s the problem? It’s at least as many lives being saved, and the extra funds might actually increase the supply of organs.
But, mainly, I’m offended by the notion that there’s something horrible about paying the donor. The doctors and nurses don’t expect their contribution to be free, how dare they demand that anybody else go uncompensated?
Favoring the young over the old? But wait, I thought you said that closing Illinois’ budget problems should be paid for by the young to benefit the old? At least that is what the old liberals told me a few weeks ago.
“The older I get, the more I believe that younger people should be privileged in the allocation of such scarce resources. I’ve already had the opportunity to complete my education, to have relationships, to marry and raise my children. My 12- or 18- or 25-year-old peers have not had the opportunity to experience these things.”
But, that isn’t your decision to make for every older person. What if you were 65 with a disabled child still dependant on you? What if you’d worked from the age of 16 to 65 at a job that you hated, and you were finally free when the diagnosis came in? Might you feel differently? I’m 40, and I don’t think I’d be ready to step asside for a totally unrelated young person if it came down to it.
“Where do donor preferences fit in here? I haven’t really thought about who should get my kidneys, and I’m not sure what I would conclude, but surely there ought to be room to take that into consideration.”
Are we just talking about age, or preferences more generally? I don’t think we should we allow donors to discriminate based on race, religion, sexual orientation, etc.. Why make an exception for age?
“If rich people can get higher priority for organs that actually match them, OTOH, what’s the problem?”
I have two problems with it:
First, this is not a zero sum game. It is not the case that as long as we keep performing X transplants, X lives will be saved. The current triage system is set up to maximize the number of people who live to recieve a transplant and then survive the surgery. Changing the order with money will reduce the number of people who survive for several reasons. If people who can do without an organ for a few months get to buy their way ahead of people who need that organ NOW, only one of those two people will survive instead of both surviving. If rich people with terrible prognoses are allowed to buy their way ahead of more healthy patients with a better chance of recovery, often two people will die, both the person who received the transplant and the person denied it. Under the current system, the person with the good prognosis will usually survive. If rich people with active drug problems are allowed to keep buying new organs, two, three or even more more people could die for each wealthy drug addict saved. The only way adding money to the selection criteria would not increase deaths is if money was only taken into consideration when all other factors are equal.
However, my main problem is it that it sends the message that the lives of the rich are worth more than the lives of the poor. Moreover, because wealth is inequally distributed in our society for historical reasons, it will favour patients who are dispoportionately white. But, I don’t expect Brett to agree that that would be a problem.
I have a problem with this.
It is a very slippery slope from “younger is more worthy” to someone is “less or more worthy” for other reasons. Let’s say someone at 48 is at the top of the waiting list, but the livers that become available go to 25, 35, and 40 year olds, but not the 48 year old because she’s older. But say she also happens to be a PhD working for the UN High Commission for Refugees helping save millions of lives a year. Does this make her more worthy of the liver transplant than the 25 year old who happens to be a drug addict? Actually on one level I’d probably argue “Yes”. But, stop. How can anyone justify making that decision? That means you’ve just decided that the 25 year old addict is NOT worthy of the transplant which is simply wrong: the opportunity provided by a new liver could well be the opportunity for the 25 year old to turn their life around and make a huge contribution to (say) helping other drug addicts. We just don’t know. It is not possible to make fair judgment calls on these things. At the same time, it WOULD be a tragedy for the 50 year old to miss out on a liver - the world loses a valuable contributor. Really, I think the only fair way is the first-come-first-serve waiting list.
(Disclosure of conflict of interest: I am 40 and looking down the barrel of a liver transplant in 3-5 years time. Apart from being fearful of the whole catastrophe I am fearful of exactly this kind of judgment call that could jeopardize my own chances at continuing my life’s work which is far from complete. Perhaps by 65 I’d feel differently, but knowing how I feel know, I’m not so sure.)
The correct policy is that no one over 18 gets an organ … Any organ … Who has not signed up to donate an organ in event of death at age 18 or within a year of passage of this new policy. Adults who sign up past 18 come behind all adults and their children who signed up at 18.
Children whose parents have signed up to donate get organs ahead of children whose parents have not signed up to donate. Organs to non donors only when there is no donor in position to benefit from the organ and it would be wasted otherwise.
Presto … Those with religious scruples against organ donation are protected and need never worry about committing evil or inducing it. And a much, much vaster pool of donors.
Should have noted: I’m signed up for organ donation, bone-marrow tissue matches, and have given more than fifteen gallons of O- blood, the most sought-after kind (universal donor blood type).
JMG: “no-one gets an organ … who has not signed up to donate an organ.” Fine except that because of my condition they won’t take my organs even though they are welcome to them all.” You’ll probably find that for many people in my situation that is the case….
Ben: Just to be clear, 40 is YOUNG. Good luck and God speed dude.
“First, this is not a zero sum game. It is not the case that as long as we keep performing X transplants, X lives will be saved.”
I absolutely agree with this, and as I said, there’s no point in allocating organs contrary to medical criteria. But who’s assuming a zero sum game here? I suggested that allowing people with the money to buy higher priority would provide funds which could be used to save more lives. IOW, I’m suggesting the opposite of a zero sum situation: That the number of lives saved could be INCREASED by putting more money into the system.
<i"However, my main problem is it that it sends the message that the lives of the rich are worth more than the lives of the poor. Moreover, because wealth is inequally distributed in our society for historical reasons, it will favour patients who are dispoportionately white. But, I don’t expect Brett to agree that that would be a problem."
