PHIL103: Moral and Political Philosophy

The allocation of kidneys occurs under circumstances not paralleled in the case of other organs because candidates for transplantation are drawn exclusively from patients already within a dialysis program. This introduces the difficulty that, whereas selection to receive a kidney is determined by clearly defined and promulgated criteria that are uniformly applicable nationally, selection to enter dialysis programs is affected by a variety of sets of guidelines. In some cases uniform criteria for entry to dialysis are being formulated. However, in other instances, individual clinics have their own guidelines, not all of which are readily available. This lack of transparency precludes ethical assessment of the procedures employed and this should occasion concern: it is an ethical issue in itself. As kidneys can be preserved safely by simple cold storage for at least twenty-four hours, the results of a blood T-cell cross match and tissue matching can be available before transplantation is undertaken. Because of the length of waiting lists, several potential recipients are commonly equally well matched with each presenting donor. Allocation of kidneys should be organized on a national basis so that recipients with the closest tissue matching with the donor are selected to receive the organs. This provides the best chance of success. Currently, kidneys are raised by allocation of transplant resources allocated to potential recipients according to the best available tissue match. If there are no suitably matched potential recipients on the national waiting list, the length of time on dialysis usually determines the recipient. Factors such as recipient age, period on dialysis, pre-sensitization to tissue antigens, presence of diabetes mellitus and the previous receipt of a transplant are likely to be taken into account.

The concept of distributive justice – how to fairly divide resources – arises around organ transplantation. Distributive justice theory states that there is not one "right" way to distribute organs, but rather many ways a person could justify giving an organ to one

Particular individual over someone else. Equal access criteria include:

• Length of time waiting (i.e. first come, first served)

• Age (i.e. younger to younger, older to older or youngest to oldest)

• Organ type, blood type and organ size

• Distance from the donor to the patient

• Level of medical urgency

Equal access supporters believe that organ transplantation is a valuable medical procedure and worth offering to those who need it. They also argue that because the procedure is worthy, everyone should be able to access it equally.

Successful transplants are measured by the number of life years gained. Life years are the number of years that a person will live with a successful organ transplant that they would not have lived otherwise. This philosophy allows organ procurement organizations to take into account several things when distributing organs that the equal access philosophy does not – like giving a second organ transplant to someone who's already had one or factoring in the probability of a successful medical outcome.

Three primary arguments oppose using the maximum benefit distribution criteria. First, predicting medical success is difficult because a successful outcome can vary. Is success the number of years a patient lives after a transplant? Or is success the number of years a transplanted organ functions? Is success the level of rehabilitation and quality of life the patient experiences afterward? These questions pose challenges to those attempting to allocate organs using medical success prediction criteria. The second argument against maximum benefit distribution is that distributing organs in this way could leave the door open for bias, lying, favoritism and other unfair practices more so than other forms of distribution due to the subjective nature of these criteria. Third, some ethicists argue against using age and maximizing life years as criteria for distributing organs because it devalues the remaining life of an older person awaiting a transplant. Regardless of how old someone is, if that person does not receive a transplant they will still be losing "the rest of his or her life," which is valuable to everyone.