Closing the Organ Gap: A Reciprocity-Based Social Contract Approach

Organ transplantation has become a proven, cost-effective lifesaving treatment, but its promise is contingent on the number of available organs. The growing gap between the demand and supply results in unnecessary loss and diminished quality of life as well as high costs for surviving patients and health insurers. Twenty years after the enactment of the National Organ Transplantation Act, it is time to rethink the moral basis and overall design of organ transplantation policy. We propose a national plan for organ transplantation insurance under which the federal government would assume responsibility for increasing the organ supply and would cover all costs associated with transplantation for patients not otherwise covered.     

The politics of organ transplantation: a parable of our time

This paper reviews the historical development of federal government policy for kidney, heart, and liver transplantation. It examines several political dimensions of whole organ transplantation: the role of the print and broadcast media; the management of organ procurement; the certification of transplant centers; the evaluation of new surgical procedures; and the issues of financing, distributive justice, and rationing of scarce medical resources. The author finds that the media, though powerful in affecting transplant policy, have not been subjected to critical analysis. Organ procurement modifications, driven by a need orientation toward closing the gap between actual and desired levels of performance, may have adversely affected performance. The case of liver transplantation suggests the need for improved institutions and mechanisms for evaluating new surgical procedures. Finally, states that confront the need to meet a binding budget-balancing requirement may allocate funds away from expensive medical procedures that benefit the few toward basic services that benefit the many; the Oregon and Virginia Medicaid programs exemplify this point.     

Laypeople's ethical concerns about a New Israeli organ transplantation prioritization policy aimed to encourage organ donor registration among the public

A new policy recently enacted in Israel promises preferred status in receiving organs for transplantation to individuals who register to be organ donors and to their close family members. Proponents believe it will increase the supply of organs for transplantation from the deceased. Ethical issues were raised in government committees appointed to discuss the policy before its approval, but discussions among laypeople were not solicited. This study aimed to elicit laypeople's views about the policy by conducting thirteen group interviews and thirty-six individual interviews. Participants included religious and nonreligious people, immigrants, and Arabs. Some participants thought the law would contribute to fairness by prioritizing those willing to give, but others articulated ethical concerns that were not emphasized by scholars, in particular that the policy would add to the erosion of social solidarity, increase divisiveness, and enable people to abuse the system. Mistrust in the health care system emerged as a prominent reason for not registering as an organ donor. Implications about the importance of transparency in the organ transplantation system as a basis for an information campaign, social norms regarding organ donation, and the public's involvement in policy issues on organ donation are discussed.     

The Politics of Appointment and the Federal Courts'Role in Regulating America: U.S. Courts of Appeals Judgeships from T.R. to F.D.R.

Historians and political scientists have noted that appointments of judges to the U.S. Courts of Appeals are not determined by senatorial courtesy alone. What has not been adequately explained is why and when a president defers to a senator's choice rather than seek to control the selection. This article attempts to understand the politics of federal appellate court appointments. The author first identifies a major change in the work of the courts of appeals during the years 1900-1945—the growth in review of the actions of newly created federal regulatory agencies. Then, by examining Justice Department files and presidential correspondence, he discoveres three patterns of appointment emerging in the same period. The patterns vary with presidential perceptions of the role of the federal government and of the courts of appeals' ability to affect accomplishment of administration goals. Appointments during the first years of the presidencies of Theodore and Franklin Roosevelt and during the Harding and Coolidge administrations were dominated by patronage concerns. Those administrations yielded to the recommendations of senators and demonstrated no interest in the policy-making potential of these courts. In the two other patterns the White House played a more active role, with senators more often deferring to the president's selection. Concerns about professionalism dominated selections in Taft's and Hoover's administrations: because they recognized the policy importance of those judgeships but saw the role of government as limited, they sought judicial craftsmen who would make policy only incrementally. Policy concerns dominated selections during Wilson's administration and the latter years of both the Roosevelts' administrations: Justice Department officials screened nominees to determine their policy orientation, because federal appellate court judgeships were perceived as crucial policy positions that could affect the president's ability to implement his reform programs.     

