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States' rights or patients' rights? The new politics of organ allocation
The House of Representatives recently passed legislation that effectively prevents the enactment of governmental rules that would establish a new national system for allocating solid organs for transplant taken from donors after they die. The new system would treat organs as a national resource, with allocation being determined by severity of illness and time on the waiting list, no matter where the patient is in the country. But this would mean that areas of the country with the highest donation rates would see more organs leave their states than come in, making them net exporters of organs. Many states have therefore objected to the new system, and some have even gone so far as to pass their own laws barring organs collected in the state from leaving. Whose rights ought to win out -- statesí citizens and organ transplant centers, or sick patients whose illnesses donít respect state boundaries?
Itís geography, stupid
The existing system of organ allocation is regional, with the country divided geographically into a number of multi-state organ procurement organizations (OPOs). Under this system, priority is given first to patients waiting for a transplant within the region in which donated organs are collected. That means that patients have shorter waits for organs like livers in regions that have a higher rate of organ donation, and likewise wait longer in regions with lower donation rates. This has created what some consider an unfair system, in which medical factors (severity of need, time on the waiting list) are only part of what determines how long patients wait for organs, and equally sick patients in the south wait longer than those in the upper Midwest.
Historically, part of the reason for a regional system was that highly perishable organs wouldnít last long enough to allow them to be transported over long distances. But an organ could easily be flown or drove within a smaller region of the country, assuring that they would be transplanted within the small window of opportunity. But with the advent of overnight and even same day delivery services, we now have guarantees that organs will "absolutely, positively be there overnight."
Transplants pay, so hospitals fight for them
A system that was created to accommodate the limits of both the techniques of transplant medicine and the countryís transportation infrastructure became complicated by the realities of medical economics. Organ transplants are both prestigious for hospitals and medical centers, and a profitable part of the business of medicine. This has created a bigger incentive to fly patients to where the organs are collected than to ship organs to the patients, since that would mean that another transplant group would perform (and benefit from) the surgery.
Equal access for all-but only if youíre a frequent flyer
Because of the regional system, transplant patients often rack up many frequent flyer miles. If they can afford to fly to a transplant center to be worked up and agree to return on a momentís notice, patients can list themselves on multiple regional transplant lists, effectively multiplying the chance of receiving an organ. This effectively creates a system by which potential organ recipients can buy greater access to organs, which is certainly outside the spirit of a system that pretends not to consider ability to pay in organ allocation decisions. The federal governmentís proposed national system would dispense with regional variation, multiple waiting lists, and the incentive for states to treat organs like a commodity.
However compelling these arguments may sound, disparities based on geography donít seem to matter if youíre waiting in Minnesota, where your wait is likely to be shorter. But the same patient in Mississippi would have a different perspective on waiting time, and thatís precisely the point. Patientsí lives are no less valuable when we cross state lines, and our organ allocation system needs to reflect this fact or we risk a new kind of war between the states.
"Ethics Matters" Archive
where you'll find other columns from Jeffrey Kahn
on a wide range of bioethics topics.
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