Racial Priorities for Kidney Transplants

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Some persons have suggested that the current system of allocating kidneys for transplant is biased against African Americans and should be changed to include race as a factor in determining allocation of organs (Ayres et al., 1993). Although African Americans disproportionately end up on dialysis with end-stage kidney disease, they receive disproportionately fewer of the kidneys available for transplant. A number of factors explain this difference, including the requirement of a close enough match between donor and recipient to ensure that the graft will take (Epstein et al., 2000). Because African Americans share fewer HLA antigens with whites, who are also the most frequent organ donors, they are often the poorest match and the most infrequently transplanted.

As a result, some persons have suggested that the matching requirement be altered to enable more African Americans to obtain kidney transplants, or that African Americans be allocated a share of kidneys regardless of matching. An explicit preference for African American kidney transplant recipients, however, would be difficult to justify. African Americans currently on the transplant list are not claiming previous illegal discrimination. Nor, if they would not do as well with donated organs because of HLA mismatch, is it tenable to give them a share of donated kidneys proportionate to their numbers on the list. Such a preference would reduce the likelihood that donated kidneys functioned properly in recipients and could reduce the willingness of people to donate.

However, other actions to improve minority access to kidney transplantation in other ways would be acceptable. Education programs directed to

African Americans about their high risk for kidney disease and steps to better inform them of transplant alternatives are clearly in order (Ayanian et al., 1999). They are directly health related, and no individual is denied a needed therapy as a result, as is the case with racial preferences in access to donated kidneys.

C. HEALTH CARE VOUCHERS FOR PARTICULAR RACIAL or Ethnic Groups

Suppose the government gave each African American person a $5000-per-year voucher to buy health insurance, but only African Americans got this benefit. Although intended to overcome years of medical underservice for the African American community, this program has the appearance of a naked preference for African Americans rather than a program that is trying to improve African American health care. No whites might be denied something that they otherwise would have received, but because they are being excluded on the basis of race, strict scrutiny of the program's racial criteria would be required.

Its supporters would have to show that making a voucher program accessible to all would be too expensive and that African American health was so much worse than the health of whites that no other way to meet their needs would exist, a highly implausible claim. A compensatory argument would face the same difficulty that arises in justifying affirmative action in education or employment on this basis—that present beneficiaries of the racial preference were victims of past illegal discrimination. Although the voucher program discussed here is unlikely to be enacted, such a program helpfully shows that meaningful limits on the use of race in health care do exist.

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