Equity in Transplant Accessibility (original) (raw)

Bioethical triangle of transplants

Background: Organ transplantation is one of the highest forms of medical procedures due to the many technical implications as well as to new frontiers to be conquered while searching for new therapeutic options that reach far beyond ordinary decisions. Although technical skills were developed primarily, it was not until immune reaction to rejection was understood and control of biological variables achieved that transplantation acquired a greater scope. Bioethical performance is currently a challenge. As a human multidisciplinary activity, this is not without bias or skew. Therefore, the social and cultural context in the deontological and bioethical sense acquire the greatest relevance, particularly when values and principles inherent to human life are taken into account along with the complex angles derived from human interactions in the bioethical triangle. Conclusions: This triangle is represented by the individual requiring an organ, the person who is the donor under specific circumstances, and the individuals who are responsible for procurement, transplantation and evaluation of the validity of this therapeutic option.

The National Organ Transplantation Act after Twenty Years: A Time for Reform ?

Organ transplantation has become a proven, cost-effective lifesaving treatment, but its promise is contingent on the number of available organs. The growing gap between the demand and supply results in unnecessary loss or diminished quality of life as well as high costs for surviving patients and their insurers. Twenty years after the enactment of the National Organ Transplantation Act, it is time to rethink the moral basis and overall design of organ transplantation policy. We propose a system of national organ insurance based on a social contract of reciprocal obligation under which aggregated present consent to donate guarantees future availability of organs for those who need them, at least to the level that prevents death while awaiting an organ. The national insurance plan will cover all peri -and post transplantation costs to all. By presuming consent to enroll, we align the default with widespread expectations of reciprocity and mutual self -interest, and surmount barriers to consent that have undermined the spirit of the current legal regime. Individuals who prefer not to be either recipients or donors would be able to opt out of the insurance system.

Equal Treatment for Disabled Persons: The Case of Organ Transplantation

Mill is famous for his clever preliminary solution to the conflict between justice and utility-maximizing. In Chapter 5 of Utilitarianism he notes that, because of declining marginal utility, one can often maximize utility by concentrating resources on the worst-off in society, thus providing a utilitarian explanation for our intuition that the worst off have special moral claims. In medical ethics, reflection on cases of persons with severe, chronic disabilities challenges this felicific, if fallacious, resolution (Mill, 1967, pp. 391–434). These persons can sometimes command enormous quantities of medical resources, but gain only marginal benefit from them. An organ transplant for someone who is worst off because she has only a short time to live would, for example, target the worst off, but produce only small benefit. Thus proposals for aggressive medical intervention to bring those with disabilities to levels of nearer normal health or restore them to that status provide a criti...

Public and Private Regulation of Organ Transplantation: Liver Allocation and the Final Rule

Journal of Health Politics Policy and Law, 2007

The allocation of cadaveric organs for transplantation in the United States is governed by a process of private regulation. Through the Organ Procurement and Transplantation Network (OPTN), stakeholders and public representatives determine the substantive content of allocation rules. Between 1994 and 2000 the Department of Health and Human Services conducted a rulemaking to define more clearly the public and private roles in the determination of organ allocation policy. Several prominent liver transplant centers that were losing market share as a result of the proliferation of transplant centers used the rulemaking as a vehicle for challenging the local priority for organ allocation inherent in the OPTN rules. The process leading to the Final Rule provides a window on the politics of organ allocation. It also facilitates an assessment of the strengths and weaknesses of private rulemaking. Overall, private rulemaking appears relatively effective in tapping the technical expertise tacit knowledge of stakeholders to allow for the adaptation of rules in the face of changing technology and information. However, the particular system of representation employed may give less influence to some stakeholders than they would have in public regulatory arenas, giving them an incentive to seek public rulemaking as a remedy for their persistent losses within the framework of private rulemaking.

