Should criminals have equal access to scarce medical treatments?

[okarol]

The God Committee
Should criminals have equal access to scarce medical treatments?

By Sally Satel
Posted Tuesday, June 17, 2008, at 3:33 PM ET

According to a recent investigation by the Los Angeles Times, four members of the yakuza, the Japanese mafia, received liver transplants at the UCLA medical center between 2000 and 2004. Two of the four men later gave a $100,000 contribution to the medical center, prompting speculation that a cash promise got them bumped to the head of the transplant waiting list. The story suggested that this revelation could "have a chilling effect on organ donation." That worry already seems well-founded. "I'd say kill the gang members and take their organs to give to law-abiding citizens," read one of the hundreds of hostile posts on the Times' Web site. "You're not getting mine!" said another. "I'm removing my name from the Donor list immediately." A third charged that UCLA actually stands for "Universally Corrupt Liver Auctioneers."

In an op-ed, UCLA tried to defend itself. Dr. Gerald S. Levey, dean of the David Geffen School of Medicine at the university, denied that the men had been whisked in for operations ahead of others. As for the public outcry surrounding the moral standing of the Japanese men, he said, "those who argue that criminals should not get transplants are on shaky ethical ground. Do we want to force caregivers to make a life-or-death decision based on whether a patient is a 'good' or 'bad' person?"

It's a perfect storm of ethical anxieties: good organs going to bad people; medical professionals (perhaps) on the take; and, not least, a shudder of xenophobia. Levey is, of course, on entirely safe ground in arguing that physicians should not withhold vital treatment from their patients. But when resources are scarce—transplantable organs being the classic example—should some institution pass judgment when facts about a patient's criminality are known? No, says the United Network for Organ Sharing, which coordinates procurement and distribution of organs from the newly deceased. As Mark Fox, former head of the UNOS ethics committee, told me, "Once patients have been placed on the waiting list, the list itself is blind to whether you are a saint or sinner, a celebrity or a derelict."

There was a time, however, when character did determine access to scarce treatment. In devising a way to select patients, physicians imagined that the public preferred to think of decision-makers as wise stewards of scarce resources. In 1962, Seattle's Swedish Hospital established what later came to be called the "God Committee." Formally known as the Admissions and Policy Committee of the Seattle Artificial Kidney Center at Swedish Hospital, its task was to decide which terminal patient would get access to scarce dialysis machines, or artificial kidneys, as they were called then.

The committee grew out of a medical breakthrough achieved by Dr. Belding Scribner of the University of Washington. He succeeded in converting acute dialysis (good for perhaps six weeks) into a chronic procedure that could last many years. At the time, 10,000 Americans were estimated to be dying from renal failure each year. Scribner's discovery made Seattle a center for the new field of nephrology, and when the Artificial Kidney Center opened in the city in January 1962, it was the only dialysis center in the country. There were three treatment slots and about 60 patients in the surrounding area who needed them. Scribner argued that choosing among medically eligible candidates was not a clinical deliberation; it was a societal one. And, as such, the burden of choice should be shared by the public.

The Seattle committee was composed of seven lay people—a lawyer, a minister, a housewife, a state government official, a banker, a labor leader, and a surgeon who served as a "doctor-citizen"—and was among the earliest instances, if not the first, of physicians bringing nonprofessionals into the realm of clinical decision-making. The members, all unpaid, insisted on anonymity. They considered the prospective patient's marital status, net worth, nature of occupation, extent of education, church attendance, number of dependents (the more kids or dependent relatives, the better the chance of being chosen), and potential to resume work. They struggled with the ultimate question of who should be saved: the person who contributes the most to society or the one whose death would impose the greatest burden on society, in the form of children left without care or resources.

In November 1962, Life magazine ran Shana Alexander's now-classic story about the committee. The article, "They Decide Who Lives, Who Dies," drew national attention to in the drama playing out in Seattle. As Alexander showed, the members of the committee took their Solomonic charge very seriously. "As human beings ourselves," one told her, "we rejected the idea instinctively, of classifying other human beings in pigeonholes, but we realized we had to narrow the field somehow." Thirty years later, Alexander gave a speech titled "Covering the God Committee," and from that point, the name stuck.

Critics of the God Committee charged that rationing by measure of human worth was an affront to the ideal of equality. But in the face of scarcity, choices need to be made. As the technology for dialysis spread across the country, other selection committees were established. But they were less explicit than the first Seattle effort had been about making judgments about human worth. "Physicians learned from Seattle to avoid the 'costs' of being highly visible in decision-making about who received treatment," says Richard A. Rettig, a political scientist who chronicled the social history of dialysis policy. They made their choices based on predictions of which patients would be able to adhere to the demands of dialysis treatment (strict diet, meticulous hygiene, and reliable attendance several times a week) and which were likely to return to a socially useful role.

