Definition of the problem: Even after the new German legislation about organ donors and transplantation (“information solution”), the question of criteria for distributing the organs is still not solved. The various alternatives to solve this problem face different social acceptance and economic efficiency.Arguments: Medical criteria (e.g. HLA compatibility) and non-medical criteria (e.g. willingness to pay of the patients) are valued on the basis of generally accepted objectives (e.g. equal access to health services or low costs). As an innovative form (...) of organ distribution systems the club solution is introduced. It allows the donor to realise preferences regarding use of the organs.Conclusion: Scoring systems may help to increase the transparency of organ allocation. From an economic point of view medical criteria have to be weighted more than non-medical criteria. (shrink)

On December 17, 1999, President Clinton signed the Ticket to Work and Work Incentives Improvement Act of 1999, which instituted a 90-day comment period for the amended Organ Procurement and Transplantation Network Final Rule, a comprehensive set of guidelines that would affect how organs are allocated throughout the country. Barring further legislative action, the Final Rule, which has been over five years in the making, will be effective on March 16,2000.The Final Rule, issued by the Department of Health and (...) Human Services pursuant to the National Organ Transplant Act, was originally publishedApril 2, 1998. It provided a number of substantive changes to the process through which organs are allocated by the United Network for Organ Sharing, a private, non-profit organization charged with administering the national organ transplantation network. (shrink)

There is at present a divide in the geographical literature between those interested in distributive justice as a social value and those who seek to implement distributive plans on the basis of efficiency of resource use. The former are 'social geographers' interested in equity as a social value, and the latter are 'practical' economic and locational geographers. This divide mirrors one existing elsewhere in social science between Rawlsian liberalism and utilitarian planners. Here we argue that equality and efficiency are related (...) values that cannot be separated easily in the analysis of practical problems. Data on the distribution of transplantable human organs are considered in a practical consideration of this approach. The case-study suggests that inequality of distribution appears to effect adversely the general organ supply. Stated positively, the data suggest that, to the extent that equality of service is an objective, that goal may positively impact on organ supply. More generally, the conclusion argues for a conjoining of theoretical and practical geographical approaches where a scarce resource must be allocated across a dispersed population. (shrink)

The ability to keep someone alive by replacing one or more of their major organs is an astounding achievement of 20th-century medicine. Unfortunately, the current supply of transplant organs is much lower than the need or demand for them, which means that thousands of people die every year in the U.S. alone for lack of a replacement organ.

Definition of the problem: The article discusses the ways in which sociological analyses can contribute to the problem of a just allocation of scarce donor organs.Arguments: It is argued that this contribution consists primarily in the demonstration of the ethical, rather than medical nature of the problem itself. Only if its ethical nature is acknowledged will it be possible to come to a proper understanding of the several dilemmas involved and to consider adequate means for handling them.

In lieu of an abstract, here is a brief excerpt of the content:Organ Transplant AllocationPat Milmoe McCarrick (bio)The introduction of the antibiotic, cyclosporin, which enhances the success rate of transplantation surgery, has resulted in the steady growth of organ transplantation since the mid-1980s. This growth increasingly focuses ethical interest on both the procurement and the allocation of human organs. Not everyone who might benefit from organ transplants can receive them since the number of patients in need (...) of organs far exceeds the number of organs available. Each year the waiting list for transplants increases by 20 percent, but the number of donated organs has remained stable for the past five years (Lawry 1994).Organ transplantation surgery performed on rock stars, sports heroes, politicians, and television celebrities brings questions about the fair allocation of scarce resources to the attention of everyone. Abigail Trafford, editor of Washington Post Health, wonders whether "new livers for hard livers" can be deserved when not enough organs are available for everyone who needs them. Writing about the dilemma of just allocation of organs, she calls famous recipients "poster patients" or "health care celebrities of medical catastrophe" (Trafford 1994). Personal responsibility—the viewpoint that "medical treatment should not be an entitlement program for profligate living"—is an emerging moral consideration according to Trafford. Deciding whose standards and values should apply to the allocation of organs raises many questions. Popular arguments for keeping the current criteria for allocation include: these patients are sick and therefore should be treated, regardless of the cause of their illness; former substance abusers should be able to benefit from their present abstention; physicians should treat anyone who is ill; and although many human illnesses may be caused by individual behavior, such behavior is not always used as a reason to deny care (Trafford 1995).Prior to 1984, when the government established regulations governing organ transplantation, organs routinely were given to the patients of the surgeons who excised them (Prottas 1994). In an effort to achieve a more equitable method of distribution, Congress passed the National Organ Transplant Act of 1984 (Pub. [End Page 365] L. No. 98-507, amended by Pub. L. No. 100607 and Pub. L. No. 101-616), which established a national Organ Procurement and Transplantation Network (OPTN) to improve the effectiveness of organ procurement, organ distribution, and transplant activities. The United Network for Organ Sharing (UNOS) received the federal government contract to be the OPTN.UNOS and its 66 regional organ procurement organizations (OPOs) around the nation have carried out the mandate since 1986. It requires hospitals that receive Medicare or Medicaid funds and perform transplants to belong to the network and to allocate organs according to network policies. UNOS maintains the national computer registry to match donor organs with individual recipients. In distributing organs, UNOS is required by law to use a fair and equitable system based on accepted medical criteria. UNOS regularly reevaluates its policies to ensure that organ donation and recipient selection meet criteria of efficiency and equity (UNOS Update 11 (8), 1995).At the end of June 1995, 278 transplant centers were in operation in the United States: almost all of them (247 centers) transplanted kidneys; 167 did hearts; 119, pancreases; 114, livers; 93, heart-lung; 88, lungs; 26, intestines; and only 19 centers performed pancreas islet cell transplants (UNOS Update 11 (8): 28, 1995). The number of patients waiting for organ transplants in July 1995 totalled 41,075: 29,274 were waiting for a kidney transplant; 4,937, liver; 3,298, heart; 1,816, lung; 1,223 kidney-pancreas; 240, pancreas; and 211, heart-lung (UNOS Update 11 (8): 40-41, 1995).OPOs are located in different geographic areas across the country, each with different organ needs, lengths of waiting lists, or with lists in areas with large older populations making it more difficult to find suitable donors. Black recipients often wait longer due to complex reasons including sensitization or rarer blood and antigen types (UNOS 11 (8): 31-32, 1995). When an organ becomes available, the OPO involved identifies a potential recipient from the UNOS list and offers it to the patient's surgeon. If no match can be made locally, the organ is next offered within a UNOS region, and finally, to... (shrink)

