The U.S. Organ Procurement System

作者:Kaserman, David L./ Barnett, A. H.

页数:192

出版时间:2002-1

价格:$ 22.60

isbn号码:9780844741710

具体描述

The organ procurement system in the United States has failed patients awaiting transplants, as evidenced by years-long waiting lists, with many patients declining in health or dying before a suitable organ donor is found. The cadaveric organ shortage can be remedied by allowing for organ purchases and sales, to encourage families of the deceased to donate the organs. This monograph is part of AEI's Evaluative Studies Series. The series aims to enhance understanding of government programs and to prompt continual review of their performance. David L. Kaserman is the Torchmark Professor and chairman of the Department of Economics at Auburn University. A. H. Barnett is a professor in, as well as the chairman of, the Department of Economics, International Studies, and Public Administration at the American University of Sharjah in the United Arab Emirates. A summary of the book follows. The first successful human organ transplant in the United States was performed on December 23, 1954, when a kidney was transplanted from a living donor who was an identical twin of the recipient. Since then, the ability to use organ transplants to save the lives and improve the health of thousands of patients suffering from kidney, heart, liver, and other organ failures has improved dramatically. New immunosuppressive drugs and advanced surgical techniques have allowed the successful use of cadaveric donor organs and, thereby, expanded the set of organs for which transplantation is a viable treatment. As a result, the number of organ transplants performed in this country has now grown to approximately 22,000 each year. Despite the tremendous successes that have been achieved, transplantation technology has failed to realize its full promise because of a chronic shortage of cadaveric organs that are made available for that use. The sad fact is that every year for the past three decades the number of cadaveric organs supplied has fallen well short of the number demanded. As a consequence, many patients are denied timely access to this life-saving treatment modality. Those who are deemed medically suitable candidates for transplantation are placed on organ waiting lists, where they often remain for one or more years before an acceptable organ becomes available. While they wait, these patients' health declines, making successful treatment increasingly problematic. Indeed, many of them die before a suitable donor organ is found. As of June 25, 2001, more than 77,000 patients were waiting for an organ transplant. Approximately 7,000 patients died in the preceding year as still more were added to the lists. And as the shortage continues, the length of the lists grows, waiting times increase, and the death toll rises. Importantly, the cadaveric organ shortage is not attributable to an inadequate number of potential organ donors. Of the 2 million or so deaths that occur in the United States each year, estimates indicate that somewhere between 13,000 and 29,000 occur under circumstances that would allow the organs of the deceased to be transplanted. Of these, only 5,843 (or 28 percent of the midrange of the estimates of the number of potential donors) yielded organ donations in 1999. Given the number of potential donors, then, organ collections could easily double or perhaps even triple without exhausting the existing potential supply. Thus, the organ shortage is the product of an ill-conceived public policy that fails to achieve higher collection rates from the available pool of donors. That policy, often referred to as the "altruistic system" of organ procurement, operates (as this name implies) entirely on the basis of unpaid donors. In the typical situation, the families of recently deceased accident or stroke victims who have been declared brain dead are asked for permission to remove the organs of the deceased for use in transplantations. Under the National Organ Transplant Act of 1984, any payment or other form of compensation to encourage the family to donate the organs is strictly proscribed by federal law. As a result, while the suppliers of all other inputs used in a transplant operation are paid market-determined prices, the parties who hold the key that makes transplantation possible cannot be paid. History of the Transplant System Notably, this system has evolved more by historical accident than conscious design. It grew out of a public policy that was intended for use with living, related kidney donors only. Because the earliest transplants were performed exclusively with kidneys donated by the recipients' living relatives, all organ transplant candidates brought the necessary donor with them when they checked into the hospital. If there was no acceptable living donor, there could be no transplant operation. As a result, there were no waiting lists and no apparent shortage. Moreover, under the living related donor system, there was no obvious need for any payment to encourage donor cooperation. The affection associated with the kinship between the donor and recipient was generally