Medicine can be an enormous force for good—and that very power raises difficult issues. One issue is figuring out who gets access to that healing power, and why, and when. Organ donation offers a particularly difficult case. How do we decide who gets a heart or a liver when there are simply not enough to go around? This is the question of microallocation; who gets which specific resources. [Read an article about an "Introductiuon to Micro-Allocation" by Michael A. Gillette, Ph. D., Bioethical Services of Virginia, Inc.]
But transplant technology also raises more general questions: Is this the best place to focus our efforts when there are so many other types of medical care that cost less and generate greater benefits? These are macroallocation questions: how, on a large scale, do we as a society decide to spend the funds we have available for health care? The United States and Canada, for example, have followed different paths in distributing health care. It’s worth thinking about how those two different systems look from a Christian perspective.
Let’s begin with questions about who is eligible to receive specific resources. We’ll use organ transplants as our central example, although the discussion applies to other limited resources as well: beds in intensive care units or nursing homes; respirators, especially if the community faces a serious outbreak of influenza; or access to MRI scanners and other diagnostic tools.
Donor organs are in very short supply. Over 100,000 people are on waiting lists but only around 40,000 organs are donated each year. Why the shortage of donors? For one thing, newer safety regulations (such as motorcycle helmet and seat belt laws) mean fewer people die in accidents now than in the past. (Young, healthy accident victims offer the best source of organs.) Many people don’t sign their donor cards for religious or personal reasons, and even if an accident victim’s card is signed, hospitals generally won’t harvest organs without the family’s consent. Some organs and tissue, of course, can come from living donors (kidneys, bone marrow, sometimes a lobe of a liver), but with the exception of bone marrow, these pose a significant risk to the donor.
When there is simply not enough of any resource to go around, society needs to come up with a system of distribution that allows people to have at least a fair shot at that resource. Putting such a system in place for organ transplants has been extremely difficult. In the early days, transplant decisions were made either by individual doctors or committees formed for that purpose. Both regularly used “social worth” criteria for deciding who deserved the organs: they would favor patients who appeared to be good, worthwhile citizens. People who had professional careers, children, and stable home lives were placed ahead of those who experienced periods of joblessness or who had substance abuse problems or a few close family members.
As this system of making decisions came under scrutiny, critics argued that reserving organs for people who meet certain social standards is unfair and unjust. Today health care systems try to use only medical criteria to make decisions about who gets organs. These criteria include general health, blood-type compatibility, and ability to deal with the after-effects of the surgery. (Transplants require antirejection drugs that can have unpleasant side effects and must be taken regularly. Patients need to be capable of keeping to a schedule, or they need family members who will take care of them.) But the line between social and medical criteria is a blurry one. People with stable families are less of a medical risk for transplant follow-up care—so this social issue is medically relevant, as are issues of substance abuse and healthy lifestyle.
Another set of issues revolves around people’s ability to pay. In order to be placed on a waiting list, patients need to show that they have the means to pay for the transplant, either by private insurance or some other source of financing. Medicaid covers some transplants in some states but not in others. We’ve all seen change jars on the counter in convenience stores seeking donations to help pay for a person’s transplant fees—an indication of how many folks don’t have the financial resources to be eligible for transplants. This raises the same issues as social worth criteria—if it is wrong for people to be excluded from life-saving technology on the basis of social position, isn’t it also wrong for them to be excluded on the basis of financial considerations?
Publicity can also factor into the selection process. People who are famous or who have media attention drawn to their case often seem to receive organs ahead of others. In 1995, Mickey Mantle received a donated liver after just two days on the waiting list. This generated intense public debate that was particularly contentious because of Mantle’s history of alcohol abuse. In Mantle’s case, though, the issue at stake was tissue compatibility. Shortly after his transplant, another liver with a similar tissue match had to be sent elsewhere for lack of a suitable recipient. Even so, the concerns raised in the Mantle case are legitimate—celebrity status should not be a factor in the selection process for receiving organs.
Still another set of issues arises over the question of whether the selection process should favor those who are the sickest (and so, some argue, the neediest) or those who are the healthiest (and thus most likely to be successful candidates and to be able to use the organ for the longest period of time). Arguments can be made on both sides: the sickest are most likely to die without the transplant, but to deny healthier candidates an organ and give it to someone so sick that he or she doesn’t survive the surgery seems morally problematic.
Today organ allocation is governed by a set of guidelines created by the United Network for Organ Sharing (UNOS). This organization was created to make organ allocation fairer and more transparent and to coordinate organ transplantation. UNOS provides information about organ transplant policies, sponsors public debate, and ensures accountability for the whole process.
The policymakers of UNOS are responsible for establishing a fair set of guidelines to govern access to organs. But an important, broader question remains. Should we try to provide organ transplants to all who could benefit from them? Is this really the best policy for United States medicine?