Organ transplantation has given hope when formerly death was inevitable. But the replacement of vital organs highlights major moral and philosophical problems in medicine concerning the role of physicians and nurses, patient autonomy, and respect for the dying and the dead. These include the morality of excising organs from a healthy donor, and related problems regarding an individual’s consent to have organs removed for the benefit of others. These problems are not restricted to live organ donation: cadaveric (...) class='Hi'>organ removal raises problems over the definition of death, and raises further questions of fundamental moral and philosophical concern over the procurement and distribution of organs. Guiding decisions in these areas is a mass of empirical knowledge, scientific theory, and philosophical beliefs concerning what it means to say that someone is dead or alive, or whether given persons are competent to make a decision, or whether other considerations should override a competent decision. These questions call for investigation of conceptual matters and moral principles, and are by no means exclusively determined by medical expertise. (shrink)

There are not enough solid organs available to meet the needs of patients with organ failure. Thousands of patients every year die on the waiting lists for transplantation. Yet there is one currently available, underutilized, potential source of organs. Many patients die in intensive care following withdrawal of life-sustaining treatment whose organs could be used to save the lives of others. At present the majority of these organs go to waste.In this paper we consider and evaluate a range of (...) ways to improve the number and quality of organs available from this group of patients. Changes to consent arrangements (for example conscription of organs after death) or changes to organ donation practice could dramatically increase the numbers of organs available, though they would conflict with currently accepted norms governing transplantation.We argue that one alternative, Organ Donation Euthanasia, would be a rational improvement over current practice regarding withdrawal of life support. It would give individuals the greatest chance of being able to help others with their organs after death. It would increase patient autonomy. It would reduce the chance of suffering during the dying process. We argue that patients should be given the choice of whether and how they would like to donate their organs in the event of withdrawal of life support in intensive care.Continuing current transplantation practice comes at the cost of death and prolonged organ failure. We should seriously consider all of the alternatives. (shrink)

Recent disputes over whether older people should pay more for health insurance, or receive lower priority for transplantable organs, highlight broader disagreements regarding the legality of using age-based criteria in health care. These debates will likely intensify given the changing age structure of the American population and the turmoil surrounding the financing of American health care. This Article provides a comprehensive examination of the legality and normative desirability of age-based criteria. I defend a distributive justice approach to age-based criteria and (...) contrast it with two prevailing theoretical approaches to age-based criteria, nondiscrimination and discretion. I propose a detailed normative framework for the use of age-based criteria in health care, the lifetime justice approach, that considers the future life patients can gain from treatment and the past years of life they already have experienced. -/- This paper is available by open access from the Boston College Law School Digital Commons. (shrink)