thought to be sufficient to motivate the requisite organ supply. And, where it was not, any necessary payment (or coercion) between family members could easily be arranged without resorting to the sort of middlemen generally required for market exchange. Such intrafamily cajoling by emotional pressure or outright payment also remained out of sight of the transplant centers and attending physicians. Therefore, a system of "altruistic" supply seemed to make sense in this setting, and reliance upon such a system did not seriously impede the use of this emerging medical technology. Indeed, it seemed to work quite well. That situation gradually changed, however, as new drugs began to allow the use of cadaveric donor organs and transplant success rates improved. Apparently, sometime during the 1970s, organ waiting lists began to arise as transplant candidates formed queues for needed cadaveric organs. The existing organ procurement system, however, was never altered to meet the needs of the greatly expanded pool of potential recipients created by the new technological opportunities. While some minor modifications have been implemented and considerable sums spent to educate the public regarding the virtues of organ donation, the basic system of complete reliance upon altruism to motivate supply has not changed. As a result, we have come to the current tragic situation in which thousands of patients die each year for lack of a suitable donor organ. These deaths have sparked considerable debate about how best to reform the U.S. organ procurement system to increase cadaveric donations. That debate, in turn, is reflected in a large and growing literature in which a variety of alternative policy proposals have been advanced. These proposals are surveyed in Chapter 3 of this monograph. While some authors have argued for continued reliance upon the current system with, perhaps, an appeal for increased educational expenditures, most now recognize that more fundamental policy change is required. The five most common proposals that have appeared in the literature are: (1) presumed consent, (2) conscription, (3) required request, (4) compensation, and (5) cadaveric organ markets. The first three of these proposals have, to varying degrees, been implemented either in the United States or abroad. In Chapter 3, we describe how each of these policies operates. We then demonstrate that, under reasonable assumptions regarding cadaveric organ supply and demand curves, the proposal to allow cadaveric organ markets to form clearly dominates all other policy options on social welfare grounds. Indeed, the organ market proposal appears to be the only alternative likely to eliminate the organ shortage entirely. Moreover, we estimate that, relative to the current system, creation of a market for procurement of cadaveric kidneys alone would, conservatively estimated, increase social welfare by over USD 300 million per year. Expanding the market system of procurement to other solid organs, then, would be likely to expand these welfare gains to well over USD 1 billion per year. And these welfare gains would be accompanied by several thousand lives saved annually. Despite the likelihood of such superior performance, however, the organ market proposal is not ubiquitously supported by those writing in this area. Both ethical and economic objections have been raised against the use of this most promising policy option. Upon inspection, however, these objections are found to be attributable, to a large degree, to: (1) some rather dubious ethical positions that have, in fact, been shown to be either logically weak or outright specious; (2) some fundamental misconceptions about how markets in general and organ markets in particular might operate in practice; and (3) several implicit (and empirically unlikely) assumptions regarding underlying structural parameters of cadaveric organ supply and demand curves. Chapter 4 addresses the first two sources of opposition, while Chapter 6 attempts to shed some light on the third. Importantly, we demonstrate in these chapters that none of the objections that have been raised in the literature to date is supported by either straightforward economic theory or empirical evidence. A dispassionate, objective analysis of the relevant arguments reveals no sound basis for rejecting the cadaveric organ market proposal. That is not to say, however, that sound economic reasons do not exist for particular interest groups to oppose this policy option. As with any policy change, there are parties likely to win and parties likely to lose from the formation of organ markets and resolution of the shortage. Chapter 5 focuses on the possibility that suppliers of transplant-related services - including, among other things, UNOS (an organization that maintains the nation's organ transplant waiting lists), organ procurement organizations, and transplant centers - could, in theory, suffer a decline in profits or a reduction in (or elimination of) the demand for their services if the organ market proposal were adopted. In addition, other parties providing substitutable services, such as dialysis clinics, could e...

