MEDICINE KIDNEY TRANSPLANTS : Study Finds Blacks Less Likely to Get Surgery, but Discounts Racism Claims
Black Americans who need kidney transplants are significantly less likely to receive them than whites, but the reasons have more to do with biology and socioeconomics than with so-called “bedside racism,” according to the authors of a comprehensive new study.
The conclusion, published today in the New England Journal of Medicine by a group of transplant physicians, is the latest effort to address a trend that has troubled the medical profession for several years: Although black people are four times more vulnerable than whites to kidney failure, studies have shown that when transplants become available, they tend to go to white patients.
In 1985, only 21% of all kidney transplants went to blacks, even though they accounted for 28% of the patients with serious kidney disease, according to the federal Health Care Financing Administration. Figures from the United Network for Organ Sharing in Richmond, Va., indicate that although blacks make up about a third of the nearly 18,000 people on the national waiting list, they received only about 20% of the kidney transplants last year.
Previous studies have theorized that subconscious bias might account for part of the inequity in transplant rates.
But today’s report--a review of existing data by a committee of the American Society of Transplant Physicians--concluded that “it is likely that both biologic and socioeconomic differences between blacks and whites contribute to this inequality.”
“We never found anywhere that there is any willful discrimination against blacks or other minorities,” said Dr. Gabriel M. Danovitch, a co-author of the study and a professor of medicine at UCLA.
Rather, Danovitch said, the little hard evidence available points to a variety of complex factors, ranging from a lack of health insurance among blacks to differences in blood types that make many black patients incompatible with the majority of organs in the donor pool.
For example, the study found, white families are two or three times more likely than blacks to donate a deceased relative’s organs for transplantation.
In 1989, 8% of kidney donors were black and 84% were white, according to the United Network for Organ Sharing. The remainder came from other ethnic groups.
Blacks have a much higher incidence of hypertension and diabetes that can result in kidney failure, and thus are over-represented on the waiting list for kidney transplants. But because of genetic differences in blood and tissue types, many black people cannot accept organs taken from whites. Thus, they are forced to compete for a much smaller organ pool.
“We strongly feel that the differences could be improved if we could encourage donations by racial minorities,” Danovitch said.
Another possible factor, the study found, may have to do with variations in insurance coverage. Although Medicare pays much of the cost of transplants for most people, it does not offer complete coverage in every state. Poorer blacks may be unable to afford the remaining costs, and may therefore be considered less suitable candidates for transplants, the study noted.
Other factors may have to do with whether a patient is a good risk for a transplant, the physicians found. For example, the study noted, doctors may not offer transplants to black patients because they may suspect them of alcohol and drug abuse, which would undermine the surgery.
“The prevalence of heroin abuse may be higher in blacks than in whites,” the authors explained.
Also, transplant survival rates are about 10% lower in black patients than in whites, and some black patients may choose to remain on dialysis rather than run the risk of a failed operation, said Dr. Martin G. White of Dallas, another of the study’s authors. The authors said it is unclear why transplant survival rates might be lower in black patients, but it could be because so many receive kidneys from whites or because poorer blacks cannot afford follow-up medication.
Bioethicists lauded the committee for taking on the highly charged issue of race and medicine but faulted the study for downplaying the possibility of bias within the medical profession.
Studies have found that the disparity in kidney transplants persists even when the black and white patients come from similar socioeconomic backgrounds, and even after black patients make it onto the transplant waiting list. Last year, the U.S. Department of Health and Human Services reported that blacks patients in line for new kidneys wait almost twice as long as whites, 13.9 months on average compared with 7.6 months.
In that report, the department’s inspector general theorized that “subconscious bias” against blacks may be part of the explanation--a possibility that has been raised by other experts to help explain the lack of minority access to health care in general.
The new study found no clear evidence of bias, but ethicists contend that the issue is not resolved.
“I think their concern is to meet the charge that racism may be appearing at the bedside, and I think they do explain--to some extent, accurately--that it isn’t true,” said Dr. Arthur Caplan, a bioethicist at the University of Minnesota. “But there are going to be differences in the (physician’s) view of a patient, depending on whether he has a job or owns a home or abuses drugs,” Caplan said. “Those things correlate strongly in our society with race, and if we use them as a criteria in determining who gets a transplant, then racism enters through the back door.”