Convergence Between Europe and America: The Transition from Industrial to Innovation Policy

Traditionally, the U.S. and Western Europe have chosen different policies to foster commercial innovation. Whereas (federal) government intervention in the U.S. has required strict justifications and has been mainly indirect, most governments on the other side of the Atlantic have played an explicit and more active role in the economy. However, recent developments indicate a convergence between Europe and America, both in type of policy measures and their legitimation. Within a framework of risk profiles and a typology of justifications, we examine several U.S. and European programs (Etzkowitz, 1997). We find that the main reason for convergence in policy agendas and measures seems to be an incorporation of perceived missing links in the innovation systems in response to reciprocal competitive pressures. Hence, the federal government is aiming to play a more direct role in the U.S., while the university sector and technology transfer becomes increasingly integrated in European innovation policies.     

The role of professional associations in technology transfer

This study analyzes the role of public service professional associations or professional interest groups (PIGs) in municipal government technology transfer. The purpose of the study is to examine the role of professional associations in technology transfer and to suggest a number of policy recommendations to assist these associations and the federal government in promoting innovations as potential solutions to local government problems.     

Three meanings of capacity; or,why the federal government is most likely to lead on insurance access issues

This essay considers on what health policy issues the federal government is best able to lead. Positive leadership requires knowledge, power, and will. The federal government has different supplies of each for different aspects of quality of, cost of, and access to health care. Here I review technical capacity to attain desired ends, define the institutional strengths and weaknesses of the federal government, and outline current dynamics of the national political process. This analysis suggests both prospects for and some characteristics of successful policy. The federal government is more likely to lead on insurance than on other health policy issues because its supply of relevant knowledge and power is relatively high on insurance issues and the political barriers are lower than conventional wisdom suggests. But that leadership could take the form of either the expanding or contracting of access to insurance.     

Delegation and Defensive Legislative Strategies in Brazil

In the course of the legislative process, legislators choose how much policy discretion to delegate to the executive branch. Uncertainty about policy outcomes and bureaucratic intentions weighs heavily in such decisions. In Brazil, executive control over the budget creates uncertainty about the availability of discretionary spending, which results in comparatively high levels of delegation in the legislature's direct‐spending decisions. I demonstrate that sidelining the legislature from the budget in order to insulate government spending from political pressures diminishes the value of legislative work in Brazil and reinforces historical patterns of policymaking centered on the federal executive.     

The Role of the United States Supreme Court in Shaping Federal Drug Policy

Through judicial review, the United States Supreme Court has played a pivotal role in deciding and/or interpreting the constitutionality of legislation. Since the passage of the Pure, Food and Drug Act in 1906, the Supreme Court’s role has been integral in formulating drug policy. In some instances, the Court’s decisions have limited the authority of the federal government, while in others have greatly expanded this authority. As a direct result of the decision-making of the Supreme Court, limitations have periodically been placed on Congress to regulate controlled substances. Many people, who were perceived as medical patients, became criminal drug users. The Court has restricted and later approved of the use of drugs during the free exercise of religion. Lastly, the Court has continually reinforced the supremacy of the federal government over the states, in turn limiting the ability of the states to consider marijuana legislative reform.     

Beyond "safe and effective": the role of the federal government in supporting and disseminating comparative-effectiveness research

Over the past century, medical advancements have resulted in tremendous health gains for Americans. Although the federal government has played a prominent role in ensuring that new treatments are safe and effective, questions about which medical treatments work best under which circumstances have largely remained unanswered. Thus, the federal government's recent major investments in comparative-effectiveness research have potential to play a significant role in helping both patients and health care providers navigate the vast array of available treatment options, as well as in improving the quality, efficiency, and delivery of health care system-wide. Yet, the controversial nature of the government's foray into comparative-effectiveness research also suggests that the path toward realizing these goals may be treacherous. This Article describes the rationales for federal support of comparative-effectiveness research and potential models for that involvement, analyzes the federal government's recent investments in the research, and concludes with predictions about the probable outcomes of these investments. While increased federal support for comparative-effectiveness research is unlikely to achieve all of the benefits anticipated by its supporters, it is a crucial step toward ensuring that Americans are able to take full advantage of the benefits of medical innovation     

