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Priority Setting in the Assessment for Kidney Transplant Candidacy: a Canadian Case Study
Linköping University, Department of Medical and Health Sciences, Health and Society. Linköping University, Faculty of Health Sciences.
Joint Center for Bioethics, Deptartment of Surgery, Faculty of Medicine, University of Toronto, Canada.
(English)Manuscript (preprint) (Other academic)
Abstract [en]

The benefits of kidney transplantation for treating kidney failure are well documented in terms of life expectancy, quality of life, and cost savings, making it the treatment of choice. It is however limited by the chronic shortage of kidneys. This study’s objective is to examine the fairness of the priority setting process underpinning the assessment for kidney transplant candidacy in one of Canada’s largest transplant programs at the Toronto General Hospital (TGH). This is done in reference to the Accountability for Reasonableness; a leading international framework in health care priority setting.

The study relies on three sources for data collection: semi structured interviews, process observation, and review of relevant documents.

The process underpinning the assessment for kidney transplantation is based on clusters of medical criteria reflecting the Canadian national consensus guidelines on eligibility for kidney transplantation. The process is permeated by ethical principles such as: maximizing benefit, equal treatment, and respect for autonomy; which are widely considered relevant in the distribution of scarce medical resources and in medical ethics generally. The criteria for assessment are well publicized and easily accessible while appeals through second opinions are well developed and supported. The process underpinning access to kidney transplantation at the TGH readily satisfies the conditions for fairness in references to the Accountability for Reasonableness framework.

National Category
Health Care Service and Management, Health Policy and Services and Health Economy
URN: urn:nbn:se:liu:diva-71311OAI: diva2:447221
Available from: 2011-10-11 Created: 2011-10-11 Last updated: 2011-10-11Bibliographically 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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Omar, Faisal
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Health and SocietyFaculty of Health Sciences
Health Care Service and Management, Health Policy and Services and Health Economy

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