Where have all the organs gone?
The subtitle for this column ought to be "and where should they be going?" Tommy Thompson, the Bush administration's Secretary of Health and Human Services, recently announced that new federal rules introduced by his predecessor for the allocation of organs for transplant would be revised, and that a new program focused on increasing organ donation would be launched. The Gift of Life Donor Initiative makes donor cards compatible across all 50 states and includes a partnership with employers, unions and employee groups to create a national network for encouraging organ, blood and bone marrow donation.
But the new programs put off long-awaited new rules that were proposed to change a system that had been regionally focused into more of a national network for allocation of kidneys, hearts, livers and other organs. Can we afford to focus on increasing the donation of organs as a way to avoid dealing with how we allocate them?
Shifting focus to donation
Rather than focusing on the allocation of organs, the new HHS proposal is designed to increase the rate of organ donation, in order to reduce the worry about how organs are allocated. But it is hard to imagine the plan being so successful that the supply of organs will increase to meet demand -- nearly 75,000 people are waiting for an organ at any given time.
There is ample evidence about the barriers to donation -- decisions must be made as a loved one is dying, under the time pressure created by the requirements that preserve organs' quality for transplant. And some traditionally medically under-served populations worry that their medical care will be compromised if they agree to be an organ donor. It isn't clear how the new HHS programs will overcome these challenges, though bringing programs into the workplace undoubtedly will help educate many more people about the importance of organ donation.
Enabling choice or devaluing life?
Does such a policy empower people to choose how best to die or does it devalue life by making death too easy? The Dutch policy permits patients to request that euthanasia be performed if they become physically unable to make their wishes known when the time comes. This is intended to make sure patients have their wishes honored, but also turns over to the physician discretion about when to perform death. Requiring at least two physicians to decide offers some safeguard, but removing the final decision from patients opens the door for potential missteps, especially since legalization of euthanasia may lead to an expectation that patients will use it.
Disparities likely will remain -- the donation of organs around the United States varies widely by region. States in the upper Midwest have much higher rates of organ donation than states in the South. Under the older system of allocation, donated organs are distributed first within the region; only if no suitable recipient is found within a region will an organ be sent elsewhere. This means that there are more organs for transplant available in high donating regions than in areas with lower donation rates, leading to different patient waiting times by region.
On its face, no one could argue that this is the fairest way to allocate a scarce lifesaving resource. The regional system was created in the early days of organ transplant largely to cope with imitations on the distance that organs could be shipped. But that was before the availability of same-day shipping -- now organs can easily be shipped from one coast to the other if that's where the next eligible patient is waiting.
Unfortunately, these facts matter less than the politics of geography. Under a national allocation plan, states with higher donation rates (such as Wisconsin, Secretary Thompson's home state) would become net exporters of organs, meaning fewer patients waiting there and fewer procedures for their transplant centers to perform. Largely because of these concerns, the states that would see a net outflow of organs have lined up against nationwide allocation, even though it is difficult to argue against giving patients equal access to organs wherever they are.
In the end any successful approach will take into account the fact that politics are part of policymaking. Increased donation, especially in regions with historically lower donation rates, will go some way toward making politics less important. The goal is clear -- make more organs available for more patients. Policies need to be aimed at both increasing organ donations as well as creating a system that allocates them in the fairest ways possible.
"Ethics Matters" Archive
where you'll find other columns from Jeffrey Kahn
on a wide range of bioethics topics.
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