Diana Hawashin, Dunia J. Mahboobeh, Khaled Salah, Raja Jayaraman ¡ 7 authors
Todayâs a large number of blood donation management systems fall short in providing traceability, immutability, transparency, audit, privacy, and security features. Also, they are vulnerable to the single point of failure problem due to centralization. In this paper, we propose a private Ethereum blockchain-based solution to automate blood donation management in a manner that is decentralized, transparent, traceable, auditable, private, secure, and trustworthy. The proposed solution stores non-critical and large data off-chain using the decentralized storage of the InterPlanetary File System (IPFS). We present the system architecture, sequence diagrams, entity-relationship diagram, and algorithms to briefly explain the working principles of our blood donation management solution. We evaluate the performance of our solution in terms of efficiency and effectiveness through performing security analysis. We make our smart contract code publicly available on Github1.
COVID-19 made the world stop, with people trapped inside their homes and governments trying to restrict the public movement. However, to accomplish this, one big problem that emerged and outscored everything else was catering to the day to day necessary items of the people without human involvement. In this regard, we propose a blockchain-enabled secure communication framework for delivering the goods in COVID-19 like scenarios by leveraging the drones that are available with commercial retail providers. The blockchain scheme is used to create smart contracts to build the trust of buyers and sellers on the framework as the payments are made through the smart contract executions. The blockchain based order processing ensures the integrity and authenticity of the information. Moreover, a communication model is presented along with the order, delivery and payment phases. The results prove the effectiveness of the proposed scheme by evaluating it based on gas price, transaction time, and mining time.
Mark Gaynor, Janet E. TuttleâNewhall, Jessica Parker, Arti Patel ¡ 5 authors
This study aims to review current issues regarding the application of blockchain technology in health care. We illustrated the various ways in which blockchain can solve current health care issues in three main arenas: data exchange, contracts, and supply chain management. This paper presents several current and projected uses of blockchain technology in the health care industry. We predicted which of these applications are likely to be adopted quickly and provided a supply chain example of tracking the transportation of organs for transplantation.
BACKGROUND: The widespread death and disruption caused by the COVID-19 pandemic has revealed deficiencies of existing institutions regarding the protection of human health and well-being. Both a lack of accurate and timely data and pervasive misinformation are causing increasing harm and growing tension between data privacy and public health concerns. OBJECTIVE: This aim of this paper is to describe how blockchain, with its distributed trust networks and cryptography-based security, can provide solutions to data-related trust problems. METHODS: Blockchain is being applied in innovative ways that are relevant to the current COVID-19 crisis. We describe examples of the challenges faced by existing technologies to track medical supplies and infected patients and how blockchain technology applications may help in these situations. RESULTS: This exploration of existing and potential applications of blockchain technology for medical care shows how the distributed governance structure and privacy-preserving features of blockchain can be used to create "trustless" systems that can help resolve the tension between maintaining privacy and addressing public health needs in the fight against COVID-19. CONCLUSIONS: Blockchain relies on a distributed, robust, secure, privacy-preserving, and immutable record framework that can positively transform the nature of trust, value sharing, and transactions. A nationally coordinated effort to explore blockchain to address the deficiencies of existing systems and a partnership of academia, researchers, business, and industry are suggested to expedite the adoption of blockchain in health care.
In mass disasters with multinational victims, it is critical to identify the deceased for judicial, ethical, religious and human rights reasons, as well as to allow the next of kin to complete the grieving process. Disaster Victim Identification (DVI) process is a complex procedure where Post-mortem (PM) identifying data, essentially fingerprints, DNA and dental, is collected in order to be compared with equivalent Antemortem (AM) data related to the missing persons list. Although there are solutions used in the field of human identification, they all fall short of equipping them with the tools needed for achieving human identification in a timely manner. Initially, it is significantly challenging to manage missing person lists containing years, and sometimes decades, of family AM data resourcesâ updates. Furthermore, there is currently no record of any holistic technical solutions for managing both AM and PM for human identification to support collaborative multinational and interjurisdictional processes. Blockchain technology provides the tools to facilitate building trustworthy, secure and holistic ecosystems, and it can disseminate siloed AM and PM data across systems, protecting data breaches, redundancies, inconsistencies, and errors. As such, blockchain technology can revolutionize the human identification process worldwide in terms of managing missing person lists, AM data repositories for living people, PM data repositories of recovered unidentified victims, and contribute to the comparison of compatible biological profiles for definitive identification. Using real-world scenarios, the authors propose a number of promising use cases to attain a holistic understanding of the challenges, and present how blockchain technology meets such challenges and facilitates multi-jurisdictional data information-sharing in conjunction with the forthcoming circulation of patientsâ electronic medical and dental records.
