Academic journal article The Hastings Center Report

Directed Donation: The Relevance of Race

Academic journal article The Hastings Center Report

Directed Donation: The Relevance of Race

Article excerpt

In August 1990 the Office of the Inspector General released for comment a draft report entitled The Distribution of Organs for Transplantation: Expectations and Practice. [1] The finding in the draft report receiving the widest media attention was that blacks on kidney waiting lists wait almost twice as long as whites for a first transplant, even when such factors as blood type, age immunological status, and location are taken into account. The OIG report has added fuel to the ongoing debate about the racial factors in kidney allocation.

Studies have suggested that perceptions of inequity in organ distribution influence the decisionmaking process that black Americans go through when offered the opportunity to donate their own organs or those of a relative, and contribute to the low rate of black organ donation. This is especially tragic in light of the high rate of renal disease and the difficulty in antigen matching and successful transplantion among black Americans. [2]

The 1986 report of the Task Force on Organ Transplantation acknowledged that blacks are neither transplanted nor represented on kidney transplant waiting lists in numbers that reflect their proportion of the population on dialysis. However, it offered no insights into the medical and social problems that complicate the prospects of the black kidney recipients. Instead the task force limited itself to laudable and safe recommendations opposing "favoritism, discrimination on the basis of race, or sex, or ability to pay," proposing that "the effect of mandated organ sharing be constantly assessed to identify and rectify imbalances that might reduce the access of any group." [3]

The present United Network for Organ Sharing (UNOS) point system for allocation of donated kidneys to needy recipients is based on medical criteria predicting the chances of a successful graft, as well as the length of the patient's waiting time on the list. [4] The public attentino given to the draft report of the Office of the Inspector General has added to the pressure on UNOS to reexamine their allocation system for racial bias.

In other arenas of social policy such as education and employment, when patterns of discrimination against black people have been exposed, affirmative action policies have been proposed or implemented as remedies. How about affiramtive action for kidneys too? To suggest that the race of a donor or recipient might be used as a factor in kidney allocation conjures up images of South Africa, where precautions have been taken to prevent the blood and organs of donors from one race being used by a recipient from a different race. Any proposals for race-based allocation of kidneys must therefore be carefully made and argued on ethical and medical grounds. Even if such arguments have merit, the political prospects for "affirmative action" in kidney allocation would be questionable.

The Medical Evidence

The draft report from the Office of the Inspector General is only the latest in a series of studies over the past decade that have documented disadvantages faced by black prospective kidney recipients. Not only do blacks receive proportionately fewer kidneys, they also experience a 10 to 20 percent lower graft success rate. [5] The Patient Care and Education Committee of the American Society of Transplant Physicians has recently published the best overview of the literature and the issues. [6] The research on racial factors in the disparate success rates provides mixed data that make definitive medical conclusions difficult to reach. Since the allocation system used by UNOS relies heavily on probability of graft success as a major criterion for awarding points to people on the waiting list, the relationship between the two must be examined.

Since 1977 a variety of studies have reported that black recipients have significantly lower survival rates than white recipients, and that kidneys from black donors appeared not to have survived as well in recipients of either race. …

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