Exchanging kidneys: How much unfairness is justified by an extra kidney and who decides?

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DITORIAL

Exchanging Kidneys How Much Unfairness Is Justified by an Extra

Kidney and Who Decides

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HE SCARCITY OF kidneys has spawnedcreative ways of obtaining more organs

ne type of innovative program is the exchangef kidneys In its simplest form blood-type orross-match incompatibilities are surmountedhen 2 couples with reciprocal incompatibilitiesarticipate in a ldquopaired exchangerdquo12 For ex-mple a kidney from one husband with bloodype A is given to another manrsquos blood-type-Aife and in turn that man gives his blood-

ype-B kidney to the first manrsquos blood-type-Bife These exchanges are performed simulta-eously so that no one can renege In July 2003he concept of a ldquopaired exchangerdquo was extrapo-ated an additional step when the first ldquotriplewaprdquo was performed at Johns Hopkins Hospi-al In what the lead surgeon called logistically aonumental experience simultaneous surgeryas performed on 6 people Julia Tower whoanted to donate her kidney to Jeremy Weiser-arschoff the 13-year-old son of a friend had a

are tissue type that made her the only availableonor for Tracy Stahl Stahl had antibodies thatade it very difficult to find a compatible donorower gave Stahl her kidney and in returneremy got a kidney from Paul Boissiere a0-year-old man from Coral Gables FL whoas incompatible with his intended recipient

IR) his fianceacute Germaine Allum The swap wasompleted when Allum got a kidney from Stahlrsquosister Connie Dick who was unable to donate totahlThese relatively simple exchanges when

erformed with appropriate informed consentre morally appropriate however a more com-lex indirect-exchange protocol adopted innited Network for Organ Sharing (UNOS)egion 1 raises an interesting ethical dilemmahis program3 creates an alternate allocationystem that retains as live donors people whore incompatible with their IR because oflood group A B and O incompatibility orross-match results In exchange for donatinglive kidney to a compatible stranger on the

eceased donor waiting list the donorrsquos IR isiven allocation priority and the right of first

efusal of the next available compatible de-

merican Journal of Kidney Diseases Vol 44 No 6 (December) 2

eased kidneya This exchange arrangement isesigned to give the live donorrsquos IR ldquosufficientriority in kidney allocation to get them trans-lanted expeditiouslyrdquob

Because a live kidney is retrieved from some-ne who otherwise probably would not haveonated the protocol increases the total numberf kidneys available for transplantation Becauseidney transplantation obviates the need for dialy-is and in occasional cases can be life savinghe protocol has utilitarian value However theres a moral cost for this increased utility that iseasured in the unfairness to people on the

eceased donor waiting list especially thoseith blood type O4cd who will be bumped

a Exceptions that retain a greater priority over the IRnclude zero-antigen mismatched combined kidneypan-reas transplantation patients who are highly sensitizedero-antigen mismatched isolated kidney patients prior liv-ng donors subsequently listed for transplantation UNOSaybacks highest scoring high panel reactive antibody can-idates pediatric candidates who surpassed their transplanthreshold goals and emergency status patients

b Potential IRs are excluded when they are unlikely toenefit from the proposed program For example IRs withanel reactive antibody levels greater than 20 are not listedecause these antibodies markedly decrease the likelihoodhat a compatible deceased kidney will become availableatients with a relatively short wait for a kidney also mayot benefit from this program

c Data from UNOS Region 1rsquos experience with this ex-hange protocol confirm the anticipated disadvantage tolood-type-O patients on the deceased donor waiting listeventeen of the first 19 incompatible intended live donorecipients were blood type O (FL Delmonico MD per-onal communication June 2004) Delmonico et al4 notedhat ldquomost candidates who were by-passed on the day thathe allocation priority was awarded to the exchange recipi-nt waited only several weeks to months longer than theyould have without the exchange processrdquo

Received May 18 2004 accepted in revised form August 2004This work was made possible by a grant in memory of

arold Karp by the Karp Family FoundationAddress reprint requests to David Steinberg MD Hema-

ology Department Lahey Clinic 41 Mall Road BurlingtonA 01805 E-mail davidsteinberglaheyorgcopy 2004 by the National Kidney Foundation Inc0272-6386044406-0020$30000

doi101053jajkd200408034

004 pp 1115-1120 1115

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DAVID STEINBERG1116

erhaps repeatedly so that live donor IRs can gethe next available kidney This will increase theait for blood-type-O patients already on theeceased donor transplant waiting listThe formidable ethical challenge of this ex-

hange protocol is to define how much unfair-ess if any is justified by its added utilityhould the goal be to retrieve the most kidneysossible regardless of inequity Should all unfair-ess be considered wrong even if that meansbtaining fewer kidneys Or should a compro-ise position be adopted

