Who Gets the Kidney?

Who Gets the Kidney?

The following editorial appeared in the Chicago Tribune on Friday. March 16:

For years, the system for parceling out kidneys to those who need transplants hasn't changed all that much. If you need a kidney transplant, you basically get in line and wait your turn. It may take two years or 10, depending on what part of the country you live in, among other things. A 70-year-old may get an organ before a 15-year-old. When your name reaches the top of the list, and a suitable organ becomes available, you receive the transplant, unless you're too sick to survive the surgery.

This has been considered the fairest way to distribute a precious commodity in short supply. But that system is inefficient. It wastes some kidneys. It favors some merely because of where they live. People with short expected life spans receive kidneys that could last much longer, and vice versa. It needs to change.

Fortunately, there's a dramatic new formula under discussion by the nation's organ transplant network that seeks to change how kidneys are doled out. Under this concept, doctors would assess the benefit of a kidney transplant largely by estimating the number of extra years of life a transplant could confer. That is, how long a patient with failing kidneys might expect to survive after a transplant versus how long the same patient might live without the transplant, on dialysis alone. Kidneys would go more often to those who could live longest after the transplant.

Put simply: Youth would rule. Younger people would receive transplants at the expense of older people.

This will obviously disturb some people, who argue the policy suggests the life of a 30-something person is more valuable than that of an older person.

That is clearly not the intent. Instead, the goal is to wring the most benefit from each transplanted kidney. A similar concept is already part of the system to determine who receives a lung transplant.

The current policy of distributing kidneys looks equitable on the surface. But it isn't because the wait time affects different people in different ways, says Dr. Mark Stegall, chief of transplantation surgery at the Mayo Clinic and the head of the committee that is mulling the proposed changes. Some people who die on the waiting list could have lived a long time with a transplant, but not on dialysis, he says. For others, the time gained by transplant over dialysis is small.

Transplanting organs into those who can live longest and healthiest won't always serve the greater good. What if the 65-year-old who doesn't get the kidney is on the brink of a medical discovery that would save millions? What if the 25-year-old who gets the organ fritters his or her life away, never producing anything of value? Should it matter, say, if the patient is a skydiver or in a risky profession? Or if the patient is a smoker? Obese? A drug abuser? An alcoholic?

Those questions are largely, and rightly, beyond the scope of what's being discussed. The point is to create a system based as much as possible on objective medical criteria.

And let's remember, this change is necessary because of one sad fact: Transplantable organs are in short supply. There's roughly one kidney from a deceased donor for every seven people on the waiting list. They must be rationed. The hope here is that debates like this will encourage more people to donate so that such proposals would be unnecessary. The most direct incentive would be to pay modest compensation to the families of those who donate. Unfortunately, that idea hasn't gained much traction.

And so, every day doctors are forced to make these life and death calculations. Researchers have estimated that under a new formula, life expectancy for kidney transplant patients would improve by about 30 percent. That's huge. Translated, it means that thousands of transplant recipients in the U.S. would be expected to live an extra 11,457 years under the new allocation scheme. Think about all those extra years with a father or mother, a sister, a brother, a cousin, a friend. What an amazing gift.

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