Commentators sometimes note that medicine is a victim of its own success. Most businesses go bankrupt because they aren’t very good at what they do; medicine risks going bankrupt because it is very, very good at what it does. We see this dynamic at work in the field of organ transplants. Before transplants were widely available, people with organ failure would die. The medical costs of end-of-life care were fairly limited. Now a person with end state renal disease can be kept alive indefinitely on dialysis or can receive a kidney transplant (the success rate for kidney transplants are very high). The cost of dialysis is, on average, $65,000 per year. Kidney transplant surgery costs about $102,000, and the cost of antirejection drugs and follow-up care ranges from $6,000 to $10,000, depending on other complications such as diabetes.
When the treatment was less effective, people with kidney disease generated fairly few expenses. Now that far better treatments are available, the expenses associated with renal disease have skyrocketed. And this is true of almost every area of health care. The better we get at offering high-technology treatments for health problems, the more people will use them, and the less we can all afford health insurance.
At the same time that these high-tech interventions for relatively few people are generating skyrocketing health care expenses in the United States, millions of people lack basic care (including prenatal care and regular checkups). For society as a whole, basic care is far more effective in terms of dollars spent.
These broader issues will not go away any time soon. As Christians we should have a voice in the national conversation about health care. Our concern for justice prompts us to think through what sorts of health care our society should provide for all its members. Certainly some level of basic care should be available for everyone. At the same time, recognizing that resources are finite, and that we also need to provide services such as police protection, education, and environmental oversight for the public good, we also need to be realistic about the limits of the care we can provide.
The idea that all members of society deserve some basic level of health care raises two difficult questions. First, what is that basic level of health care? Whatever level we decide upon, we are certain to face difficult issues when individuals want and need more care but don’t have the money to pay for it. Using citizen focus groups and extensive statewide discussions, the state of Oregon tried to define basic care for its citizens and settled on a list of medical treatments that could be offered to all citizens. They also had to decide which treatments would not be covered—and liver transplants were among them. Within a year, a young boy whose family had a very low income needed a liver transplant. Without it he was sure to die. At first the state refused to pay, but the public was outraged and operation was covered.
This worked out well for the boy who needed a liver. But it did not work so well for the many Oregonians who then lost insurance coverage because the state could no longer afford to provide care for all. The fact is that individual life-or-death cases often capture enough media attention to determine policy without any careful discussion about what that change in policy means for thousands of other people.
The second difficult question raised by the idea of basic care concerns the definition of membership in the community. We in the United States can be justly proud of our heritage as a nation of immigrants. But many citizens object to providing medical care for immigrants, regardless of their legal status, and several states have passed legislation prohibiting Medicaid care for immigrants. This is hard to justify from a Christian perspective. Deuteronomy 24 reminds us that the poor and needy, whether citizens or aliens, are to be treated justly.
A just legal system should take account of the differences between legal immigrants, illegal immigrants, and citizens. But whatever policies we as a nation put in place to respond to the medical needs of legal or illegal immigrants, the Christian community must speak out against unjust or vicious responses. Immigrants are fellow image bearers of God, and we can never justify treating them as anything less.
It is interesting to compare the results of health care systems that provide care for all their citizens (Canada and Great Britain, for example), and those that use mixed systems of government funding, private insurance, and the free market to distribute health care, such as the United States. Most free market proponents argue that any system of universal health care would be far more expensive than a free market system. But analysis of health care in these countries does not bear this out: although both Canada and Great Britain and spend quite a bit less, per capita, than the United States, their health care (measured in terms of infant mortality, longevity, and the like) is slightly better. Both the Canadian and British systems limit access to a variety of procedures, either in the form of lengthier waits for some procedures or more stringent limitations on who qualifies for certain transplant procedures. Americans have not traditionally been willing to accept such limits to access.
As we’ve seen, the fair allocation of health care raises difficult questions from a Christian standpoint. On the one hand, we should be critical of a sense of entitlement and the demand for all the latest technology. On the other, we are to be concerned with providing care for everyone. As a society, our answers to these questions say much about which people we value—and which we do not.
Contemporary high-tech medicine is a wonderful gift for which we can thank God. At the same time, it raises unexpected and very difficult questions about what sorts of treatment we can fund, for whom, and under what circumstances. These are difficult questions because the answers may not be the ones we want to hear. Remembering that it is not medicine that provides our lives with meaning and salvation allows us to keep these issues in perspective as we try to address them as a community. One thing is sure: there are no easy answers when it comes to deciding whether to fund basic care for chronic conditions or high-tech care for extreme conditions. We don’t have enough resources to provide both, and either answer leaves someone without needed care.
But we do know that Christians are called to speak up for the most vulnerable in our society and to make sure that their needs are met. As a society, we may freely debate and reason together about these matters. As hard as that conversation may be, it is one we need to engage in humbly, prayerfully, lovingly, and honestly.
Reprinted with permission from Bioethics: A Reformed Look at Life and Death Choices by Ruth Groenhout © 2009 Faith Alive Christian Resources. To order a copy call (800) 333-8300 or visit www.faithaliveresources.org or www.calvin.edu/campus-store.