Should criminals have equal access to scarce treatment?

Health and medicine explained.
June 17 2008 3:33 PM

The God Committee

Should criminals have equal access to scarce medical treatments?

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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.

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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.

Sally Satel is a psychiatrist and resident scholar at the American Enterprise Institute.

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