A deadly organ-donor system

by Jeff Jacoby

RIGHT ON THE HEELS of the recent news that Apple CEO Steve Jobs underwent a liver transplant came the speculation that he had somehow gamed the organ donation system in order to jump to the head of the waiting list. It was widely noted that Jobs's transplant took place at a hospital in Tennessee, some 2,000 miles from his home in California. That suggests he had registered with more than one regional transplant center. Multiple registrations aren't against the rules but they can be an expensive proposition, since the patient must be able to travel at a moment's notice when the organ becomes available, and since insurance companies generally won't pay for evaluations at more than one hospital. Jobs, a billionaire, may thus have benefited, frets USA Today, from "a loophole that favors the rich."

Had Jobs traveled to Tennessee to consult a highly sought-after medical specialist, or to acquire a piece of cutting-edge medical equipment, or to undergo a rare and difficult brain operation -- or to buy a Smoky Mountains mansion, for that matter -- nobody would be grumbling about loopholes or wondering whether rules had been manipulated. When it comes to doctors' services or medical technology or surgical procedures -- or real estate -- people understand that suppliers generally charge what the market will bear.

The same economic system that generally makes good health care available to all does price certain products and services high enough that only the wealthy can afford them. It isn't news that the world's finest surgeon commands a high fee, or that the latest "miracle" drugs tend to be expensive, or that billionaires can afford things that mere mortals can't.

Yet when it comes to the donation of human organs, countless people believe that the market must be prevented from functioning.

Under current law, an organ may be transplanted to save a patient's life only if it was donated for free. Federal law makes it "unlawful for any person to knowingly acquire, receive, or otherwise transfer any human organ for valuable consideration for use in human transplantation." The surgeon who performed Jobs's liver transplant, the hepatologist who diagnosed him, the anesthesiologist who managed his pain, the nurse who assisted during the procedure, the medical center that provided the facilities, the pharmacy that supplied his medications, even the driver who brought him to the hospital -- all of them were paid for the benefits they rendered. Only the organ donor (or the donor's family, if the liver came from a cadaver) could receive nothing except the satisfaction that comes from performing an act of kindness.

That, many say, is as it should be: Organs should be donated out of goodness alone; otherwise the rich might exploit the poor. Others flatly oppose any hint of commerce in human organs. Opening the door to "financial incentives," declared the Institute of Medicine in 2006, could "lead people to view organs as commodities and diminish donations from altruistic motives."

Unfortunately, altruistic motives aren't enough. I carry an organ donor card and think everyone should, but only 38 percent of licensed drivers have designated themselves as organ donors. Thousands of organs that could be used to save lives and restore health are lost each year, buried or cremated with bodies that will never need them again.

No one would dream of suggesting that medical care is too vital or sacred to be treated as a commodity, or to be bought and sold like any other service. If the law prohibited any "valuable consideration" for healing the sick, and allowed doctors to practice medicine only if they did so for free, the result would be far fewer doctors and far more sickness and death.

The result of our misguided altruism-only organ donation system is much the same: too few organs and too much death. More than 100,000 Americans are currently on the national organ waiting list. Last year, 28,000 transplants were performed, but 49,000 new patients were added to the queue. As the list grows longer, the wait grows deadlier, and the shortage of available organs grows more acute. Last year, 6,600 people died while awaiting the kidney or liver or heart that could have kept them alive. Another 18 people will die today. And another 18 tomorrow. And another 18 every day, until Congress fixes the law that causes so many valuable organs to be wasted, and so many lives to be needlessly lost.

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Lack of NHS cash puts British bottom of league for fertility treatment

Couples in the UK have less chance of IVF treatment than those in Montenegro

Poor NHS funding of IVF means that infertile British couples are among the least likely in Europe to receive the treatment they need to start a family, new official figures have shown. The latest European league table of access to fertility treatment has placed Britain 11th of 13 countries providing data for 2006, with only Germany and Montenegro providing fewer cycles of IVF in proportion to their population.

Infertile couples in Denmark and Belgium, which finish first and second in the table, are more than three times more likely to have IVF than those living in Britain, the new figures collected by the European Society of Human Reproduction and Embryology show. While Denmark conducts 2,337 IVF cycles per million inhabitants and Belgium conducts 2,187, Britain conducts just 729.

