Categories
Ethical Considerations Living Kidney Donor Organ Allocation

Rationing – the dirty word in the healthcare debate

Browsing through SRTR stats the other day, I ran across this data regarding kidney graft (transplanted organ) survival rates for those 65+ at the time of transplant.

Note: I really would like to see this broken down further by age so it would be possible to know how the graft survival is affected by each subsequent year. I’m also notating the year(s) when the info was compiled because they vary a bit. I’m guessing SRTR wanted as recent data as possible due to advances in anti-rejection meds and the like.

This applies to those receiving a living donor kidney:

3 months (2005-2006): 96.9%
1 year (2005-2006): 94.4%
5 years (2001-2006): 73.1%
10 years (1996-2006): 36.3%

If asked, a transplant professional will claim a living donor kidney lasts, on average, 15 years. Clearly that is not the case for this demographic.

With the knowledge that kidney transplants are not cures, and that a person can survive on dialysis (so the lack of a transplant is not condemning someone to die as popular opinion might think), should our transplant system reexamine the notion of giving living donor kidneys to those 65 and older?

The usual immediate reaction to this sort of proposal is a hearty “No!”, bringing to mind so-called death panels, or as I like to call it, ‘putting grandma on the ice floe’. But as I just stated, no one is being denied treatment. The national waiting list with deceased donor kidneys, dialysis, plus relevant medications and other therapies, are available.

There’s still a lot of cringing and that’s okay. No decent person really wants to see anyone die, even if we all intrinsically know that death is inevitable. In the U.S. we’re all brainwashed into believing that modern medicine should be employed until all avenues are exhausted, no matter the cost. A suggestion such as this would require a paradigm shift.

All transplant professionals acknowledge a severe kidney shortage, and living donor kidneys are seen as most valuable. So, does it makes sense for two-thirds of this precious resource to be destroyed in less than ten years on those 65 and over when 60-plus% of living donor kidneys given to receipients 64 and younger are still kicking at the ten year mark?

Let me put it another way – The transplant industry has lulled itself into believing that living donation is ‘ethical’ because the ‘benefit’ to the recipient outweighs the ‘risk’ to the living donor. But not all living kidney donors go on to have happy endings, and the more years spent as a one-kidneyed person, the higher the risk and incident of hypertension, cardiac issues and kidney disease/failure.

A. 1-2 living donors die per year, within 90 days of surgery. How many years should the recipient ‘get’ out of that kidney in exchange for their donor’s life?

B. Was condemning Daniel Huffman, 17, to sixty years with one kidney, not to mention the relinquishment of his dreams as a football player, worth the ‘benefit’ his 60-something-year-old, diabetic grandmother received from his kidney? Does it matter that her diabetes will eventually destroy the transplanted kidney too, if a pancreas transplant is not done? Or that Daniel committed suicide eight years later?

C. In the U of Minnesota study the media-types like to quote, the reported incident of end-stage renal disease (ie. in need dialysis/transplant) in living kidney donors was 180 per million in comparison to 268 per million in the general population. How many years should a transplanted kidney survive to compensate for putting another, previously healthy, person in dire straits with their own renal health?

Transplant recipients will never be free of their kidney disease, and living donors will never regain their pre-donation health and life. If we are to continue using living people for their kidneys, we must start examining each transplant in a greater context than what can be gained by the recipient. As Dr. Murray would say, it is our moral duty.

3 replies on “Rationing – the dirty word in the healthcare debate”

Part 2

quote
So, does it makes sense for two-thirds of this precious resource to be destroyed in less than ten years on those 65 and over when 60-plus
unquote
I was under the impression that most living donors were related or known to the recipient and if doctors chose to forbid a 65 year old from receiving that kidney then the donor just would not donate. We had a husband donate his kidney to his 70 year old wife, I think he was 72 years old.

quote
But not all living kidney donors go on to have happy endings, and the more years spent as a one-kidneyed person, the higher the risk and incident of hypertension, cardiac issues and kidney disease/failure
unquote
Would be good if you could give us a link to proof of this as personally I do not believe it at all. The risk is if you lead a bad lifestyle and not a healthy one. That is the choice of the donor not becuase of only one kidney. You eat too much sugar you will get diabetes whether one or two kidneys, makes no difference. And if one kidney fails due to diabetes or other disease then both do, so having only one makes very little difference. In fact by donating it has been shown that the person has excellent health via all the tests gone through and so far less likely to suffer any disease or illness that would affect the remaining kidney.

quote
Transplant recipients will never be free of their kidney disease, and living donors will never regain their pre-donation health and life
unquote
It all depends what was wrong with their kidneys as to whether they will stay healthy. Someone with a damaged kidney due to an accident for example that then leads to kidney failure, they should lead a perfectly healthy life after transplant. As for the donor, there is no reason at all why donors should not continue to lead very healthy lifestyles. Of course as a person gets older their age dictates their life anyway, so regardless of one or two kidneys everyone's lifestyle will deteriorate over time, but not due to only having one kidney. Generally donors lead a far healthier lifestyle than most people. There are quite famous sports people with only one kidney who are far healthier than some with two.
At the end of the day if a husband wants to try and save the life of the wife he is devoted to, or the sister save her brother or a neighbour a friend, it is their choice and their right to do so. Just as people have also given parts of their live and lungs to those they love. The love for that person far far outweighs the small risks involved in donating a kidney and is their choice to do so and should always remain their choice to be able to do so.

