Comments on: Maladministration of Organs

By: Ardeth

Ardeth — Sun, 06 Aug 2006 16:51:25 +0000

This is my first blog comment. I am, what is called in the business, a donor Mom. That means my child died, and her organs were donated. About a year after her death, I used my experience to volunteer to educate in the local high school Drivers’ Ed classes, so that students would know what they were signing up for, IF they put ORGAN DONOR on their licenses. Since I was a teacher/principal, the local Organ Procurement Agency was happy to get my services. I have since spent a lot of time educating myself on the fascinating/heart-breaking process called organ donation. You have said many correct things on this blog. I only wish to correct one mistake which is crucial to people’s understanding. IN THE UNOS SYSTEM, HOW MUCH MONEY YOU HAVE, OR THE COLOR OF YOUR SKIN DOES NOT GIVE YOU PREFERENCE FOR RECEIVING AN ORGAN!! There are inherent problems in any system, and the ones where people’s lives are at stake are especially galling. UNOS is not perfect, but it is the fairest, most complexly-complete one that really caring, educated medical people can contrive to this point. It will need to change (and so will the current health care payment systems) with the continued research findings that are a part of transplantation, and with new issues that will continue to arise, such as directed living donation. Yet, I have found in the 13 years since my daughter’s death, that this area of continuously evolving medicine and all the “people stories” that are associated with the process are inspiring.
P.S. Just as I tell all my Drivers’ Ed classes, if you don’t want to be an organ donor, I totally respect your wishes. I just want you to KNOW what you are deciding.

By: Barry

Barry — Sat, 05 Aug 2006 23:41:12 +0000

Jet, you’re probably wrong. I’ve yet to see something on CT where some guy doesn’t waltz in and approve of it.

By: eudoxis

eudoxis — Sat, 05 Aug 2006 23:33:58 +0000

Okay, the poor management of the kidney transplant program at Kaiser most likely entailed multiple problems, leading to poor patient care and, possibly, wrongful deaths. I’m not defending Kaiser. I am looking at organ allocation in a broader context and with some sympathy for those who die while on the waiting list during the normal course of events, whose families won’t be lucky enough to benefit from a settlement. I just don’t think that the equity of any kind of allocation system is ethically as straightforward as some of you seem to think.

By: ned510

ned510 — Sat, 05 Aug 2006 22:36:52 +0000

you are right, this is important, but seems to have been ignored. i used to work at kaiser as an internist, and am not surprised by the story. when i first started at kaiser, people said,”why do you want to work at kaiser?” later some of those same people said, “how can i work at kaiser?” over the years things changed. when i started and for several years there after the head of the department was always one of the best clinicians; now there are physician- administrators who spend the bulk of their time in administration, are not known for clinical skills, and the bottom line has replaced primum non nocere. the second reason is that in recent years kaiser has grown, and received awards for quality of care. this led to the head of my department saying that since we were the largest provider in the community, the way kaiser did things thus was the community standard. references to the way things were done
ouside of kaiser didn’t count.
the whole thing is terribly sad.

By: jet

jet — Sat, 05 Aug 2006 21:31:56 +0000

Eudoxis,
There are inequities and then there are inequities declared the best possible solution by society. One set of inequities applied to everyone outside of Kaiser HMO of Northern California. And another set of inequities, far less fair, applied to everyone inside Kaiser HMO of Northern California.

Either you don’t understand that and think all inequities are equally unfair, or you are a jury consultant scouring the web for ways to acid test possible defenses for Kaiser’s soon to be share plummeting stock prices. Since no one could be that stupid, I’m going with hypothesis number two.

By: eudoxis

eudoxis — Sat, 05 Aug 2006 15:56:12 +0000

Those are the realities of the ways in which those waiting lists are sorted. There are many inequities because of the nature of supply and demand. If a patient is someone famous, or even just white, or male, they have a greater probability of receiving a kidney than the others on the list.

The patients at PK were forced into a narrowed pipeline with no free recourse. There is something grossly injust about that. However, if this injustice is viewed as “killing”, then, to be consistent, every patient who doesn’t get a kidney when they need one is being killed by a deliberate decision.

By: bi

bi — Sat, 05 Aug 2006 15:27:19 +0000

eudoxis: Let’s say you stop using silly thought experiments.

By: eudoxis

eudoxis — Sat, 05 Aug 2006 15:12:47 +0000

Let’s say that UCSF resorted their list based on a maximally efficient algorithm that would lead to a net reduction in morbidity after transplant. The ethical dilemma is the same, some people with high priority are shifted to low priority.

By: Steve LaBonne

Steve LaBonne — Sat, 05 Aug 2006 14:37:57 +0000

I was lucky never to get really sick either but I was terrified of doing so and having no choice but to go to their crappy hospital (that too, in a city full of world-class hospitals.) And I wasn’t too impressed with the bottom-of-the-barrel PA’s I had to see as primary care providers, or the severely limited network of specialists.

By: Barry

Barry — Sat, 05 Aug 2006 14:31:33 +0000

edudoxix: “no medical malpractice…..”.

BWAHAHAHAHAHAHAHAHAHAHA!

By: John Emerson

John Emerson — Sat, 05 Aug 2006 12:29:17 +0000

I was with Kaiser for 5-10 years and was perfectly happy with them. Fortunately, I never got sick in any way during that period.

Eudoxis, that logic would justify almost anything. Minimally, we have a case here where a provider killed a number of its own patients because of bureaucratic carelessness. Maximally, they killed clients for fiscal reasons. Under these particular scarcity circumstances, it may indeed be that other equally meritorious patients elsewhere benefitted from the death of the Kaiser patients, but that doesn’t really exonerate Kaiser.

By: arthur

arthur — Sat, 05 Aug 2006 02:32:05 +0000

Because of some quirks in the medicare rules, kidney dialysis is incredibly profitable for both doctors and hospitals. You might expect that would make it unprofitable for insuraers, but in fact the expense is paid by medicare for almost everyone, even people who don’t otherwise qualify for medicare. Kidney transplants are only averagely profitable, and when successful they mark the end of the billing to medicare. Draw your own conclusions.

By: eudoxis

eudoxis — Sat, 05 Aug 2006 00:42:03 +0000

The demand for kidneys outpaces supply by about a factor of 20. There is no indication that available kidneys in California were not used during this fiasco, they simply ended up in a different set of patients. Nor is there any indication of medical malpractice, in fact, the transplants that were done at KP were very successful. While there is no excuse for bureaucratic incompetence, in essence this case is about a seemingly inequitable shuffling of the priority list. A list that is not very equitable to begin with. Why is seniority a top indication of need? There is real tragedy in all this but it’s larger than this case and may even be addressed in Kieran’s book.

By: mpowell

mpowell — Fri, 04 Aug 2006 23:00:31 +0000

A class action lawsuit on behalf of the families of deceased patients seems like the most likely legal result. I suppose that is pretty inadequate. But that’s going to be a common problen when you’re talking about health care and cost-cutting measures that run south. Unfortunately, cost-cutting measures are always required at some level and sometimes its going to get screwed up. Kaiser has a particularly bad reputation for it.

By: Steve LaBonne

Steve LaBonne — Fri, 04 Aug 2006 21:53:33 +0000

Years ago when I was a postdoc at Case Western I had to suffer through a period of “coverage” by Kaiser-Permanente of Ohio. They are THE PITS. Run, don’t walk, in the opposite direction if you’re ever offered a job in which a Kaiser HMO is your only health insurance choice.