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Few hospitals offered both the expertise and the necessary facilities.
Location of the donor and the recipient also impacted availability. Human organs cool and degenerate quickly when removed from the donor. Transportation in the 50s, 60s, and 70s was in the early stages of rapid jet aircraft travel and was too slow for the transportation of organs. The donor needed to be in close proximity to the recipient which was possible with living family members and donors. Research during this time focused on immunosuppressant drugs and on methods to maintain a viable organ outside the host.
In his discussion of justice in respect to the allocation of scarce goods, Jon Elster (1992) identified three levels of scarcity: natural, quasi-natural and artificial. The availability of twins with one needing a kidney transplant and one willing to donate a kidney generates a natural scarcity similar to the availability of natural black pearls. The issue of donor organ availability began to move towards a quasi-natural scarcity in the 70s and 80s as medical advances resulted in the willingness of more hospitals and doctors to deliver transplantation services.
In the 1960s, Dr. Thomas Starzl performed the first human liver transplant and Dr. Christiaan N. Barnard performed the first successful human heart transplant (www.wikipedia.org) from non-living donors. The survival rate was so low it was measured in days. A major problem continued to be recipient rejection by the body's immune system.
Two major advances in medical research and technology occurred in the 1970s. Cyclosporine was developed in the 1970s and approved for distribution in 1983 (Kaserman and Barnett, 2002). Cyclosporine inhibits the recipient's rejection response which increases long-term survival rates. The second medical advance solved the problem of maintaining organs in a viable state for a longer period or time once removed from the body. In the 1980s Dr. Starzl introduced a procedure for 'core cooling' that extended the viability of donor organs to allow time to excise and then transport donor organs to the host location (www.wikipedia.org). These two advances, cyclosporine and cooling technology for organ transportation, moved organ transplantation into the second level of scarcity, quasi-natural, as organs could now be transplanted based on organ matching criteria with non-living donors rather than on family relationship and living donors. In 2002, 76% to 94% of heart, liver, pancreas and kidney transplant recipients survived one year or more. (Kaserman and Barnett, 1998, Consumer's Research Magazine, p. 10; OPTN/SRTR 2002 Annual Report)
With the identification of solutions for transportation and rejection, attention turned to non-living donors. Organ transplantation centers arose in a number of hospitals. An informal distribution system emerged that relied on personal relations, professional contacts, and the general proximity of a hospital with the prerequisite team and facilities to perform an organ transplant (Fentiman, 1998). The informal system, though, lacked structure, supervision and professional associations -- all of the elements that were required to ensure equity in distribution. According to Fentiman, "The crisis in U.S. organ transplantation is moral and political, not technological. It will not be resolved until Congress and the states move beyond localism to develop a uniform nationwide approach to increase organ donation; identify medically appropriate criteria for transplant recipients; and remove racial, gender, and class barriers to equitable organ allocation" (p. 31). Persons living near a major transport center had a better chance to receive an organ transplant than persons in rural areas or areas without a transplant center. Persons with comprehensive private health insurance could afford an organ transplant, a procedure not yet covered either by private health insurance or by government health programs. Persons with sufficient independent financial resources to pay the cost of the operation and the long-term care and medication were more likely to receive a transplant. The majority of persons in the United States did not have sufficient independent financial resources necessary for an organ transplant. With little likelihood to receive an organ transplant, the majority were not inclined to donate organs. A scarcity existed in donors as well as recipients (Blumstein & Sloan, 1989).
History of End-State Renal Failure and Dialysis
The history of organ transplantation followed to some extent the history of efforts to end deaths resulting from end-stage renal failure. The invention of dialysis in the 1960s provided a non-surgical solution to what had been an inevitably terminal disease (Rothblatt, 204). According to Barnett, Beard and Kaserman (1993), "Patients must remain connected to a dialysis machine for approximately two to five hours generally three times per week. This machine performs two essential functions normally provided by the kidneys -- it filters impurities from the blood and removes excess fluid" (p. 393). At that time of its introduction, dialysis offered a lifesaving solution to thousands who did not have a twin or compatible near relative willing to donate a kidney. Dialysis was expensive and hospitals with the requisite medical team and facilities were scarce. Dialysis met the conditions of quasi-natural scarcity. Demand exceeded supply. Unlike organ transplantations, dialysis was not dependent on immune conditions or any other condition other than the presence of the disease and available medical facilities and equipment. Consequently, anyone with end-stage renal disease who could pay for the treatment could benefit from dialysis.
