Sunday, October 18, 2009

The kidney supply chain

The Minneapolis Star Tribune has given its health reporter Josephine Marcotty unusual scope to write about kidney transplantation in a multi-part series on kidney failure, treatment, and transplantation, and she has done them proud.

Part 1: 'Survival of the savviest' explored the challenges of being on dialysis, waiting for a deceased donor, and looking for a live one.

"But the two supply systems -- living and deceased -- remain radically different. Organs from deceased donors are viewed as a public asset -- like national parks -- and their allocation is highly regulated for fairness and transparency. There are disparities in who earns a spot on the deceased donation list, but they are generally viewed as a consequence of inequities in the overall health care system. A living donation, on the other hand, is a private gift from one person to another. Except for a federal law that makes selling organs a felony, there is no oversight and no support for living donation by the government or the transplant community. As a consequence, finding a living donor is often a matter of wealth, social advantage -- or pure luck."

Part 2: Balancing life and death looks at the process by which willing live kidney donors are accepted or rejected, a process that involves both whether their kidney is compatible with their intended recipient, and their own health. The story says that the first undirected living donor was accepted in Minnesota. More generally,

"Competition between transplant centers is fierce. Minnesota, for example, has four hospitals that compete for kidney patients and organs. If one transplant center changes its standards, sooner or later the others often follow. One reason is that everyone, except perhaps the living donor, benefits. Patients fare better because kidneys from living people tend to be better quality than those from the deceased. The doctors have more control over the complex surgeries. Hospitals, for their part, make more money. Medicare pays an average of $106,000 for a transplant, regardless of whether the kidney comes from a living or deceased donor. And living donor transplants generally cost less -- about 15 to 20 percent less at the university hospital, for example. That means the hospital stands to make 15 to 20 percent more per surgery."... "Nevertheless, taking a kidney from a living person presents daunting ethical questions. In the early days of transplant medicine, things were simpler. Only genetically related relatives were accepted as donors. But family dynamics are complex; doctors and hospital social workers sometimes had to find ways to say "no'' on behalf of reluctant relatives who couldn't find the courage to say no themselves. "There's much more coercion in families than outside of families," said Dr. Stephen Textor, a kidney specialist at the Mayo Clinic. In other cases, saying no was next to impossible. "The people who really pushed it? Spouses," Garvey said. "You have your husband sitting in front of you, dying. They were telling us, 'Who are you to tell me I can't be a donor?' They were right." "

Kidney failure, Part 3: A revolution: trading donors is the installment that first caught my eye, as it deals with kidney exchange. Marcotty reports on what must have been some long interviews with Mike Rees, the surgeon responsible for many of the most important innovations in kidney exchange.
The article begins with this subheadline:
"Kidney exchanges use the oldest economic model of all - trade. Computer matching can start a chain of transplants, but the idea has a long way to go."

I even make a cameo appearance in her story, where I often am, on the phone:
"Then in December 2006, Rees spent an hour-and-a-half on the phone with Alvin Roth, a Harvard economist who specializes in matching theory.
Roth has devised many matching programs, including the national system that fits medical students with specialty training centers.
He also studies what has been jokingly described as "ick-onomics" -- the economics of repugnance. For instance, most people abhor the idea of selling human body parts for transplant. But trade? That doesn't usually trigger the same kind of visceral reaction, he said."

Marcotty describes how Rees initiated the first non-simultaneous chain, through the words of the altruistic donor, Matt Jones, who started it off.

"It began with Matt Jones, a 30-year-old father of five who worked for Enterprise car rental in Petoskey, Mich. He was determined to give his kidney to anyone who needed it.
His first attempt to donate fell apart when the patient unexpectedly got a kidney from the deceased list. But after putting time and money into travel and testing, and persuading his fiancé at the time that it was a good idea, he wasn't about to give up. He called Rees.
"He tells me, 'I have this idea of doing a chain,'" Jones said in an interview. "'It's never been done. There are some people who think I'm crazy.'
"I said, 'Sounds like a great idea.' "

(Mike spends a lot of time on the phone too:)

(Here's my earlier post about that first non-simultaneous chain.)