用户评价

读完这本书，我最大的感受是思维的边界被拓展了，它不仅仅是传授知识，更像是在重塑你看待整个社会体系运作方式的视角。作者在探讨系统效率和道德困境的交织点时，提出的那些发人深省的问题，至今仍在我的脑海中回荡。例如，在数据透明化和个人隐私保护之间的权衡，作者并未给出简单的答案，而是引导我们去思考这种系统内部固有的张力，以及技术进步如何不断地挑战既有的伦理底线。这本书成功地将一个看似技术性的议题，提升到了社会哲学和公共政策的层面进行审视。它迫使我跳出自己原有的知识圈层，去理解一个庞大、多方利益博弈的复杂生态是如何在压力下维持其脆弱平衡的。这是一种智识上的震撼，让我对复杂系统的研究产生了更深层次的兴趣。

这本书的装帧和印刷质量着实让人眼前一亮。那种厚重的纸张，配合着细致的字体排版，让人一上手就能感受到出版方的用心。内页的图片和图表处理得极其精良，即便是涉及复杂的生物学结构或流程图，也清晰可见，即便是初次接触这个领域的读者，也能很快抓住重点。书脊的装订非常牢固，即便是频繁翻阅，也不担心松散的问题。我特别喜欢它封面设计所采用的那种冷静、专业的色调，没有过多花哨的装饰，直接点明了内容的严肃性和深度。初读时，我花了不少时间去欣赏这种设计美学，它本身就为阅读体验设定了一个高质量的基调。拿到手上，它沉甸甸的分量，就好像是某种知识承诺的实体化，让人对即将展开的阅读旅程充满了敬意和期待。这种对物理载体的重视，在如今电子阅读盛行的时代，显得尤为珍贵，它提供了一种不同于屏幕的、更加沉浸式的知识获取体验。

这本书最让我感到惊喜的是其文本的“可读性”与“权威性”之间达成的微妙平衡。很多时候，追求权威性的著作往往牺牲了语言的流畅性，读起来佶屈聱牙；而过于追求通俗易懂的作品，又常常显得空泛无力。然而，这本著作成功地找到了一个黄金分割点。作者的用词精准，遣词造句既不失学术的严谨，又避免了不必要的晦涩。即便是面对复杂的法律条文或生物伦理的灰色地带，作者也能用清晰、简洁的句子进行阐述，不拖泥带水。我尤其欣赏作者在关键术语首次出现时，总会给予一个清晰、简洁的定义，这极大地减少了查阅词典或反复阅读的需要。这种写作风格，体现了作者对读者的极大尊重，让知识的传递效率得到了显著提升。

我必须承认，这本书的深度远超我最初的预期。原以为会是一本偏向科普性质的入门读物，但随着阅读的深入，我逐渐意识到其中蕴含的专业性和细致程度，完全达到了可以作为专业参考书的标准。特别是关于政策法规变动对实际操作影响的分析部分，作者展现了惊人的文献梳理能力和批判性思维。那些对不同州际协议间细微差异的探讨，其精确度令人咋舌，绝非泛泛而谈。很多章节的论证逻辑链条非常复杂，需要读者集中全部注意力才能完全跟上作者的思路，甚至我不得不时常回顾前面的定义和前提。这要求读者必须投入相当的精力，但回报是巨大的——它能帮你建立起一个极其坚固和多维度的知识框架，让你看问题不再是片面的，而是能从宏观到微观进行全方位的审视。

这本书的叙事节奏把握得非常到位，它不像某些学术著作那样，上来就将人淹没在一堆术语和理论的汪洋大海中。作者似乎深谙如何引导读者进入一个全新的知识领域，开篇部分使用了大量的对比和类比手法，将抽象的系统运作过程，转化为我们日常生活中能理解的场景，这种“搭脚手架”式的写作技巧，极大地降低了阅读的门槛。尤其是在介绍核心机制的章节，作者巧妙地穿插了一些历史性的案例研究，这些故事性的内容不仅充实了理论的血肉，更让原本枯燥的流程变得有张力、有温度。我发现自己经常因为一个引人入胜的插叙而停下来，思考其背后的深层含义，而不是机械地扫过文字。这种将理论与实践、历史与现实紧密结合的编排，使得知识的吸收过程变成了一场探索之旅，而非简单的信息灌输。