The UK’s performance reflects a lack of funding for IVF on the NHS. While the National Institute for Health and Clinical Excellence (NICE) recommends that primary care trusts should offer three free cycles of treatment to most infertile couples, only a quarter meet this standard. In 2006 only nine of the 161 trusts in England and Wales offered three free cycles. Many trusts also impose further restrictions, such as refusing to fund treatment when people have children from a previous relationship, and the NHS will only pay when women are under the age of 40. In Denmark and Belgium, up to six cycles of IVF are reimbursed by the state. Other leading performers in the league table, such as Iceland, Finland and Sweden, also offer more generous funding than the UK.

Clare Lewis-Jones, chief executive of the patient group Infertility Network UK, said: “We are angry that although the UK pioneered infertility treatment, we are still among the lowest providers in Europe, and these figures show that availability in the UK is less than one third of that in Denmark. “To be so far behind other countries in Europe in the provision of fertility treatment is totally intolerable. “Although there has been an improvement recently in the provision of treatment by some PCTs, there still remains considerable variation in the criteria used to determine whether or not couples can access treatment.”

Anders Nyboe Andersen, of Copenhagen University Hospital in Denmark, who led the research and presented it today at the ESHRE conference in Amsterdam, said that while funding was a major explanation for different countries’ performance, it was not the only one.

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Top doctor in Western Australia claims that colleagues operated 'without proper qualifications'

And another bullying Health Dept. that tries to get back at whistleblowers

A top surgeon at WA's biggest [government] hospital claims two doctors were conducting critical surgery without proper qualifications, The Sunday Times has discovered. Cardiothoracic surgeon John Manuel Alvarez has lodged an internal complaint in which he claims last year he warned bosses at Sir Charles Gairdner Hospital that he feared two of his peers were underqualified for the major surgery they were performing. The Sunday Times understands that some of the concerns related to whether or not the two doctors had passed specialist examinations. Both doctors are no longer at the hospital. One has left WA.

Dr Alvarez himself is being investigated by the Health Department over misconduct allegations. The Health Department started investigating him in July last year after he raised doubts about the ability of the two doctors. The Sunday Times understands that Dr Alvarez believes the inquiry is a witch hunt and was not properly conducted.

Dr Alvarez filed a writ last week seeking to restrain the Health Department from continuing with an investigation and publishing or acting on its findings of misconduct against him. He also wants to stop any future investigation of him by the department. Dr Alvarez named WA Health Minister Kim Hames as the first defendant and Kenneth John Trainer as the second defendant in the action which was filed last Friday. Mr Trainer was the independent investigator hired by the Health Department. Dr Alvarez wants damages for breach of contract with the writ alleging the investigation breached his employment contract dated July 28, 2005.

A SCGH spokeswoman confirmed that Dr Alvarez had made complaints about the quality of some of his peers who were conducting critical surgery last year. She said the hospital was unable to comment specifically on the investigation into Dr Alvarez as the matter was before the courts.

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Healthcare Reform: Will Obama Let You Into His Lifeboat?

Tough luck for the elderly, smokers, big alcohol drinkers and people who don't exercise. If you are any of those, think carefully about your vote next year

The term “lifeboat ethics” is used to describe ethical issues that arise in situations involving the allocation of limited resources. It originally came out of a landmark 1974 article by philosopher Garrett Harden in connection with ethical questions surrounding the issue of providing food aid to underdeveloped nations. He pictured wealthier nations as being like so many lifeboats---all with limited capacity, of course---afloat in a sea surrounded by many swimmers who need saving: the residents of poorer nations. His discussion there concerned the ethical guidelines that ought to govern who, if anyone, should be picked up and saved by those in the lifeboats.

The picture of the lifeboat is, quite obviously, an analogy. And from a logician’s perspective, an analogy is a tool used in a particular type of argument. If I am using an analogy to convince you of something, then I am arguing that two things, A and B, are alike in certain important respects, hence they should be seen as being alike in at least one more relevant respect: that which represents the conclusion of my argument. As a logical tool, an analogy works where it works. Its applicability is not necessarily tied down to only one situation or ethical position.

The lifeboat analogy has surfaced in several ways in the Health Care community and is relevant to the current debate over Health Care Reform. Here we are also dealing with the allocation of limited resources.

Perhaps the most legitimate use of this analogy in health care situations concerns triage decisions in disasters, both natural and man-made [what used to be called “Terrorist Incidents”]: “During overwhelming disasters, health systems must be considered lifeboats with insufficient capacity to minister to all, and thus decisions regarding who is best served by the lifeboat must be made.”

