The Milbank Memorial Fund is an endowed operating foundation that publishes The Milbank Quarterly, commissions projects, and convenes state health policy decision makers on issues they identify as important to population health.
We focus on a number of topic areas identified by state health policy leaders as important to population health.
The Center for Evidence-based Policy at Oregon Health & Science University is a national leader in evidence-based decision making and policy design.
Keep up with news and updates from the Milbank Memorial Fund. Get the latest from thought leaders, including Christopher F. Koller, president of the Fund.
We publish The Milbank Quarterly, as well as reports and issues briefs on topics important to population health.
September 2013 (Volume 91)
September 2013 | Barry Hoffmaster, Cliff Hooker
Context: For almost a decade, the Kidney Transplantation Committee of the United Network for Organ Sharing has been striving to revise its approach to allocating kidneys from deceased donors for transplantation. Two fundamental values, equality and efficiency, are central to distributing this scarce resource. The prevailing approach gives primacy to equality in the temporal form of first-come, first-served, whereas the motivation for a new approach is to redeem efficiency by increasing the length of survival of transplanted kidneys and their recipients. But decision making about a better way of allocating kidneys flounders because it is constrained by the amorphous notion of “balancing” values.
Methods: This article develops a more fitting, productive approach to resolving the conflict between equality and efficiency by embedding the notion of compromise in the analysis of a tragic choice provided by Guido Calabresi and Philip Bobbitt. For Calabresi and Bobbitt, the goals of public policy with respect to tragic choices are to limit tragedy and to deal with the irreducible minimum of tragedy in the least offensive way. Satisfying the value of efficiency limits tragedy, and satisfying the value of equality deals with the irreducible minimum of tragedy in the least offensive way. But both values cannot be completely satisfied simultaneously. Compromise is occasioned when not all the several obligations that exist in a situation can be met and when neglecting some obligations entirely in order to fulfill others entirely is improper. Compromise is amalgamated with the notion of a tragic choice and then used to assess proposals for revising the allocation of kidneys considered by the Kidney Transplantation Committee.
Findings: Compromise takes two forms in allocating kidneys: it occurs within particular approaches to allocating kidneys because neither equality nor efficiency can be fully satisfied, and it occurs over the course of sequential approaches to allocating kidneys that cycle between preferring equality and efficiency. Ross and colleagues’ Equal Opportunity Supplemented by Fair Innings proposal for allocating kidneys best exemplifies the rationality of compromise as a way of achieving the goals of making a tragic choice.
Conclusions: The attempt to design a policy for allocating kidneys from deceased donors for transplantation by balancing the values of equality and efficiency is misguided and unhelpful. Instead policymaking should both incorporate compromise into discrete approaches to allocating kidneys and extend compromise over sequential approaches to allocating kidneys.
Author(s): Barry Hoffmaster and Cliff Hooker
Keywords: allocation of health resources, kidney transplantation, compromise, tragic choices
Read on Wiley Online Library
Volume 91, Issue 3 (pages 528–557)
Published in 2013
Shifting the Paradigm: Using HIV Surveillance Data as a Foundation for Improving HIV Care and Preventing HIV Infection
Is Personality Associated with Health Care Use by Older Adults?