Lives That Depend on the Kindness of Strangers : Organ transplants: Public policy must ensure that they go to those most in need, regardless of ability to pay.
When the parents of a 7-year-old Northern California boy murdered in Italy allowed his organs to be given to people who would have died without them, it was an inspirational example of the gift of life that can come only from tragedy. Organ transplant--with the partial exception of living related donors for kidneys--is the only medical procedure in which a person can live only if another dies.
The irony is massive: the deceased must have been a relatively healthy person up until the moment of a fatal trauma. Moreover, the form of death must be such that the organs are not destroyed. The circumstances of death are generally sudden and unexpected, the most difficult on family members, and yet these are the only circumstances in which organs taken from the deceased can save someone else’s life.
While other medical procedures have benefited from miraculous advances in drugs and technology, only organ transplantation--mainly kidney, heart, liver or pancreas--is entirely dependent on the willingness of someone else to give a gift. And gift is the proper word, because federal law is clear that no money should be paid for an organ. It truly depends on the kindness of strangers.
The unique nature of a procedure that requires a “medical device” that cannot be manufactured or replicated and whose supply is not within the medical profession’s control raises important questions. Does the difference between transplantation and other procedures require that transplants be treated differently from a public-policy perspective? If so, how?
There is a defining difference. It stems from the fact that the goal of public policy regarding organ transplants is and must remain to encourage the altruism without which organ transplants would be impossible. Throughout the Western world, buying and selling of organs is prohibited. Since supply and allocation are outside the market system, there can be no increase in price when demand exceeds supply. Public policy, therefore, must in no way hinder the motivation to be generous with these precious commodities, and must provide that they will be used in an equitable fashion. There must be an atmosphere of trust and honesty that, unfortunately, is in danger of being eroded under current policy.
When a family member is approached at a time of supreme grief and shock and told that the gift of life is possible if the removal of organs is approved immediately, that person’s decision is aided by the belief that the organs will go to whomever is most in need. All too often, that belief may not be warranted. The reality of money intervenes.
Several years ago, charges would occasionally appear that it was actually possible for the rich to go to the head of the line for a transplant. If this did happen, it no longer can. The government’s oversight system supervises organ allocation too closely for such abuses. Money still matters, however, because the tens of millions of Americans who are uninsured or underinsured find access to transplantation all but impossible.
Non-renal transplants are not covered by Medicaid in every state. Medicare covers liver transplants only in rare cases. Most hospitals accept transplant candidates--who by definition will die without a new organ--only if some payment source is located beforehand. The uninsured and underinsured, therefore, need not apply.
Which should take precedence, the responsibility of the transplant system to deal equitably with all organs, or the responsibility of the payment system to set priorities?
Either reimbursement policies or organ procurement policies must be changed, and there are good reasons not to change the latter.
Organs are in ever shorter supply than money, and altruism is a social value that is rare enough as it is. To make sure that we do not break faith with donor families, we must have policies that are consistent with the goal of encouraging the generosity on which organ transplants depend. Underlying this is the recognized obligation that the gift be distributed fairly, based on the need of the recipient.
Changing policy so that the cost of an organ transplant is covered for any potential recipient would not lead to an increase in the approximately 16,000 organ transplants that take place each year. That number is rigidly limited by the number of available organs and cannot change significantly. Changing policy would, however, ensure that anyone, regardless of ability to pay, has exactly the same chance of receiving this life-saving gift as anyone else.
We must protect the values and goals of the transplant system and not squander the chance we have not only to save lives, but also to foster a sense of community and caring that enables those who have died to live on. Public policy should help institutionalize our best instincts.