This meant that the selection committees took nonmedical traits into account. For example, some tested IQ, personality, and the vocational skills of dialysis candidates. The Peter Bent Brigham dialysis program considered the likelihood of a return to productivity and cooperation with care. The Los Angeles County Dialysis Center screened for a group of medically, psychologically, and socially optimum candidates and then selected among them by lottery. The Cleveland Clinic allowed patients access to dialysis on a first-come, first-served basis and culled only if some proved unwilling or unable to cooperate once they had begun the therapy. Only a few centers explicitly disqualified candidates because of criminal records, spotty employment, or indigence. But the chances of being chosen if you fell into these categories were not good, because the traits in question suggested a lack of the material and emotional wherewithal to comply with the demands of lifelong dialysis treatment.

Soon, many of the God committees became demoralized at having to preside over so many deaths. By 1972, pressure from advocates and physician groups was strong enough to move Congress to establish universal funding for dialysis through Medicare. The supply of limited resources—dialysis machines and facilities—increased overnight. And the wrenching ethical dilemmas of allocation disappeared, along with the God committees intended to resolve them.

The legacy of the Seattle committee lives on as a historic milestone, perhaps "the birth of bioethics," in the words of bioethicist Albert Jonsen. No one wants to return to the days of the character biopsy—judging a patient's social value—in deciding who gets access to rare treatments. But the UCLA story and others like it will continue to offend our sense of fairness as long as the nation's dire organ shortage persists. The only way to dispel the ethical quandaries that stem from rationing is to expand the pool of organs so that more people can receive lifesaving transplants.

So far, we have failed on this front. After decades of public education about organ donation, the gap between supply and demand grows ever wider. Last year, more than 6,000 people died waiting for an organ that never came. Out of desperation, some patients travel abroad for transplants. They do so with the sickening knowledge that their new kidneys or livers will come from a poor native exploited by brokers in the underground organ bazaars that flourish across the globe.

It is time for the federal government to acknowledge that altruistic giving has not produced enough organs. Repealing the ban on donor compensation would permit the federal or state governments to devise a safe, regulated system in which would-be donors are rewarded for giving an organ to the next stranger on the list. If only the organ shortage itself provoked as much outrage as the UCLA mobster transplants.

http://www.slate.com/id/2193753/pagenum/all/#page_start

[angela515]

I don't think it's our job to turn people away because of being "good" or "bad" in their life... it should all be based medically as it already is.

[stauffenberg]

The American Constitution forbids 'cruel or unusual punishment' as the sanction for any crime, and this has been interpreted to mean that only imprisonment, fine, or a minimally painful execution is permissible.  Denying someone a chance of a liver transplant and condemning him to suffering and slow death from liver disease because of his criminal background is punishment by torture, which is not only unconstitutional, but also violates many international human rights conventions.

There has been much controversy over the years concerning the infamous Seattle 'God Committee' and the criteria it used to regulate access to dialysis.  Probably one of the most absurd aspects of that Committee was the presence on it of a banker, since a capitalist vulture skilled in foreclosing poor people out of their homes and seizing their property to auction it off while they are sitting on the street is hardly likely to be the best judge of ethical questions.

[rose1999]

'Criminals' are only the ones who get caught, there are people out there who are as bad as them (or worse) who just haven't been caught.  We've also had several cases recently in the UK where people have spent years in prison and now been proved innocent.......just something to think about. 

[IUNurse]

First I will say I hope I don't sound ignorant because I didn't read the article completely through.  I have heard rumors (never looked for proof though) that those who are in jail do not have to pay for dialysis or transplant.  I was told it is payed for by taxpayers.  That I do not agree with.  I know they would not be able to pay for medical treatment while incarcerated, but I do think that they should be given a bill at the time they are released!

[angela515]

I disagree IUNurse.

People who are incarcerated obviously cannot earn a living to pay for their medical expenses, so therefore it has to be paid somewhere else.

I cannot afford to pay alot of my medical treatment/care either, so I have help from programs that pay for me.

Once I am financially able to afford it, I obviously won't have that program anymore, should I get a bill for all the previous stuff now?

I cannot work at the moment, so I qualify for things.. so when I am able to work should I have to repay all that?

I don't think taxpayers should have to pay, but I do think there should be some program for that situation as well and they should not have to pay it back either.