UNFAIRNESS TO PATIENTS ONTHE WAITING LIST

The IR does not receive a deceased donoridney until after their incompatible donor hasiven a live kidney to a compatible stranger onhe deceased donor transplant waiting list

hether there is inequity when the IR gets aeceased kidney that otherwise would have goneo someone else depends on whether we focus onhe interests of individuals or the interests ofveryone on the transplant waiting list consid-red as a group If we consider all people waitingor a deceased kidney as a group the exchange isot unfair In fact the opposite is true A patientn the group of people waiting for a kidney isiven a live kidney while the group forfeits aeceased kidneye Because a live kidney survivesonger than a deceased kidney5 the exchange isore than fair to the groupHowever we should not ignore the conse-

uences to individuals because as long as weonsider ourselves worthy of moral respect con-istency requires that we give similar consider-tion to others This proposal will be unfair toertain individuals because patients with bloodype O who already have relatively long waitingimes are less likely to match with their liveonor and will disproportionately become IRsf

d Patients for whom a paired exchange can be arrangedre not considered for this program Because it is unlikelyhat blood-type-O patients will locate partners for a pairedxchange that is another reason blood-type-O patients wille overrepresented in the group of IRs

e I have considered the incompatible IR as not part of theroup although they might have been listed on the deceased

onor waiting list c

lood-type-O patients therefore will be overrep-esented in the group of IRs As a consequencendividuals with blood type O on the deceasedonor waiting list are more likely to be bumpedecause of this exchange protocol perhaps repeat-dly and theoretically indefinitely

Inequity to blood-group-O patients is acknowl-dged in the protocol as an ldquounintended conse-uencerdquo of a program designed ldquoto increasergans available for transplantation generallyrdquolthough this inequity is unintended it remains

n important moral and practical concern be-ause it can be foreseen Grouping people intooral categories by blood type is peculiar and

nderstandable only if blood type is considered aurrogate marker for individualsghi Our societyoes not demand nondiscrimination based onlood type but morally blood-type-O patientsust be considered individuals with legitimate

nterests The critical moral and practical ques-ion posed by the protocol is whether the unfair-ess to certain individuals can be justified be-ause overall more kidneys are obtained Theuthors of this protocol are sensitive to thisuandary and intend to include in their analysisthe impact of the system upon patients by bloodrouprdquo so that ldquoappropriate modificationsrdquo cane made I address the nature of the analysis thats required and suggest a way to determine the

f Blood-type-O individuals can donate to anyone but caneceive organs only from other blood-type-O individuals

g We may prohibit discrimination based on a disability orace but we do not prohibit discrimination based on bloodype However if blood grouping proved to be a surrogatearker for racial or ethnic grouping and unfairness in

rouping by blood type also entailed unfairness by racial orthnic grouping the matter would require reconsideration

h The relative importance of the individual and the grouparies in different societies In the United States consider-tions that affect individuals carry more weight than they don more socialized societies My selection of the individuals an important moral category therefore may be culturallyiased however the relative worth of individuals and theroup is not ignored because it is integral to the discussion ofow much individual inequity is justified by a benefit to theroup

i As I show in the calculations that follow the gain orelay for any individual equals that of the person at the topf their blood type waiting list Tabulation by blood type isorally significant only to the extent that it also reflects

onsequences for individuals

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EDITORIAL 1117

egree of inequity that is morally permissible tobtain more kidneys

CAN INDIVIDUAL INEQUITY BE MEASURED

In the context of this discussion inequity andnfairness refer to a deviation from rules in-ended to be uniformly applied Other factorseing equal kidneys for transplantation are allo-ated according to position on the transplantaiting list Giving a kidney to an IR who hasot duly waited his or her turn in line is unfairecause it trumps the rights of those who haveollowed what they have understood to be theules This exchange program is unfair in theame way it is unfair to sneak onto a ticket linehead of those who have patiently waited theirurn Although some philosophers have allowedhat unfairness ldquocould be overridden by signifi-ant utilityrdquo6 when this is done justification isequired especially when the stakes are high