People do die on dialysis. Some also live horrendous lives on it. Only just recently someone had a transplant which gave them back their life as they spent 9 hours per day every other day on dialysis. Not everyone is 3 hours three times a week. She would not have survived into old age on dialysis. A transplant is the only hope for some people and many do die while wiating for a kidney, dialysis does not save their life it only prolongs it for so long. Noone can say how long someone will live on a transplanted kidney before they need another one. Many people live for 20+ years (not sure where your stats came from) and someone has even still got the same kidney they had 40 years ago. Others only last a few years, unfortunately there is no way to tell how long a living kidney will last so that equation should not be used in determining who dies and who doesnt. If a donor wants to give their kidney – let them. It is not for doctors to play God or to decide whether someone can give a kidney to their loved one or neighbour or best friend. Doctors should be grateful there is one less on the waiting list.

More to the point it should be made automatic that everyone is on the organ donor register and have to opt out if they dont want to. Many many more lives can be saved from deceased organs if only people signed up.

Hi,
Part 1
Quote
With the knowledge that kidney transplants are not cures, and that a person can survive on dialysis (so the lack of a transplant is not condemning someone to die as popular opinion might think),
unquote
Firstly people don't always live a long life on dialysis, it all depends how bad your kidneys are; what caused the kidney failure and other health aspects concerned with the kidney failure. Many people die while on dialysis waiting for a kidney transplant. So for quite a lot of people a transplant is the only thing that will save their life even if it means a second tranplant later.

quote
giving living donor kidneys to those 65 and older?
unquote

The usual immediate reaction to this sort of proposal is a hearty "No!",
unquote
Maybe that is the case in the USA but here in the UK it is most definitely not. 65 years of age is not classed as old here and the majority of people including health officials would not think twice about offering a living kidney to someone that age.

"Firstly people don't always live a long life on dialysis,"

People die after transplants too. In fact, some people who were functioning just fine on dialysis see their health deteriorate after a transplant. That's the point: there are no cures and no guarantees. The difference is that dialysis does not put another human being at risk.

"So for quite a lot of people a transplant is the only thing that will save their life even if it means a second tranplant later."

1. Again, transplants are NOT cures. Kidneys do NOT 'save a life'.

2. Each time a transplant fails, a recipient becomes sensitized and it is more difficult to find another compatible kidney. Exactly how many living donors lives must be compromised for the sake of one recipient? How much more valuable is a recipient over a donor (or donors)?

"I was under the impression that most living donors were related or known to the recipient and if doctors chose to forbid a 65 year old from receiving that kidney then the donor just would not donate."

Refer to Paired Kidney Donation, Kidney Chains and Anonymous/Stranger/Altruistic donation.

"Would be good if you could give us a link to proof of this as personally I do not believe it at all. "

Refer to the 'risks' page at http://www.livingdonor101.com. All stats are taken from research studies which are referenced in the site's bibliography.

"The love for that person far far outweighs the small risks involved in donating a kidney and is their choice to do so and should always remain their choice to be able to do so."

Relinquishing a major organ is not a 'small' risk. The clinical term the transplant industry utilizes is 'minimal' risk, which actually refers to clinical trials (so are living donors test subjects?) and the definition of 'minimal' is risk akin to that faced during normal, every day activities. Last time I checked, a hangnail would not kill me, cause permanent nerve damage, hernias, testicular swelling or kidney failure.

Case Western Reserve University's bioethics department appeared before a US public policy org protesting the characterization, and the Canadian org responsible for conducting research on living donation is also challenging its use.

"not sure where your stats came from"

I clearly linked where my stats originate – the Scientific Registry of Transplant Recipients. The .pdf docs are publicly accessible. Also see http://www.optn.org

"It is not for doctors to play God"

They do it every day.

I suggest reading "Doing Harm: living organ donors, clinical research and The Tenth Man" by C. Elliot from The Journal of Medical Ethics in 1995 and "Harm, ethics committees and the gene therapy death" by Julian Savulescu, also from the Journal of Medical Ethics in 2001. There is more to practicing medicine than 'patient autonomy', which you seem to stress in your comments.

Add Your Thoughts