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?

Kidney tubules under the microscope
Kidney tubules under the microscope

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?"

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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.

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