The changes in waiting time that can be as-ribed to this exchange program can be approxi-ated for each person on the deceased donoraiting list I identify individuals by blood type

nd numerical position on the waiting list If asart of this exchange program the first blood-ype-A patient on the deceased donor waiting listeceives a kidney from a living donor 4 weeksefore that patient otherwise would have gotten aeceased donor kidney patient A2 on the waitingist moves to the top of the list 4 weeks earlierhan otherwise If a second blood-group-A liveidney is given to patient A2 at 3 weeks earlierhan they otherwise would have gotten a de-eased kidney patient A3 goes to the top of theist 3 weeks earlier Because of these live dona-ions at this point patient A3 has saved 7 weeksf waitingIf a deceased blood-type-A kidney subse-

uently is diverted to an IR who is blood type And another deceased blood-type-A kidney doesot become available for 3 weeks the net timeaved for patient A3 decreases to 4 weeks Be-ause the net time saved by the patient on top ofhe deceased donor blood-type-A waiting listlso is saved by everyone behind him or her athis point everyone on the blood-type-A de-eased donor list will have saved 4 weeksrsquo wait-

ng time Anyone who henceforth joins the blood- t

ype-A deceased donor waiting list will haveaved 4 weeks of waiting timejk

When a deceased donor kidney that wouldave gone to patient O1 on the blood-group-Oeceased donor waiting list goes instead to an IRnd the next deceased blood-type-O kidney doesot become available for 4 weeks patient O1 andveryone behind him currently and henceforth iselayed by 4 weeksl If a second blood-type-Oidney is obtained for an IR and the next blood-roup-O kidney does not become available for 5eeks patient O1 and all behind him will have

t that point been delayed a total of 9 weeksm Ifcontinual stream of kidneys is diverted to

lood-type-O IRs the delay for blood-type-Oatients can be indefiniteThe benefit of this exchange proposal to blood-

roup-O individuals on the transplant waiting lists delayedn until the time the first blood-group-OR would otherwise have reached the top of theaiting list At that pointo everyone then andenceforth behind the IR saves waiting timeecause the IR having preferentially alreadyeceived a kidney is not there If for exampleveryone on the blood-type-O waiting list has

j The net time saved for a patient when he or she is addedo the waiting list equals the time saved for the patientirectly ahead of them In the unlikely event that a bloodroup waiting list should empty and unused kidneys becomevailable theoretically the time henceforth saved by thisrogram should be reduced by the time the list remainsmpty

k For various reasons such as emergency status or thevailability of a zero-mismatched kidney patients may noteceive a kidney in the temporal order they were placed onhe waiting list For simplicity I have ignored this consider-tion and refer to my calculations as approximate

l Actual delays encountered by bypassed patients in UNOSegion 1 where this exchange protocol has been imple-ented ranged from 4 days to more than 398 days and

veraged more than 908 days for each bypassed patientFL Delmonico MD personal communication June 2004)

m In the unlikely event the waiting list emptied the nextatient joining the list will not have been delayed at allecause of this exchange program A patient cannot beelayed longer than their actual wait If there was a rapidnflux of available kidneys a patientrsquos delay because of thisxchange program could be limited to the actual time it takeshem to reach the top of the waiting list

n Except for recipients of a donorrsquos live kidneyo The IR would be added to the deceased donor waiting

ist with a special designation so it can be determined when

he IR would have reached the top of the waiting list

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DAVID STEINBERG1118

ecause of this exchange program waited a netxtra 36 weeks at the time an IR would haveeached the top of the list but is not there and as

result 4 weeks of waiting is saved the netdded waiting time is reduced to 32 weeks Athe time the first blood-type-O IR would haveeached the top of the list patients on the blood-ype-O waiting list begin to accrue benefits Ifhe benefits accrue faster than kidneys continueo be diverted the net excess waiting time forlood-type-O patients will decrease and viceersa However it may be a few years before therst blood-type-O IR would have reached the topf the list therefore a long time may elapseefore there is any correction of the inequity tolood-type-O patients Also at the time the firstlood-type-O IR would have reached the top ofhe list there will have been many other blood-ype-O IRs therefore only a fraction of theumulative inequity will be corrected

A running tabulation can be kept of the approxi-ate time delays and accelerations for each

ndividual on the waiting list It should be pos-ible to estimate the net time delay caused by therotocol for each blood-group-O patient by theime they eventually receive a kidney and thenalculate the average delayp for deceased donorist blood-type-O patients considered as a groupt also should be possible to note the maximumelay inflicted on any one individual