The scarcity of livers available for transplants forces tough choices upon us. Lives for those not receiving a transplant are likely to be short. One large group of potential recipients needs a new liver because of alcohol consumption, while others suffer for reasons unrelated to their own behaviour. Should the former group receive lower priority when scarce livers are allocated? This discussion connects with one of the most pertinent issues in contemporary political philosophy; the role of personal responsibility in (...) distributive justice. One prominent theory of distributive justice, luck egalitarianism, assesses distributions as just if, and only if, people's relative positions reflect their exercises of responsibility. There is a principled luck egalitarian case for giving lower priority to those who are responsible for their need. Compared to the existing literature favouring such differentiation, luck egalitarianism provides a clearer rationale of fairness, acknowledges the need for individual assessments of responsibility, and requires initiatives both inside and outside of the allocation systems aimed at mitigating the influence from social circumstances. Furthermore, the concrete policies that luck egalitarians can recommend are neither too harsh on those who make imprudent choices nor excessively intrusive towards those whose exercises of responsibility are assessed. (shrink)

Recently, debate about the distribution of scarce organs for transplantation has focused on whether patients should have the right to place themselves on waiting lists at several transplant centers, thereby gaining an advantage over other potential recipients. This article explores the social and ethical issues raised by multiple listing, contrasting policies adopted at the national level with those implemented in New York State. It concludes by examining the implications of the debate for broader questions about entitlement and access (...) to health care. (shrink)

The United Network for Organ Sharing , the national organisation responsible for transplantable organ distribution in the United States, recently condemned the direct solicitation of organs in situations “where no personal bond exists between the patient and the donor or donor family”.1 UNOS worries that “such appeals, although well-intentioned, compromise the principle of fairness” or worse, “may divert organs from patients with critical need to those who are less ill.”.

According to the United Network for Organ Sharing http://www.unos.org), over 4,100 Americans are currently candidates for heart transplants, meaning that they desperately need them, they satisfy the criteria for "medical utility" (i.e., a transplant will probably keep them alive), and they have adequate insurance or other funding to cover their cost. Unfortunately the supply of hearts in this country doesn't even come close to meeting the demand: only 2,202 heart transplants were performed last year. Thus, every day some (...) Americans die waiting for new hearts. (shrink)

Background: Some members of the general public feel that patients who cause their own organ failure through smoking, alcohol use, or drug use should not receive equal priority for scarce transplantable organs. This may reflect a belief that these patients (1) cause their own illness, (2) have poor transplant prognoses or, (3) are simply unworthy. We explore the role that social acceptability, personal responsibility, and prognosis play in people's judgments about transplant allocation. Methods: By random allocation, we (...) presented 283 prospective jurors in Philadelphia county with one of five questionnaire versions. In all questionnaires, subjects were asked to distribute transplantable hearts between patients with and without a history of three controversial behaviors (eating high fat diets against doctors’ advice, cigarette smoking, or intravenous drug use). Across the five questionnaire versions, we varied the relative prognosis of the transplant candidates and whether their behavior caused their primary organ Results: Subjects were significantly less willing to distribute organs to intravenous drug users than to cigarette smokers or people eating high fat diets (p le; 0.0005), even when intravenous drug users had better transplant outcomes than other patients. Subjects’ allocation decisions were influenced by transplant prognosis, but not by whether the behavior in question was causally responsible for the patients’ organ failure. Conclusion: People's unwillingness to give scarce transplantable organs to patients with controversial behaviors cannot be explained totally on the basis of those behaviors either causing their primary organ failure or making them have worse transplant prognoses. Instead, many people believe that such patients are simply less worthy of scarce transplantable organs. (shrink)

It is common to interpret Rawls's maximin theory of justice as egalitarian. Compared to utilitarian theories, this may be true. However, in special cases practices that distribute resources so as to benefit the worst off actually increase the inequality between the worst off and some who are better off. In these cases the Rawlsian maximin parts company with what is here called true egalitarianism. A policy question requiring a distinction between maximin and "true egalitarian" allocations has arisen in the arena (...) of organ transplantation. This case is examined here as a venue for differentiating maximin and true egalitarian theories. Directed donation is the name given to donations of organs restricted to a particular social group. For example, the family of a member of the Ku Klux Klan donated his organs on the provision that they go only to members of the Caucasian race. While such donations appear to be discriminatory, if certain plausible assumptions are made, they satisfy the maximin criterion. They selectively advantage the recipient of the organs without harming anyone. Moreover, everyone who is lower on the waiting list is advantaged by moving up on the waiting list. This paper examines how maximin and more truly egalitarian theories handle this case arguing that, to the extent that directed donation is unethical, the best account of that conclusion is that an egalitarian principle of justice is to be preferred to the maximin. (shrink)

