Normative and prescriptive criteria: the efficacy of organ transplantation allocation protocols

Normative criteria adopted to assure just, equitable, and efficient allocation of donor organs to potential recipients has been widely praised as a model for the allocation of scarce medical resources. Because the organ transplantation program relies upon voluntary participation by potential donors, all such programs necessarily rely upon public confidence in allocation decision making protocols. Several well publicized cases have raised questions in North America about the efficacy of allocation procedures. An analysis of those cases, and the relevant technical literature, suggest consistent structural deficits exist in the organ allocation process as it is applied by many individual transplantation centres. These irregularities are based upon both the failure of rank waiting as a method to guarantee just treatment and a general failure to recognize the extent to which prescriptive criteria--social values--are commonly used to screen potential organ transplant candidates. Resulting idiosyncratic determinations, and a devaluation of rank waiting as a criterion, raise fundamental questions regarding justice, fairness, and equability in the application procedure at large. To correct these structural problems in organ allocation procedures, a multicriterion model defining prescriptive criteria through the Analytic Hierarchy Process (AHP) is proposed.