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2001 (23) Heft 2

Making Choices in Organ Allocation


Guest-Editors: Marlies Ahlert / Hartmut Kliemt

Abstracts | Inhalt

1. Introduction

Hartmut Kliemt
Organtransplantation im Eurotransplantverbund. Geschichtliche, medizinische und organisatorische Aspekte

Abstract: To facilitate access fort he wider international audience interested in issues of organ allocation the texts in this volume are all in English. But in view of the fact that ANALYSE & KRITIK, though an international journal, is published in Germany it seemed appropriate to provide a German introduction and overview. This overview outlines the background of organ donation and transplantation as seems useful for the 'uninitiated' reader and positions the papers of the volume on the intellectual map. In the end the articles of the volume speak for themselves while the comments that conclude it may be helpful as springboards for further critique.

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2. Theoretical and Programmatical Perspectives on Organ Allocation

Marlies Ahlert / Gundolf Gubernatis / Hartmut Kliemt
Kidney Allocation in Eurotransplant. A Systematic Account of the Wujciak-Opelz Algorithm

Abstract: In the Eurotransplant region transplantable kidneys from cadaveric donors are allocated according to the Wujciak-Opelz algorithm. This paper shows that the algorithm as it stands fulfils certain normative standards of a more formal nature while violating others. In view of these insights, it is explored how the algorithm could perhaps be improved. Even if issues of substantial rather than formal adequacy need to be addressed separately, analyses as presented in this paper can prepare the ground for a discussion of substantive normative issues. In any event, axiomatic accounts can tell us something about what we are in fact doing when using a procedure like the Wujciak-Opelz algorithm.

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Matthias Hild
Fair Kidney Allocation Based on Waiting Time

Abstract: We study the allocation of cadaveric donor kidneys for transplantation based merely on waiting time. This simple allocation rule turns out to possess very attractive ethical and medical properties. Current allocation rules, on the other hand, violate some basic requirements of distributive justice. Perhaps for fear of exacerbating these problems, these rules also fail to consider criteria such as sex, age and race although certain combinations of these criteria are known to affect graft survival rates. We demonstrate that allocation by waiting time automatically protects disadvantaged patient types and puts them in a near optimal position. The inclusion of sex, age and race will therefore not lead to morally unacceptable allocations. This allows individual patients to improve the expected survival time of their graft relative to the status quo without being penalized by the allocation rule. Moreover, decisions about when to start compromising on expected graft survival rates in favour of shorter waiting times are made locally by patients and their medical advisers rather than by a centralized protocol.

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3. On the Evolution of the Organ Allocation Algorithm

Marlies Ahlert / Hartmut Kliemt
A Lexicographic Decision Rule With Tolerances. The Example of Rule Choice in Organ Allocation

Abstract: The implementation of the Wujciak algorithm as a new rule for organ allocation by Eurotransplant is of considerable interest for the theorist of choice making. In the process reformers accepted the status quo in principle but expected that their potential opponents would be willing to make minimal or 'tolerable' concessions. Thereby the consensual introduction of new dimensions of value and reforms of allocation practices based thereupon became viable. The paper characterizes a decision procedure based on ,almost lexicographically pre-ordering established values and practices, in a stylized manner, presents a formal reconstruction of it and points out some of its potential implications for rule choices in general.

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Werner Güth / Hartmut Kliemt / Thomas Wujciak
Hard Choices Softened Locally. Enacting New Rules for Organ Allocation

Abstract: The implementation of a new kidney allocation algorithm by Eurotransplant was a 'rule choice' with serious ethical, legal, and political implications. Eurotransplant made that choice in view of a careful analysis of empirically predictable consequences of alternative rule specifications. This paper studies in a stylized way how the decision on the allocation algorithm emerged. Hopefully an understanding of central features of the described successful case of initiating improvements may be helpful in other cases with a similar structure.

