The goal of this study was to explore public attitudes toward the trade off in kidney allocation between transplant efficiency (which is partially based on antigenic similarity between the donor and the patient, and leads to a disadvantage for African Americans because of the racial distribution of antigenic types) and patient waiting time equity.

Data for this study were derived from a survey of 380 people assigned to jury duty at one courthouse in Philadelphia. Subjects were given information about transplantation for end stage renal disease (ESRD), the shortage of kidneys, and the factors used in distributing kidneys, which include the likelihood that a kidney transplant with be successful. They were then randomly assigned one of four vignettes which varied in the characteristics of the recipient groups and the reasons for the groups’ different success rates. For example, the distribution of blood types in donor and recipient groups favored one type over others, the distribution of favorable transplant characteristics led to white patients having a higher chance of a successful transplant, the distribution of favorable transplant characteristics led to black patients having a higher chance of successful transplant, and the distribution of favorable transplant characteristics differed by socioeconomic group.

Subjects were then asked to distribute 100 available kidneys among the groups. Their responses were categorized as choosing 1) to distribute the majority of organs to the worse prognostic group, 2) to distribute the majority of organs to the best prognostic group (agreeing with allocation by transplant efficiency), or 3) an equitable distribution despite transplant efficiency.

The most common allocation strategy was to distribute the organs in an egalitarian manner (61.3%); 27.4% chose to give more than half of the organs to the group with the better prognosis; and 11.3% chose to give more than half of the organs to the group with the worse prognosis, that is, to the group with the longer expected waiting time. It is interesting that only 17 subjects (4.5%) gave all 100 organs to those with the best prognosis—which is the distribution that would maximize the number of successful transplants. (However, most of the subjects did not understand how to maximize the number of successful transplants; only 18.2% correctly estimated this.) Subjects’ allocation decisions were not influenced by their gender, education, or age, and the effect of race was only marginally significant. Neither white nor African American subjects made decisions favoring their own racial group more frequently than their decisions to favor the other racial group.

Interesting patterns in the responses were found based on the vignette type. That is, the decision to allocate organs to the better prognostic group was most frequently chosen if the vignette was related to blood type (40% of those receiving the blood type vignette chose to allocation by transplant efficiency). This decision was less frequently chosen if the vignette was related to SES (11%) or racial group (28-30%). Furthermore, subjects were less likely to favor the better prognostic group if the vignette forced them to choose a racial group (28-30%) than a SES group (11%). Finally, there were no differences in the results obtained from subjects receiving the vignettes that indicated transplant efficiency favored either the black or the white racial group.

The authors conclude that this study contributes to a growing literature that highlights the importance that people place on equality in distributing scarce health care resources. “A majority of people felt that small difference in outcome, such as those between complete and partially matched kidney transplants do not justify allocation policies that generate significant discrepancies in waiting times for transplant candidates. The transplant system would better represent public values by placing a greater emphasis on waiting time.”