Prottas J M
Brandeis University, Bigel Institute of Health Policy, Heller Graduate School, Waltham, Massachusetts 02254.
Transplant Proc. 1989 Jun;21(3):3426-9; discussion 3440-4.
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.
目前允许非居民外国人获得器官移植的政策既不公平也不一致。这些政策仅适用于某些移植手术，且未考虑其在外国人之间的歧视性影响。鉴于我们对美国境外需要移植的人数和特征完全一无所知，这些政策更没有涉及公平获取的意义。最引人注目的是，现行政策部分通过根据患者接受移植的地点（在美国境内或境外）来施加限制，从而禁止基于患者居住地点的歧视。单名单政策更多是政治妥协、机构利益以及专业自主权原则的错误应用的结果，而非任何一致的政策或逻辑的产物。在这种杂乱无章的理由中，有一个论点确实突出——即应该基于慈善的理由与非居民分享器官。然而，即使在此处，这一立场的当前形式也是不充分的，也许是因为它尚未被系统地应用于器官分配问题。慈善论点包含两个要素，义务的性质以及承担义务的主体。以其通常形式，慈善义务要求将资源从富有者转移到贫困者。需要一个更微妙和复杂的表述，才能将这一义务应用于器官移植中普遍存在的普遍贫困状况。这是否可行还有待观察。还有一个问题是，这个论点必须向谁提出。慈善的一个最低要求是分享自己的资源，而不是他人的资源。这不可避免地将我们引向器官分配的永恒问题：这些器官是谁的？我们可以轻易说出它们不是谁的；它们不属于医院管理人员、学术研究人员、移植外科医生或器官采购机构。就它们是国家资源而言，国会或许能够提出主张；但就将器官给予非居民会给等待器官的居民带来牺牲而言，或许应该征求他们的意见。而且他们拒绝的权利必须得到认可，因为在器官分配中，健康人有权给予的唯一真正慈善是不评判病人。