Introduction Argentina is the third most populated country in South America with an estimated population of 44,494,502. Despite having an area of 2,780,400 km2 (eighth largest in the world), 90% of the population resides in urban areas, with the majority concentrated in and around Buenos Aires. Life expectancy is 79.7 years in women and 73.6 years in men, with cardiovascular disease as the leading cause of mortality. Argentina spends approximately 10% of its gross domestic product on health care (1). There are 3.94 physicians and 4.5 hospital beds per 1000 inhabitants in Argentina (2). The physician-patient ratio is similar to that of Australia, Italy, Spain, and Switzerland, and is double than Brazil and almost four times than Chile and Peru. Argentina has a multitiered, decentralized health care system that is plagued by fragmented management and financing. There are national, provincial, and municipal governmentâsponsored health care insurances, which together with union-sponsored insurances, provide health care coverage to nearly 22 million people. An additional approximately 10% of the population has private health insurance, leaving nearly 36% of the population without health care coverage or the financial means to pay for private insurance. These individuals are cared for at cost-free public hospitals and community facilities (1,2). The first hemodialysis (HD) treatment in Argentina dates back to 1955. Five years later in 1960, the Argentine Society of Nephrology was founded (3). Epidemiology The incidence and prevalence of CKD and ESKD have been growing steadily, most likely because of increasing rates of diabetes and obesity as well as an aging population. Indeed, CKD is now the seventh leading cause of mortality in Argentina, and CKD-related deaths have increased by 15% between 2007 and 2017 (4). The National Transplantation Institute (INCUCAI) supports a National Dialysis and Transplant Registry (5,6). Patient reporting is obligatory; therefore, national data are valid and representative. Reporting is the responsibility of the dialysis center director, and it is provided online. Patient identity is preserved by data security systems. The annual incidence of ESKD is 160 patients per million population, with diabetes and hypertension as the most common etiologies (Table 1). At the end of 2018, there were 29,929 patients with ESKD on chronic dialysis, representing a prevalence rate of 673 patients per million population (Figure 1) (5,6). Of these, approximately 93.5% are on in-center HD, 6.5% on peritoneal dialysis (PD), and none are on home HD. Of the patients on HD, 70% receive dialysis via an arteriovenous fistula, 15% receive dialysis via an arteriovenous graft, and 15% receive dialysis via central venous catheters. First year and annual mortality rates on dialysis are 18% and 16.4%, respectively (Table 1), with cardiovascular cause being the most common (6). Annual mortality rate has been above 16% for the last 4 years (Figure 2). RRT in Argentina has incidence and prevalence rates above the mean for Latin America, most likely because dialysis and transplant are readily available in the country (Table 2). Nevertheless, PD is relatively less used compared with the rest of Latin America (7â9). Table 1. - Characteristics of patients on dialysis in Argentina Characteristic Value Country population 44,494,502 Patients on hemodialysis 29,929 Patients on peritoneal dialysis 1945 Patients with functioning kidney transplant 11,486 Prevalence of hepatitis B, % 0.2 Prevalence of hepatitis C, % 1 Prevalence of HIV, % 0.8 Prevalence of diabetes, % 28 Membrane dialyzer (reuse), synthetic/substituted cellulose/cellulose, % 83/14/4 Type of vascular access, native AVF/prosthetic AVF/catheter 70/15/15 Prevalence of patients with ESA, % 87 No. of hemodialysis centers 597 Hospital-based dialysis units, % 25 Nonprofit dialysis units, % 11 No. of peritoneal dialysis centers 79 Dialysis covered by insurance, % 100 Out-of-pocket expenses, % 0 Dialysis unit staffing, nurses/technicians, % 95/5 Payment per hemodialysis session, USD 55 Patient-nurse ratio in hemodialysis units, adult/pediatric 4â5/2â3 Average length of dialysis session, h 4 Minimum patient evaluation by physician per mo 4 No. of transplant centers 55 Adjusted annual mortality dialysis rate, % 16.48 Etiology of ESKD, % Diabetes 36.5 Nephroangiosclerosis 20 Unknown cause 17 GN 9 Myeloma and amyloidosis 1 Obstructive uropathy 6 Polycystic kidney disease, adult type 5 Epidemic uremic hemolytic