The distribution of life-saving medical resources: Equality, life expectancy, and choice behind the veil

Social Philosophy and Policy

Volumn 19, Issue 2, 2002, Pages 212-244

  Stein, Mark S ^a  

^a YALE UNIVERSITY   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

AGE; ANALYTICAL APPROACH; ARTICLE; DISABLED PERSON; ETHICAL THEORY; ETHICS; HEALTH CARE AND PUBLIC HEALTH; HEALTH CARE ORGANIZATION; HOSPITAL ADMISSION; HUMAN; LIFE EXPECTANCY; ORGAN TRANSPLANTATION; PHILOSOPHICAL APPROACH; PROGNOSIS; QUALITY ADJUSTED LIFE YEAR; RANDOMIZATION; RESOURCE ALLOCATION; SOCIAL JUSTICE; STANDARD; UNITED STATES;

ANALYTICAL APPROACH; HEALTH CARE AND PUBLIC HEALTH; PHILOSOPHICAL APPROACH;

AGE FACTORS; DISABLED PERSONS; ETHICAL THEORY; HEALTH CARE RATIONING; HUMANS; LIFE EXPECTANCY; ORGAN TRANSPLANTATION; PROGNOSIS; QUALITY-ADJUSTED LIFE YEARS; RANDOM ALLOCATION; RESOURCE ALLOCATION; SOCIAL JUSTICE; UNITED STATES; WAITING LISTS;

EID: 0037514505     PISSN: 02650525     EISSN: None     Source Type: Journal    
DOI: 10.1017/S0265052502192090     Document Type: Article

References (130)

1. As I have elsewhere indicated, I am an intuitionist first and a utilitarian second. See Mark S. Stein, "Utilitarianism and the Disabled: Distribution of Resources, " Bioethics 16, no. 1 (2002): 1-19; and Mark S. Stein, "Utilitarianism and the Disabled: Distribution of Life, " Social Theory and Practice 27, no. 4 (2001): 561-78.
2. As I have elsewhere indicated, I am an intuitionist first and a utilitarian second. See Mark S. Stein, "Utilitarianism and the Disabled: Distribution of Resources, " Bioethics 16, no. 1 (2002): 1-19; and Mark S. Stein, "Utilitarianism and the Disabled: Distribution of Life, " Social Theory and Practice 27, no. 4 (2001): 561-78.
3. See John E. Roemer, Theories of Distributive Justice (Cambridge, MA: Harvard University Press, 1996), 161-62, for an example of this involving infant mortality.
4. Robert M. Veatch, Transplantation Ethics (Washington, DC: Georgetown University Press, 2000), 280, 288-89.
5. I discuss this issue further in Section IIIA.
6. See, for example, John McKie et al., The Allocation of Health Care Resources: An Ethical Evaluation of the 'QALY' Approach (Aldershot, UK: Ashgate, 1998).
7. Ibid., 99-116.
8. Stein, "Utilitarianism and the Disabled: Distribution of Life." The following three paragraphs are basically a summary of the arguments offered in that essay.
9. See also Ian Shapiro, Democratic Justice (New Haven, CT: Yale University Press, 1999), 207, on the paradoxes of using life expectancy as an allocation criterion.
10. I assume, unless otherwise specified, that both candidates for treatment would die without treatment at about the same time, so that the difference in posttreatment life expectancy is the same as the difference in overall life expectancy to be gained from treating one or the other of the candidates. For a discussion of contrary cases, see Section IIIB.
11. I say "almost complete priority, " because one can imagine cases in which the candidate from the "lucky" race has a very low posttreatment life expectancy in any event.
12. Amartya Sen, Inequality Reexamined (Cambridge, MA: Harvard University Press, 1992).
13. To its credit, utilitarianism is often associated with a concern to reduce suffering among animals as well as people. However, the issue of concern for animals does not necessarily distinguish utilitarianism from other moral theories. Egalitarians could seek to equalize welfare or resources between people and animals, and rights theorists could seek (and some do seek) to protect the asserted rights of animals.