Honestly, I don't believe anyone in the world, criminal or not, should have to pay to keep themselves alive period. How inhumane.

[IUNurse]

You are right, it is sad that people have to pay to keep themselves alive.  It is sad, but the equipment and supplies are very expensive, so something has got to give.  I do think that companies that make these supplies need to make billions from the life saving supplies they make.  I have wondered if doctors should make the money they do and I think they probably should.  Otherwise there would be no incentive for people to become doctors.  It is not easy so why sould you bother if there wasn't going to be a reward at the end? 

I understand what you say about the assistance you receive to help pay your dialysis, but you did not choose to be unable to work.  Criminals choose to do stupid things, they deserve to pay the price.  I don't think they should be able to receive a free transplant while incarcerated (if that is even truly the case).  I also do believe they should  be responsible for some of the expenses that incurred (maybe not all, but some)  Would you seriously be ok finding out you were passed up for kidney transplant to some body who had been in and out of jail?  And maybe after leaving jail he is shot and killed because he went right back to the crimes he had been doing throughout his life.  I think I would be upset!

I hope that I didn't offend you or anyone else.  Just thinking about this.

[angela515]

I am not on dialysis anymore, I do not work because I live 30 miles from town and have no vehicle or DL. I get SSDI for 3 years after my transplants, so I am choosing not to work, but I am choosing not work due to circumstances as if I am still in this circumstance when my 3 yrs is up I still won't be able to work.

However, people make mistakes, and just because someone made a mistake and did something to break the law, that does NOT mean they deserve to die and not receive medical assistance. I was 18 1/2 when I broke into my ex b/f's apt to get all my stuff he wouldn't allow me to get back, was it stupid? Yes, did I deserve not to continue getting my medications for my failing kidneys? NO. I was supposed to get 4-5 years, which by then I was on dialysis, but I didn't because of harassing voicemails left by my ex and him not  showing up in court. Had I got that 4-5, I don't think making a stupid mistake like that would of constituted me not getting dialysis and getting what I "deserve".

 

[IUNurse]

If a person is in jail -you are right, he does not deserve to die.  But, I don't believe doing something stupid and ending up in prison should get  free medical treatment either.  A person in jail should be able to have treatment, but he should be paying some of this cost back when he is out of jail and back to work.

[angela515]

We shall agree to disagree. 

[IUNurse]

Sounds good to me! 

[Kitsune]

I am not on dialysis anymore, I do not work because I live 30 miles from town and have no vehicle or DL. I get SSDI for 3 years after my transplants, so I am choosing not to work, but I am choosing not work due to circumstances as if I am still in this circumstance when my 3 yrs is up I still won't be able to work.

However, people make mistakes, and just because someone made a mistake and did something to break the law, that does NOT mean they deserve to die and not receive medical assistance. I was 18 1/2 when I broke into my ex b/f's apt to get all my stuff he wouldn't allow me to get back, was it stupid? Yes, did I deserve not to continue getting my medications for my failing kidneys? NO. I was supposed to get 4-5 years, which by then I was on dialysis, but I didn't because of harassing voicemails left by my ex and him not showing up in court. Had I got that 4-5, I don't think making a stupid mistake like that would of constituted me not getting dialysis and getting what I "deserve".

 

.



angela515,

There is a lot wrong with your post and I'm gonna lay it on the line for you, since you don't seem to get it on your own:

First off, you are now able-bodied and can work, but you now tell us that you choose not to? I am currently on dialysis waiting for a transplant thinking about what I am going to do with my life if and when I recieve a transplant, and you're more worried about sitting your deadbeat butt on the internet talking on message boards, about how now able-bodied people should be able to get Medicare because they don't want to haul their butts out there and get decent jobs so they can have insurance? You're pitiful and it's because of people like you that the government does that to people who cannot work...ever.

Numbe two: You whine about the 4-5 years you were owed for breaking and entering like you were a child who knew no better but you were an adult not a child when you broke into your ex-boyfriend's apartment and made your little "mistake". Come on, you knew better than that, I mean I knew better than to do things like that from the age of seven, no matter what my reason was.

Dialysis or no dialysis, breaking and entering for any reason is a serious crime and you should've gotten that time you were owed, and should have been lucky he didn't see you in there and break your neck, therefore eliminating the need for an kind of medical treatment at all.

No you did not deserve to die for that, but you did deserve to sit in prison, and yes they do have dialysis machines and kidney medications in correctional facilities,and they could have used those on you. And your boyfiend is not off the hook either. He should have gotten time as well for his harassing phone calls and not appearing in court, which is contempt.