Federal laboratories: Economic development and intellectual property constraints

The United States is increasingly looking at ways to link public-sector investments in science and technology with national economic-development goals. The federal laboratories are a reflection of this trend and much has been done to make them a more attractive source for innovative ideas in the private sector. One significant change that has resulted in making the laboratories more interactive with US industry has been the easing of government patent policy for both government-and contractor-operated national laboratories. However, there still are intellectual-property constraints, especially in the areas of technical data and software, that need immediate attention if the full intent of technology-transfer legislation is to be met. Previously he was a science policy analyst in the US General Accounting Office's Resource, Community and Economic Development Division.     

Chronic disease and disadvantage: the new politics of HIV infection

HIV infection is now perceived as the end stage of a chronic disease that is spreading most rapidly among blacks and Hispanics. The politics of the HIV epidemic in the 1980s were dominated by four interacting factors: fear and fascination; who had the disease and to whom it seemed to be spreading; the endemic problems of United States social policy; and the impact on policy of advances in scientific knowledge. This paper analyzes the political history of each of these factors and describes the dominant policies of the federal government and the states regarding HIV in the areas of surveillance, prevention, research, and financing. Four uncertainties will have a profound influence on the future politics of the HIV epidemic: how the states and the federal government will address the general problems of paying for the care of people with chronic diseases and providing access to care for the uninsured and the underinsured; the number and distribution of the sexual behaviors that transmit infection with HIV and the effectiveness of policies to persuade people to modify these behaviors; precisely who uses addictive drugs and the effectiveness of measures to change their behavior; and the natural history of the virus.     

Legislators as Lobbyists

Public policy is produced by elected and unelected officials and through the interactions of branches of government. We consider how such interactions affect policy implementation and representation. We argue that legislators try to influence bureaucratic decisions through direct communication with federal agencies, and that such contact is effective and has consequences for policy outcomes. We provide empirical evidence of this argument using original data about direct communication between members of Congress and the U.S. Department of Labor (DOL) along with decisions made by the DOL regarding trade and redistributive policies. We find that direct contacts influence DOL decisions, and the agency is more likely to reverse previous decisions when requested to do so by legislators. Our results challenge key assumptions and findings in the previous literature and have important implications for interbranch relations and informal means of control over the implementation of national policy.     

THE PROSECUTION AND PUNISHMENT OF INTERNATIONAL TERRORISTS IN FEDERAL COURTS: 1980–1998*

Research Summary: This study reports findings from the American Terrorism Study. The data show that from 1980 to 1998, the U.S. government periodically tried accused domestic and international terrorists through the use of traditional criminal trials. The extent to which federal prosecutors “explicit politicized” these trials (and the success that the politicization had) varied among the types of terrorist groups. Explicit politically was not found to be successful in trials of domestic terrorists but seemed to work for trials involving international terrorists. Over the 20‐year period, however, federal prosecutors began to rely more heavily (and more successfully) on the politicization of the criminal acts by international terrorists. The results also show that international terrorists, like their domestic counterparts, are much less likely to plead guilty. Finally, the study shows that these traditional trials have resulted in international terrorists being punished more severely than domestic terrorists. Unfortunately, the practice of performing these politicized trials within the venue of the federal court system may have been compromised by defense strategies that capitalized on the due process procedures so prominent in the U.S. system of justice. In the wake of the terrorism attacks in September 2001 by foreign nationals, the federal government began to take the next step in its “war against terrorism” by instituting the use of military tribunals. Policy Implications: Although the federal government has been relatively successful in the prosecution of terrorism in America in the past two decades, the movement toward the use of military tribunals has perhaps become inevitable (as the use of the traditional criminal trial for international terrorists manifests weaknesses). In the short term, it is likely that several international terrorism cases stemming from the September 2001 attacks and other subsequent attacks (which may be presumed) will be tried in federal courthouses across the country (even with the advent of military tribunals). Federal prosecutors will need to be trained on the specifics of trying these kinds of cases. In the long term, the use of military tribunals will provide greater ease of prosecution for the federal government. Long‐term consequences such as retaliatory attacks and attacks aimed at the release of political prisoners cannot be ignored by policy makers.     