14. Ronald Dworkin, Sovereign Virtue: The Theory and Practice of Equality (Cambridge, MA: Harvard University Press, 2000), 285-303.
15. My definition of welfare egalitarianism is even a little broader than Dworkin's; he hesitates as to Sen. Ibid.
16. Frances M. Kamm, Death and Whom to Save from It, vol. 1 of Morality, Mortality (New York: Oxford University Press, 1993), 237.
17. Ibid., 243.
18. He Sumner has advocated something close to such a life-satisfaction conception of utility. L. W. Sumner, Welfare, Happiness, and Ethics (Oxford: Oxford University Press, 1996).
19. Broome, "Good, Fairness and QALYs, " in J. M. Bell and Susan Mendus, eds., Philosophy and Medical Welfare (Cambridge: Cambridge University Press, 1988), 70.
20. A description and critique of the DALY measure, see Trude Arnesen and Erik Nord, "The Value of DALY Life: Problems with Ethics and Validity of Disability Adjusted Life Years, " British Medical Journal 319, no. 7222 (1999): 1423-25.
21. e et al. note that public-opinion surveys have found some support for the view that some priority in the distribution of life should be given to "children and young adults -particularly those with dependent children." See McKie et al., The Allocation of Health Care Resources, 118.
22. John Harris, "More and Better Justice, " in Bell and Mendus, eds., Philosophy and Medical Welfare, 92; Michael Lockwood, "Quality of Life and Resource Allocation, " in Bell and Mendus, eds., Philosophy and Medical Welfare, 50.
23. John Harris, "More and Better Justice, " in Bell and Mendus, eds., Philosophy and Medical Welfare, 92; Michael Lockwood, "Quality of Life and Resource Allocation, " in Bell and Mendus, eds., Philosophy and Medical Welfare, 50.
24. Lockwood, "Quality of Life and Resource Allocation, " 50.
25. Veatch, Transplantation Ethics, 336-51; Kamm, Death and Whom to Save from It, 234-40.
26. Veatch, Transplantation Ethics, 336-51; Kamm, Death and Whom to Save from It, 234-40.
27. For discussions of equality and time, see Larry S. Temkin, Inequality (Oxford: Oxford University Press, 1993), 232-44; and Dennis McKerlie, "Equality and Time, " Ethics 99, no. 3 (1989): 475-91. These authors do not focus on the distribution of life.
28. For discussions of equality and time, see Larry S. Temkin, Inequality (Oxford: Oxford University Press, 1993), 232-44; and Dennis McKerlie, "Equality and Time, " Ethics 99, no. 3 (1989): 475-91. These authors do not focus on the distribution of life.
29. This would not be a case of "leveling down" to equality; we would only be harming those who are better off if we could to some extent help those who are worse off.
30. See, for example, Judith Jarvis Thomson, The Realm of Rights (Cambridge, MA: Harvard University Press, 1990), 135-48.
31. See Section V below.
32. Or, equivalently, we must be confident that the difference between the less urgent candidate's life expectancy with treatment and his life expectancy without treatment is greater than the difference between the more urgent candidate's life expectancy with treatment and her life expectancy without treatment. Suppose that we can give life-saving treatment either to A or to B. Candidate A would die without treatment in one month, and she would die with treatment in six months. Candidate B would die without treatment in ten months, and he would die with treatment in fourteen months. Here, B would have a longer posttreatment life (fourteen months versus six months), but life-year maximization tells us to give the treatment to A, the more urgent candidate, because she would gain five additional months of life, while B would gain only four additional months of life. Equivalently, the fourteen-month posttreatment life of B, the less urgent candidate, would be one month shorter than the sum of (1) the posttreatment life of A, plus (2) the difference between the remaining life of B without treatment and the remaining life of A without treatment.