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4. Empirical Findings on Value Judgements Concerning Organ Allocation

Marlies Ahlert / Gundolf Gubernatis / Ronny Klein
Common Sense in Organ Allocation

Abstract: In a questionnaire study on organ allocation 348 students of medicine (102) and economics (246) at the universities of Halle (114 students) and Hannover (234 students) responded to questions concerning their basic attitudes toward alternative criteria of organ allocation. Medical criteria were widely accepted by the respondents. Considerations concerning the patient's value to society were seen as being of minor importance. With respect to reciprocity, we could detect a high share of respondents who would favor former living donors and discriminate against murderers. Among considerations of fairness, the criterion of waiting time gained the highest support. Furthermore, majorities favored the view that health-compromising behavior and differences in age should play a role. Economic considerations were strongly rejected as criteria of organ allocation.

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Adele Diederich
A Rational Reconstruction of Expert Judgements in Organ Allocation. A Conjoint Measurement Approach

Abstract: The Eurotransplant Kidney Allocation System (ETKAS) emerged from the XCOMB model by Wujciak and Opelz (1993a;b), who applied computer simulation studies to create an allocation algorithm. The present study investigated how experts would allocate a donated organ to patients on the waiting list with respect to the five allocation factors proposed in the ETKAS (number of mismatches, mismatch probability, waiting time, distance, international exchange balance). The expert's evaluations were compared to the ETKAS points as well as to factor weights established in mandatory allocation guidelines which are based on the German law for organ allocation (Transplantationsgesetz). The investigation was carried out using a conjoint analysis. Overall, the results indicate a fairly high degree of agreement between the expert's opinions and the existing allocation system ETKAS and even more so for the allocation guidelines in particular with respect to the factors 'Mismatches', 'Mismatch', 'Probability', and 'Waiting time'.

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Marlies Ahlert
Patterns of Decision Making in Kidney Allocation

Abstract: Experts in the field of organ transplantation had to rank order a set of 32 patients according to their priority in receiving a donated kidney. The patients were described by the five characteristics that are incorporated in the kidney allocation algorithm applied by ,Eurotransplant,. The priority rankings as defined by the experts were analyzed and patterns of decision making identified in the rankings investigated in this study. All patterns could be explained by some type of lexicographical ranking. The larger group of experts preordered tissue compatibility or, more technically speaking, the criterion of HLA match, while the complementary group applied the criterion of the length of waiting time first. Analyzing the finer decision structures of expert rankings and comparing the method of pattern exploration with a conjoint measurement analysis led to two follow-up questions: First, how can the value judgments of the experts be described adequately? Second, which type of aggregated ordering derived from the individual rankings represents them best?

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5. Further Thoughts and Comments

Georg Marckmann
The Eurotransplant Kidney Allocation Agorithm Moral Consensus or Prgamatic Compromise?

Abstract: The selection and balancing of values for the Eurotransplant kidney allocation algorithm poses both practical and ethical challenges. The paper argues that any allocation algorithm can only be justified by reference to some substantive conception of a good life that reflects our value preferences regarding the allocation of scarce donor kidneys. It is concluded that the criterion of HLA compatibility maximizes overall rather than individual utility. The paper emphasizes that good pragmatic arguments for maintaining the primacy of HLA matching can never replace a more systematic, independent ethical justification. As neither the selection nor the balancing of the different allocation criteria are based on an explicit ethical justification, the paper concludes that the choice of the Wujciak-algorithm was rather a product of pragmatic compromise than moral consensus.

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Axel Ockenfels / Joachim Weimann
The Supply Side of Organ Allocation

Abstract: The benefits of a large organ pool accrue not only to the actual organ recipients themselves, but to others as well due to the insurance it provides against having to wait 'too long' for an organ transplant. We argue that this public good character of a large organ pool makes it economically and ethically justifiable to design a market mechanism that boosts the number of donors. Most importantly, such a mechanism has the potential to substantially alleviate the troubling equity and efficiency problems on the demand side while, at the same time, being entirely independent of the allocation algorithm used for the distribution of organs.

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Thomas Schmidt
Distributive Justice in Kidney Allocation

Abstract: For patients suffering from renal failure, cadaveric donor kidneys are a scarce and valuable good. In 1996, the Eurotransplant International Foundation implemented a new kidney allocation system. The aim of this paper is to identify and discuss issues of distributive justice in kidney allocation, with an emphasis in the basic features of the new Eurotransplant system. Particular consideration is given to waiting time and medical success.

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