Considering the Role of Public Health

1. Introduction What are the chances that a 13-year-old child with end stage renal disease (ESRD) will undergo a kidney transplant, or at least be treated with dialysis? Sadly, the answer is not only clinical but also sociological in nature, deeply rooted in economic, political, and social structures. If, for example, this child lives in a lower- or middle-income country, her chances of being diagnosed in time to receive such care are low (Muralidharan/White 2015; Muller 2016). However, if this child was born in a Scandinavian country, she would have a good chance of receiving a transplant that would lengthen her life by many years. The gap between organ demand and available supply, even in countries where it has been reduced slightly in recent years, is abysmally large. Patients across the globe die every day awaiting a needed organ. In the United States, for example, a significant disparity between organ supply and demand remains, even as a record number of transplants have been performed. Data from early 2020 provided by The United Network for Organ Sharing indicates that 112.605 Americans are in need of an organ transplant. But in 2019 there were only 39.718 successful organ transplantations (from both living and dead donors). Supply is not meeting, nor will meet, demand (UNOS 2020). We all know that health disparities exist. In transplant medicine, however, disparities and equity are generally discussed by bioethicists in terms of access to transplantation for ESRD and other chronic health conditions that lead to transplant. In this paper, we show why transplant bioethics alone cannot solve many of the problems facing transplant medicine, and we turn instead to public health for answers. In general, public health employs policies of prevention to address conditions before they develop into chronic or fatal diseases. We believe there is an unmet need to discuss prevention in the context of organ transplantation and to explain how public health ethics approaches could both contribute to reducing the organ shortage and provide moral guideposts for such an approach. As public health practitioners, we also believe our moral obligation is to assist those with inherited, chronic, and acute conditions before transplants become necessary. Thus, in this paper we argue that the field of transplant medicine will be better able to address its challenges if it incorporates prevention