33. In practice, the imminence criterion is tied to the present moment, as there are always people who are about to die.
34. Veatch, Transplantation Ethics, 299.
35. Jon Elster, Local Justice: How Institutions Allocate Scarce Goods and Necessary Burdens (New York: Russell Sage Foundation, 1992).
36. See Section V below.
37. Kamm states that "one year to a 20-year-old may, morally speaking, be worth three to a 60-year-old." See Kamm, Death and Whom to Save from It, 316. For the reasons given in the text, I conclude that, at least in this example, Kamm actually gives life expectancy at least as much weight as age.
38. An advocate of random allocation might (or might not) give preference to candidates who had never previously received scarce life-saving medical resources.
39. John Harris, "Justice and Equal Opportunities in Health Care, " Bioethics 13, no. 5 (1999): 392-404; John Harris, "Would Aristotle Have Played Russian Roulette?" Journal of Medical Ethics 22, no. 4 (1996): 209-15; John Harris, "Double Jeopardy and the Veil of Ignorance - A Reply, " Journal of Medical Ethics 21, no. 3 (1995): 151-57; Harris, "More and Better Justice, " 75-96.
40. John Harris, "Justice and Equal Opportunities in Health Care, " Bioethics 13, no. 5 (1999): 392-404; John Harris, "Would Aristotle Have Played Russian Roulette?" Journal of Medical Ethics 22, no. 4 (1996): 209-15; John Harris, "Double Jeopardy and the Veil of Ignorance - A Reply, " Journal of Medical Ethics 21, no. 3 (1995): 151-57; Harris, "More and Better Justice, " 75-96.
41. John Harris, "Justice and Equal Opportunities in Health Care, " Bioethics 13, no. 5 (1999): 392-404; John Harris, "Would Aristotle Have Played Russian Roulette?" Journal of Medical Ethics 22, no. 4 (1996): 209-15; John Harris, "Double Jeopardy and the Veil of Ignorance - A Reply, " Journal of Medical Ethics 21, no. 3 (1995): 151-57; Harris, "More and Better Justice, " 75-96.
42. John Harris, "Justice and Equal Opportunities in Health Care, " Bioethics 13, no. 5 (1999): 392-404; John Harris, "Would Aristotle Have Played Russian Roulette?" Journal of Medical Ethics 22, no. 4 (1996): 209-15; John Harris, "Double Jeopardy and the Veil of Ignorance - A Reply, " Journal of Medical Ethics 21, no. 3 (1995): 151-57; Harris, "More and Better Justice, " 75-96.
43. Broome, "Good, Fairness and QALYs, " 57-73; John Broome, "Selecting People Randomly, " Ethics 95, no. 1 (1984): 38-55.
44. Broome, "Good, Fairness and QALYs, " 57-73; John Broome, "Selecting People Randomly, " Ethics 95, no. 1 (1984): 38-55.
45. Dan W. Brock, "Justice and the ADA: Does Prioritizing and Rationing Health Care Discriminate against the Disabled?" Social Philosophy and Policy 12, no. 2 (1995): 159-85; Dan Brock, "Ethical Issues in Recipient Selection for Organ Transplantation, " in Deborah Mathieu, ed., Organ Substitution Technology: Ethical, Legal, and Public Policy Issues (Boulder, CO: Westview Press, 1988), 86-99.
46. Dan W. Brock, "Justice and the ADA: Does Prioritizing and Rationing Health Care Discriminate against the Disabled?" Social Philosophy and Policy 12, no. 2 (1995): 159-85; Dan Brock, "Ethical Issues in Recipient Selection for Organ Transplantation, " in Deborah Mathieu, ed., Organ Substitution Technology: Ethical, Legal, and Public Policy Issues (Boulder, CO: Westview Press, 1988), 86-99.
47. See, for example, John Rawls, "Social Unity and Primary Goods, " in Amartya Sen and Bernard Williams, eds., Utilitarianism and Beyond (Cambridge: Cambridge University Press, 1982), 159-85; Bruce Ackerman, Social Justice in the Liberal State (New Haven, CT: Yale University Press, 1980), 46-48; and Dworkin, Sovereign Virtue, 11-64.
