While I was browsing Red Orbit (www.redorbit.com) today, I came across a pretty interesting article detailing recent developments regarding the process of kidney donation (article linked below). The article explains that a third of patients needing kidney donations either will not receive one or will not receive a successful one because their bodies are hypersensitive to receiving a donated organ. In order to assist these patients, doctors are now trying to trick the immune system, the article explains, and one successful method has been a combination of blood cleansing and cancer drugs.
The article also chronicles the major changes that the kidney distribution system is undergoing in the United States. Patients in need of a new kidney are often forced to wait for years for a match. The article states that the time on the waiting list can last from for to five years, and 4,000 patients pass away annually while waiting. Thus, if the new “tactics” that scientists are developing to aid that considerable third of patients with sensitive immune systems are increasingly successful, it would seem at first glance that the time on waiting lists should drop.
Or should they? It is not clear in the article, or perhaps I just missed it, how the national waiting list would be affected if suddenly a third of those patients in need of kidneys could viably accept a donation. Is the fact that they (currently) would likely reject a kidney already factored into their position on the list? As I am a mere law student and a medical laymen, if anyone has any insight I would love to be educated.
What the article does explain, however, is that the system for kidney distribution in the United States is undergoing a major overhaul. The United Network for Organ Sharing is considering proposed changes to the system, one of which being determining waiting periods by kidney deterioration as opposed to how early someone is put on the transplant list. Another suggestion is to consider the patient’s age and medical condition. These proposed changes strike me as a very utilitarian approach to the donation system, and seem to prioritize donation based on need. Intuitively, this seems like sound logic, but I think it does raise some ethical issues. Is it really relevant how old someone that needs a kidney is? How does age factor into who deserves to get a kidney first? Is a middle aged woman’s life less valuable than a teenager’s, simply because she has lived longer? Would her children think so? Or is a patient in need of a kidney that also has another medical issue less deserving than one that simply needs a kidney?
While these proposed changes make sense at first glance, I think they run a slippery slope. I take no issue with prioritizing donation by need (by looking at deterioration of the kidney, for example), but if you start considering age and other medical conditions, in my opinion it must be done with reservation. I believe the intent is good, but evaluating the value of people’s lives comparatively must be done with extreme caution.
The article can be found here: http://www.redorbit.com/news/health/1587820/kidney_transplant_list_undergoing_renovations/index.html
3 comments:
Thanks for the article - I did not know that UNOS was considering an overhaul to the kidney distribution system. I can't provide you an education on organ allocation, but I can share the little I know about how decisions are made (and some alternatives that have been advocated and may be under consideration).
As you suspect, it is highly unlikely that people with 'sensitivities' described in the article make the cut to be on the list, so adding them could increase the recipient pool. But, many people currently on the waiting list have previously received kidney transplants that failed (I don't know the exact figure, but it is significant). Presumably, decreasing the chances of rejection would take these individuals off the waiting list.
So what will it be? More? Less? I don't know, but isn't the new therapy worth pursuing if the available kidneys are not 'wasted' and patients do not have to undergo repeated surgeries?
CRITERIA: UNOS follows current federal considerations for organ allocation including: length of waiting time; accepted medical and scientific criteria; and equitable access without favoritism, political influence, or discrimination based on race, sex, or financial advantage. The American Medical Association advocates for criteria based almost solely on clinical efficiency (which is somewhat at odds with the federal requirement that equity be given equal consideration). It sounds like the proposed changes are more in line with the AMA position - particularly if they are considering adapting the clinically dubious "first-come, first-served" notion of equitable access. Age can be a legitimate factor in the context of overall physical health, but would not be determinative in the clinical efficiency model.
It will be interesting to see what changes are under consideration. As determined by the AMA, unacceptable criteria include: ability to pay; the contribution of the patient to society; perceived obstacles to treatment; contribution of the patient to his or her own medical condition; and the patient’s past use of health care resources. But, you don't have to look too hard to find arguments in favor of each one of these criteria. Others have argued that any criteria are essentially unfair and would prefer to see organ allocations based on a lottery. Still others propose that admission to a waiting list be based on 'modified altruistic reciprocity' - a fancy term for a pay-to-play approach where the cost of admission to a waiting list is prior registration as a potential donor.
Who knows where we'll end up or how new treatments will influence future decisions about allocations?
FYI - Now I think I'm going to comment on your comment about the triage model for vaccinations under threat of epidemic. ... and sorry this got so long. But it's your fault for making an interesting post!
PJM
Thanks for the additional info! The clarification helps, and while it seems the subject is still up in the air, I agree that the UNOS criteria, at least at face value, seems to be more in-line with the AMA in that it is based around clinical efficiency.
I also agree with your comment that the new treatment is certainly worth pursuing even if it adds additional names to the recipient pool if less kidneys will be "wasted." Initially, I did not stop to consider that a patient who gets a donation may find himself or herself right back on that list if that donation fails. Regardless of the criteria used for allocation, I would surmise nobody would actually be opposed to having as many successful transplants as possible.
A really great movie is "Dirty Pretty Things." It stars Chiwetel Ejiofor, who plays a Nigerian cab driver in London who mans the front desk of a hotel at night but who was formerly a doctor in Africa, and Audrey Tautou (from "Amelie"), who plays a Turkish maid in the same hotel and who is Ejiofor's roommate. The manager of the hotel runs an illegal operation at the hotel where immigrants sell a kidney in exchange for passports with new identities. Learning of Ejiofor's past as a doctor, the manager pressures Ejofor to harvest kidneys, but he refuses. The film evolves into an action-packed love story with the seedy underbelly of London's organ black market as the backdrop. The film was nominated for an Academy Award for Best Original Screenplay and won a British Independent Film Award for "Best Independent British Film" in 2003.
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