syndrome 0.5 Other 5 Cause of death, % Cardiovascular 50 Infection 25 Neoplasia 6 Other 19 Source: Argentinean Registry of Dialysis and Transplantation (5,6). AVF, arteriovenous fistula; ESA, erythropoiesis-stimulating agents; USD, United States dollars. Figure 1.: Annual prevalence of dialysis patients ( 5 , 6 ).Figure 2.: Annual dialysis mortality rate . Rate is expressed in deaths per 100 patients at risk with 95% confidence interval bars. Source: Argentinean Registry of Dialysis and Transplantation (5,6). Table 2. - Comparison of RRT between Argentina and Latin America Argentina Latin America Prevalence of patients with ESKD under RRT (dialysis and transplant) a 976 805 Dialysis incidence rate a 160 154 Kidney transplant rate a 30 21 Patients on peritoneal dialysis, % 6.5 11.5 Nephrologist a 30 18 aRates are expressed per million population. Source: Latin American Registry of Dialysis and Transplantation (7). Structural Organization and Logistics of Dialysis Argentina has dialysis units in both hospital and private settings. There are a total number of 597 dialysis centers in the country. Eleven percent (68 centers) of these centers are government owned, 377 (63%) are independent dialysis centers, and the rest (152 centers; 26%) are owned by foreign dialysis companies. One hundred eighty-seven dialysis units are in the province of Buenos Aires, and the rest are located throughout the rest of the country. Dialysis is covered by patientsâ union health system or health insurance; ultimately, the government pays if the patient does not have insurance. Government coverage is universal if a patient does not have union or health insurance. This includes illegal immigrants, noncitizens, and refugees. Payment for HD and PD is capitated at approximately United States $700 per month or United States $55 per HD session. Physicians across the country are paid by monthly salaries, and some also have private practice. PD solutions are not manufactured in the country and are, therefore, imported. Bundle HD and PD payment includes vascular access, erythropoietin, appropriate vaccination, and transfer to and from the dialysis unit. Monthly reimbursement is irrespective of procedure number. Average HD sessions last for 240 minutes, with 95% of patients receiving three or more dialysis sessions per week (5,6). Online hemodiafiltration has been recorded since 2015. Approximately 20% of HD centers have this technology. Although 70% of patients on incident dialysis start with a temporary catheter as their vascular access, at 6 months into treatment most have permanent vascular access. Seventy percent of prevalent patients have an arteriovenous fistula. Nephrologists insert all temporary catheter access. Permanent HD catheters are placed by nephrologists also but mostly by vascular surgeons. Arteriovenous fistulas are 100% done by vascular surgery. Interventional nephrologists do not perform arteriovenous fistulas. Almost 87% of the patients are on erythropoietin or similar agents, and synthetic HD membranes are most commonly used. (Table 1) (5,6). The advent of technologic advancement, biosecurity implementation, and specific treatment has decreased the prevalence of hepatitis B, hepatitis C, and HIV in the dialysis population (0.2%, 1%, and 0.8%, respectively). Isolation of patients with hepatitis B is mandatory. No formal end-of-life care support programs are available in Argentina. Staffing of Dialysis Units Argentina is third among Latin American countries considering nephrology physicians per million inhabitants (Table 2) (7,8). There is one nephrologist for every 40 patients, and a nephrologist must be present in the dialysis unit at all times. There are approximately 80 renal fellows in training per year. Most patients are seen daily or at least four times a month. In continuous ambulatory peritoneal dialysis, they are seen once a month. Historically, non-nurse technicians accounted for the majority of dialysis personnel, but this has progressively decreased to approximately 5%. Nurses now provide the lionâs share of dialysis care. The main driving force for this change occurred 10 years ago when regulations were changed to increase the number of dialysis nurses taking care of these patients. The nurse to patient ratio is four to five adult patients per nurse in HD units and two to three children per nurse in pediatric units. In PD, the ratio is 20 adult and 15 pediatric patients per nurse (5,6). No formal dialysis nurse certification is in place in the