The Content Analysis of the Russian Federal and Regional Basic Legislation on the Cultural Policy

The content-analysis of the Russian federal and regional basic legislation on the cultural policy has indicated a need in a deep revision of all existing regulatory legal acts, which support the state cultural policy implementation towards building a universal terminology and vesting the functions on the cultural policy implementation in the government as opposed to the statement of the departmental specific approach to the culture.     

Guilty Property: A quantitative analysis of civil asset forfeiture

The objective of this article is to explore how property seized under the federal civil-judicial forfeiture laws for drug law violations is proceeded against by the government. The methodology is primarily exploratory. A sample of federal civil-judicial drug forfeiture cases is described and then analyzed in regard to the relative importance of the cases’ characteristics. The findings raise serious questions about the use of this policy and the government’s intent behind forfeiture. Implications and suggestions for future research are also presented.     

Ethical criteria for procuring and distributing organs for transplantation

This article provides an ethical analysis and assessment of various actual and proposed policies of organ procurement and distribution in light of moral principles already embedded in U.S. institutions, laws, policies, and practices. Evaluating different methods of acquisition of human body parts--donation (express and presumed), sales, abandonment, and expropriation--the author argues for laws and policies, including required request, to maintain and facilitate express donation of organs by individuals and their families. Such laws and policies need adequate time for a determination of their effectiveness before society moves to other major alternatives, such as a market. In organ allocation and distribution, which have close moral connections with organ procurement, the author defends the judgment of the federal Task Force on Organ Transplantation that the community should have dispositional authority over donated organs, that professionals should be viewed as trustees and stewards of donated organs, and that the public should be heavily involved in the formation of policies of allocation and distribution. Concentrating on policies being developed in the United Network for Organ Sharing, the author examines the point system for cadaveric kidneys, the access of foreign nationals to organs donated in the U.S., and the multiple listings of patients seeking transplants. He concludes by identifying two major problems of equitable access to donated organs that will have to be addressed by social institutions other than UNOS: access to the waiting list for donated organs and the role of ability to pay in extrarenal transplants.     

Administering Entitlement: Governance,Public Health Care,and the Early American State

This article explores the federal marine hospitals of the early republic, the first public health care system in US history. Beginning in 1798, the federal government collected twenty cents per month from mariners' wages and used this revenue to subsidize medical care for sick and disabled merchant mariners. Previous studies have traced links between marine hospitals and modern public policy. By studying governance from the bottom up, this article takes a different approach. I argue that jurists, physicians, and officials' regulation of sailors' entitlement to public health care facilitated and reflected a transformation of national authority. Between 1798 and 1816, sailors' entitlement was a local matter, based on the traditional paternalist understandings of maritime laborers as social dependents. By 1836, though, the federal Treasury redefined entitlement around a newly calculus of productivity: only the productive were entitled to care at the marine hospitals. This story about governance, federal law, and political economy in the early United States suggests that the early American state was a more vibrant participant in the market and society than has been previously understood.     

Horses or unicorns: can paying for performance make quality competition routine?

The competitive benefits of pay-for-performance (P4P) financial incentives are widely assumed. These incentives can affect health care through several mechanisms, however, not all of which involve competition. This insight has three implications. First, federal antitrust enforcement should continue to scrutinize P4P arrangements. Second, government needs to play a larger role in P4P than through antitrust oversight. Third, widespread enthusiasm for a particular health policy reform does not relieve policy makers of the obligation to understand its theoretical basis.