48. See, for example, John Rawls, "Social Unity and Primary Goods, " in Amartya Sen and Bernard Williams, eds., Utilitarianism and Beyond (Cambridge: Cambridge University Press, 1982), 159-85; Bruce Ackerman, Social Justice in the Liberal State (New Haven, CT: Yale University Press, 1980), 46-48; and Dworkin, Sovereign Virtue, 11-64.
49. See, for example, John Rawls, "Social Unity and Primary Goods, " in Amartya Sen and Bernard Williams, eds., Utilitarianism and Beyond (Cambridge: Cambridge University Press, 1982), 159-85; Bruce Ackerman, Social Justice in the Liberal State (New Haven, CT: Yale University Press, 1980), 46-48; and Dworkin, Sovereign Virtue, 11-64.
50. Harris, "More and Better Justice, " 93.
51. Broome, "Good, Fairness and QALYs, " 58-59.
52. Harris, "Justice and Equal Opportunities in Health Care, " 399.
53. Brock, "Justice and the ADA, " 168. The example Brock gives also involves a difference in quality of life, but I think that the difference in life expectancy does all of the intuitive work.
54. Ibid., 169.
55. Ibid.
56. Brock's weighted lottery might also give a greater chance to candidates who would have a better posttreatment quality of life, but I will ignore that issue here and focus on life expectancy.
57. John Rawls, A Theory of Justice (Cambridge, MA: Harvard University Press, 1971), 168. For an argument that the equiprobability assumption is required by the fundamental principle of equal respect for persons, see Ken Binmore, Playing Fair, vol. 1 of Game Theory and the Social Contract (Cambridge, MA: MIT Press, 1994), 338.
58. John Rawls, A Theory of Justice (Cambridge, MA: Harvard University Press, 1971), 168. For an argument that the equiprobability assumption is required by the fundamental principle of equal respect for persons, see Ken Binmore, Playing Fair, vol. 1 of Game Theory and the Social Contract (Cambridge, MA: MIT Press, 1994), 338.
59. A hypothetical-choice device is only utilitarian if the hypothetical choosers are risk neutral with respect to utility or welfare, not if they are risk neutral with respect to wealth. A hypothetical-choice device in which choosers were risk neutral with respect to wealth would be a wealth-maximizing system.
60. John Harsanyi, "Cardinal Utility in Welfare Economics and in the Theory of Risk-Taking, " Journal of Political Economy 61, no. 5 (1953): 434-35; John Harsanyi, "Cardinal Welfare, Individualistic Ethics, and Interpersonal Comparisons of Utility, " Journal of Political Economy 63, no. 4 (1955): 309-21; John Harsanyi, Rational Behavior and Bargaining Equilibrium in Games and Social Situations (Cambridge: Cambridge University Press, 1977), 48-83.
61. John Harsanyi, "Cardinal Utility in Welfare Economics and in the Theory of Risk-Taking, " Journal of Political Economy 61, no. 5 (1953): 434-35; John Harsanyi, "Cardinal Welfare, Individualistic Ethics, and Interpersonal Comparisons of Utility, " Journal of Political Economy 63, no. 4 (1955): 309-21; John Harsanyi, Rational Behavior and Bargaining Equilibrium in Games and Social Situations (Cambridge: Cambridge University Press, 1977), 48-83.
62. John Harsanyi, "Cardinal Utility in Welfare Economics and in the Theory of Risk-Taking, " Journal of Political Economy 61, no. 5 (1953): 434-35; John Harsanyi, "Cardinal Welfare, Individualistic Ethics, and Interpersonal Comparisons of Utility, " Journal of Political Economy 63, no. 4 (1955): 309-21; John Harsanyi, Rational Behavior and Bargaining Equilibrium in Games and Social Situations (Cambridge: Cambridge University Press, 1977), 48-83.