Ethical dichotomies in organ transplantation a time for bridge building

General Hospital Psychiatry, 1996

Rapid advances of the past 15 years have resolved many of the technical and immunologic limitations to organ transplantation. With the success rates that can now be achieved, there is increased attention to the limited supply of donor organs and to cost considerations, the remaining obstacles to wide application of organ transplantation. Competition for organs and for funding demands greater focus on patient selection and resource allocation. As Charles Taylor, philosopher and political scientist, has written, ethical formulations inevitably conflict when each is taken to its logical end point. In the 1960s, a life boat ethics framework predominated for selection of transplant recipients. The opposing egalitarian framework of recent decades has allowed for enrollment of older transplant recipients and those with histories of substance abuse. In the United States, alcoholic liver disease has been the most common indication for orthotopic liver transplantation since 1987. Among those awaiting transplantation, urgency has been a priority over time waiting. But many potential transplant candidates who are young and who appear relatively stable die while waiting. Despite the shortage of cadaveric organs, physicians and ethicists have for the most part eschewed rewards or reimbursement for living related organ donation. Such conventions are a function of the prevailing zeitgeist and are susceptible to a paradigm shift in parallel with overall changes in societal regulation of medical practice. Theorists and practitioners are immersed in the trends of the day and the approach at each moment seems preferable to that of the moment preceding. From a practical standpoint it may be possible to bridge disparate ethical constructs. For example, in the wait for solid organ transplantation, a bicameral approach could alternatively accommodate time waiting and urgency. Selection of older patients and those with a past substance abuse history could be limited to those with the best prognosis for compliance and posttransplantation quality of life. Living organ donors and families of nonliving donors could receive incentives of a noncoercive nature that would stimulate participation without sacrificing altruism. Creative approaches are needed to improve fairness and efficacy in solid organ transplantation.

Revisiting multi-organ transplantation in the setting of scarcity

2014

In the setting of organ scarcity, the ethics of multiorgan transplantation (MOT) deserve new examination. MOT offers substantial benefits to certain recipients, including avoiding serial surgeries. However, MOT candidates in the United States commonly receive priority for their nonprimary organ over many individuals who need that organ, which may undermine equity. The absence of standard criteria for MOT eligibility also enables large and unfair regional variation in MOT, such as simultaneous liver-kidney transplantation. Unfortunately, MOT may also undermine utility (optimal patient and graft survival) in circumstances where providing multiple organs to one person fails to achieve the greater collective benefit attained by providing transplants to multiple people. Policy reforms should include the adoption of minimal clinical criteria for MOT candidacy with the attendant goal of decreasing regional variation in MOT. In the future, these minimal criteria can be revised to accommodate new research about which patients derive the most benefit from MOT. Incentives to perform MOT should also be reduced, such as by including MOT outcomes in center-specific reports. These reforms run the risk that the transplant community could be perceived as abandoning MOT candidates, but offer an opportunity to align transplant practice and ethical principles.

A quiet revolution in organ transplant ethics

A quiet revolution is occurring in the field of transplantation. Traditionally, transplants have involved solid organs such as the kidney, heart and liver which are transplanted to prevent recipients from dying. Now transplants are being done of the face, hand, uterus, penis and larynx that aim at improving a recipient's quality of life. The shift away from saving lives to seeking to make them better requires a shift in the ethical thinking that has long formed the foundation of organ transplantation. The addition of new forms of transplants requires doctors, patients, regulators and the public to rethink the risk and benefit ratio represented by trade-offs between saving life, extending life and risking the loss of life to achieve improvements in the quality of life.

Perceptions of Efficacy, Morality, and Politics of Potential Cadaveric Organ-Transplantation Reforms

and JD candidate at Yale Law School. The authors thank Kim Krawiec and Phillip Cook, the special editors of this issue of Law and Contemporary Problems and the organizers of the accompanying symposium, as well as that symposium's participants, especially commentator Julia Mahoney. We also thank Michael Gill, who reviewed an early draft of this article. We appreciated the editorial support of Claire DeMarco at Harvard Law School, and we thank Rogers College of Law Associate Dean Kirsten Engel for funding our research. 7 Opt-out systems (also known as presumed-consent or default-rule systems) have been used successfully in Europe, 8 and they have been endorsed by many scholars in the United States.