Cover image for Scarce goods : justice, fairness, and organ transplantation
Scarce goods : justice, fairness, and organ transplantation
Koch, Tom, 1949-
Personal Author:
Publication Information:
Westport, Conn. : Praeger, 2002.
Physical Description:
xvii, 250 pages : illustrations ; 24 cm

Format :


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RD120.7 .K63 2002 Adult Non-Fiction Central Closed Stacks

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In 1841 the American sailing ship William Brown struck an iceberg. About half of the passengers and all of the crew were saved in two small, open boats. The next night, half of the passengers in the larger long-boat were thrown overboard because the boat was overfull. This was the first case of lifeboat ethics, of hard choices in the face of scarcity. Since then the question has been who should die so that others, equally needy, might live? Both the case of the William Brown and the ethics it spawned have been used in recent years to describe the problem of health care rationing generally, and organ transplantation specifically.

Koch reexamines and reinterpretes the paradigm case of lifeboat ethics, the story of the William Brown , not as an unavoidable tragedy, but as an avoidable series of errors. Its relation to more general issues of distributive justice are then considered. The lessons learned from both the historical review and its application to distributive principles are then applied to the problem of graft organ distribution in the United States. Through the use of maps, the problem of organ distribution is considered at a range of scales, from the international to the urban. The contextual issues become more evident as one moves from international to hemispheric, fron national to regional, and then local systems. Finally, Koch reviews the lessons in light of other problems of distribution in the face of scarcity. The central lesson-that scarcity is exacerbated where it is not in fact created by our distributive programs-is explored thoroughly. The result is no good choices for anyone and the continuation of the scarcity that for most seems inevitable, but, from the evidence provided, is itself an outcome of inequalities of distribution at different scales of society. Of particular interest to students, scholars, and policymakers involved with issues of planning and health care economics, medical geography, and concepts of justice.

Author Notes

Tom Koch is a writer and bioethicist specializing in medical ethics. A frequent contributor to newspapers, magazines, and the CBC Radio, he is the author of 11 books. Dr. Koch also is a forum associate at the David Lam Center, Simon Fraser University and an associate of the Center on Aging at The University of Hawaii

Reviews 1

Choice Review

Research and analysis of issues involved in the complexity of equitable distribution of organs for transplantation demonstrates that there are no simple answers to this problem. Koch, a writer and bioethicists, uses the story of an 1800s shipwreck as a framework for analysis of the ethical decisions that must be made when there is a scarcity of resources, whether it be space for survival or organs for transplantation. Using the incident that gave rise to the origin of "lifeboat ethics" as background, he identifies the decisions that were made and the likely rationale for them. He applies this knowledge to the search for a means for equitable distribution of organs for transplant in the US and throughout the world. He demonstrates the need to correct inequities in availability and quality of health care for the poor, before a plan for equitable distribution is possible. His thorough analysis is documented with many current and classic references as well as an extensive bibliography. A key point is that the language of ethics can add to the confusion surrounding issues, which vary according to the setting of the problem. Graduate students; faculty; professionals. V. B. Byers emerita, SUNY Upstate Medical University

Table of Contents

Tables and Figuresp. ix
Prefacep. xi
Acknowledgmentsp. xv
1 Lifeboat Ethics and the Case of the William Brownp. 1
Health Carep. 5
The William Brownp. 8
The Gulf Streamp. 10
A Constructed Talep. 15
The Trialp. 17
Lifeboat Ethics Reduxp. 18
The Titanticp. 19
2 The Scales of Justice: Principles and Practicep. 23
Distributive Justicep. 25
Scarcityp. 28
Justice Rationalesp. 32
Critiquesp. 41
Transplantationp. 44
A Geographical Approachp. 45
3 Scarce Goods: The Contexts of Solid Organ Transplantationp. 49
Transplantation: The Early Yearsp. 50
Cyclosporine: Transforming Scarcityp. 52
A National Systemp. 54
National Organ Transplant Actp. 57
Regionalizationp. 61
An Examplep. 64
Discussionp. 70
4 The Scale of Justice: Theories and Realitiesp. 73
Perspective and Scalep. 75
Global/International Scalesp. 78
Hemispheric Perspectivep. 85
Justice and Scalep. 92
5 Disappearing States: The Scale of the Nationp. 95
Regional Inequalitiesp. 99
Centers of Excellencep. 107
Distant Citiesp. 109
Redistrictingp. 113
Travel Time (Distance)p. 115
Discussionp. 123
6 The Scale of the City: Distant Communities and the Problem of Supplyp. 125
Rural versus Urban Carep. 126
OPO Performancep. 128
Demographics and Membershipp. 131
Poverty and Racep. 140
A Sense of the Gamep. 145
Application: Southern Californiap. 146
Discussionp. 149
7 The Lifeboat's Choicep. 151
Lifeboat Seatsp. 153
Resultsp. 157
Q-Analysisp. 166
Discussionp. 170
8 Justice in Ethic's Lifeboatp. 175
Dimensionalityp. 177
Participationp. 180
Philosophical Concernsp. 183
Reasons and Personsp. 189
The Scarcities We Createp. 191
Afterwordp. 193
Holmes' Legacyp. 195
Abundance and Scarcityp. 196
Notesp. 199
Bibliographyp. 223
Indexp. 241