Although transplantation surgeries are relatively successful and save the lives of many, only few are willing to donate organs. In order to better understand the reasons for donation or refusing donation and their implications on and influence by public policy, we conducted a survey examining public views on this issue in Israel. Between January and June 2010, an anonymous questionnaire based on published literature was distributed among random and selected parts of Israeli society and included organ recipients, organ (...) donors, soldiers, university and high school students, and the general population. The analysis of 799 questionnaires revealed that, although 74.7 percent have not signed a donor card, 60.8 percent of participants consider doing so. Additionally, 54.3 percent of respondents objected to giving or receiving compensation for donation, and, if at all, priority in transplantation care is the most desired form of such compensation. The health status of the donor and knowing that donation saves lives or that there exists a shortage of organs for transplantation are the two factors most affecting motivation to donate. Lack of information, relatives’ views on donation, and type of organ involved in donation are factors most inhibiting donation. Willingness to donate is significantly affected by the proximity of the recipient to the donor. With regard to most organs, their contribution to one’s sense of “self” and its symbolic role strongly affects motivation to donate, except for donation to relatives. Compensation for organ donation has little effect on motivation to donate during life and after death. Our findings suggest new ways to construct a more effective public policy on this issue. (shrink)

Rationing of healthcare resources is a strategy for crisis-aversion or crisis-prevention with its ethical roots in the theory of distributive justice. It exemplifies, the simplistic notion of conse...

Resource constraints in developing countries compel policy makers to ration the provision of healthcare services. This article examines one such set of Guidelines: A patient dialysing in the state sector in South Africa may not refuse renal transplantation when a kidney becomes available. Refusal of transplantation can lead to exclusion from the state-funded dialysis programme. This Guideline is legally acceptable as related to Constitutional stipulations which allow for rationing healthcare resources in South Africa. Evaluating the ethical merit of the Guideline, (...) and exploring the ethical dilemma it poses, proves a more complex task. We examine the actions of healthcare professionals as constrained by the Guideline. From a best interests framework, we argue that in these circumstances directing patient decision making is not necessarily unethical or unacceptably paternalistic. We then scrutinise the guideline itself through several different ethical ‘lenses’. Here, we argue that bioethics does not provide a definitive answer as to the moral merit of rationing dialysis under these circumstances, however it can be considered just in this context. We conclude by examining a potential pitfall of the Guideline: Unwilling transplant recipients may not comply with immunosuppressive medication, which raises questions for policies based on resource management and rationing. (shrink)

Morality, Mortality as a whole deals with certain aspects of ethical theory and with moral problems that arise primarily in contexts involving life‐and‐death decisions. The importance of the theoretical issues is not limited to their relevance to these decisions; however, they are, rather, issues at the heart of basic moral and political theory. This first volume comprises three parts. Part I, Death: From Bad to Worse, has with four chapters, and an appendix, discussing death and why it is bad for (...) the person who dies. Part II, Saving Lives: General Issues, has six chapters, and explores a cluster of moral problems that arise in saving lives. The general question raised is whether we should always, in aiding life, act so as to save the greater number of lives or to produce the greatest amount of good. Part III, Scarce Resources: Theoretical Issues, Specific Recommendations, and Organ Transplants, has five chapters, and deals with the problem of the acquisition and distribution of organs for transplantation. It allows us to apply the theoretical discussion of saving lives and relevant/irrelevant utilities presented in the previous parts. However, the discussion can be understood independently of the first two parts, and the conceptual issues and procedures on which it focuses are relevant to dealing with any scarce resource, including money and time, which are needed to use other plentiful resources. Although the book contains much theoretical and methodological argument, it is firmly grounded in practical ethical issues, and is illustrated throughout by examples. (shrink)

Patient autonomy and distributive justice are fundamental ethical principles that may be at risk in liver transplant units where decisions are dictated by the need to maximise the utility of scarce donor organs. The processes of patient selection, organ allocation and prioritisation on the wait list have evolved in a constrained environment, leading to high levels of complexity and low transparency. Regarding paternalism, opaque listing and allocation criteria, patient factors such as passivity, guilt, chronic illness and sub-clinical encephalopathy (...) are cited as factors that may inhibit patient engagement. Regarding justice, established regional, gender and race based inequities are described. The paradox whereby hepatologists both advocate for individual patients and discharge their duty of stewardship to apportion organs according to larger utilitarian principles is explored. Competing subjective factors such as physicians’ perception of moral responsibility, the qualitative nature of expert medical assessment and institutional or personal loyalty to re-transplantation candidates are described. Realistic limits of self-determination and justice are discussed, and possible future directions in terms of patient involvement proposed. (shrink)

Should the nation provide expensive care and scarce organs to convicted felons? We distinguish between two fields of justice: Medical Justice and Societal Justice. Although there is general acceptance within the medical profession that physicians may distribute limited treatments based solely on potential medical benefits without regard to nonmedical factors, that does not mean that society cannot impose limits based on societal factors. If a society considers the convicted felon to be a full member, then that person would be entitled (...) to at least a decent minimum level of care — which might include access to scarce life-saving organs. However, if criminals forfeit their entitlement to the same level of medical care afforded to all members of society, they still would be entitled to a kind of rudimentary decent minimum granted to all persons on simple humanitarian grounds. Almost certainly this entitlement would not include access to organ transplants. (shrink)