63. William Vickrey, "Measuring Marginal Utility by Reactions to Risk, " Econometrica 13, no. 4 (1945): 319-33; William Vickrey, "Utility, Strategy, and Social Decision Rules, " Quarterly Journal of Economics 74, no. 4 (1960): 507-35.
64. William Vickrey, "Measuring Marginal Utility by Reactions to Risk, " Econometrica 13, no. 4 (1945): 319-33; William Vickrey, "Utility, Strategy, and Social Decision Rules, " Quarterly Journal of Economics 74, no. 4 (1960): 507-35.
65. They are not so considered by everyone. See Roemer, Theories of Distributive Justice, 143 ("Harsanyi's aggregation theorem is not a theorem about utilitarianism").
66. I say "essentially utilitarian" because of the focus on relative benefit. However, a hypothetical-choice device could exclude considerations relevant to utilitarian analysis if it forced us to consider the interests only of candidates for treatment. See Stein, "Utilitarianism and the Disabled: Distribution of Life, " 575-76 (regarding the effect of discrimination on the general disabled community).
67. Ronald Dworkin, "What Is Equality? Part 2: Equality of Resources, " Philosophy and Public Affairs 10, no. 4 (1981): 283-345 (hereinafter "Equality of Resources"). Dworkin has recently republished "Equality of Resources, " virtually unchanged, as chapter 2 of his book Sovereign Virtue.
68. Ronald Dworkin, "What Is Equality? Part 2: Equality of Resources, " Philosophy and Public Affairs 10, no. 4 (1981): 283-345 (hereinafter "Equality of Resources"). Dworkin has recently republished "Equality of Resources, " virtually unchanged, as chapter 2 of his book Sovereign Virtue.
69. Ronald Dworkin, "Will Clinton's Plan Be Fair?" New York Review of Books, January 13, 1994, 20-25. Dworkin has republished most of "Will Clinton's Plan Be Fair?" as chapter 8 of Sovereign Virtue, under the title "Justice and the High Cost of Health."
70. Ronald Dworkin, "Will Clinton's Plan Be Fair?" New York Review of Books, January 13, 1994, 20-25. Dworkin has republished most of "Will Clinton's Plan Be Fair?" as chapter 8 of Sovereign Virtue, under the title "Justice and the High Cost of Health."
71. Norman Daniels, Am I My Parents' Keeper? An Essay on Justice Between the Young and the Old (Oxford: Oxford University Press, 1988), 40.
72. I have previously made an argument along these lines about Dworkin's system, with respect to the distribution of non-life-saving resources between the disabled and the non-disabled. See Mark S. Stein, "Ronald Dworkin on Redistribution to the Disabled, " Syracuse Law Review 51, no. 4 (2001): 987-1014.
73. Dworkin, Sovereign Virtue, 311-17.
74. Ibid., 316.
75. Ibid., 315.
76. A version of maximin that considered the young as "worse off" than the old would not necessarily approve of heroic measures to keep the old alive, but it could easily approve of heroic measures to keep the terminally ill young alive. While at one point Dworkin refers to the distribution of resources between the young and the terminally ill old (ibid 314), at other points he indicates that the prudent insurance test would not approve of massive expenses to buy short life extensions for terminally ill people in general (ibid., 315).
77. Ibid., 317-18.
78. Dworkin, "Equality of Resources, " 298 n. 6, reprinted in Dworkin, Sovereign Virtue, 478 n. 5.
79. Dworkin, "Equality of Resources, " 298 n. 6, reprinted in Dworkin, Sovereign Virtue, 478 n. 5.
80. Ibid.
81. Ronald Dworkin, Taking Rights Seriously (Cambridge, MA: Harvard University Press, 1978), 151.
82. In Sovereign Virtue, in a chapter on income support and American welfare reform, Dworkin briefly and opaquely rejects the idea that his system, based on hypothetical choice, is actually a version of utilitarianism. See Dworkin, Sovereign Virtue, 349-50. However, Dworkin does not appear to be aware of the main similarity between his system and utilitarianism, namely, the way in which his system, like utilitarianism, distributes resources to people who would derive greater benefit from those resources, even if those people are already better off than others. This is precisely what sets a maximizing theory like utilitarianism (or the life-expectancy approach) apart from egalitarian theories.