Similar to the history of organ transplantation, medical facilities with the requisite medical team and dialysis equipment were scarce and expensive in the 1960s. The number of available facilities could not meet the number of persons who needed dialysis. This scarcity resulted in a very controversial issue (Barnett et al., 1993). This scarcity of resources begs the question, "Who would decide which patients should be accepted for dialysis and who should be allowed to die?" The issue received national attention when Life magazine published an article in November 1962, "They Decide Who Lives, Who Dies," about the patients selected for treatment by a Seattle, Washington dialysis committee. The decision-making criteria included social standing, financial resources as well as issues of medical status. Seattle's "God Committee" served a valuable purpose: identifying nationally the problem of distributive justice when medical solutions were scarce (Alexander 1962, p. 125).
These occurrences also highlighted the inability of the American Market economy to solve the problem. As long as the equipment and the lack of medical resources meant access would be limited to the rich and famous, no market solution was available. No equitable solution existed for the scarcity of dialysis availability. End-stage renal disease, however, was much more common and more publicized than the shortage of organ donation. By the 1970s the history of organ transplantation and end-stage renal disease diverged dramatically.
In 1972, national debate and media attention resulted in a vote to fund dialysis centers for all citizens with end-stage renal disease regardless of their financial standing or social position. In this regard, Ford and Kaserman (1993) report that the growth in the dialysis industry and the provision of dialysis to a wider spectrum of American citizens is attributable to a 1972 amendment to the Social Security Act which ". . . authorizes the federal government to pay 80% of the cost of treatment (by either dialysis or kidney transplantation) of all citizens suffering from renal failure. The End Stage Renal Disease (ESRD) program, which is operated under Medicare, grew from $229 million in its initial year (serving 11,000 patients) to $3.7 billion in 1988 (serving 110,000 patients)" (p. 783). During the period from 1988 to 2003, the number of Americans who received dialysis almost doubled, to 325,000 with another 100,000 beginning dialysis treatment every year since meaning that today, approximately 825,000 Americans receive dialysis treatments (McCarthy, 2005). The cost associated with the provision of dialysis for patients today is approximately $66,000 per patient each year, and by 2010, the total costs associated with delivering dialysis will exceed $1 trillion annually (Lysaght, 2002).
Moreover, the increasing costs associated with its delivery are not the only drawback to an equitable provision of dialysis for everyone in the country who needs it to stay alive. Dialysis provides a chronic treatment for kidney disease but not without an adverse impact on the person's quality of life. The treatment restricts the recipient's freedom of movement and requires adherence to a strict treatment routine. Kidneys have been and still are the organs with the largest number of candidates on the organ transplant waiting lists (www.unos.org). Although the treatment extends a person's life, dialysis is not the solution of choice (Rothblatt, 2004).
History of Blood, Semen and Other Fluids and Tissue Donations
Besides organs, a number of fluids and tissues have been transferred successfully from one body to another for purposes ranging from life support to personal preference. For instance, a surgical team from France succeeded in a partial facial transplant procedure in 2005 by replacing damage areas (nose, lips, and chin) of a woman's face with skin and underlying tissues from a dead donor (Medical transplantation, 2007). Further, as recently as November 2008, a face was transferred from a living donor to a recipient with severe facial disfiguration…[continue]
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It now applies to a wide range of generation technologies, including but not limited to solar thermal electric, photovoltaics, wind, and geothermal electric (DSIRE). For solar systems, the credit is "equal to 30% of expenditures, with no maximum credit. Eligible solar energy property includes equipment that uses solar energy to generate electricity…" (DSIRE). For small wind turbines, the credit is "equal to 30% of expenditures, with no maximum credit"
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