The Australian Federal Government has announced a two-year trial scheme to compensate living organ donors. The compensation will be the equivalent of six weeks paid leave at the rate of the national minimum wage. In this article I analyse the ethics of compensating living organ donors taking the Australian scheme as a reference point. Considering the long waiting lists for organ transplantations and the related costs on the healthcare system of treating patients waiting for an organ, (...) the 1.3 million AUD the Australian Government has committed might represent a very worthwhile investment. I argue that a scheme like the Australian one is sufficiently well designed to avoid all the ethical problems traditionally associated with attaching a monetary value to the human body or to parts of it, namely commodification, inducement, exploitation, and equality issues. Therefore, I suggest that the Australian scheme, if cost-effective, should represent a model for other countries to follow. Nonetheless, although I endorse this scheme, I will also argue that this kind of scheme raises issues of justice in regard to the distribution of organs. Thus, I propose that other policies would be needed to supplement the scheme in order to guarantee not only a higher number of organs available, but also a fair distribution. (shrink)

This book offers a new theory of property and distributive justice derived from Talmudic law, illustrated by a case study involving the sale of organs for transplant. Although organ donation did not exist in late antiquity, this book posits a new way, drawn from the Talmud, to conceive of this modern means of giving to others. Our common understanding of organ transfers as either a gift or sale is trapped in a dichotomy that is conceptually and philosophically (...) limiting. Drawing on Maussian gift theory, this book suggests a different legal and cultural meaning for this property transfer. It introduces the concept of the 'divine lien', an obligation to others in need built into the definition of all property ownership. Rather than a gift or sale, organ transfer is shown to exemplify an owner's voluntary recognition and fulfilment of this latent property obligation. (shrink)

This issue’s “Legal Briefing” column covers legal developments pertaining to organ donation and allocation. This topic has been the subject of recent articles in JCE. Organ donation and allocation have also recently been the subjects of significant public policy attention. In the past several months, legislatures and regulatory agencies across the United States and across the world have changed, or considered changing, the methods for procuring and distributing human organs for transplantation.Currently, in the U.S., more than 100,000 persons (...) are waiting for organ transplantation. In China, more than 1.5 million people are waiting. Given the chronic shortage of available organs (especially kidneys and livers) relative to demand, the primary focus of most legal developments has been on increasing the rate of donation. These and related developments are usefully divided into the following 12 topical categories: 1. Revised Uniform Anatomical Gift Act2. Presumed Consent and Opt-Out3. Mandated Choice4. Donation after Cardiac Death5. Payment and Compensation6. Donation by Prisoners7. Donor Registries8. Public Education9. Other Procurement Initiatives10. Lawsuits and Liability11. Trafficking and Tourism12. Allocation and Distribution. (shrink)

The benefits of a large organ pool accrue not only to the actual organ recipients themselves, but to others as well due to the insurance it provides against having to wait ‘too long’ for an organ transplant. We argue that this public good character of a large organ pool makes it economically and ethically justifiable to design a market mechanism that boosts the number of donors. Most importantly, such a mechanism has the potential to substantially (...) alleviate the troubling equity and efficiency problems on the demand side while, at the same time, being entirely independent of the allocation algorithm used for the distribution of organs. (shrink)

This essay argues that considerations of justice that govern the morality of self-defense are also relevant in some cases in which organs are allocated for transplantation in conditions of scarcity. The essay's main substantive claim is that in general alcoholics are morally liable to be assigned a lower priority in the distribution of livers for transplantation because of their own responsibility for their need for a transplant. There are, however, practical obstacles to giving lower priority in the (...) class='Hi'>distribution of medical resources generally to those who are responsible for their own illnesses, and it may seem unfair to single out alcoholics but not others for lower priority. (shrink)

Over 115 000 people are waiting for life-saving organ transplants, of whom a small fraction will receive transplants and many others will die while waiting. Existing efforts to expand the number of available organs, including increasing the number of registered donors and procuring organs in uncontrolled environments, are crucial but unlikely to address the shortage in the near future and will not improve donor/recipient compatibility or organ quality. If successful, organ bioengineering can solve the shortage and improve (...) functional outcomes. Studying manufactured organs in animal models has produced valuable data, but is not sufficient to understand viability in humans. Before risking manufactured organ experimentation in living humans, study of bioengineered organs in recently deceased humans would facilitate evaluation of the function of engineered tissues and the complex interactions between the host and the transplanted tissue. Although such studies do not pose risk to human subjects, they pose unique ethical challenges concerning the previous wishes of the deceased, rights of surviving family members, effective operation and fair distribution of medical services, and public transparency. This article investigates the ethical, legal and social considerations in performing engineered organ research on the recently deceased. (shrink)

"Fascinating....An imaginative, deeply engaging philosophical adventure."--Ethics. "Will quickly become, in debates concerning the sorts of distribution problems Kamm is concerned with, what Rawls's Theory of Justice is for more general debates about distributive justice."--Journal of Medical Ethics.