HOW MUCH UNFAIRNESS IS ACCEPTABLE

This exchange proposal harbors several ineq-ities The donor gives a live kidney while his orer IR gets a deceased kidney this is not anqual exchange because a live kidney is betterhan a deceased kidney Although an attempt isade to perform transplantation on the IR expe-

itiously the transplantations are not simulta-eous If the IR dies or ceases to be a transplantandidate before receiving a kidney the liveonor will have given a kidney and his or her IRill not have gotten a kidney in return These

nequities although significant should be knownn advance to the live donor who can considerhem acceptable or refuse to donate This distin-uishes them from inequities to individuals onhe transplant waiting list especially blood-

p The median delay could prove preferable

ype-O patients who have no choice in theatterThe most important ethical issue in this proto-

ol is the likely harm to blood-group-O patientse are forced to ask how much if any7 added

ndividual waiting time for some is justified byhe extra kidneys obtained for others Althoughhilosophers have argued that fairness can beacrificed for utility they have not provided anyenerally accepted formula to balance equity andtility in specific circumstances such as thoseresented by this exchange protocol Any at-empt to balance the cost of added waiting timeor blood-group-O patients against the materialain of a kidney by blood-group-A -B and -ABatients will be problematic because the benefito one group does nothing to negate the sufferingf the otherThe overall utility of the protocol can beeasured by the total number of extra kidneys

btained Even if it was assumed reasonable tosk the person on top of the list to wait 4 moreeeks so an extra kidney could be added to the

otal pool those extra weeks are cumulative foratients not at the top of the list In this protocolaximum utility is achieved when no limit is

laced on the number of exchanges performedlood-group-O patients on the deceased donoraiting list would be bumped continually asore kidneys were obtained Maximal utility

hen would be obtained but at the cost of maxi-al unfairnessIf it was decided that maximal unfairness was

oo extreme to be acceptable 2 parameters couldecome useful the average delay experienced bylood-group-O patients before they got a kidneynd the maximum cumulative time delay experi-nced by any one person If a concern withairness was deemed important we should askhat the acceptable average delay is for blood-roup-O patients and what the longest delay ishat any individual should experience A state-ent of the type that follows then could beadeq 30 extra kidneys were obtained because

f this protocol at the cost of an average delay forlood-group-O patients of 3 months and a maxi-um delay for any one patient of 13 months We

hen would have the data to weigh utility against

q The numbers used are examples not actual data

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EDITORIAL 1119

airness and ask whether the results were morallycceptable

Other examples of a conflict between utilitynd fairness in transplantation have been notedn organ given to a younger person may provideore ultimate good than one given to an older

erson although both may be equally deservingn inherent conflict between utility and fairnessr

as been noted in the HLA-based allocation ofidneys for transplantation HLA matching ldquoim-roves the outcome of transplantation (utility)ut decreases the number of nonwhites whondergo transplantation (equity)rdquo8 A recent studydvocates eliminating priority given to HLA-Bocus matching because that would shift organsrom whites to nonwhites by 40 with greaterairness to a minority group while decreasingraft survival by only 2 however the elimina-ion of both HLA-B and HLA-DR matchingould increase further the shift of organs fromhites to nonwhites to 52 and result in evenreater fairness but at a bigger cost in grafturvival The elimination of HLA-DR typingas not advised because the cost in terms of graft

ejection was deemed too high No method wasrovided to explain how these decisions wereade9 although one might suspect the guiding

rinciple was to increase equity when the cost intility was perceived to be lowZenios et al10 proposed a solution to the prob-

em of inequity to blood-type-O patients Insteadf using self-selected blood-group-ABO randomive donors the transplant team should chooserom all possible live donors and preferentiallyelect blood-type-O donors Their calculationsndicate this would mitigate the unfairness tolood-group-O individuals Ross and Woodle11

lso support the preferential selection of blood-ype-O donors if protocols can be developed thatre not coercive Until it is shown that the prefer-ntial selection of blood-type-O donors can bemplemented successfully unfairness to blood-ype-O patients on the waiting list will remain anmportant consideration

r That HLA typing is disadvantageous to minorities isore accurately unfortunate rather than unfair because the

iscrimination is the result of biology not human agencyhe selection of HLA type as a criterion for transplantation

ermits us to speak of unfairness a

A SUGGESTED SOLUTION

In situations in which 2 ethical principles aren conflict when one cannot be honored withoutiolating the other compromise may be desir-ble Compromise would acknowledge respector both principles and limit the degree to whichny one of them is violated I suggest this ex-hange protocol be considered morally permis-ible because more kidneys will be obtained anduffering will be relieved but only if its unfair-ess is constrained by limiting the time delaysmposed on patients with blood type Os In thisanner utility is respected because more kid-