You sound like the typical bleeding-heart transplant patient who thinks they shouldn't have to work if they don't please and  is so glad to be alive that they forget about good, honest people who are dying and instead focus on the rights of criminals to live. I hope I am not like you when I get a kidney, and you give me inspiration as what not to be.

Now,  "Chandi's Side Of Things":

Ok, so an organ goes to a pimp who has 20 underage prostitutes instead of a 6th grade math teacher who stays after class because he or she wants to see the students succeed. So, basically, you have enabled a criminal who will continue to do wrong to live while a valuable member of society dies. Sorry, but if a teacher and a pimp are both up for a kidney or whatever, make the pimp stay on the machine. He gets to live, but not in the way he thinks he should, therefore it is not truly cruel as you are giving him proper medical care for his condition, that, and he is technically uninsured. That, and organs are too valuable a resource to waste on worthless pieces of human excrement like that, no matter what bleeding-heart liberals say.

Plus, they don't have insurance, which according to the medical profession's own rules, means these people should have no "access to this scarce and lifesaving procedure." Hell, they let innocent children die without even the most basic of medical care due to it daily. And then, just like it is done to others without insurance, send him a bill for every stinking penny and send collection agencies after him until he pays. Why are criminals so special that they get it all for free, while there are single mothers who work 12 hours a day but yet cannot afford to get the most basic of medical care for themselves and their children and cannot get Medicare or Medicaid because they make $1 over what the limit is. We, as a country really need to rethink our attitudes, because criminals get rewarded for being sociopathic and antisocial, while people who try to do the right thing get jacked over.

I have even read of articles that refer to criminal's "inability to obtain a transplant due to lack of proper insurance" as "heartbreaking" while merely stating the fact that many law-abiding people can't even get dialysis.
 
This needs to stop. While you are in prison, you should have access to food (very basic), water (nothing else), shelter (your cell), clothing (white shirt, white pants, socks, sneakers, not name brand), and basic medical care (that means dialysis, not transplantion) and you should be charged for every bit of it just like everyone else is.  The USA has turned prisons into the Hilton, since now in prison you get weight rooms, cable TV, video games, smoking areas, dirty magazines, medical care to rival the best hospitals and your visitors can buy you items out of the vending machines. What do you learn in there these days? Nothing.

[glitter]

Ok, so an organ goes to a pimp who has 20 underage prostitutes instead of a 6th grade math teacher who stays after class because he or she wants to see the students succeed. So, basically, you have enabled a criminal who will continue to do wrong to live while a valuable member of society dies. Sorry, but if a teacher and a pimp are both up for a kidney or whatever, make the pimp stay on the machine. He gets to live, but not in the way he thinks he should, therefore it is not truly cruel as you are giving him proper medical care for his condition, that, and he is technically uninsured. That, and organs are too valuable a resource to waste on worthless pieces of human excrement like that, no matter what bleeding-heart liberals say.

I do not agree with criminals getting kidney transplants -if they are incarcerated.

I would hesitate to deny a transplant based on how much someone contributes to society...if they have served their time, fine let them have an equal chance, people do change. When you start asking questions like, What do you do for a living-  determining if someone is 'worthy' of a kidney.....so what if it was a lawyer, and a politician, or a maid? The maid would get it morally- LOL- I just think its wrong to use moral judgements to give out kidneys- as long as you are not in jail. and who gets to choose?

[paris]

Just need to say,  Angela515 has many serious health issues, with kidney's being just one.  Lupus, fused ankles, pain add to the list.

[Romona]

Also I want to add that she is furthering her education as well.

[monrein]

I hope Angela is OK, haven't heard from her in a little bit. 

[twirl]

Angela515              PM me since she made this last post
it was in August
would write the date but I just deleted the message
but it has not been that long ago
but still I wish we would hear from her

[MIbarra]

you're more worried about sitting your deadbeat butt on the internet talking on message boards, about how now able-bodied people should be able to get Medicare because they don't want to haul their butts out there and get decent jobs so they can have insurance? You're pitiful and it's because of people like you that the government does that to people who cannot work...ever.

Who are you to decide who is able bodied to work? Do you work?
I continued to work while on dialysis. Not only did I teach, but I was also team leader of our grade level, did afterschool tutoring, and tutored in my home on the side. So, that means you can get your behind off of these message boards and do something more productive with your life, correct?

Just because someone has a transplant, doesn't mean they're cured. Everyone's body reacts differently to dialysis and trasnsplantation. Honestly, sometimes I feel more tired now than I did on dialysis because of some of the meds I'm taking.

To sum it up, it's not really your business who goes to work and who gets assistance.