Allocation of Indivisible Life-Saving Goods With Both Intrinsic and Relational Quality: The New Deceased-Donor Kidney Allocation System

• Author: Laura Wilk,David L. Weimer
• DOI: 10.1177/0095399716647156
• Published date: 01 January 2019
• Date: 01 January 2019
• Subject Matter: Articles

https://doi.org/10.1177/0095399716647156

Administration & Society

2019, Vol. 51(1) 140 –169

© The Author(s) 2016

Article reuse guidelines:

sagepub.com/journals-permissions

DOI: 10.1177/0095399716647156

journals.sagepub.com/home/aas

Article

Allocation of Indivisible

Life-Saving Goods

With Both Intrinsic and

Relational Quality: The

New Deceased-Donor

Kidney Allocation System

David L. Weimer1 and Laura Wilk1

Abstract

Allocation of scarce heterogeneous life-saving goods confronts society

with profound challenges that are analytically complex and morally laden.

Deceased-donor kidneys for transplant are heterogeneous in terms of

relational and intrinsic quality. In 2014, the Organ Procurement and

Transplantation Network implemented a new allocation system that more

explicitly takes account of intrinsic quality. We trace the evolution of the

new allocation system with particular attention to the role of evidence

and the ways that concerns about equity were solicited, assessed, and

taken into account in modifying the original proposal. These deliberations

show the potential for stakeholder rulemaking to integrate evidence and

values.

Keywords

stakeholder rulemaking, organ transplantation, intrinsic quality, relational

quality, kidney allocation, medical governance

1University of Wisconsin–Madison, WI, USA

Corresponding Author:

David L. Weimer, University of Wisconsin–Madison, Bascom Hill, Madison, WI 53706, USA.

Email: weimer@lafollette.wisc.edu

647156AASXXX10.1177/0095399716647156Administration & SocietyWeimer and Wilk

research-article2016

Weimer and Wilk 141

Introduction

Kidney transplantation to treat end-stage renal disease (ESRD) benefits both

patients and society. Transplantation generally offers patients greater longev-

ity and higher quality of life than dialysis, the only currently available alter-

native treatment. Transplantation involves substantially lower medical costs

on average than dialysis over the life-course of patients with ESRD (Held

et al., 2016). With more than 5% of Medicare expenditures paying medical

expenses for patients of all ages with ESRD (U.S. Renal Data System, 2014),

transplantation is also fiscally desirable. However, as well known, the limited

supplies of deceased-donor kidneys and difficulties in finding willing and

appropriate live donors create a severe rationing problem with literally life

and death consequences. Unlike most stylized rationing problems that focus

on the allocation of a scarce indivisible good of limited quantity but uniform

quality, informed rationing of kidneys must take account of great heterogene-

ity in the quality of the scarce good. The allocation rules for deceased-donor

kidneys that had been in place until December 4, 2014, emphasized waiting

time to promote equity. The quality of available kidneys was addressed rela-

tionally, that is, the biological appropriateness of kidneys for specific patients.

The new allocation rules take much greater account of intrinsic quality to

increase efficiency in the use of the limited supply of deceased-donor kidneys

by better matching expected graft life to expected longevity to reduce both

the need for second transplants and wasted graft life.

We focus on the process that led to this non-incremental revision of alloca-

tion rules by the Organ Procurement and Transplantation Network (OPTN).

Extending over more than a decade, the process involved extensive modeling

by the Scientific Registry of Transplant Recipients (SRTR) and the tacit

knowledge of transplant professionals to predict the consequences of rule

changes as well as extensive consultation with stakeholders to value these

consequences. Perhaps more than any other area of medical governance, the

process demonstrates the application of evidence-based medicine to improve

health outcomes.

We seek to make contributions to scholarship in two ways. First, we docu-

ment the process that produced the new kidney allocation system to provide

a window for assessing “stakeholder rulemaking” as practiced by the OPTN

(Weimer, 2010b). In particular, we show the potential for a transparent and

evidence-based rulemaking process to produce substantial gains in the effi-

ciency of the allocation of scarce life-saving resources despite strong con-

cerns about, and interests in, distributional impacts.

Second, we explore the complexities of the allocation of scarce goods with

heterogeneous quality. Although the medical ethics literature abounds with