Altruism, motivation, and allocation: giving and using human organs.

With tens of thousands of waiting recipients but only 4000-5000 organs available annually, there is a chronic and largely insatiable demand for organ transplants. This article draws on three sources of data regarding the sources of organs donated: a survey of the families of organ donors, a survey of the general public, and a prospective data collection effort from organ procurement agencies. It considers which Americans are willing to engage in this kind of altruism. Furthermore, it discusses the obligations imposed on the nation's public organ procurement and allocation system by the fact that organs are obtained as gifts. It argues that, as all Americans may be asked to donate and there would be social costs to excluding some from a moral community to givers and recipients, all Americans ought to have equal access to organ transplantation.

Competition for altruism: bone and organ procurement in the United States.

The number of "units" of human bone used during surgical procedures has grown to almost a quarter of a million. Medical demand for such bone is expanding rapidly and the nation's bone-banking system is struggling to grow apace. Unfortunately, because of this growth, bone banks must compete with organ banks for access both to hospitals and to potential donors. This conflict can, and may already be, negatively affecting the supply of transplantable tissues and organs. The nature of this conflict is affected by current law and public policy, but those effects are little understood and perhaps not intended.

The willingness to give: the public and the supply of transplantable organs.

We report the results of a representative random-sample telephone survey of the public's willingness to donate organs. Our goal was to identify differences within the public and target groups who might be receptive to educational efforts to increase donation. We distinguish differences in attitude and demographic characteristics in three groups: those committed to donation, those opposed, and those who might change their opinions with more specific information. While approval of donation is nearly universal, only about half of the public would donate a relative's organs when they do not know the relative's preference. Whites, higher-income individuals, and those with higher educational levels were more favorable. Those who might change their minds fall midway between those committed and those opposed, both demographically and by attitude. They include more nonwhites and more individuals with incomes less than $25,000 than members of the group committed to donation. Targeting public education messages to this group is likely to have the most success in reducing the gap between supply and demand for human organs.

Case management for frail elders: the Robert Wood Johnson Foundation's Program for Hospital Initiatives in Long-Term Care.

This evaluation of 24 hospital-based case management services found that case management could take a variety of forms, ranging from postacute medical management service to planning community-based care for potential long-term care users. Future research should concentrate on documenting the costs and outcomes of various models of case management in acute care settings.

Nonresident aliens and access to organ transplant.

The present policies for allowing nonresident aliens access to organ transplantation are neither fair nor consistent. They apply only to some transplants, and they take no account of their discriminatory effect among foreigners. Much less do they deal with the meaning of fair access, given our complete ignorance of the number and character of those outside the United States in need of a transplant. Most strikingly, present policy prohibits discrimination based on where a patient lives in part by imposing it based on where the patient is to receive a transplant, here or abroad. The one-list policy is more a result of political compromise, institutional interest, and the misapplication of the principle of professional autonomy than of any consistent policy or logic. In this mishmash of justification, one argument does stand out--that sharing organs with nonresidents ought to be done on the grounds of charity. Yet even here, the present form of this position is inadequate, perhaps because it has not been systematically applied to organ distribution issues. An argument for charity contains two elements, the nature of the obligation and the subject on whom the obligation rests. In its ordinary form, the obligation of charity requires a transfer of resources from wealth to poverty. A more subtle and complex formulation is required to apply this obligation to the conditions of universal poverty pertaining in organ transplantation. It remains to be seen if this is possible. There is also the question of to whom the argument must be made. A minimal requirement of charity is that one shares one's own resources, not those of another. Inevitably, this brings us to the perennial question of organ distribution: Whose organs are these? We can easily say whose they are not; they do not belong to hospital administrators, academic researchers, transplant surgeons, or organ procurement agencies. Insofar as they are national resources, Congress may be able to stake a claim; but insofar as giving organs to nonresident imposes sacrifices on residents awaiting an organ, perhaps they should be consulted. And their right to refuse must be accepted, for in organ distribution, the only real charity the well have a right to dispense is not to judge the sick.

The organization of organ procurement.

