The Politics of Livers

A few weeks back, NPR’s Planet Money podcast talked about recent changes to the way the organ transplant system for lungs and livers function. As is their wont, they looked at the system as a market, albeit an unusual one in that it is illegal to buy or sell organs. However, I think the system is better viewed as a political one – instead of doctors as market actors, they’re representatives trying to balance personal self-interest with their responsibilities to both their broad and narrow constituencies.

The gist of the podcast is that, prior to 2002, the order in which patients were allocated new livers depended on a formula that took various indicators of health into consideration – primarily blood tests, but also whether the patient was in the ICU. As one can imagine, this lead to patients on the waiting list remaining in the ICU perhaps more was strictly necessary. After the rules changed to consider only blood tests, the percentage of patients receiving livers who were in the ICU dropped from 24% to 13%. In an interview with a doctor involved in lung transplants, the doctor said that the organ transplant list had to be set up not only to deliver organs efficiently to patients who needed them most, but also to control doctors from gaming the system. A doctor trying to do the best thing for his patient could end up killing another patient somewhere else.

Now, instead looking at how much light the market metaphor can shine on the doctors, think about how much the experiences of the doctors critique the logic of representative democracy. The citizens are the patients, trying to obtain scarce goods and services from the government as quickly as possible. The doctors are their elected representatives, who as a whole control the way the system functions but as individuals try to obtain goods and services for their constituents, the patients. The organ transplant system itself is the political structure, its institutions and norms.

The problem with the liver transplant system was that when each doctor tried to do the best he could for his patient (by unnecessarily admitting them to the ICU), not only did it directly harm other patients on the waiting list, but it unnecessarily cost the healthcare system as a whole millions of dollars as liver patients ate up resources in order to game the system. Heeding only the will one’s narrow constituents does not an efficient system make.

The need to win reelection was certainly designed as a check on the actions of representatives. However, representatives were also supposed to consider the common good of the country as a whole, not just that of their constituents, while leading the country. The hope that one man, elected by his peers, could put aside short-sighted or oppressive or parochial concerns and act in pursuit of the common good was one not-insignificant advantage they saw over direct democracy.¹

Think of that famous line from Federalist 57:

The aim of every political constitution is, or ought to be, first to obtain for rulers men who possess most wisdom to discern, and most virtue to pursue, the common good of the society; and in the next place, to take the most effectual precautions for keeping them virtuous whilst they continue to hold their public trust.

Making individual representatives subject to election by a narrow subset of the population was a means to that second goal, not the first. But as organ transplant system showed, even doctors – who had taken an oath to do no harm – were liable to sacrifice the common good in the name of their narrow constituency. In order to stop, they had to change the rules of the game.