Donating, distributing and ultimately transplantingorgans each has distinct ethical problems. In thispaper I suggest that the first ethical question is notwhat should be done but what is a fair way in whicheach of these problems can be addressed. Experts –whether these be transplant surgeons, policy analysts,political scientists or ethicists – can help guidebut cannot by themselves make such decisions. Inmaking these decisions the difference betweenidentified and non-identified lives is crucial. Isuggest that an approach in which reason is temperedby compassion (...) (``compassionate rationality'') whendealing with identified lives and in whichcompassion is controlled by reason (``rationalcompassion'') in dealing with unidentified lives mustserve us well. Ultimately decisions of this sort areprone to sturdy democratic process which is possibleonly when the preconditions of person, economic andeducational democracy are met. (shrink)

Background Design thinking is a tool for generating and exploring ideas from multiple stakeholders. We used DT principles to introduce students to the ethical implications of organ transplantation. Students applied DT principles to propose solutions to maximise social justice in liver transplant allocation. Methods A 150 min interactive workshop was integrated into the longitudinal ethics curriculum. Following a group didactic on challenges of organ donation in the USA supplemented by patient stories, teams of students considered alternative solutions (...) to optimise fairness of organ distribution and ethical implications of changing the current model. Facilitators led students through DT steps of empathy, defining the team’s point of view, ideating on potential solutions, prototyping a specific idea and testing the idea through oral presentation, with questions and answers by peers and faculty. The curriculum was evaluated with presurveys and postsurveys including quantitative and open-ended items. Results 100 first year medical students participated. Before the session, 75.3% of students had no practical experience with DT. Following participation, students reported an increased understanding of the current liver transplant allocation system and an increased appreciation of shortcomings of the current organ allocation system. After the session, 73.8% of students felt that DT could be used to approach complex health system problems. Discussion Students participating in a DT workshop displayed improved knowledge and attitudes toward organ transplantation and DT. In this pilot study, DT showed promise as a student-led approach emphasising collaboration and creativity in ethics curricula in medical education. (shrink)

There is something about the debate over reproductive technologies of all kinds—from coerced use of Norplant to trait-selection technologies, to issues surrounding in vitro fertilization, to fetal tissue transplantation—that seems to invite dubious analogies. A Tennessee trial court termed Mary Sue and Junior Davis's frozen embryos “in vitro children” and applied a best-interests standard in awarding “custody” to Mary Sue Davis; the Warnock Committee drew an implicit analogy between human gametes and transplantable organs in its recommendation of a voluntary, nonprofit (...) system for collecting and distributing gametes in the United Kingdom; Owen Jones compares the right to trait-selection to the right to abortion; Robert Veatch once claimed that if a woman had signed an organ donation card and then died while pregnant, she had in effect given consent to the attempt to sustain the pregnancy after her death; John Robertson has argued that contract pregnancy poses no problems we have not already encountered with adoption; and Andrea Bonnicksen has compared the wonders of preembryonic genetic screening to the riches housed in the gold museum in Bogota, Colombia. (shrink)

This book sets forth a novel theory of distributive justice premised on the fundamental moral equality of persons. It argues that, subject to certain limitations on personal sacrifice, no one should have less valuable resources and opportunities available to him than anyone else, simply invirtue of some chance occurrence the risk of which he did not choose to incur. Applying this principle to the distribution of wealth and income, the specification of property rights, and the allocation of scarce medical (...) resources, Professor Rakowski reaches challenging, often unconventional,conclusions. He further criticizes the economic analysis of law as a normative theory, and develops an alternative account of tort law.Among the topics discussed are the principles by which earnings, wealth, and gifts should be taxed; whether the compulsory removal of organs for transplantation can be justified; how doctors and public officials should make life-or-death decisions when all those endangered cannot be saved; and themorality of killing human beings and nonhuman animals. (shrink)