The American organ procurement system has improved and matured in the last five years. At the same time, the basic challenges facing it have remained substantially the same because the moral and legal framework of the system has not changed. Success at organ procurement continues to depend on the voluntary cooperation of medical professionals and the families of potential organ donors. The generosity of the American public is so great that the primary challenge facing organ procurement agencies is obtaining cooperation from hospitals and medical professionals. This calls for a "marketing" orientation aimed at those hospitals and professionals who are most likely to treat potential donors. The last five years have seen a more general acceptance of this appreciation of the central task of organ procurement. As a result, the overall effectiveness of the system has improved, as measured by the number of organs procured on a per capita basis and by the number of multiorgan donors obtained. Much of this improvement can be attributed to the diffusion of organizational techniques and approaches, and this diffusion has been encouraged by the involvement of national organizations and public bodies in the organ procurement community. The system remains uneven in its effectiveness and further improvement is possible. It is also possible that the next general round of improvement will result from the application of businesslike information management and marketing techniques.

A descriptive framework for new hospital roles in geriatric care.

Changes in demographics and in the operating environments of acute care hospitals have resulted in the development of new geriatric service products. Presented in this article is a framework for describing the variety of new services in terms of sponsor goals and core activities. Five broad types of geriatric service developments are described: geriatric medical care, post-acute care, transition management, chronic care, and information services. Assessing the implications of new services for the organizational functioning of hospitals is discussed, followed by an examination of the potential contributions of new geriatric services to the quality and accessibility of geriatric care.

Shifting responsibilities in organ procurement: a plan for routine referral.

KIE: It is claimed that the primary factor affecting the supply of transplantable organs is the cooperation of health professionals. Organ procurement agencies (OPAs) must obtain timely access to potential donors who are mainly identified and contacted by the nurses and neurophysicians in intensive care units (ICUs). The discretion of medical personnel is limited to their judgment about medical suitability for donation while required request laws ensure that the family is offered the option of organ donation. Prottas argues that the hospital and its staff do not have a right to stand between the family and OPAs and that the principle of required request should be implemented through a policy of "routine referral." This policy would require hospitals routinely to inform OPAs of admissions of potential organ donors, thereby increasing OPA access independently of ICU staff behavior. Medical staff would still determine donor suitability and the time when the OPA could contact the family.^ieng

Health professionals and hospital administrators in organ procurement: attitudes, reservations, and their resolutions.

The responses of hospital administrators, directors of nursing, intensive care unit nurses, and neurosurgeons are reported to a range of inquiries designed to measure their commitment to organ procurement and thereby identify impediments limiting their cooperation with organ procurement efforts. Descriptive and multivariate statistical techniques are used to analyze data collected from each group. We find general approval for organ procurement but serious hesitation about dealing with donor families, particularly among physicians. Physician support for donation, moreover, is the strongest predictor of other professionals, attitudes toward donation. Neurosurgeons and intensive care unit nurses who believe organ procurement is a professional responsibility have the fewest reservations about facilitating organ donation.

The complexities of managed care: operating a voluntary system.

The implementation of state-sponsored voluntary case management programs for public assistance recipients creates provider and recipient recruiting problems that are unique to the state's economic environment, its political climate, its historic relationship with providers, its program goals, and its implementation strategies. This implementation study discusses the factors that influenced the operationalization of the Massachusetts managed care program for AFDC families. The issues of provider recruitment and recipient enrollment are examined in relation to the formal program goals of cost containment and access. The operational and bureaucratic problems the state Medicaid staff has experienced in maintaining the program evokes questions of who should administer the programs, who the best types of providers are in light of program goals, and how recipients can be enrolled in a voluntary program.

In organ transplants, Americans first?

KIE: This case study involves a foreigner who has come to the United States hoping to obtain a kidney transplant. The woman's chances are not good because her funds are exhausted, kidneys are scarce, and U.S. citizens normally are given priority for available organs. Three commentators are asked on what grounds the decision to transplant non-immigrant aliens should be made, and by whom. Prottas, a member of the U.S. Task Force on Organ Transplantation, argues that, when a U.S. citizen and a non-resident are both suitable candidates, the former should take precedence by virtue of membership in the community that donated the organ. Jonasson, chair of the Task Force, urges an equitable allocation of organs, with five or ten percent reserved for foreigners. Kleinig, a philosopher, draws attention to international contributions to transplant technology, and advocates allocating perhaps ten percent of donated organs to non-residents.^ieng