??? I don’t think the fact that wealthy people can pay for things poor people can’t afford means their lives are somehow worth more. Rather, it suggests that these things have costs, and that things that cost something usually get allocated to people willing and able to pay for them. It’s got nothing at all to do with somebody’s worth as a person.
Three short comments:
(1) See yesterday’s Op-Ed in the New York Times by Christopher Longo, an Oregon death-row prisoned who’d like to make his organs available after his execution, but won’t be allowed to do so;
(2) Reread Larry Niven’s short story, “The Jigsaw Man”;
(3) Give me odds that Dick Cheney won’t get a new heart.
First, my understanding is that the policy isn’t to automatically prefer younger recipients but to prefer them for organs from younger donors, in order to reduce their need for subsequent donations, that is, to match the organ to the donee by approximate age. That is actually a policy that could reduce the need for donations, at least modestly, and therefore help everyone in the pool. The policy could also result in older recipients getting a preference for organs of older donors — and I think that would also be fair.
Second, the mismatch between donors and donees is only going to get worse, because better medical care means fewer people die as a result of the kinds of accidents that generate organs of all kinds — just as it means more people are surviving to need organs.
Third, the issue of living donation could ameliorate the situation somewhat, but anyway you look at living donation other than friend to friend or family to family, you see real problems, at least with kidneys: the people who are most in need of the money are those with higher relative risks of subsequent kidney disease. The burden of disease is distributed quite disproportionately in our society, and kidney failure is usually the end result of a long slow decline that starts with hypertension, diabetes and obesity. At the very least, you should match living donation with some kind of insurance schemed to reduce its risks, and I mean, even its long-term risks.
Fourth, it almost doesn’t matter whether you can buy and selling “living” donations because any living donation reduces the mismatch among donations for the rest of the pool. The real problem would be for families donating the organs of a decedent to conduct an auction to the highest matching bidder. UNOS and the organ distribution system generally could not survive if UNOS becomes the equivalent of an auctioneer. I think it’s well past the point where we should be paying all donors (or their heirs) a flat, relatively modest but not insignificant fee (let’s say: $10,000).
Kate,
Me: “Where do donor preferences fit in here? I haven’t really thought about who should get my kidneys, and I’m not sure what I would conclude, but surely there ought to be room to take that into consideration.â€
You: Are we just talking about age, or preferences more generally? I don’t think we should we allow donors to discriminate based on race, religion, sexual orientation, etc.. Why make an exception for age?
I actually don’t have anything specific in mind. It may be that donor preferences shouldn’t be considered, or it may be that honoring them would increase the supply of organs, or it may be that we should regard organs as no different than the donor’s bank account, to be disposed of in accordance with the donor’s wishes. I’m just raising the question, really.
re: Lainie Friedman Ross
She comes regularly to the Childhood Ethics meetings here in Seattle, which are then shown on UWTV.
I have learned much from her (and others, particularly Norman Fost) regarding legal and medical issues related to children.
She is the real deal AND a very entertaining speaker.
… it suggests that these things have costs, and that things that cost something usually get allocated to people willing and able to pay for them.
People already pay the costs of kidney transplants. They pay for the surgeries and all related costs (or their insurers do). People who don’t have insurance or the money to pay cash for those services are already left to die (in the U.S., anyway). What you’re suggesting is that we create a bidding war to allocate a free but scarce resource. As a result, life or death operations would become more available to the wealthy and less available to everyone else. To my mind, the decision to allocate resources in that way implies that those who have money are worth more than those who do not.
And why the question marks? I said that I thought you’d disagree with my objection, and you do.
How would a youngest-first mesh with the current (nominally) sickest-first policy? Is it an absolute measure (in which case the old would be completely barred from transplants, except for the old rich)? Where would the age cutoff be, or would it be some kind of scale, perhaps based on the number of adjusted years of life a transplant was expected to produce? The devil is in the details for proposals like this.
Which is why I’m with Ben: as soon as you start playing who-deserves-more-life cards things get intensely complicated with results that no one may want. (Which is not to say that the current system is any good, but it’s important to remember that it was put in place specifically in response to the practice of having committees that rated people as more or less deserving of a transplant.)
paul, once again, my understanding of the policy is to try to match organs with life expectancy. Indeed, I think this is already done to some extent when a donor is older, although I don’t know how much. I think the intent is not to prefer youth per se, but to try to decrease over time the absolute number of transplants an individual will likely need in a lifetime. That benefits everyone in the pool — because at any given time both young and old are in the same pool with someone who needs a second or even a third kidney.
I think there may be ways to tweak the policy as well — for instance, making sure that no one can be bumped because of an age based policy more than once.
I also wonder whether doctors are already informally engaging in practices such as this.
Barbara: I guess for me the big question is how you calculate life expectancy. If you want accuracy, it can’t be a straight aged-based calculation (especially with the wide range of pre-existing morbidities among transplant patients). But once you start formally including other factors things get troubling very quickly.
But paul, this is how the organ allocation system works as a general proposition — how do you define “sickest?” Or “likely to survive surgery” or, even more ominously, “likely to comply with post-operative requirements?” (which is often enough, reduced to a calculation of access to family resources and insurance). Moreover, descending into the “sickest” state is likely to correlate negatively with survival (hence the need for “not so sick he’ll die during surgery”). Age and life expectancy based on age are objective, compared to these kinds of judgments.
The main point is, doctors already infuse the process with subjective judgments, even (or maybe especially) if their bias is unconscious. There is almost no way to make it otherwise.