The recent Lancet reports that Israel will implement a new law in January 2010 intended to increase the number of deceased organ donors. The country has among the lowest rates of organ donation: only 1 in 10 have signed a donor card compared with 1 in 4 in the United Kingdom and 1 in 3 in the United States. The core of the idea is that the promise of priority will encourage more people to sign their organ donor cards.
The Lancet’s brief description:
People who are prepared to sign donor cards themselves receive priority when they are in need of an organ transplant. Increased priority is also given to first degree relatives of those who have signed donor cards, to first degree relatives of those who have died and given organs, and to live donors of a kidney, liver lobe or lung lobe who have donated for as yet undesignated recipients.
Some important details:
Candidates under 18 and those unable to express their wishes due to physical or mental disability will retain their priority status versus an adult who merits priority.
Should two such people be eligible for the same [heart, liver, or lung], their priority status under the new law would decide who receives the organ.
And why not? The stark reality is that every country that has a deceased donation program has to ration organs. It is perfectly reasonable to offer advantage based upon someone’s willingness to help others.
Those who claim that only medical criteria should determine who receives a transplant may not realize that there are many non-medical advantages embedded in the current U.S. system. We already give living donors priority should they ever need a transplant, as well we should. Recall Steve Jobs’s liver transplant—he took understandable advantage of the United Network for Organ Sharing (UNOS) policy that allows one to relocate to a region where the transplant wait list is shorter. Also, patients have a much better chance of being listed, regardless of medical need, if they have private insurance.
I applaud the logic and spirit of the Israeli program—and think we should do the same thing (see Lifesharers.org, and sign up now if you agree)—and am very eager to see what the two-year evaluation shows. Given Israel’s low rates of donation and the now-limited options for going abroad to obtain a transplant in other countries (the Israeli government no longer pays for transplants obtained in countries that outlaw organ sales), perhaps the new law will have an effect. However, relatively few people need organs and healthy people are unlikely to think they are at risk, so a program based on the idea that “I should give if I want to get” may not be intrinsically persuasive. We’ll see.
One other point—this one in response to the superb Alex Tabarrok, who has written, “one advantage of a no-give, no take system over paying for organs is that most people find this type of system to be fair and just—those who are willing to give are the first to receive should they one day be in need.” I agree fully with Tabarrok that the Israeli system will appeal to common intuitions of fairness, but I hasten to add that deceased donation, as important as it is, will not be an answer in and of itself.
Why? Because there are not enough eligible posthumous organs. Of the roughly 2 million Americans who die annually, relatively few possess organs healthy enough for transplanting. The number is estimated to range between 10,500 and 13,000, representing less than 1 percent of all deaths each year. Moreover, when unaware of the preference of their loved ones, only about half of families give permission for the organs to be retrieved at death. The number of deceased donors in 2008 as reported by UNOS (7,188) is consistent with these realities. Consider this in the context of a 83,000-plus waiting list for kidneys. Incidentally, this built-in constraint on the number of potentially transplantable kidneys underscores the limits of why a “presumed-consent” law—a policy in which all individuals are presumed to be organ donors at death unless they explicitly indicated otherwise while living—is unlikely to yield a huge windfall of transplantable kidneys. (I mention kidneys because they are the organ in most need. Those waiting for any organ equal 105,600. From one donor, multiple organs are obtained.)
Here is a short radio clip that captures the essence of the debate.
From a psychiatric standpoint, there is not yet enough information available to answer the key question surrounding Jared Lee Loughner: at what point, if any, in the last few years did the mental health surveillance and treatment systems break down? Were there periods along the way where Loughner could have justifiably been coerced into treatment? We simply don’t know yet.