Is It Fair to Sacrifice Lives?

By Charles T. Carlstrom and Christy D. Rollow
July 31, 1998

Amidst a firestorm of controversy in the medical and political communities, Health and Human Services Secretary Donna Shalala has proposed changing the rules for organ transplants. Since whether or not a transplant patient receives an organ can mean the difference between life and death, potential transplant policy changes are extremely important.

Traditionally, the United Network for Organ Sharing — a nonprofit organization — has set transplant policies, but huge disparities in waiting times have led to this unprecedented change. HHS has decreed that organs must be allocated without regard to geography and that priority must be given to those whose need is most immediate.

This mandate has triggered an unprecedented debate about who should get scarce organs. Unfortunately, the debate has focused on relatively less important concerns about equity. HHS has highlighted the unfairness of some patients’ waiting two to three times longer than others simply because of their location. Members of the Congressional Black Caucus have complained that the proposed regulations would further increase the wait for blacks compared to whites. Legislators from small states have responded that large states would benefit, while others have complained that the new rules would favor large transplant centers.

Mysteriously, however, the most important measure of the mandate has been ignored: will it save lives? Surely that is the most important measure of equity. The effect that these regulations — and allocation methods in general — have on the number of lives lost while awaiting a transplant has been missing almost entirely from the debate. There is an unspoken belief that allocating organs is a zero-sum game — that the allocation method doesn’t affect the number of lives lost. In fact, however, the allocation method strongly affects how many patients will live.

Organ transplants have saved countless lives, but the severe shortage of transplantable organs has required some tough decisions.

Current rules established by UNOS specify that donated livers must stay within a particular region and go to the sickest patients first. But a “sickest-first” policy is myopic, because it ignores the impact that today’s decision has on the number of deaths over time. The two-year organ-graft survival rate for patients who are in intensive care before their transplants is approximately 50 percent, compared to a whopping 75 percent for transplantees who are still relatively healthy. Given those differences, it makes sense to perform transplants on patients before they become critically ill.

UNOS’s rules, however, reflect an attempt to balance the competing concerns of equity and efficiency. The cost in terms of efficiency (that is, the number of lives lost) is mitigated by the regional nature of the system, which often results in healthier patients receiving transplants. New regulations threaten to skew the balance. A national distribution system coupled with a sickest-first allocation policy would dramatically increase these inefficiencies; the average liver patient would be in even worse health at the time of transplant and have an even lower chance of survival.

The crucial question of how this mandate would affect other organs has been lost in the debate. In deciding who receives a given kidney, for example, a patient’s health is rarely considered because patients can live with dialysis treatments. Instead, the primary factor is the quality of the biological match between donated organ and prospective patient. Unlike a sickest-first policy, allocating organs to those with the best biological match is extremely efficient: the one-year kidney-transplant survival rate for well-matched kidneys jumps 13 percentage points above that for poorly matched ones.

Given the mandate for a national distribution of kidneys, however, UNOS is discussing de-emphasizing biological matching in favor of waiting time, a seemingly more equitable allocation method. This is because, although a nationwide matching system would save additional lives, its impact would further widen the disparity between blacks and whites — since a national system would indirectly place greater emphasis on biological matching. Already, blacks wait twice as long as whites for kidney transplants.

The longer waiting time is due to the disproportionate number of blacks suffering from hypertension and diabetes — the major causes of kidney failure — and not to discrimination. Furthermore, the quality of the biological match is usually better when donor and recipient are of the same race. The fact that blacks as a group demand more kidneys than they supply largely explains the discrepancy between waiting times. To minimize the importance of biological matching because of its racial impact would, in effect, place a higher value on the lives of some patients than others.

Organ transplants have saved countless lives, but the severe shortage of transplantable organs has required some tough decisions. The debate needs to be refocused. A squabble about winners and losers has intruded on what we should be discussing: how to design an efficient system that best uses our extremely scarce and valuable supply of organs. While fairness is an appropriate concern when discussing organ transplants, we must guard against the unfairness of a transplant policy that allows needless deaths and focuses on less relevant concerns. A national transplant policy should have exactly one goal — saving as many lives as possible.

Charles T. Carlstrom is a Ph.D. economist, and Christy D. Rollow is a research associate at the Federal Reserve Bank of Richmond. They have previously written on organ rationing for the Cato Journal.