These “high-consequence event” situations have something in common with the original analogy that is so obvious it may easily be overlooked. The lifeboats and the individual swimmers are in the water because a disaster has just occurred; a ship has slipped beneath the waves. Sometimes I think that using lifeboat ethics type cases as if they should furnish us with generally applicable moral guidelines is a little like bringing up the experience of the Donner Party to introduce a discussion about whether cannibalism should be seen to be more acceptable morally than is generally recognized.

Lifeboat ethics cases do not provide us with examples for general moral guidance but instead present situations that are so extreme that they force us to raise questions about whether, in them, some generally accepted moral guidelines and ordinary standards of professional ethics may justifiably be suspended. Indeed, the Homeland Security study mentioned above recognizes this:

“The threshold for what constitutes life-sustaining care could also be lowered if staff degradation and or physical plant damage prevent the delivery of advanced acute and critical care therapies. Depending on the scope, magnitude, and duration of the disaster, sufficiency of care could mean little more than providing intravenous fluids or ventilator-assisted breathing.”

The translation of the above is that under the extreme circumstances it finds itself in, the staff will just have to do the best it can with what resources it has and cannot morally or reasonable be expected to do much more.

But not everyone agrees with my view that Lifeboat Ethics cases are best used to discuss exceptions to general moral guidelines rather than to set the guidelines themselves. And since Obama has insisted on many occasions in the past, especially when running in the primaries against Hillary Clinton, that it is his health care plan we are considering when we discuss the plan soon to be presented to Congress, it is I think reasonable to now ask relative to some important situations, whether Obama would let you into his lifeboat.

Situation One: Are you over 70 years old? If so, then you have real reason to worry about whether he will let you in. Developers of his plan understand that the bulk of the nation’s health care resources are used by senior citizens and they are looking for ways to ration care to the elderly.

In our last article we looked at an argument they favor which would ration care to the elderly and terminally ill based on a Cost-Benefit Analysis. Another plan now being seriously considered here and in Great Britain is to set an arbitrary age cap on receiving health benefits. This hearkens back to an idea originally espoused as far back as 1987 by Daniel Callahan, that humans have an average expected life span (figures of 70 yrs. to 85 yrs. have been mentioned in discussions of this point) and persons who have lived up to this age have no right to expect that we extend them medical care beyond it.

In other words, we are not here talking about a situation where, for example, if two patients, a 75 year old and a 25 year old were competing for the same donated liver, then the relative age of the patients would be one factor health care workers could take into account when making the decision as to who gets the organ. This proposed policy would instead use age alone as the sole criterion for denial of care. And it would not be health care workers but government who would exclude the 75 year old by setting a standard which would deny him/her from receiving health benefits on the basis of age alone!

A point made in these discussions is that such a person has put in enough innings in the game of life and its time to pull them out of the game and put another younger person in, whether they want to come out or not. They will thus not be brought on board the lifeboat of health care.

Situation Two: Are you ill as the result of a lifestyle choice? For example, have you been a heavy smoker or drinker and now things have caught up with you? You should have serious worries about whether Obama will let you into his lifeboat, even if you are not now at an advanced age. Hershel Elliot, an ardent supporter of Harden’s work, succinctly summarized its relevance to healthcare rationing by lifestyle in a 2003 article when he said, “You are unlikely to learn to take care of your health, if you are free to abuse your body by overeating, lack of exercise, and dangerous behavior while society must pay the costs of restoring your health. When individuals are free to damage their own health and society has to pay the costs of curing them, medical costs can spiral out of control.”

Of course, his conclusion is that since these individuals’ health situations came about as a result of their own behavior arising from their lifestyle choices, then society has no moral responsibility to bring them aboard the lifeboat of healthcare and is justified in leaving them alone in the water to suffer the consequences of their choices. Not only will care be rationed on the basis of lifestyle choices in the proposed Obama plan, but government bureaucrats will use the threat of denial of care as the basis for meddlesome intervention into people’s private lifestyle choices. If the government is picking up the bill, either in whole or in part, then these choices are not private anymore!

Curiously, the one application of Garrett Harden’s Lifeboat analogy that his followers judiciously choose to leave out when they apply his views to healthcare, but which might be the most relevant, is the one he himself made in his original article in connection with our moral obligation to supply food aid to poor nations. And that point, which is just as applicable to healthcare, is that Marxist-inspired, redistributionist ethics won’t work. If we apply the Marxist principle of “to each according to his needs” and bring 100 additional needy swimmers out of the water into a nearly full lifeboat that only holds 60, then the lifeboat sinks and everyone loses out.

And sadly, this could be the impact of the Obama, socialist-inspired, universal healthcare plan: it will either sink the US healthcare system lifeboat or drain the economy that keeps it afloat.

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