Faculty Bibliography

Those who advocate rationing access to health care to control escalating costs must adequately examine the field of organ transplantation, where rationing has been a harsh fact of life for many years. In our society, two paradigmatic cases illustrate rationing: a lifeboat with too many passengers aboard for the supply of food and water to keep alive, and battlefield triage with more wounded soldiers than medical personnel available to treat them. Examination of these cases reveals four criteria that must be fulfilled for rationing to be the only possible response to a resource shortage: Nothing can be done to stretch or divide the available resource to meet the needs of all seeking access to it. Those who seek access to the scarce resource need it to survive. Nothing can be done to increase the supply of the resource that is available. The resource is recognized as a benefit by both those who seek it and those who can provide it. For the most part, transplant decisions are surrounded by secrecy, and public input is minimal. Although many centers use psychosocial as well as medical criteria in deciding whom to admit to transplant programs, no consistent criteria have been developed among transplant centers. This secrecy and inconsistency could damage public support of organ transplant programs. If rationing is instituted in other areas of health care, public input must be sought in establishing equitable standards. The scarcity of organs for transplant cannot be changed, but this is not true in other areas of health care, where we can choose to build more facilities, eliminate waste, and dispense with unnecessary services.(ABSTRACT TRUNCATED AT 250 WORDS)

Total joint replacement has restored function and provided comfort to many patients who would otherwise have suffered. However, success and widespread diffusion of this procedure pose a number of important questions. The patient's and the doctor's criteria of success may not be the same: Which are to be used? Health resources are becoming limited: Should money be spent to restore function and for pain relief to those late in life or past their work life? Who makes this choice? A medical technology is tested in the best of settings but routinely practiced in many: How should society and health care professionals monitor the results of surgery? Who should do surgery and where should it be done?

The field of medical rehabilitation is relatively new.... Until recently, the ethical problems of this new field were neglected. There seemed to be more pressing concerns as rehabilitation medicine struggled to establish itself, sometimes in the face of considerable skepticism or hostility. There also seemed no pressing moral questions of the kind and intensity to be encountered, say, in high-technology acute care medicine or genetic engineering.... Those in biomedical ethics could and did easily overlook the quiet, less obtrusive issues of rehabilitation.... The Hastings Center set out in 1985 to rectify that situation.... To explore the issues, the Center assembled a group of practitioners in the field, Hastings Center staff members, and individuals experienced in other areas of medical ethics.... The report that follows was written by Arthur Caplan and Daniel Callahan, assisted by Dr. Janet Haas of the Moss Rehabilitation Hospital in Philadelphia....

KIE: The shortage of organs and tissues for transplantation in infants is particularly severe. Caplan considers the moral and public policy implications of utilizing abortuses and brain dead or anencephalic infants as donors. Arguments favoring their use include the potential benefits for research, benefits to existing infants born with fatal conditions, the ethical cost of relying on primates as sources of organs, and the providing of solace to grieving parents. Arguments against their use include the potential for coercion or conflict of interest in parental decisions about donation, the possibility that abortion may be encouraged, the fact that brain death is difficult to diagnose in infants while organ procurement from anencephalics may be considered murder, and the charge that an increase in infant transplants would be too costly. Caplan concludes that the arguments for using abortuses, anencephalics, and brain dead infants as organ and tissue donors outweigh the arguments against.