83. Norman Daniels, Just Health Care (Cambridge: Cambridge University Press, 1985); Daniels, Am I My Parents' Keeper?
84. Norman Daniels, Just Health Care (Cambridge: Cambridge University Press, 1985); Daniels, Am I My Parents' Keeper?
85. Daniels, Just Health Care, 57.
86. Ibid.
87. Ibid., 41.
88. Ibid., 35.
89. Ibid.
90. Daniels, Am I My Parents' Keeper? 40.
91. Ibid., 68.
92. Ibid., 75.
93. Ibid., 79.
94. Ibid, (emphasis added).
95. Ibid., 94-95.
96. Ibid., 95.
97. Ibid., 79.
98. Ibid., 95.
99. I believe that Thomson also borrows elements of utilitarianism when she argues that it is permissible to kill one person in order to save five if such a decision would be to the ex ante advantage of all six people. See Thomson, The Realm of Rights, 135-95. But space does not permit a full discussion of Thomson's theory.
100. Volker H. Schmidt, "Selection of Recipients for Donor Organs in Transplant Medicine, " Journal of Medicine and Philosophy 23, no. 1 (1998): 51-58.
101. UNOS is a private entity that performs quasi-public functions. UNOS administers the Organ Procurement and Transplantation Network (OPTN). The OPTN is also a private entity, but it is authorized by law to oversee numerous aspects of transplant medicine in the United States. See 42 U.S.C. §§ 273-74 (1999); and 42 C.F.R. pt. 121 (1999). In most respects, it has been accurate to say that UNOS is the OPTN, but the identity of these two quasi-official bodies may now be diverging.
102. UNOS is a private entity that performs quasi-public functions. UNOS administers the Organ Procurement and Transplantation Network (OPTN). The OPTN is also a private entity, but it is authorized by law to oversee numerous aspects of transplant medicine in the United States. See 42 U.S.C. §§ 273-74 (1999); and 42 C.F.R. pt. 121 (1999). In most respects, it has been accurate to say that UNOS is the OPTN, but the identity of these two quasi-official bodies may now be diverging.
103. Sheryl Gay Stolberg, "The Unlisted: Live and Let Die over Transplants, " New York Times, April 5, 1998, sec. 4, p. 3. The story quotes bioethicist Arthur Caplan as saying: "We love to fight as a society over who gets a transplant from the waiting list. What we are ashamed of asking is who gets on the waiting list. That is where the fiercest, toughest rationing takes place."
104. Ibid.
105. See, for example, Schmidt, "Selection of Recipients for Donor Organs in Transplant Medicine, " 55, for statistics concerning kidney transplants in Germany.
106. It used to be thought that a patient over 50 was too old for a heart transplant. See Special Advisory Group, National Heart, Lung, and Blood Institute, "Contraindications to Heart Transplantation, " in Mathieu, ed., Organ Substitution Technology, 308. Just in the few years between 1996 and 2000, the percentage of organ transplants going to patients over 65 has been rising. UNOS, "UNOS Critical Data: Transplants by Recipient Age, " available on-line at www.unos.org/newsroom/critdata_transplants_age.htm [retrieved July 5, 2001].
107. It used to be thought that a patient over 50 was too old for a heart transplant. See Special Advisory Group, National Heart, Lung, and Blood Institute, "Contraindications to Heart Transplantation, " in Mathieu, ed., Organ Substitution Technology, 308. Just in the few years between 1996 and 2000, the percentage of organ transplants going to patients over 65 has been rising. UNOS, "UNOS Critical Data: Transplants by Recipient Age, " available on-line at www.unos.org/newsroom/critdata_transplants_age.htm [retrieved July 5, 2001].