Should organ transplants be given to patients who have waited the longest, or need it most urgently, or those whose survival prospects are the best? The rationing of health care is universal and inevitable, taking place in poor and affluent countries, in publicly funded and private health care systems. Someone must budget for as well as dispense health care whilst aging populations severely stretch the availability of resources. The Ethics of Health Care Rationing is a clear and much-needed introduction (...) to this increasingly important topic, considering and assessing the major ethical problems and dilemmas about the allocation, scarcity and rationing of health care. Beginning with a helpful overview of why rationing is an ethical problem, the authors examine the following key topics: What is the value of health? How can it be measured? What does it mean that a treatment is "good value for money"? What sort of distributive principles - utilitarian, egalitarian or prioritarian - should we rely on when thinking about health care rationing? Does rationing health care unfairly discriminate against the elderly and people with disabilities? Should patients be held responsible for their health? Why does the debate on responsibility for health lead to issues about socioeconomic status and social inequality? Throughout the book, examples from the US, UK and other countries are used to illustrate the ethical issues at stake. Additional features such as chapter summaries, annotated further reading and discussion questions make this an ideal starting point for students new to the subject, not only in philosophy but also in closely related fields such as politics, health economics, public health, medicine, nursing and social work. (shrink)

A recent organ distribution scandal in Germany raises questions of general importance on which many thousands of lives may well depend. The scandal in Germany has produced reactions that are likely to occur whenever and wherever distribution irregularities occur and become public knowledge. After it had become known that physicians in three German hospitals were in the habit of manipulating records in order to fast-track their patients’ cases, the country experienced a decrease of available organs by a (...) staggering 40% in October 2012. Even though this loss of trust by donors and their families is understandable, and potentially a legitimate form of protest against wrongful distribution, the withdrawal of agreement to serve as a posthumous donor in response to irregularities also inevitably results in avoidable poor outcomes for highly vulnerable individuals. In this paper, we provide a moral analysis of such dilemmas and make recommendations as to the way forward. (shrink)

The allocation of scarce health care resources such as flu treatment or organs for transplant presents stark problems of distributive justice. Persad, Wertheimer, and Emanuel have recently proposed a novel system for such allocation. Their “complete lives system” incorporates several principles, including ones that prescribe saving the most lives, preserving the most life-years, and giving priority to persons between 15 and 40 years old. This paper argues that the system lacks adequate moral foundations. Persad and colleagues' defense of giving (...) priority to those between 15 and 40 leaves them open to the charge that they discriminate unfairly against children. Second, the paper contends that the complete lives system fails to provide meaningful practical guidance in central cases, since it contains no method for balancing its principles when they conflict. Finally, the paper proposes a new method for balancing principles of saving the most lives and maximizing life-years. (shrink)

Biomedical sciences cannot answer the question who should be saved from death if not everyone can be. This is an ethical issue. However, we face exactly this question when deliberating on the criteria for organ allocation. The main aim of this article is to formulate a pluralistic theory of just distribution of organs, which incorporates the tenets of utilitarianism, egalitarianism and sufficientarianism. Each constituent theory adopts a different value as a criterion for organ allocation. For utilitarianism it (...) is a health benefit for the patient, for egalitarianism it is the ratio of deserts and health-related well being, for sufficientarianism what is important is that the candidate for a transplant be situated below the sufficientarian threshold. The article presents a proposal to reconcile these three competing theories. (shrink)

The allocation of scarce health care resources such as flu treatment or organs for transplant presents stark problems of distributive justice. Persad, Wertheimer, and Emanuel have recently proposed a novel system for such allocation. Their “complete lives system” incorporates several principles, including ones that prescribe saving the most lives, preserving the most life-years, and giving priority to persons between 15 and 40 years old. This paper argues that the system lacks adequate moral foundations. Persad and colleagues' defense of giving (...) priority to those between 15 and 40 leaves them open to the charge that they discriminate unfairly against children. Second, the paper contends that the complete lives system fails to provide meaningful practical guidance in central cases, since it contains no method for balancing its principles when they conflict. Finally, the paper proposes a new method for balancing principles of saving the most lives and maximizing life-years. (shrink)

Studying the most ethical way to allocate scarce medical resources has been of interest within the last year, due to shortages associated with the COVID-19 pandemic. This study aimed to establish differences between what healthcare providers (HCP) and laypeople consider to be the most ethical way to prioritise the distribution of scarce resources. Healthcare providers ( n = 100) and laypeople ( n = 102) were asked to rank ethical principles from most to least ethical for the allocation of (...) ICU beds in a COVID-19 outbreak, COVID-19 vaccinations and organ transplantation, and the rankings from each scenario across the two groups were compared. Results indicated that HCPs preferred utilitarian principles informed by medical knowledge, such as ‘prognosis’, whereas laypeople preferred less situation-specific and prioritarian principles, such as ‘sickest first’, replicating pre-pandemic findings. Laypeople showed increased in-group agreement when ranking principles, potentially due to the collective experience of the pandemic. Demographic variables such as older age, identifying as Black, Asian or minority ethnic and greater experience with COVID-19, were also associated with a preference for ‘prognosis’. (shrink)

