Rationing Transplants: An Ethical Problem

On November 1, 1999, Walter Payton, former Chicago Bears running back, died waiting for a liver transplant. Payton’s death re-opened the nation’s attention to the issue of organ donation. The National Organ Transplant Act of 1984 (NOTA) made giving or receiving compensation for organ donation illegal in the United States. Currently in the United States there exists a large shortage of viable organs which are allowed to be used for transplant. In this lesson students will be asked to research the issue of organ donation, and to debate, in a class discussion, the different alternatives which are being proposed to meet the demand for organ transplants using economic analysis.

On November 1, 1999, Walter Payton, former Chicago Bears running back, died waiting for a liver transplant. Payton’s death re-opened the nation’s attention to the issue of organ donation. The National Organ Transplant Act of 1984 (NOTA) made giving or receiving compensation for organ donation illegal in the United States. Currently in the United States there exists a large shortage of viable organs which are allowed to be used for transplant. In this lesson students will be asked to research the issue of organ donation, and to debate, in a class discussion, the different alternatives which are being proposed to meet the demand for organ transplants using economic analysis.

• Explain the consequences of a non-market rationing process.
• Evaluate the consequences of restricting organ transplants to U.S. citizens.
• Discuss alternative policies to reduce the scarcity of organs for transplant.

Economics

This lesson uses the example of liver transplants to provide students with practice in applying their decision making skills. It stresses difficult decisions related to handling scarcity. More people require liver transplants than can be provided, given the limited number of donated livers. Students consider alternative methods for rationing organ transplants and evaluate how each method influences the relative scarcity of the resource.

Reasoning

Economics reasoning can help students to explain human actions and anticipate the consequences of policies in emotionally and ethically charged issues just as it helps with the analysis of ethically simpler issues, such as car sales. In most hospitals, doctors and advisory boards establish the criteria for allocating the available organs. These criteria may include age, potential match to avoid the body’s rejection, ability to pay, and citizenship. Students should see this issue as yet another example of rationing a scarce resource; they also should see that different rationing methods establish incentives which encourage potential patients to behave in a manner which may enhance their chances of obtaining the operation.

• Bad Prognosis- Payton’s Liver Disease Progressing Faster than Expected: This February 1999 Sports Illustrated article discusses Pro Football player Walter Payton’s liver disease progressing faster than expected.
  sportsillustrated.cnn.com/football/nfl/news/1999/02/12/payton_health/
• The Economics of Organ Donation: George Mason Economist Russ Roberts hosts a weekly podcast known as Econtalk, on this installment Roberts sits down with Richard Epstein, a professor of law at the University of Chicago. Roberts and Epstein discuss the market for kidneys. The web site also provides readings and links related to the podcast which students are encouraged to research.
  http://www.econtalk.org/the-economics-of-organ-donations/
• National Transplant Assistance Fund and Catastrophic Injury Program: This is the homepage for the NTAF. Here is where students will view the UNOS National Patient List.
  www.ntafund.org/
• United Network for Organ Sharing- Newsroom: There is a severe organ shortage in this country. Despite continuing efforts at public education, misconceptions and inaccuracies about donation persist. This website offers a list of the most common myths along with the actual facts.
  https://unos.org/transplant/facts/

Links on Markets for Organ Donation:

• Jason, Gary. The Market for Body Parts, Liberty Magazine October, 2007.
  https://www.academia.edu/24470129/The_Market_for_Body_Parts_2007_
• Psst, wanna buy a kidney?, The Economist Magazine, Nov. 16th, 2006.
  https://www.economist.com/leaders/2006/11/16/psst-wanna-buy-a-kidney?story_id=8173039
• Williams, Walter E. My Organs Are for Sale: Why is Selling Organs Illegal? The Freeman Magazine. Vol. 52, Issue 10. Oct. 2002.
  https://web.archive.org/web/20121107083600/http://www.thefreemanonline.org/columns/my-organs-are-for-sale/
• Dubner, Stephen J. Is America Ready for an Organ-Donor Market? Freakonomics. May, 2006.
  http://freakonomics.com/2006/05/15/is-america-ready-for-an-organ-donor-market/
• Beard, T. Randolph. The Failure of U.S. Organ Procurement Policy. Regulation Magazine. Winter 2008.
  https://object.cato.org/sites/cato.org/files/serials/files/regulation/2007/12/v30n4-3.pdf

Links on Opt-Out Organ Donation:

• Carney, Scott. The Case for Mandatory Organ Donation. Wired.com. May 8th, 2007.
  www.wired.com/medtech/health/news/2007/05/india_transplants_donorpolicy
• Thaler, Richard T. Opting In v. Opting Out. New York Times. Sept. 27th 2009.
  https://www.nytimes.com/2009/09/27/business/economy/27view.html
• Opt-In or Opt-Out. UK Transplant.
  www.uktransplant.org.uk/ukt/newsroom/statements_and_stances/statements/opt_in_or_out.jsp
• Gundle, Kenneth. International Lessons for Moving Forward With “Opt-Out” Organ Donation in the US.
  www.sfms.org/AM/Template.cfm?Section=Home&SECTION=Article_Archives

First, use the Web to learn more about Walter Payton’s prospects for receiving a liver transplant. Read two articles at CNNSI

Does Payton’s status as a former pro football player make it easier for him to get a transplant? [He has to wait in line like everyone else. However associates have offered use of the Chicago Bears’ private plane to get him to the hospital in case a donor becomes available.]

Knievel Counsels Sweetness – Why does Kneivel suggest that Payton go to Florida? [shorter waiting list]

What does Dr. Ramos say affects the length of time a patient waits? [degree of illness and organ match]

View the UNOS National Patient List (see Organ and Tissue Donation)

What is the total number of people awaiting transplants? [58,000]

How many are on the list for a liver transplant? [10,358]

How many people received transplants during 1997? [21,497]

Based on these numbers, approximately how many years do recipients need to wait? [At least 2 years]

Given that Payton has about two years to live with his current liver, how could you make sure he gets his new liver in time? [Make sure the selection criteria takes into account severity of disease.]

Visit the https://unos.org/transplant/facts/ – What is the purpose of this section? [Educate potential donors.]

How will education affect the supply of donors. [Dispelling myths and reducing reluctance of people to donate organs should increase the supply of organs.]

Pretend you are a member of a surgical team in a leading U.S. hospital. As a team, you must decide which patients should receive liver transplants as donated organs become available. Recently your hospital received an organ donation from the family of an accident victim. As best as your team can determine, each of the three candidates’ bodies would accept the liver without major threat of rejection. The cost of this operation, surgical fees and hospital care, would come to approximately $50,000. Decide which patient will receive the liver transplant operation. Identify the criteria you used to evaluate each patient.

Potential Liver Transplant Recipients

1. A 40-year-old Canadian male construction worker with a wife and five children. Until recently, he provided most of the family’s income. Now his wife works at part-time jobs to earn the family income. His insurance would cover about one-half of the costs of the operation and post-operative medical care.
2. A 30-year-old female working as a sales representative for the regional telephone company. She has no family. She plans to marry as soon as her health improves as a result of the liver transplant. Her health insurance will cover the costs of the operation.
3. A 45-year-old former pro-football player with a wife and children. His health insurance will cover the cost of insurance.

What economic principles apply in this situation to help us understand the problem? [Scarcity forces people to choose among alternative ways to use limited resources. Scarcity forces people to set up a rationing scheme to distribute limited goods and services.]

Suppose a member of Congress, reacting to the large number of liver transplants provided for non-U.S. citizens, introduced a bill to require an “Americans First” policy. This policy would require all hospitals and organ procurement agencies to provide organ transplants to foreign nationals only after conducting a lengthy, thorough and unsuccessful search for a suitable U.S. recipient.

View Interactive Activity

1. Would such a law change your earlier decision on the transplant recipient?
2. Would such a law increase or decrease the supply of donated livers?
3. Would such a law help increase or decrease the number of people who want an organ transplant?
4. How might other countries react to such a law?
5. Do you think the legislator feels that Americans are more deserving of a transplant?
6. Whose interest is he serving?

For discussion:

1. Would an “Americans First” policy influence of the decisions of doctors? [Yes, but they might not feel that the best health-related criterion was being followed]
2. How would an “Americans First” policy change patient incentives? [Foreign nationals requiring a transplant operation would make every effort to obtain U.S. citizenship or to obtain an illegal organ transplant if none were available in their own country.]
3. Is an “Americans First” policy on liver transplants different from other trade restriction laws? [Such a policy would be very similar to restrictions on the sale of other, less controversial goods and services.]
4. Do non-market rationing programs correct the problem and provide equal treatment to everyone? [No, because scarcity still exists and kidney transplants will be allocated according to other, equally arbitrary rules regarding recipient qualifications. Discrimination will exist depending upon the criteria used to allocate scarce organs.]