Harvesting Organs From the Poor. The American Way.

More sophisticated than whacking someone over the head and stealing their organs.

The papers and media are full of talk about former Vice President Dick Cheney’s recent heart transplant. There was much discussion about whether at age 71 he was too old, or whether he took advantage of special privileges to jump the line of thousands of others hoping to receive this potentially life-extending procedure. I am not prepared to comment on most of that: whether you call it an organ-allocation process or rationing, some will always consider themselves lucky, and others losers. I wish Mr. Cheney well.

Organ transplantation is often considered one of the triumphs of modern medicine. It has also made a lot of money for hospitals and doctors who do the procedures. Think of all the ads and press coverage we hear as hospitals seek to enhance their prestige and to attract other customers. The year I worked in Congress, Washington was attacked by lobbyists seeking to gain advantage in the national system of allocating donated organs. As much as these highly paid armies spoke of fairness, better outcomes, more equitable distribution, and the like; all of us staffers knew they were just fighting over the money. It was a cynical business.

The line in yesterday’s Associated Press’ coverage that caught my eye and reminded me of the institutional disparity of medical care in America was the explanation that patients can improve their chances of receiving an organ by getting on more than one transplant list “if they can afford the medical tests that each center requires to ensure eligibility, and can afford to fly there on short notice if an organ becomes available.” Of course Mr. Cheney had special advantage: he had money, health insurance, and people on his side!  I would hope for the same.

In yesterday’s Supreme Court questioning related to challenges to our new health care reform laws, Supreme Court Chief Justice John Roberts and Justice Scalia are reported to have complained that the law under review “would make people get insurance for things they may not need, such as transplants or pregnancy services.” But isn’t that the whole point about buying insurance? You pay for things you hope you will never need (unless you are involved in insurance fraud). It is disturbing to me to hear such words attributed to our highest judicial policymakers. We can’t pick and choose among which diseases may visit us in the future. By the logic of these jurists, we men should have much lower insurance premiums than women. I thought that issue was settled long ago, or were Justices Roberts and Scalia thinking ahead to their future participation in litigation over mandated coverage of contraceptives?  I hope they were just playing at being devil’s advocates.

A few years ago when I was still a healthcare lobbyist here in Louisville, I became involved in another transplantation controversy. I was then surprised to learn that the local hospital that had the monopoly on solid organ transplantation would not perform a kidney transplant on a Medicare patient regardless of age. Although these patients had health insurance, the argument was made that they could not afford the medicines necessary to suppress transplant rejection and that therefore the procedure would be wasted. Nice! And these were patients who had health insurance! I wonder what happened to patients who had no insurance at all?

And there lies the hypocrisy of these matters. There are a host of local and federal laws designed to increase the number of organs available for transplantation. I think of this every time I am asked to sign the back of my driver’s license. Hospitals have procedures in place to systematize asking the families of the dead or mostly dead for organ donation. These organ procurement mechanisms are applied across the board to the rich and the poor regardless of color. We put the weight of government behind asking people and their families to donate organs into a segregated system that denies them a reciprocal benefit. Why are we comfortable with that? In my vision of healthcare, the purpose of health insurance is to spread the risk of the few among the resources of the many. Is the American Way really all about hoarding what we have until we need help ourselves? I hope not.

Peter Hasselbacher, M.D.
March 28, 2012