country. Transplantation in Argentina The International Registry of Organ Donation and Transplantation reports that in 2019 there were approximately 1674 kidney transplants (1325 from deceased donors and 349 from living donors) in Argentina. There were 69 simultaneous kidney-pancreas transplants, 19 kidney-liver transplants, and 5 kidney-heart transplants. More men (62%) were transplanted than women. The availability of kidney transplants differs regionally around Argentina, with approximately 6546 patients with ESKD currently on the transplant list waiting for a new kidney. Average waiting time on the transplant list is over 4 years. Swap living kidney transplants have occurred, but there are very few cases (5). Transplantation is regulated by the INCUCAI (5,6). Since 2004, the INCUCAI has supported a National Dialysis and Transplant Registry. Patient reporting is obligatory, and therefore, national data are valid and representative. The INCUCAI in conjunction with the Argentine Society of Nephrology analyzes and reports the data of the National Dialysis and Transplant Registry (5,6). The INCUCAI, the Argentine Society of Nephrology, and the Argentine Transplant Society promote organ donation campaigns regularly. A recent law has declared the general population as presumed donors, and this has increased donation by 20%â25%. There are barriers to donation, but none are due to social or cultural barriers. Some of these barriers include logistics of organ harvesting and transportation in a large country, insufficient organ harvesting teams in some regions, etc. Future Directions and Challenges RRTs are accessible and available in Argentina, and utilization rates are acceptable compared with other countries in the region. It will be challenging to improve what is currently available with limited economic resources. An advanced kidney care program is not available nationwide and needs to be designed and implemented to guarantee early and programmed dialysis initiation and preemptive transplant when possible. PD is underused in Argentina for many reasons: peritoneal solutions are not manufactured in the country and are expensive, and most nephrologists have not been trained in PD because HD has been the predominant form of dialysis historically. Because many patients still begin dialysis without previous planification, the preferred dialysis modality used in urgent situations is HD through temporary catheter access. Training and economic incentives will help develop PD further. Home HD will most likely be set aside for some time. This technology is not available yet, and no reimbursement plans are underway for this dialysis modality. Disclosures G.J. Rosa Diez is employed by Fressenius. The remaining author has nothing to disclose. Funding None.
Gamze Gßrsoy, Charlotte M. Brannon, Eric Ni, Sarah Wagner ¡ 6 authors
Abstract The genomic characterization of individuals promises to be immensely useful for biomedical research and healthcare. However, a critical barrier to expanding personal genome sequencing is achieving secure, high-integrity storage of raw data. While cloud storage offers solutions to access such data from any place and device, the vulnerabilities of centralized storage in relation to security, data integrity, and robustness, such as single points of failure, have not yet been addressed. Blockchain is a potential alternative to these storage modes. However, storing large-scale data on blockchain can be challenging due to slow transaction speeds, the potential for chains to reach large sizes, and limitations on querying data stored on-chain. Currently, several genomic storage applications incorporate blockchain, but likely because of these challenges, many use blockchain only to facilitate and log data-access transactions, rather than to store raw genomic data on-chain. While this secures the process of data access, it does not secure the data itself, which is often stored off-chain (i.e. in a cloud or file-hosting services). Here, we developed a novel method of storing reference-aligned reads on-chain in a private blockchain network. We also developed tools for accessing and analyzing the on-chain data. We addressed the challenges of on-chain data storage by minimizing the data inserted to the chain using reference-based data compression techniques and by binning the on-chain data by genomic location to reduce retrieval times. Our tools provide open-source blockchain-based storage and access for advanced genomic analyses such as variant calling.
