Saturday, February 26, 2011

Changing Who Gets a Kidney

The nonprofit that oversees how human kidneys are distributed to people in need of a transplant is trying to change the distribution rules. Their goal is to maximize the number of years of life that a donated kidney can provide by changing how recipients are chosen.

The United Network for Organ Sharing (UNOS), which oversees organ donations from cadavers (not living donors), currently distributes kidneys based on who has been on the waiting list the longest. This process favors older patients over younger ones. A new UNOS plan that is currently open for public comment would prioritize kidney recipients based on two factors: the recipient's potential lifespan post-transplant (used when distributing the healthiest available kidneys), and whether the recipient's age is within 15 years of the donor.

These changes would most likely benefit patients who are younger than 50 years old more than the current system does. Recipients ages 50 and older would probably be less likely to receive a kidney under the proposed plan than under the current plan. Details about the plan are available online in the UNOS report "Concepts for Kidney Allocation."

In response to accusations of age discrimination, the report points out that since 1990, the percentage of potential recipients between ages 18 and 49 who have received a transplant has decreased, while the percentage of potential recipients ages 50 and older who received a transplant increased. The new plan was proposed to make the distribution system more fair.

Over 80,000 Americans are on the waiting list for a kidney, according to the National Kidney Foundation, and there are not enough kidneys available for everyone in need. The question is how to manage the valuable resource of a donated kidney.

A Washington Post article by Rob Stein about the proposed changes raises the larger question of how to ration limited health care resources. University of Pennsylvania bioethicist Arthur C. Caplan told Stein that the UNOS proposal "could have implications for other decisions about how to allocate scarce medical resources, such as expensive cancer drugs and ventilators during hurricanes and other emergencies."

Caplan explained, "We don't want to talk about rationing much in America. It's become taboo in any health-care discussion. But kidneys reminds us there are situations where you have to talk about rationing. You have no choice."

The UNOS report is grappling with a very complex topic, and it is the product of almost six years of work. I'm impressed by its attempt to analyze and improve an established system for kidney distribution. Academically, the topic is fascinating: what criteria do you use to make decisions about medical ethics?

But I have also interviewed kidney recipients, and those still on the waiting list, for stories I have written. I can't forget that there are so many individuals whose chances for a healthy or extended life are directly affected by UNOS policies; whatever UNOS decides, there will be winners and losers.

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