The NY Times (“In Discarding of Kidneys, System Reveals Its Flaws“) had an interesting article on one of the main issues of Kidney allocation:
Last year, 4,720 people died while waiting for kidney transplants in the United States. And yet, as in each of the last five years, more than 2,600 kidneys were recovered from deceased donors and then discarded without being transplanted, government data show.
The question is why. One may conclude that the system is just inefficient, yet a closer look reveals that this inefficiency is rooted in many important principles, regulations, and incentives, all while attempting to create a fair system. In order to better understand the issues, we need to understand how kidneys are being allocated in the US: The country is divided into 58 districts. When a kidney of a deceased person becomes available, the system allocates it to the person with the highest priority within that region. This priority is a function of the waiting time, whether a recipient is a child or not, as well as other factors. The system does not consider the projected life expectancy of the recipient or the urgency of the transplant. The allocation is initially local, and only when there is no match, the search expands to other regions. All of that is done while competing against the clock: Kidneys start to degrade after 24-36 hours. The system is allowed to make offers to only a limited set of hospitals at any point in time, and these, in turn, have an hour to respond.
The consequence of the above-described system is that people that are at the top of the list may have an incentive to turn down a kidney if they believe that the “quality” of the kidney is not as high as they wish. With every decline, the time passes, and the likelihood of discarding the kidney goes up. If this is not complicated enough, in an attempt to improve the quality of care, the government may have made things even worse. In 2007, the federal agency that manages Medicare began to require that the number of failures of each program be below a certain level. If not, programs are flagged, and then put on probation.
In interviews, dozens of transplant specialists said the threat of government penalties had made doctors far more selective about the organs and patients they accepted, leading to more discards. “When you’re looking at organs on the margins, if you’ve had a couple of bad outcomes recently you say, ‘Well, why should I do this?’ ” said Dr. Lloyd E. Ratner, direct of renal and pancreatic transplantation at NewYork-Presbyterian/Columbia hospital. “You can always find a reason to turn organs down. It’s this whole cascade that winds up with people being denied care or with reduced access to care.
What’s the solution? Suggestions to account for the recipient’s age and life expectancy were declined since they discriminate on the basis of age (which is against the law in the US.) Another proposal would give individuals in different age brackets equal chance to get a transplant in a given year, all while allocating the “best” kidneys to the youngest recipients. These will only solve part of the incentives