Organ donation after cardiac or circulatory death (DCD) has been introduced to increase the supply of transplantable organs. In this paper, we argue that the recovery of viable organs useful for transplantation in DCD is not compatible with the dead donor rule and we explain the consequential ethical and legal ramifications. We also outline serious deficiencies in the current consent process for DCD with respect to disclosure of necessary elements for voluntary informed decision making and respect for the donor's (...) autonomy. We compare two alternative proposals for increasing organ donation consent in society: presumed consent and mandated choice. We conclude that proceeding with the recovery of transplantable organs from decedents requires a paradigm change in the ethics of organ donation. The paradigm change to ensure the legitimacy of DCD practice must include: (1) societal agreement on abandonment of the dead donor rule, (2) legislative revisions reflecting abandonment of the dead donor rule, and (3) requirement of mandated choice to facilitate individual participation in organ donation and to ensure that decisions to participate are made in compliance with the societal values of respect for autonomy and self-determination. (shrink)

How should UNOS deal with the presence of scientific controversies on the risk factors for organ rejection when designing its allocation policies? The answer I defend in this paper is that the more undesirable the consequences of making a mistake in accepting a scientific hypothesis, the higher the degree of confirmation required for its acceptance. I argue that the application of this principle should lead to the rejection of the hypothesis that ‘less than perfect’ Human Leucocyte Antigen (HLA) matches (...) are an important determinant of kidney graft survival. The scientific community has been divided all along on the significance of partial antigen matches. Yet reliance on partial matches has emerged as one of the primary factors leading blacks to spend a much longer time than whites on the waiting list for kidneys, thereby potentially impacting the justice of the kidney allocation policy. My case study illustrates one of the legitimate roles non-epistemic values can play in science and calls into question the ideal of a value-free science. (shrink)

The European Clinical Trials Directive (EU 2001; 2001/20/EC) was introduced to improve the efficiency of commercial and academic clinical trials. Concerns have been raised by interested organizations and institutions regarding the potential for negative impact of the Directive on non-commercial European clinical research. Interested researchers within the European Group for Blood and Marrow Transplantation (EBMT) were surveyed to determine whether researcher experiences confirmed this view. Following a pilot study, an internet-based questionnaire was distributed to individuals in key research positions in (...) the European haemopoietic SCT community. Seventy-one usable questionnaires were returned from participants in different EU member states. The results indicate that the perceived impact of the European Clinical Trials Directive has been negative, at least in the research areas of interest to the EBMT. (shrink)

Living kidney transplantation offers the best results for patients with end-stage renal disease (ESRD). This form of transplantation is no longer restricted to genetically or emotionally related donors, as shown by the acceptance of non-directed living anonymous donors, and the development of exchange programmes (EPs). EPs make it possible to perform living kidney transplantation among incompatible pairs, but while such programmes can help increase living organ donation, they can also create a degree of unfairness. Kidney transplant recipients in (...) the O blood group are at a disadvantage when it comes to EPs because they can only receive organs from O donors, whereas O donors are universal donors. This poses a major challenge in terms of distributive justice and equity. A way to remedy this situation is through altruistic unbalanced paired kidney exchange (AUPKE), in which a compatible pair consisting of an O blood group donor and a non-O recipient is invited to participate in an EP. Although the AUPKE approach appears fairer for O recipients, it still raises ethical questions. How does this type of exchange affect the donor/recipient gift relationship? Should recipients in compatible pairs receive a ‘better organ’ than the one they would otherwise have received from their intended donor? Finally, what is the role of transplant teams in AUPKE? This article will examine the organisational and ethical challenges associated with EPs and AUPKE, and compare different EP policies in countries where such programmes exist. (shrink)

Transplant centers and physicians in the United States have limited guidance on the information which they can and cannot provide to transplant candidates regarding donors of potential organs. Patients may refuse organs for a variety of reasons ranging from pernicious requests including racism to misinformation about emerging medicine as with the COVID-19 vaccine and infection. Patient autonomy, organ stewardship, and equity are often at odds in these cases, but precedent indeed exists to help address these challenges. This (...) work uses such cases to highlight the urgent need for uniform, national policy prohibiting informational requests unrelated to well-established risks. (shrink)

During the last two decades a broad and intensive discussion has taken place in the field of medical ethics. Especially in the English-speaking countries, “Biomedical Ethics” have developed as a part of secular, philosophical moral theory. Two ethical problems in organ transplantation – living organ donation and organ allocation – illustrate that this transition reflects both the complex ethical questions raised by rapid changes in the biological sciences and in health care, and the fact that traditional Hippocratic (...) ethics have proven to be inadequate in several respects. (shrink)

Samuel J. Kerstein develops a new, broadly Kantian account of the ethical issues that arise when a person treats another merely as a means. He explores how Kantian principles on the dignity of persons shed light on pressing issues in modern bioethics, including the distribution of scarce medical resources and the regulation of markets in organs.