The organ donation system in the United States is centralized and difficult to audit by the general public. This centralized approach may lead to data integrity issues in the future. The Organ Procurement and Transplant Network (OPTN) was built and maintained by a non-governmental organization called the United Network for Organ Sharing (UNOS) under its proprietary UNet(SM) umbrella platform. This platform is made up of proprietary closed source software and does not provide the general public easy access to the organ transplant data for auditing. This study investigates the feasibility, challenges, and advantages of a blockchain-based OPTN. A prototype of a blockchain-based OPTN was created using the Hyperledger Fabric framework. The policies and guidelines issued by the United States Department of Health and Human Services for UNOS and the OPTN were used as the basis of this prototype. Four factors were identified to have a direct effect on the performance of this system, viz. max batch time out, max block size, endorsement policy, and transaction rate. Additionally, two variants of the blockchain chaincode were also developed. The first variant performed the organ-candidate matching inside the blockchain (Scheme A), and the second variant performed it outside the blockchain (Scheme B). Analysis of these data showed that Scheme A outperformed Scheme B in all experiments for write-operations. However, the read operations remained unaffected by any of the experiment variables in the given environment. Based on these results, it is recommended to perform the organ-candidate matching on the blockchain with the max batch time out close to the transaction rate.
Internet of Things have brought exciting changes in the social norms, work environments and the prospects for future generations. These devices (Things) have already changed the way our networks are used for communication. With the introduction of machine to machine communication (M2M), where devices communicate without human involvement to perform routine day to day tasks.
An advantage of blockchain protocols is that a decentralized community of users may each update and maintain a public ledger without the need for a trusted third party. Such modifications introduce important economic and ethical considerations that we believe have been not been considered among the community of blockchain developers. We clarify the problem and provide one implementable ethical framework that such developers could use to determine which aspects should be immutable and which should not.
We propose that blockchain technology complemented by secure computation methods can foster implementation of a learning healthcare system (LHCS) by minimizing upfront patient-facing compromises with unsurpassed data security and privacy, and by optimizing the systemâs fulfillment of its obligations to respect patients through transparency, engagement, and accountability. We demonstrate how a blockchain-enabled LHCS could foster patient willingness to contribute to learning by providing desired security and control over health data. In addition, secure computation methods could enable meta-analysis without exposing individual-level data, thus allowing the system to protect patientsâ privacy while simultaneously learning from their data. The transparency and immutability of blockchain ledgers would also support the publicâs trust in the system by allowing patients to audit and oversee which of their data are used, how they are used, and by whom. Furthermore, blockchain communities are community-governed peer-to-peer networks in which sharing builds mutually beneficial value, offering a model for engaging patients as LHCS stakeholders. Smart contracts could be used to ensure accountability of the system by embedding feedback mechanisms by which patients directly and automatically realize benefits of sharing their data.
Yan Zhuang, Lincoln Sheets, ZonâYin Shae, Yin-Wu Chen ¡ 6 authors
Patient recruitment for clinical trials is known to be a challenging aspect of clinical research. There are multiple competing concerns from the sponsor, patient and principal investigator's perspectives resulting in most clinical trials not meeting recruitment requirements on time. Conducting under-enrolled clinical trials affects the power of conclusive results or causes premature trial termination. The Blockchain is a distributed ledger technology originally applied in the financial sector. Its features as a peer-to-peer system with publicly audited transactions, data security, and patient privacy are a good fit for the needs of clinical trials recruitment. The "Smart Contract" is a programmable self-executing protocol that regulates the blockchain transactions. Given current recruitment challenges, we have proposed a blockchain model containing multiple trial-based contracts for trial management and patient engagement and a master smart contract for automated subject matching, patient recruitment, and trial-based contracts management.
Blockchain-based platforms are emerging to provide solutions for technical and governance challenges associated with genomic data sharing. Providing capabilities for distributed data stewardship and participatory access control along with effective ways for enforcement of the data access agreements and data ownership are among the major promises of these platforms.