eys are retrieved but equity also is respectedecause unfairness is limitedThat still leaves the average and maximum

cceptable unfair delays undefined How shouldhese determinations be made

Because no theory or equation can provide annswer we are forced to define a process that canead to a morally acceptable solution The latehilosopher John Rawls12 as a matter of socialustice advocated decision making behind a ldquoveilf ignorancerdquo in which one did not know theirersonal situation and whether they would ben-fit or be harmed by a policy The acceptableelays for blood-type-O patients could be deter-ined in this mannerPatients on the waiting list with end-stage

idney disease who either did not know theirlood type or did not know its significance in thisontext would be asked to state the average andaximal cumulative individual delays that would

e acceptable to them for the utilitarian benefitsf this exchange program The question alterna-ively could be phrased in terms of ldquosome factorrdquoithout reference to blood type Individualsould not know whether they would be the ones

o get a live kidney sooner than otherwise aeceased kidney years sooner than otherwise ore bumped and forced to wait longer for aeceased kidney No one would know whetherhey were one of the potential winners or losers

People with end-stage renal disease can bestppreciate the significance of prolonging dialysisherapy and they constitute the affected popula-

s If by chance another group such as blood-group-Aatients were disadvantaged the same principles would

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DAVID STEINBERG1120

ion If members of the group of almost 60000eople in the United States waiting for a kidneyid not know where they stood personally theyould have an incentive to make a judgment that

airly balanced the interests of those who wouldenefit and those who would be disadvantagedA survey of group sentiment might present

echnical problems but these should be resolvedy focus groups or other polling techniques Theedian advocated time of acceptable average

nd maximal delays should be strongly influen-ial if not determinative A running tabulationould be kept of individual delays and accelera-

ions related to this exchange program any ex-hange likely to cause the average or the maxi-um delay to exceed the acceptable limits would

e prohibited and the exchange program woulde at least temporarily suspendedAnswering an ethical question with a surveyay not be philosophically satisfying but it has

he advantage of allowing the population mostntimately affected by this protocol to resolve itsost vexing moral conundrum When performed

ehind a veil of ignorance it also fosters a searchor the answer that best balances the interests ofoth winners and losers This approach wouldlace a brake on the understandable desire of theransplant community to retrieve as many kid-eys as possible but the endorsement of unre-tricted inequity might undermine trust in theransplant community and ultimately be moreostly

Members of the transplant community mightbject to giving laypersons significant influencen the development of a transplant protocol Itust be recognized that the balancing of fairness

nd utility despite many technical considerationsltimately is a moral question for which theransplant community does not have special ex-ertise It could be argued that by incorporatinghe beliefs of the community of patients support

or this exchange protocol will increase and B

ympathy for the transplant communityrsquos devil-sh dilemma of being forced to be unfair to helpore patients will be enhanced

David Steinberg MDLahey Clinic Medical Center

Burlington Massachusetts

REFERENCES

1 Ross LF Rubin DT Siegler M Ethics of a paired-idney exchange program N Engl J Med 3361752-17559972 Delmonico FL Exchanging kidneysmdashAdvances in

iving donor transplantation N Engl J Med 3501812-18140043 Local Voluntary Alternative System for Assigning Pri-

rity in Kidney Allocation to Original Intended Recipientsf Living Donor Kidneys August 25 2003 list of 14roposals pp 5-22 Approved UNOS Board of Trustees000 initiated 2001 Available at wwwoptnorgoliciesAndBylawspublicCommentproposalsArchiveaspccessed July 20 20044 Delmonico FL Morrissey PE Lipkowitz GS et al

onor kidney exchanges Am J Transplant 41628-16340045 Terasaki PI Cecka JM Gjertson DW Takemoto S

igh survival rates of kidney transplants from spousal andiving unrelated donors N Engl J Med 333333-336 1995

6 Kamm FM Morality Mortality Death and Whom toave From It Oxford NY Oxford University 1993 p 1097 Ross LF Zenios S Practical and ethical challenges to

aired exchange programs Am J Transplant 41553-15540048 Roberts JP Wolfe RA Bragg-Gresham JL et al Effect

f changing the priority for HLA matching on the rates andutcomes of kidney transplantation in minority groupsEngl J Med 350545-551 20049 van Rood JJ Weighing optimal graft survival through

LA matching against the equitable distribution of kidneyllografts N Engl J Med 350535-536 2004

