Organ transplant rationing: a window to the future?

Those who advocate rationing access to health care to control escalating costs must adequately examine the field of organ transplantation, where rationing has been a harsh fact of life for many years. In our society, two paradigmatic cases illustrate rationing: a lifeboat with too many passengers aboard for the supply of food and water to keep alive, and battlefield triage with more wounded soldiers than medical personnel available to treat them. Examination of these cases reveals four criteria that must be fulfilled for rationing to be the only possible response to a resource shortage: Nothing can be done to stretch or divide the available resource to meet the needs of all seeking access to it. Those who seek access to the scarce resource need it to survive. Nothing can be done to increase the supply of the resource that is available. The resource is recognized as a benefit by both those who seek it and those who can provide it. For the most part, transplant decisions are surrounded by secrecy, and public input is minimal. Although many centers use psychosocial as well as medical criteria in deciding whom to admit to transplant programs, no consistent criteria have been developed among transplant centers. This secrecy and inconsistency could damage public support of organ transplant programs. If rationing is instituted in other areas of health care, public input must be sought in establishing equitable standards. The scarcity of organs for transplant cannot be changed, but this is not true in other areas of health care, where we can choose to build more facilities, eliminate waste, and dispense with unnecessary services.(ABSTRACT TRUNCATED AT 250 WORDS)