The United Network for Organ Sharing (UNOS) recently released organ procurement guidelinesfor public comment that are sure to prompt ethical debate.
In the first overhaul of the system in 25 years, UNOS announced younger, healthier people will be given priority preference for kidneys over older, sicker people.
This is a major change over the previous system which favored patients on a waiting list – first come, first served – irrespective of age or health condition.
The impetus behind the new system is to maximize the number of years of the kidney by pairing it with the health status of the recipient.
In a Washington Post article, Kenneth Andreoni, associate professor of surgery at Ohio State University and chair of the UNOS committee reviewing this policy, said, “We are trying to best utilize the gift of the donated organ. It is an effort to get the most out of a scarce resource.”
While this step is hailed by some surgeons, bioethicists and patient representatives as an improvement in kidney distribution, others worry it could alter the pattern of organ donation and penalize middle-aged and elderly people. Bioethicist Lainie Friedman Ross at the University of Chicago noted in the Post article, “There are a lot of people in their 50s and 60s … [who] could have 20 or more years of life. We are making it harder for them to get a kidney that will function for that length of time. It is age discrimination.”
Is this age discrimination or is it making the best use of a scarce resource?
There are 87,000 Americans on a waiting list for a donor kidney, and only 17,000 will get one each year. How to make the best use of a life-saving, but limited, resource is at the heart of a broader ethical debate in healthcare. Arthur Kaplan, bioethicist at the University of Pennsylvania, tells the Post, “It’s a big shift …This moving away from the save-the-sick-strategy to try to get a bigger yield in terms of years of life saved.” He notes this approach could have implications about allocation for other medical resources such as expensive cancer drugs and ventilators in emergency situations.
This brings up one of the most explosive words in the healthcare lexicon: rationing.
Most health professionals acknowledge that scarce resources will be, by necessity, rationed. Yet this concept is anathema to the American public. Who wants to deny their grandmother a life-extending cancer drug, even if that drug costs $100,000 a month and extends life by three months? Research shows most Americans want everyone to have access to organs, with no restrictions on age or health. Yet this national generosity regarding access to resources is at odds with the availability of these resources.
The difficulty in addressing this issue is the very volatility of the “R” word. Opponents of health reform used the specter of rationing to argue against the Affordable Care Act. It has become almost impossible to have a balanced conversation on this topic and yet it is increasingly urgent that we do so. With an American turning 50 every seven seconds, the baby boomers are poised to represent 45 percent of the population by 2015, a statistic that is threatening to overwhelm the healthcare system.
Allocating medical resources will be a national priority – one that healthcare professionals, bioethicists and the public will all weigh in on. The first step in addressing these issues is to stop demonizing the “R” word and admit that we have to make difficult choices – choices that will not please everyone.
Whether you agree or disagree with the new criteria set forth by UNOS, I view it as an attempt to use limited resources in a way that will do a maximum of good. They should be applauded for the courage to tackle this difficult issue despite the chorus of critics. We can only hope that more healthcare professionals will follow UNOS’ lead in addressing medical allocation issues with an eye towards moral and practical solutions. It is a conversation that will engage all levels of society, and one we cannot afford to put off.
Nancy Hicks is a senior vice president at Ketchum’s Washington, D.C., office, and serves as associate director of Ketchum’s North America Healthcare Practice.