Possible Changes in Patient Priority for Kidney Transplants — Highlights the Inescapable Rationing Element in Medicine

© 2011 Peter Free

 

24 February 2011

 

 

First, people who assume that medicine is not now rationed are either wealthy or ignoring reality

 

Resources are almost always limited.  Limited resources always limit access.  Limited access is the equivalent of rationing.

 

Political battles for or against “rationing” medical care are silly.  What is really at issue is deciding who is going to get what and at what quality.

 

The American political right likes to scream about the horror of rationing under a single payer health insurance system, deliberately obscuring the fact that wealth versus poverty already rations access to medical resources.

 

Translated, the Right Wing’s anti-rationing mantra means that the Fat Cats who directly or indirectly own the resources in question don’t want to share them more broadly.  Broad sharing, absent a parallel higher quality system, would most probably bring the Fat Cats’ profits and personally-received quality of medical care down.

 

This is not a difficult subject analytically.

 

Ethically, it can be.  Take the new demographics-based proposal regarding the prioritization of kidney transplants.

 

 

Proposed new kidney transplant patient priority lists, as an example of medical rationing exposed

 

The nation's organ-transplant network is considering giving younger, healthier people preference over older, sicker patients for the best kidneys.

 

Instead of giving priority primarily to patients who have been on the waiting list longest, the new rules would match recipients and organs to a greater extent based on factors such as age and health to try to maximize the number of years provided by each kidney - the most sought-after organ for transplants.

 

The ethically fraught potential changes, which would be part of the most comprehensive overhaul of the system in 25 years, are being welcomed by some bioethicists, transplant surgeons and patient representatives as a step toward improving kidney distribution.

 

But some worry that the changes could inadvertently skew the pool of available organs by altering the pattern of people making living donations.

 

Some also complain that the new system would unfairly penalize middle-aged and elderly patients at a time when the overall population is getting older.

 

© 2011 Rob Stein, Under kidney transplant proposal, younger patients would get the best organs, Washington Post (24 February 2011) (paragraphs split)

 

 

It is the change that catches attention, not the entrance of an actual rationing component

 

In the past, length of time on an organ transplant waiting list favored older, sicker patients.  The older one is, the more likely one is to have been sick longer.

 

The proposed kidney transplant priority change simply moves rationing, which once favored older patients, to benefit younger patients.  The inherent rationing element will not change.  Transplantable kidneys are a limited resource.

 

The charge that this change from older to younger kidney recipients would be “age discrimination” is accurate, but ethically meaningless.  It was “youth discrimination” (a version of age discrimination) when older, sicker patients received transplants instead of younger ones who had less seniority on the transplant list.

 

 

One doesn’t get anywhere useful, when one lets emotion triumph over facts and sound thinking

 

The facts are that people die, and older people die at higher rates than younger people.

 

Older people, by definition, have fewer quality years left, no matter how quality is measured.  Past-middle age people also (generally) contribute quantifiably less to the society at large in those ways that Americans particularly tend to value.  American culture demonstrably does not value age.

 

This cultural devaluation of older people is changing slightly, now that the once-youth-flaunting Baby Boomers are entering the Zone of Decrepitude.

 

Predictably, they will be the ones whining about proposed changes in medical prioritizations (and anything else that diminishes the Boomers’ sense of self and generational worth).

 

From a utilitarian standpoint, it make sense to benefit young people over old people, when it comes to giving them organs that would result in comparatively longer lives, filled with quantifiably greater productivity, according to what Americans purport to value.

 

 

A hypothetical example of utilitarian philosophy in action

 

The house is aflame.  Inside, are a reasonably healthy teenager and a 65-year-old.  You can only save one.  You don’t know either.  Whom will you save?

 

 

The problem with ethics is that unexamined assumptions decide outcomes

 

For example, we foreclose the kidney transplant discussion with inapplicably broad charges like “age discrimination.”

 

Age discrimination originated in employment, where discriminating against older workers solely on the basis of age may be counterproductive (health costs aside).  There is a measureable knowledge base and efficiency that can accompany older people’s workplace experience.  That is so, at least in those industries that do not rely on the creatively productive flashes of insight that we tend to think accompany youth, rather than age.

 

But medicine is not the employment sector.  Consequently, in medical matters, thoughtless charges of “age discrimination” are less apt to fit fairly or accurately.

 

From my perspective, the transplant conundrum is a no-brainer.  Being in my mid-sixties, were I in the hypothetical burning house, I would insist that you save the teenager.  I would feel the same way, if the teenager and I needed the same one kidney.

 

 

Everybody dies, but death’s timing is important on utilitarian grounds

 

If we assume that (a) life has value and (b) life’s incremental quality tends to wane with age, then it makes sense to make initial youth-favoring ethical choices.  At least as to people who have demonstrated self-aware consciousness and overall physiological (and perhaps moral) fitness for the journey.

 

You see how many assumptions loaded this last paragraph?

 

Ethics are not easy.  And assumptions determine the outcome.