Organ transplantation as a high-cost surgical and medical procedure poses an extraordinarily rich and complex set of social, ethical, and policy issues.
A June 1988 symposium at Vanderbilt University gathered leaders in a wide variety of fields to synthesize the current state of knowledge concerning organ transplantation policy and to access policy options. Collected here are the revised papers presented at that symposium; also included is one influential earlier paper on the same topic. Together, they constitute a major contribution to the debate on organ transplantation policy and its moral, legal, financial, and political implications.
Organ Transplantation Policy
Issues and Prospects
By James F. Blumstein, Frank A. SloanDuke University Press
Copyright © 1989 Duke University Press
All rights reserved.
ISBN: 978-0-8223-0939-0Contents
Acknowledgments,
Introduction,
Government's Role in Organ Transplantation Policy,
Introduction,
The policy context,
The federal government's evolving role in organ transplantation,
An antitrust perspective on organ transplantation policy,
Conclusion,
References,
The Organization of Organ Procurement,
Organ procurement agencies,
The production function of organ procurement,
Penetrating the market,
Recent growth in the organ procurement system,
The effectiveness of organ procurement,
Explaining success: Changes and growth,
Conclusion,
References,
The Economics and Ethics of Markets for Human Organs,
The Current Legal Regime,
Markets for Procuring Organs,
Markets for cadaveric organs,
Markets for organs from living donors,
Too many organs?,
Markets for Allocating Organs,
Distributional consequences,
Market pricing in the context of insurance,
Would market allocation raise the cost of transplants?,
Property rights under the existing system,
Conclusion,
References,
Ethical Criteria for Procuring and Distributing Organs for Transplantation,
Ethical principles, property rights, and human body parts,
Methods of acquiring organs for transplantation,
The equitable distribution of donated HBPs,
Conclusion,
References,
Is There a Rationale for Regionalizing Organ Transplantation Services?,
Introduction,
Methods of regionalizing transplant centers,
Empirical evidence on outcomes and cost for designating transplant centers,
Empirical analysis of kidney transplant outcomes and charges,
Discussion,
References,
Government Funding for Organ Transplants,
Patterns of payment for organ transplants,
Arguments for and against government payment for transplants,
Principles for government payment policy,
Conclusion,
References,
The Politics of Organ Transplantation: A Parable of Our Time,
Introduction,
Overview of organ transplantation policy,
Major political issues of organ transplantation,
Conclusion,
References,
Liver Transplantation in Massachusetts: Public Policymaking as Morality Play,
Act one,
Act two,
Reviewing the performance,
References,
Index,
Contributors,
CHAPTER 1
Government's Role in Organ Transplantation Policy
James F. Blumstein, Vanderbilt University
Abstract. This paper initially considers ways of thinking about organ transplantation: Should it be treated as a catastrophic disease or as an ordinary and accepted medical procedure? The analysis then shifts to the role the government has played in influencing organ transplantation policy. The federal government's involvement initially stemmed from its role as payer for end-stage renal disease services. In recent years, the rationale for intervention has changed, and the mechanism for implementing regulatory oversight has shifted to a private network run for the government by the United Network for Organ Sharing (UNOS). The government has delegated much policymaking authority to UNOS, although the author demonstrates that this is not required by the applicable legislation. The article raises questions about the relationship between UNOS and the federal government, about potential conflicts between UNOS guidelines and state laws under the Uniform Anatomical Gift Act, and about the ideological stance undergirding much of current federal policy in the organ transplantation arena.
Introduction
It is difficult to develop a neutral framework for analyzing organ transplantation policy. No matter how one shapes the issues, a bias seems to drive the analysis. Indeed, the policy analyst being initiated into the complex world of organ transplantation policy comes away from an initial immersion struck by the overwhelming overlay of ideology—sometimes express, but often implicit—that permeates the field. Given the high stakes involved—for payers, for providers, and most especially for patients—it is perhaps unsurprising that ideology seems to have played and continues to play such a fundamental role in the evolution of public policy. Despite the dramatic progress that has characterized the field of organ transplantation, it seems universally agreed that significant problems continue to beset the organ transplantation enterprise, particularly (although not exclusively) in the area of transplantable organ supply (U.S. DHHS 1986). Ideological dogma may have contributed to these problems by excessively and prematurely influencing public policy.
In what follows, I will first consider the broader health policy context within which organ transplantation policy issues must be analyzed. I will show how different theoretical perspectives influence the debate about governmental financing for organ transplantation. I will then examine the development of federal organ transplantation policy and place it within the broader context of health policy evolution. The analysis will show that government's role as payer in the kidney area has explained much of government's initial regulatory thrust but that government's regulatory role—and its rationale for intervention—have changed considerably in the past several years.
The development of organ transplantation policy has been driven by a philosophical or ideological perspective that is fundamentally different from the perspective that has driven other facets of health policy in the last decade. This development has been influenced by the 1986 report of the national Task Force on Organ Transplantation and facilitated by a privately operated transplantation network that, with acquiescence and tacit approval from the U.S. Department of Health and Human Services (DHHS), has embraced the ideology of the task force. It is interesting to speculate whether this difference reflects a principled departure from the procompetitive approach that has been ascendant recently in other facets of the health policy arena (Blumstein and Sloan 1981; Greenberg 1988), or whether it reflects a confrontation with and rejection of the modish, procompetitive ideological mainstream.
In any event, as I discuss briefly in the concluding section, there may be constraints external to organ transplantation policy that act to delimit the noncompetitive or even anticompetitive aspects of organ transplantation policy as developed independently by the transplantation network. To the extent that the autonomy of the transplantation network is observed (so that its decisions reflect private concerted action of a potentially anticompetitive character as enforced by federal mandate), the policies of the network are likely to become subject to serious antitrust scrutiny and potential challenge. The antitrust laws, therefore, may well be invoked to contest the propriety of the threat that evolving organ transplantation policy poses to the competitive norms embraced by those antitrust laws.
The policy context
Organ transplantation as a catastrophic disease. At the most basic level, organ transplantation policy is a subset of a broader, generic health policy issue—the problem of coping with the costs of...