The electronic sharing of medical imaging data is an important element of modern healthcare systems, but current infrastructure for cross-site image transfer depends on trust in third-party intermediaries. In this work, we examine the blockchain concept, which enables parties to establish consensus without relying on a central authority. We develop a framework for cross-domain image sharing that uses a blockchain as a distributed data store to establish a ledger of radiological studies and patient-defined access permissions. The blockchain framework is shown to eliminate third-party access to protected health information, satisfy many criteria of an interoperable health system, and readily generalize to domains beyond medical imaging. Relative drawbacks of the framework include the complexity of the privacy and security models and an unclear regulatory environment. Ultimately, the large-scale feasibility of such an approach remains to be demonstrated and will depend on a number of factors which we discuss in detail.
Who shall live when not all can live? Although this question has been urgently forced upon us by the dramatic use of artificial internal organs and organ transplantations, it is hardly new. George Bernard Shaw dealt with it in âThe Doctor's Dilemmaâ: Sir Patrick.Well, Mr. Savior of Lives: which is it to be? That honest decent man Blenkinsop, or that rotten blackguard of an artist, eh?Ridgeon.It's not an easy case to judge, is it? Blenkinsop's an honest decent man; but is he any use? Dubedat's a rotten blackguard; but he's a genuine source of pretty and pleasant and good things.Sir Patrick.What will he be a source of for that poor innocent wife of his, when she finds him out?Ridgeon.That's true. Her life will be a hell.Sir Patrick.And tell me this. Suppose you had this choice put before you: either to go through life and find all the pictures bad but all the men and women good, or go through life and find all the pictures good and all the men and women rotten. Which would you choose?1 A significant example of the distribution of scarce medical resources is seen in the use of penicillin shortly after its discovery. Military officers had to determine which soldiers would be treatedâthose with venereal disease or those wounded in combat.2 In many respects such decisions have become routine in medical circles. Day after day physicians and others make judgments and decisions âabout allocations of medical care to various segments of our population, to various types of hospitalized patients, and to specific individuals,â3 for example, whether mental illness or cancer will receive the higher proportion of available funds. Nevertheless, the dramatic forms of âScarce Life-Saving Medical Resourcesâ (hereafter abbreviated as SLMR) such as hemodialysis and kidney and heart transplants have compelled us to examine the moral questions that have been concealed in many routine decisions. I do not attempt in this paper to show how a resolution of SLMR cases can help us in the more routine ones which do not involve a conflict of life with life. Rather I develop an argument for a particular method of determining who shall live when not all can live. No conclusions are implied about criteria and procedures for determining who shall receive medical resources that are not directly related to the preservation of life (e.g. corneal transplants) or about standards for allocating money and time for studying and treating certain diseases.Just as current SLMR decisions are not totally discontinuous with other medical decisions, so we must ask whether some other cases might, at least by analogy, help us develop the needed criteria and procedures. Some have looked at the principles at work in our responses to abortion, euthanasia, and artificial insemination.4 Usually they have concluded that these cases do not cast light on the selection of patients for artificial and transplanted organs. The reason is evident: in abortion, euthanasia, and artificial insemination, there is no conflict of life with life for limited but indispensable resources (with the possible exception of therapeutic abortion). In current SLMR decisions, such a conflict is inescapable, and it makes them so morally perplexing and fascinating. If analogous cases are to be found, I think that we shall locate them in moral conflict situations.An especially interesting and pertinent one is U.S. v. Holmes.5 In 1841 an American ship, the William Brown, which was near Newfoundland on a trip from Liverpool to Philadelphia, struck an iceberg. The crew and half the passengers were able to escape in the two available vessels. One of these, a longboat, carrying too many passengers and leaking seriously, began to founder in the turbulent sea after about twenty-four hours. In a desperate attempt to keep it from sinking, the crew threw over board fourteen men. Two sisters of one of the men either jumped overboard to join their brother in death or instructed the crew to throw them over. The criteria for determining who should live were ânot to part man and wife, and not to throw over any women.â Several hours later the others were rescued. Returning to Philadelphia, most of the crew disappeared, but one, Holmes, who had acted upon orders from the mate, was indicted, tried, and convicted on the charge of âunlawful homicide.âWe are interested in this case from a moral rather than a legal standpoint, and there are several possible responses to and judgments about it. Without attempting to be exhaustive I shall sketch a few of these. The judge contended that lots should have been cast, for in such conflict situations, there is no other procedure âso consonant both to humanity and to justice.