Marcotty continues the story of non-simultaneous chains: "In March, Rees described his chain in a New England Journal of Medicine article titled "A nonsimultaneous, extended, altruistic-donor chain.... The number of transplants from swaps and chains is growing exponentially. In July, an eight-way multi-hospital series of transplants was conducted in four states over three weeks. In March, a series of six transplants was conducted at three hospitals around New York in 36 hours.
In Boston last spring, kidney exchanges were one of the hottest topics at the American Transplant Congress, a major international conference. Hundreds of surgeons, nurses and social workers absorbed PowerPoint slides that illustrated intricate webs of matches by race, age, medical condition, genetics and blood type. Instead of presentations on anti-rejection drugs, they learned about software programs."

Part 4: The ethics of kidney donation: Two views

The two views are pro and con on whether compensation for donors would improve the supply of donor kidneys, or whether this is too repugnant to contemplate. The pro position is taken by Dr. Arthur Matas, an eminent surgeon and former president of the American Transplant Society. His bottom line:

"It is immoral to stand by and watch patients die when we have the means to save them. A regulated system of compensation for donation has the potential of saving lives, shortening the waiting list and improving transplant outcomes. A regulated system protects the interests of donors. Unless Congress lifts the ban against compensation and allows pilot programs, we are guaranteed more needless death and suffering."

The con position is taken by Jeffrey Kahn, a bioethicist. His bottom line:

"Organ donation has always relied on the altruism of donors and their loved ones, with the hope that any risk for the patient is balanced by the benefit of the good deed. But most people have a price at which they might ignore whatever qualms they have about donation and become willing sellers. That changes the relationship -- from giving a gift to being paid enough to ignore the risk.
A market allows this shift, and it is a change we should be loath to accept."


Diane Franks said...

I do not think anyone should be paid a profit for donating. It would then gather in those only after the money and risks will be ignored. But I do believe people should be compensated for out of pocket expenses such as wages and after care treatment etc. Here in the UK it is different as our health care is automatically given to us for life - we don't pay extra for it, so we know that if any medical after care is required due to donating, it is there for us for however long we require it. In some cases we can get compensated for out of pocket expenses but each case is viewed separately by the hospital in question and reimbursement is at their discretion.

RationalThinker said...

So according to Diane Franks, adults would act irresponsibly when it comes to donating an organ. As if we're all just a bunch of ignorant children who only see piles of money and not the risks of dying on the operating table or living the rest of our lives with only one kidney. So what if they're acting irresponsibly. If a donor wants to do it, let him! It's his decision, isn't it? It's his organ, isn't it? It's that kind of busybody attitude that keeps government in charge and the people as mere slaves to their master. Also, she paints a pretty terrific picture concerning health care in the UK, doesn't she? Saying England's health care is "automatically given to us for life" reminds me of fairy tales that were read to me when I was young. You left out one important detail, Diane. Who pays for your "free" health care? Do you think the money just falls from the sky? Or is it that doctors and everyone else involved in health care simply refuse to be compensated for their services? Nothing is free, especially when government is there handing it out.

Diane Franks said...

RationalThinker just wants to stir things up I think. I never said anyone would act irresponsibly when donating an organ. But you only have to look at the black market in organ sales to know it is the poorest of people, who are not necessarily in good health themselves, that are at the front of the queue to sell their organs. If it becomes legal to sell your organ then why did not the people who then put their hand out for money not donate their organ before? So yes, it will mainly gather in those that want the money far more than those who want to donate purely because they want to help someone.

Also please read what I say carefully. I did not say we do not pay for our health care. I also did not say it was free - did I? I said we do not pay extra. There is a difference. We pay a very small amount from our salaries, and I mean a very small amount that covers many benefits, health care being one of them.

I have actually already donated a kidney to a stranger and did it willingly. I received no compensation at all and did not ask for any or want any. The risks are minimal yet the benefits to the recipient are priceless. I would actually have been insulted to have been offered any money to save someone else's life.

All health systems have their faults and I do not deny the NHS has some. But on the whole it is by far the very best system in the world and I would not swop it for any other, especially not the one in the USA where I know of people not getting the dialysis they need because they do not have health insurance as it is too expensive. Everyone deserves health care regardless of how little money they have. At least in the UK everyone, no matter how poor, gets full healthcare. Not everyone contributes towards the system either. If you are poor you dont have to contribute but you still get the exact same good healthcare as those that can.

As for donating organs in general. I do not believe most countries have done as much as they can to promote organ donation. Spain has the highest rate of donation in the world. Many countries could look to them to improve their donation rates. Until all other possible avenues have been fully tried I do not believe we should be offering money for organs from Living Donors. For organs from deceased there could be incentives to sign the organ donor register.

I think most people can see through you RationalThinker....