280 C. Kierans
Despite the apparent functioning of this system, not everyone who
needs a transplant gets one. What is more the rhetoric of entitle-
ments to health services, free at the point of delivery, does not ensure
that the supply of deceased-organs-for-transplant—dependent on vol-
untary public participation—meets demand. Organs are inevitably
rationed, which implies that inequalities of access follow, with benefi-
cial treatments unavailable for some.^8 To manage this process, patients
are “wait-listed” according to criteria such as time on the organ wait-
ing list, severity of illness, Human Leukocyte Antigen (HLA) matching,
prognostic information, age of recipient. These variables are, in turn,
translated into quantifiable values, giving rise to a points-based sys-
tem, used to generate another body of metrics: Quality Adjusted Life
Years (QALYs)—that is, the number of “healthy” years a person can be
expected to live as a result of an intervention. Needs-based resourcing,
rather than payment-based resourcing, generates a system of value to
help determine the relationship of cost to benefit. While this is argu-
ably a different production of value than in Mexico, it is also one which
ostensibly determines who gets access to what. The DH has estimated
that kidney transplantation is cost effective at a threshold of £30 K
per QUALY (Cronin 2016 ). However, as demand for organs has out-
stripped supply, there are, today, almost 10,000 people waiting for
a transplant, with many dying before they get to the head of a queue
organised according to a range of bureaucratic and organisational for-
matting requirements.
What is important in all of this is that inequalities in access to organ
transplantation have their own local registers within the particular polit-
ical economies of health care of which they are a part. In the UK, for
example, this has found expression in the difficulties experienced by
members of minority ethnic groups in acquiring organs-for-transplant.^9
Minority ethnic groups have a statistically greater need for a kidney
transplant, yet are comparatively less likely to obtain one, a problem
often framed as owing to poor levels of donation among such classified
groups. As I have argued elsewhere, this is less a social or cultural con-
cern than an outcome of the scientific practices which underpin blood
and antigen matching (for discussion, see Kierans and Cooper 2011 ).