I enjoyed The God Committee by Dr. Satell. Dr. Satell was one of the authors along with Dr. Hippen of Code Red which I posted about last April. Both articles are a call for repeal of the ban on organ donor compensation. This article from Dr. Satell comes at the issue in an interesting way, first by giving a concise review of the recent news regarding liver transplants and Japanese mobsters down at UCLA and then reviewing the "Seattle Experience" - our use of an anonymous committee in the '60s to overtly ration access to ongoing hemodialysis.
I Enjoy Reading an Opposing View
Putting aside discrepancies in how I've heard the Seattle story told and the version presented in The God Committee, I object to equating kidney and liver transplants. There is not a viable longterm replacement for the liver - liver dialysis may someday be a reality but not yet - there is a viable longterm replacement for the kidney. And there is the matter that people have but one liver, altruistic living liver donation is not an option. These differences are enough it seems to me that increasing life saving postmortem liver, heart and lung transplantation through compensation, is not the same issue as increasing living donor kidney transplant - or bone marrow, which I rarely see mentioned - through compensation.
Peter's post on Monday addressed the idea that I have addressed too - we question the ethics of touting an urgent need to increase the supply of kidneys based on conventional dialysis outcomes. Peter has emailed some of the people taking a position on compensation to increase living kidney donation - the authors of various articles - we have to figure out how to share the interesting discussion he's initiated. I take the position that increasing kidney donation must be done understanding there are other ways to improve ones renal replacement therapy. The goal is not transplant per se, the goal is living the life you were meant to live; transplant is not typically life saving. My understanding of the situation makes me uncomfortable with compensation, though I would put reimbursement for donor expenses in another category, with a different ethical calculus.
Seattle Lives
When I think of the Seattle Experience I think of the compromises that had to be made in the name of the greater good. By the time Congress established the dialysis program under Medicare in 1972 hemodialysis schedules had been optimized to accommodate the greatest number of people with the resources available.
Logistically providing four hour treatments, three days a week allows six people to share a machine. This was a compromise, a compromise to stretch resources was for the greater good, and it only impacted those who could not dialyze at home, about 60% of the Seattle dialysis population at the time. I understand why all those clinics mentioned in The God Committee had to live with tough rationing constructs back in the '60s. My question is why are we living with this same rationing today? The dialysis rationing implicit in a three day a week schedule lives on today. Indeed it thrives, with over 90% of all dialyzors surviving on incenter three day a week, short hemodialysis. What's our excuse for rationing? Money? If it is money than we should compare the global costs of all modalities.
I look forward to more posts on kidney procurement ethics from Peter and Anna. And comments, as always, are invited - whether you are on the sharp or dull end of the needle.
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