108. For example, the recipient of the first self-contained, battery-powered, artificial heart had been rejected as a candidate for a human heart transplant "because he had kidney failure and abnormally high blood pressure in blood vessels in his lungs which made a transplant unlikely to succeed." Lawrence K. Altman, "The Doctor's World-For Heart Surgeons, Many Careful Steps, " New York Times, July 10 2001 F1.
109. UNOS Policy 3.6, available on-line at http:/ /www.unos.org/ About/policy_policies03_06.
110. However, patients with chronic liver failure in Status 2A may be as close to death as are patients in Status 1. See ibid. for a full description of medical urgency statuses for livers.
111. UNOS Policy 3.7, available on-line at http:/ /www.unos.org/ About/policy_policies03_07. htm [retrieved July 1, 2001].
112. See ibid. for a full description of these statuses.
113. Ibid.
114. For livers, the Eurotransplant website lists, as allocation criteria, "blood group, the donor's weight, clinical urgency and waiting list." For hearts and lungs, Eurotransplant lists "blood group, the donor's height and weight, clinical urgency and waiting list." This information is available on-line at http:/ /www.eurotransplant.nl/about.cfm?content=20 [retrieved July 15, 2001].
115. UNOS Policy 3.6; UNOS Policy 3.7.
116. UNOS, "Response to HHS Concerns about UNOS Statements Regarding the Regulations, " available on-line at http:/ /www.unos.org/newsroom/archive_other_regs_response_ 061798.htm [retrieved July 1, 2001].
117. Children, especially, can benefit from split-organ transplants. See Mark A. Hardy and Elliott R. Goodman, "Transplantation, " Journal of the American Medical Association 271, no. 21 (1994): 1716-17.
118. For example, UNOS Policy 3.7.7 states that candidates for a heart/lung transplant will receive such a transplant if they are either (1) at the top of the heart list in priority, or (2) at the top of the lung list, and there is no suitable Status 1A heart candidate. See UNOS Policy 3.7.7, available on-line at http:/ /www.unos.org/ About/policy_policies03_07.htm [retrieved July 1, 2001].
119. This issue is the subject of some controversy, which I do not here address. See Institute of Medicine, Committee on Organ Procurement and Transplantation Policy, Organ Procurement and Transplantation: Assessing Current Policies and the Potential Impact of the DHHS Final Rule (Washington, DC: National Academy Press, 1999), 94-121.
120. Veatch, Transplantation Ethics, 325-35.
121. Age is a priority factor among pediatric candidates for kidney transplants, and pediatric candidates generally have priority with respect to organs from pediatric donors.
122. Henry Sidgwick, The Methods of Ethics, 7th ed. [1907] (Indianapolis, IN: Hackett Publishing Company, 1981), xxii.
123. Veatch, Transplantation Ethics, 312-13, 337; Schmidt, "Selection of Organ Recipients, " 56-58.
124. Veatch, Transplantation Ethics, 312-13, 337; Schmidt, "Selection of Organ Recipients, " 56-58.
125. Veatch, Transplantation Ethics, 337.
126. Yes, this is a tendentious statement, but egalitarian theorists make similar statements about their own favored theories, and without a trace of irony!
127. UNOS, "2000 SR and OPTN Annual Report, " table 54, available on-line at http:// www.unos.org/data/anrpt00/ar00_table54_11-li.htm [retrieved July 5, 2001].
128. Institute of Medicine, Organ Procurement and Transplantation, 88, 170-71.
129. For an extended account, see Veatch, Transplantation Ethics, 363-87. A national list would be more feasible for livers than for hearts and lungs, as livers can survive longer outside the body.
130. Institute of Medicine, Organ Procurement and Transplantation, 96. The Institute of Medicine is another private entity that is quasi-public in function. It is affiliated with the National Academy of Sciences and often provides advice to the federal government in the United States.