â Counsel for Holmes, on the other hand, maintained that the âsailors adopted the only principle of selection which was possible in an emergency like theirs,âa principle more humane than lots.âAnother version of selection might extend and systematize the maxims of the sailors in the direction of âutilityâ; those are saved who will contribute to the greatest good for the greatest number. Yet another possible option is defended by Edmond Cahn in The Moral Decision. He argues that in this case we encounter the âmorals of the last days.â By this phrase he indicates that an apocalyptic crisis renders totally irrelevant the normal differences between individuals. He continues, In a strait of this extremity, all men are reducedâor raised, as one may choose to denominate itâto members of the genus, mere congeners and nothing else. Truly and literally, all were âin the same boat,â and thus none could be saved separately from the others. I am driven to conclude that otherwiseâthat is, if none sacrifice themselves of free will to spare the othersâthey must all wait and die together. For where all have become congeners, pure and simple, no one can save himself by killing another.6 Cahn's answer to the question âwho shall live when not all can liveâ is ânoneâ unless the voluntary sacrifice by some persons permits it.Few would deny the importance of Cahn's approach although many, including this writer, would suggest that it is relevant mainly as an affirmation of an elevated and, indeed, heroic or saintly morality which one hopes would find expression in the voluntary actions of many persons trapped in âborderlineâ situations involving a conflict of life with life. It is a maximal demand which some moral principles impose on the individual in the recognition that self-preservation is not a good which is to be defended at all costs. The absence of this saintly or heroic morality should not mean, however, that everyone perishes. Without making survival an absolute value and without justifying all means to achieve it, we can maintain that simply letting everyone die is irresponsible. This charge can be supported from several different standpoints, including society at large as well as the individuals involved. Among a group of self-interested individuals, none of whom volunteers to relinquish his life, there may be better and worse ways of determining who shall survive. One task of social ethics, whether religious or philosophical, is to propose relatively just institutional arrangementsâwhich criteria and procedures of selection is most satisfactory in view of the human condition (man's limited altruism and inclination to seek his own good) and the conflicting values that are to be realized?There are several significant differences between the Holmes and SLMR cases, a major one being that the former involves direct killing of another person, while the latter involve only permitting a person to die when it is not possible to save all. Furthermore, in extreme situations such as Holmes, the restraints of civilization have been stripped away, and something approximating a state of nature prevails, in which life is âsolitary, poor, nasty, brutish and short.â The state of nature does not mean that moral standards are irrelevant and that might should prevail, but it does suggest that much of the matrix which normally supports morality has been removed. Also the necessary but unfortunate decisions about who shall live and die are made by men who are existentially and personally involved in the outcome. Their survival too is at stake. Even though the institutional role of sailors seems to require greater sacrificial actions, there is obviously no assurance that they will adequately assess the number of sailors required to man the vessel or that they will impartially and objectively weigh the common good at stake. As the judge insisted in his defense of casting lots in the Holmes case: âIn no other than this [casting lots] or some like way are those having equal rights put upon an equal footing, and in no other way is it possible to guard against partiality and oppression, violence, and conflict.â This difference should not be exaggerated since self-interest, professional pride, and the like obviously affect the outcome of many medical decisions. Nor do the remaining differences cancel Holmes' instructiveness.Which set of arrangements should be adopted for SLMR? Two questions are involved: Which standards and criteria should be used? And, Who should make the decision? The first question is basic, since the debate about implementation, e.g. whether by a lay committee or physician, makes little progress until the criteria are determined.We need two sets of criteria which will be applied at two different stages in the selection of recipients of SLMR. First, medical criteria should be used to exclude those who are not âmedically acceptable.â Second, from this group of âmedically acceptableâ applicants, the final selection can be made. Occasionally in current American medical practice, the first stage is omitted, but such an omission is unwarranted. Ethical and social responsibility would seem to require distributing these SLMR only to those who have some reasonable prospect of responding to the treatment. Furthermore, in transplants such medical tests as tissue and blood typing are necessary, although they are hardly fully developed.