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Priority setting in kidney transplantation: A qualitative study evaluating Swedish practices
Linköping University, Department of Medical and Health Sciences, Health and Society. Linköping University, Faculty of Health Sciences.
Linköping University, Department of Management and Engineering, Economics. Linköping University, Faculty of Arts and Sciences. Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.ORCID iD: 0000-0002-8159-1249
Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Health Sciences.
Department of Nephrology and Transplantation, Skåne University Hospital (Malmö), Lund University, Malmö, Sweden.
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2013 (English)In: Scandinavian Journal of Public Health, ISSN 1403-4948, E-ISSN 1651-1905, Vol. 41, no 2, 206-215 p.Article in journal (Refereed) Published
Abstract [en]

Background: Kidney transplantation is the established treatment of choice for end-stage renal disease; it increases survival, and quality of life, while being more cost effective than dialysis. It is, however, limited by the scarcity of kidneys. The aim of this paper is to investigate the fairness of the priority setting process underpinning Swedish kidney transplantation in reference to the Accountability for Reasonableness (A4R) framework. To achieve this, two significant stages of the process influencing access to transplantation are examined: assessment for transplant candidacy, and allocation of kidneys from deceased donors.

Methods: Semi-structured interviews were the main source of data collection. Fifteen Interviewees included transplant surgeons, nephrologists, and transplant coordinators representing centers nationwide. Thematic analysis was used to analyze interviews, with the Accountability for Reasonableness framework serving as an analytical lens.

Results: Decision-making both in the assessment and allocation stages are based on clusters of factors that belong to one of three levels: patient, professional, and the institutional levels. The factors appeal to values such as maximizing benefit, priority to the worst off, and equal treatment which are traded off.

Discussion and Conclusions: The factors described in this paper and the values on which they rest on the most part satisfy the relevance condition of the accountability for reasonableness framework. There are however two potential sources for unequal treatment which we have identified: clinical judgment and institutional policies relating both to assessment and allocation. The appeals mechanisms are well developed and supported nationally which help to offset differences between centers. There is room for improvement in the areas of publicity and enforcement. The development of explicit national guidelines for assessing transplant candidacy and the creation of a central kidney allocation system would contribute to standardize practices across centers; and in the process help to better meet the conditions of fairness in reference to the A4R. The benefits of these policy proposals in the Swedish kidney transplant system merit serious consideration.

Place, publisher, year, edition, pages
Sage Publications, 2013. Vol. 41, no 2, 206-215 p.
Keyword [en]
Ethics, fairness, kidney transplantation, priority setting, Sweden
National Category
Social Sciences
URN: urn:nbn:se:liu:diva-71309DOI: 10.1177/1403494812470399ISI: 000315233100014OAI: diva2:447220
Available from: 2011-10-11 Created: 2011-10-11 Last updated: 2015-09-22Bibliographically approved
In thesis
1. Just Waiting: Ethical Challenges in Priority Setting Posed by Organ Scarcity in Kidney Transplantation
Open this publication in new window or tab >>Just Waiting: Ethical Challenges in Priority Setting Posed by Organ Scarcity in Kidney Transplantation
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Over the last few decades kidney transplantation has transformed from an experimental treatment to the treatment of choice for end-stage renal disease. Unfortunately, however, the established organ donation models in many countries, relying chiefly on altruism, fail to motivate a sufficient number of donors. As a consequence, many lives which could be saved are lost, and others which can be improved are left to deteriorate.

Dealing with the challenge of scarcity in kidney transplantation requires a dual approach. In the immediate term, we must ensure the fair distribution of kidney transplantation as a scarce medical resource. In the long term, we must find a policy level solution to mitigate the root issue of scarcity. The policy approach promoted in this thesis is the introduction of incentive based organ donation. Fair resource allocation, and incentive based donation are two themes which raise interesting normative questions, and ethical challenges. Each theme corresponds to two paperswhich form the basis for the thesis.

Papers I &II, evaluate fairness in the priority setting processes underpinning access to kidney transplantation; this is done both within Sweden's four transplant centers and the Toronto General Hospital in Canada. The criteria, values, and procedures used in clinical decision-making are analyzed to identify barriers to fairness and how such barriers can be removed.

Papers III and IV, propose incentive based living kidney donation and incentive based deceased donation, respectively, as policy solutions to the organ scarcity. The most frequently raised ethical objections against incentive based models are discussed in a bid to demonstrate the moral permissibility of incentive based organ donation.

The discussion about fairness, and incentive based models, highlights that the ethical challenges raised by kidney scarcity are inherently difficult. While we may not find infallible solutions we certainly can work towards better solutions. We can create clinical priority setting processes, that while not perfect, move us closer towards increased fairness by removing clear obstacles to just distribution. We can create organ donation policies while not free of ethical challenges; do not shy away from all risk, or from asking the difficult questions.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2011. 87 p.
Linköping Studies in Arts and Science, ISSN 0282-9800 ; 544Linköping Dissertations on Health and Society, ISSN 1651-1646 ; 20
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
urn:nbn:se:liu:diva-71197 (URN)978-91-7393-068-0 (ISBN)
Public defence
2011-09-29, Berzeliussalen, Campus US, Linköpings universitet, Linköping, 13:00 (English)
Available from: 2011-10-11 Created: 2011-10-05 Last updated: 2012-10-18Bibliographically approved

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