10 Zenios SA Woodle ES Ross LF Primum non noc-re Avoiding harm to vulnerable wait list candidates in anndirect kidney exchange Transplantation 72648-654 2001

11 Ross LF Woodle ES Ethical issues in increasing liveidney donations by expanding kidney paired exchangerograms Transplantation 691539-1543 200012 Rawls JA Theory of Justice Cambridge MA

elknap Harvard University 1971

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DAVID STEINBERG1116

erhaps repeatedly so that live donor IRs can gethe next available kidney This will increase theait for blood-type-O patients already on theeceased donor transplant waiting listThe formidable ethical challenge of this ex-

hange protocol is to define how much unfair-ess if any is justified by its added utilityhould the goal be to retrieve the most kidneysossible regardless of inequity Should all unfair-ess be considered wrong even if that meansbtaining fewer kidneys Or should a compro-ise position be adopted

UNFAIRNESS TO PATIENTS ONTHE WAITING LIST

The IR does not receive a deceased donoridney until after their incompatible donor hasiven a live kidney to a compatible stranger onhe deceased donor transplant waiting list

hether there is inequity when the IR gets aeceased kidney that otherwise would have goneo someone else depends on whether we focus onhe interests of individuals or the interests ofveryone on the transplant waiting list consid-red as a group If we consider all people waitingor a deceased kidney as a group the exchange isot unfair In fact the opposite is true A patientn the group of people waiting for a kidney isiven a live kidney while the group forfeits aeceased kidneye Because a live kidney survivesonger than a deceased kidney5 the exchange isore than fair to the groupHowever we should not ignore the conse-

uences to individuals because as long as weonsider ourselves worthy of moral respect con-istency requires that we give similar consider-tion to others This proposal will be unfair toertain individuals because patients with bloodype O who already have relatively long waitingimes are less likely to match with their liveonor and will disproportionately become IRsf

d Patients for whom a paired exchange can be arrangedre not considered for this program Because it is unlikelyhat blood-type-O patients will locate partners for a pairedxchange that is another reason blood-type-O patients wille overrepresented in the group of IRs

e I have considered the incompatible IR as not part of theroup although they might have been listed on the deceased

onor waiting list c

lood-type-O patients therefore will be overrep-esented in the group of IRs As a consequencendividuals with blood type O on the deceasedonor waiting list are more likely to be bumpedecause of this exchange protocol perhaps repeat-dly and theoretically indefinitely

Inequity to blood-group-O patients is acknowl-dged in the protocol as an ldquounintended conse-uencerdquo of a program designed ldquoto increasergans available for transplantation generallyrdquolthough this inequity is unintended it remains

n important moral and practical concern be-ause it can be foreseen Grouping people intooral categories by blood type is peculiar and

nderstandable only if blood type is considered aurrogate marker for individualsghi Our societyoes not demand nondiscrimination based onlood type but morally blood-type-O patientsust be considered individuals with legitimate

nterests The critical moral and practical ques-ion posed by the protocol is whether the unfair-ess to certain individuals can be justified be-ause overall more kidneys are obtained Theuthors of this protocol are sensitive to thisuandary and intend to include in their analysisthe impact of the system upon patients by bloodrouprdquo so that ldquoappropriate modificationsrdquo cane made I address the nature of the analysis thats required and suggest a way to determine the

f Blood-type-O individuals can donate to anyone but caneceive organs only from other blood-type-O individuals

g We may prohibit discrimination based on a disability orace but we do not prohibit discrimination based on bloodype However if blood grouping proved to be a surrogatearker for racial or ethnic grouping and unfairness in

rouping by blood type also entailed unfairness by racial orthnic grouping the matter would require reconsideration

h The relative importance of the individual and the grouparies in different societies In the United States consider-tions that affect individuals carry more weight than they don more socialized societies My selection of the individuals an important moral category therefore may be culturallyiased however the relative worth of individuals and theroup is not ignored because it is integral to the discussion ofow much individual inequity is justified by a benefit to theroup

i As I show in the calculations that follow the gain orelay for any individual equals that of the person at the topf their blood type waiting list Tabulation by blood type isorally significant only to the extent that it also reflects

onsequences for individuals

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EDITORIAL 1117






















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EDITORIAL 1119






















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DAVID STEINBERG1120















REFERENCES













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EDITORIAL 1117






















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EDITORIAL 1119






















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DAVID STEINBERG1120















REFERENCES














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EDITORIAL 1119






















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Documents

Exchanging kidneys: How much unfairness is justified by an extra kidney and who decides?