Who Gets a New Kidney? Healthier People Could Have Priority

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Thousands die each year because there aren't enough kidneys to go around. A new policy could rethink who should live.

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In the health sector, policy choices can be a matter of life or death. And as spending cuts hit federal and state programs, people are being forced to make hard choices.

Recently, Rob Stein of The Washington Post wrote about how the United Network for Organ Sharing, the nonprofit that manages America's organ transplant system under contract with the federal government, has proposed a new way to allocate kidneys for transplantation. Its 30-member Kidney Transplantation Committee is considering a new system that would provide kidneys to those with the best chances for survival first, in lieu of using waiting lists.

Not everyone who needs a kidney will receive one. Stein writes that more than 87,000 Americans are on a waiting list for a kidney and only about 17,000 will receive a transplant. More than 4,600 will die each year because they do not receive a kidney in time.

Using what is often called "effectiveness analysis" to determine which recipients will gain the most years of healthy life from a transplant is a new approach in a country that has been loath to consider the health implications of its health care coverage decisions. The ethical issues are not simple. The proposed approach to kidney allocation ignores the rule of rescue, which argues that the sickest must be treated first, even when money might be more efficiently spent to improve health in the broader population. It has equity implications, valuing the lives of the young more than the old. Some are already calling the proposal age discrimination.

More than 87,000 Americans are on a waiting list for a kidney and only about 17,000 will receive a transplant.

To address the ethical issues, the Committee issued a document including their full proposal (as well as other alternatives that they considered), and it has invited the public to provide comments and feedback. It notes, "This process has taken almost six years to date and has involved hundreds of individuals including transplant professionals, transplant recipients, transplant candidates, donor family members, living donors, and members of the general public."

This is an important development in U.S. health policy. There is both explicit consideration of the ethical issues raised by the recommendation and a sound evaluation of comparative effectiveness: an in-depth look at the benefits and harms of different interventions and strategies to address real-world health conditions. It is a baby step away from the current approach, which rations according to a person's access to health care services, and toward a simpler, more transparent, evidence-based decision-making process. You might not agree with the kidney transplant recommendation. And you certainly should have the opportunity to express and defend your position. But at least the government is prepared to provide enough information so you can understand why the decision was taken and appeal if necessary.

In the U.S., we don't like talking about rationing. But as hard as these discussions may be, they are necessary when resources are scarce and the health system needs to produce more "health" and not just services. Other countries often don't think about these issues the way we do. Among developed nations, the U.K. is a front-runner in thinking about rationing, and some other European nations are also keeping pace.

Strangely, it is the less affluent countries that are moving faster toward explicit priority-setting in health care. In 2010, Colombia found itself funding an increasing number of high-cost, low-impact interventions, such as bariatric surgery, while underfunding cost-effective public health interventions. This year, the country created a health technology assessment agency to carry out economic evaluations, consult and deliberate with the public and stakeholders, and recommend interventions and target groups to be included or excluded for public funding under their insurance scheme.

Can the U.S. catch up? At the Center for Global Development, we will soon convene a group of international experts to benchmark priority-setting processes and institutions worldwide and identify the strategies in this space that work the best. There may well be something in there for us Americans. Stay tuned.


Image: Tarek Mostafa/Reuters

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Amanda Glassman is the director of Global Health Policy at the Center for Global Development. She has 20 years of experience working on health and social policy and programs in Latin America and throughout the developing world.

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