Tuesday, November 13, 2007

Eureka – A High Quality Public Debate on a Hot Medical Ethics Issue!

A page 1 article on the selling of kidneys in today’s Wall Street Journal is sure to trigger extensive public discussion. We will soon see the panels of reporters that pose questions in the 2007-2008 presidential “debates” pop questions about kidney sale to the candidates.

The underlying issues are clear. Four thousand people per year in the U.S. die while on the waiting list for kidney transplant. The surgery and post surgical treatment has improved, but we do not have enough living and post-mortem donors to meet the demand. Quality of life and survival are better with transplant than dialysis. How are we to get more kidneys? Allowing sale of kidneys is an obvious possibility.

My aim in this posting is not to concentrate on the issue itself but on the quality of the Wall Street Journal article and the debate between two economists that accompanies the article. What stands out is the thoughtfulness of the arguments and the genuine debate between the economists. My own position is clear (I am firmly against organ sale) and yours may be too. But the physicians quoted in the article and the dueling economists that accompany it are truly talking to each other in a thoughtful manner.

Democratic process requires public deliberation. This has been sadly lacking in our increasingly polarized political climate. Hate-laden sound bites too often replace the reflective clash of ideas that a well governed polity needs.

The issue of kidney sale has a lot going for it as a training ground for public deliberation. The need for more kidneys is easy to understand. The question of organ sale is obviously important. But while it touches deep, theologically-connected values (the “sacredness” of market solutions on the one hand and the "sacredness” of the body on the other), there is more room for real thinking than the abortion question allows. (See my recent posting on that topic.) And it is not likely to become a playground for political pandering the way the tragedy of Terri Schiavo did.

Ethically sound governance of our health system isn’t simply a matter of coming up with the “right” answers. For many of the complex questions a health system must address, reasonable people will come to different conclusions. Improving our collective skill at thoughtful deliberation will abet two important outcomes. First, in the course of deliberation, new and better options often arise. (There is evidence for this in the exchange between the two economists.) Second, when a policy decision is finally made, those who are disappointed can more readily see the outcome as fair and move on.

At their best, journalists are not simply “reporters.” They can be “educators” as well. The Wall Street Journal’s coverage of the kidney sale issue is educative. I encourage readers to go to the site to read the article and accompanying materials, and to cast your vote in the yes/no survey. (When I voted at 12:45 the tally was 482 yeses to 260 nos.)

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