Scarce Goods: Justice, Fairness, and Organ Transplantation (review)

This is a propitious time to consider issues concerning how much of our nation's scarce resources should be allocated to health care, how much of our health care expenditures to allocate to particular segments of that sector of our economy (e.g., transplantation), and how to distribute scarce health care resources (e.g., organs) to particular individuals. Talk of government surpluses has been replaced by debate about how to manage our economy in light of a sagging stock market and increased costs for homeland security. Concern for tens of millions of U.S. citizens without public or private health care insurance has been eclipsed by a preoccupation with the particular rights of those who are insured through managed health care organizations. Important segments of the transplantation community are locked in ongoing struggles about how best to distribute organs in light of a seemingly intransigent scarcity. A rich literature exists that sets forth alternative foundational concepts and perspectives with which to approach allocation and distribution of scarce resources, particularly health care goods and services. (A selected bibliography can be obtained by e-mailing this reviewer at spece@law.arizona.edu.) There is a definite need, however, for rigorous works that extend these foundational concepts and perspectives and apply them to challenging contemporary settings. At the same time, works that simply rehearse our shortcomings, express anger or frustration about them, or exaggerate or misapprehend them can now, more than ever, do substantial harm. It is into this context that Tom Koch introduces his latest work, Scarce Goods: Justice, Fairness, and Organ Transplantation.

One of the book's strengths is a fascinating account of the facts surrounding United States v. Holmes, the famous American case involving the sinking of the William Brown and the subsequent conviction of one of the ship's sailors who carried out orders to throw passengers from an overcrowded lifeboat to save several other passengers and crew members. This case is Koch's metaphor for our general health care and transplantation systems. But because of mistakes, a disjointed organization, and the polemical nature of much of the work, one wonders whether even the historical events are reported without embellishment.

The thrust of the book is that a terrible business ethic infects the U.S. health care system and that this, in turn, makes the transplantation sector of that system both unjust and inefficient. More specifically, the inequities that beset minority, poor, and relatively rural groups in the access to both basic health care and transplantation services are highly likely to make organ donations from those groups both less attractive and less feasible. As a bare description of the terrain, there is some truth to this account. The problem is in the explanation for this state of affairs and its seeming endurance.

Koch attempts to amplify his observations and conclusions about inequities and injustices in our organ transplantation system through analogy to workings of the same suspect business ethic said to inform the institutions and events surrounding the very sinking of the William Brown. Specifically, in 1841 when the William Brown sank, Koch argues, emigrants were considered expendable commodities, rather than full members of the human community entitled to equal consideration and respect. European countries were anxious for "superfluous and unruly" citizens to emigrate, while "the United States needed new citizens to labor in both its established eastern cities and the rapidly opening West"(9).In order to minimize costs, shipping companies instructed their crews to sail the shortest routes to the United States. This took them through waters known to harbor icebergs.

At the same time, there was a deliberate choice to limit costs by carrying fewer lifeboats than necessary to save anywhere near all on board in the event of a ship's sinking. Thus, when the William Brown sank, having struck two icebergs within a span of ten minutes...