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Best kidneys should go to right recipients, bioethicist says

Brendan Smialowski / AFP - Getty Images file

Dr. Niraj Desai, center, and others prepare a kidney for a recipient during a kidney transplant at Johns Hopkins Hospital in Baltimore, Md. , in June. Proposed guidelines would change the way kidney donations are allocated.

Are you an organ donor? If not, you should be.

A lot of lives are lost every day because there simply are not enough organs to give to everyone who needs one. As of this week, more than 115,000 people are waiting for a heart, lung, liver, kidney or other organ, according to the Organ Procurement and Transplantation Network.

Still, many people don't donate their organs when they die. The reality of the shortage means that hard choices have to be made about who else may die as a result. 

Who gets a kidney? Transplant policy may change

The United Network for Organ Sharing, or UNOS, is asking for public comment on a change in how kidneys are distributed. Starting today, people can let their views be known about a policy that would mean that some who would have lived under the old rationing rule will now die, while others will have a much better shot at life.

I believe this change is fair -- and even necessary -- to ensure that those who can get the most use out of the best kidneys have access to those organs. It’s the right way to allocate a precious commodity that’s in short supply.

Why do I believe that? First, some background:

Not all donated kidneys are alike. Some kidneys are in pristine condition when they are donated, some are not. Some kidneys come from people who were in great shape but had a terrible accident involving head trauma, for instance. Others come from people who were obese, and who had just started to become diabetic when they were felled by a heart attack. Still others are kidneys that were damaged by drug overdoses when donors took their own lives.

In the past, kidneys were allocated to those in need of transplants based primarily upon waiting time and medical urgency: The sicker you were, the more likely you would be to get a kidney.

This strategy meant that some very high-quality kidneys went to some very sick patients, while some relatively poor quality kidneys went to those who were in good shape – except for their kidney failure. 

This “sickest first” distribution strategy meant that while the worst off got to be first in line, some kidneys that could have lasted a long time were lost -- wasted, essentially -- when a very sick person who got one and died anyway.

The sickest-first option, while fair to those in line, is not the most efficient way to save lives with the scarce supply of kidneys available.

Nor does a sickest-first plan save the most years of life. If young and old alike compete for organs, chances are some organs go to older people when they might have gone to others who could have lived much longer with them.

Under the new rules proposed by UNOS, wait time and medical urgency would play a lesser role. Doctors would try to decide among those waiting for organs who is most likely to both survive a kidney transplant and to live longer with a new kidney. 

The system would then seek to get the best quality kidneys to those who have the best chance of living longer with them.

Bottom line: This means is that younger people on the waiting list will have a better shot at the best kidneys since they will live longer than older people if they get one. And more poor quality kidneys are likely to go to those who are sicker and older than they have in the past.

Is this change fair? I think so.

When a vital, life-saving resource is scarce and decisions have to be made about who will be able to get access, the right thing to do is not to be biased against anyone for trivial or morally irrelevant reasons -- religion, race, eye color, gender, or occupation. 

But, when there are factors that make it less likely that a life will be saved -- old age, having other diseases like cancer or cystic fibrosis or even having a disability like drug addiction that could greatly complicate the chance at success, those factors should count.

Why are you or I willing to donate organs when we die? To save lives. And, I think, to also get the most years of life for someone else.  If those are the reasons that motivate donation, then the shift in UNOS policy toward putting the best quality kidneys in those most likely to do well with them over the long haul makes good moral sense.

Of course, the comments that will be submitted will likely reflect the difficulty of that decision. Giving the best kidneys to the youngest people will no doubt raise accusations of age discrimination, if not an outright effort to eliminate the old and sick.

There are no easy answers when rationing is the only choice. That does not mean, however, that some strategies are not better than others. When it comes to saving lives, saving more lives that last longer seems best.

Arthur Caplan is the head of the Division of Medical Ethics at NYU Langone Medical Center.

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