âMedical is not as as many since there is debate in medical about the relevant and Although can contribute little or nothing to this two may be in First, should be used only to determine the group from which the final selection will be and the attempt to of to should be Medical would exclude some but would not as a of between those who the first For example, if two for were the physicians would not choose the one with the better medical selection would be made on other Second, and should be to an absolute and should be only when they are without related to medical the to with the of which might to most significant moral questions when we to the final the of has been and the number is than the other criteria should be used? should the final selection be First, I shall examine some of the that from to make the final selection in of social these about the and of the I shall the possible for selection or criteria of social on but most they are The and to the society is although this obviously be from his of and the of his to society an is in of these social and has been to suggest the of that affect social value or we encounter the first major of this do we determine the relevant criteria of social of various social are only too does one and the of the life, that day we may how to or or the value in in the same and way that has I am not that we can or that we should attempt to do if the various social and human in could be how do we determine how much we will to Which will have in case of more in the light of which values and principles do we social possible way of determining the values which should be in selection has been by He that our medical decisions about allocating resources are on an of values by there is no way of we should be and about it. should we He that we the values that most in our society and use them as criteria for distributing SLMR. values can be by or if in this put a greater on than men would have a greater on our SLMR than of is significant and the who was SLMR in might be in as the greatest American since George is criteria that could be applied but at the and as well as individual the criteria of social value that are used in is this more than in the and decisions of the selection committee of the where such as and have been significant for determining who shall As two conclude after these criteria and they who the the way but who have so much to the making of The is no for a with bad to this first of determining social values is a only is it if not to on social but it is easy to our will be in a few and the of actions will it is to which persons will their in in and the of of For these as has might be a but we simply the to the which we must is more than when we think in make us that such an approach to SLMR is the of but this should not be The on another the approach would in the person to his social and it and the of the his as a person which be to his or to It is not at all that we are to live with these of who the artificial has we to the principle that social should determine we patients to be with only when they are go to have have a a good and to the that any for for selection is a to the of view which The is not to all but to that SLMR cases are which involve The however, can have and for from by and can go and seek for criteria for the question of life or death in the of the artificial these criteria to the of human the to which they can be little more than that at by casting The he will be to those in American medical is most to a certain or in of which when is this of the and where it only as a and It only us how all selection criteria and procedures the to us in the of the human condition and its This approach is with his view of the task of us how to and ethics, I would can help us the and in light judgments can be made. Even if all actions in SLMR should involve some may human to a greater than others. that a on any criteria is more than that at by casting selection by would the to the moral and values that we are to maintain a of is that we use some of or such as first or such as a to determine who shall be as a to when and judgments can and must be made. Edmond Cahn who the casting of lots as Cahn it, crisis involves too for and too for other as a to which human these values are with the of it is to have persons rather than determining who shall they are with the outcome of the the such as and of being which make human life it is are to be and in the the it must be that the use of seems and the of criteria in SLMR to make their as and as possible so that does not determine who shall however, the moral and values which might be supported by selection by or A more is that the procedure that I develop the relevant moral too That so the argument might the society and its and not the individual with his illness and upon SLMR. is that the values and principles at work in the may well over those in the both of their and and of the of selection in of social As âThe more is the to be made of an and the more the life and the more the for human as a moral principle I is in certain conflict situations, it a significant of by of it be as a and procedure without an the including human which might it. this about the Holmes case: of our upon as the all the and the in our should think rather of of as the of the of those individuals to one another that might have been and by casting The and which on the approach would be in his social role and can be and to by a recognition of his equal to be a is by procedures which of selection by more the by human than does It is not but it is to the of letting all die or only those who have the greatest social and argument can be by values other than individual and of value in the medical is the of between and Which selection criteria are most in with this of Which will and it? is that selection by or is from this which is to for human is an of about It is not simply the that another will a particular but more that another will him in certain will him as a As Although has to do with on a of another person, it is on a of a the to to with or live to and so to another is first of all to him to the principle of morality in his with to as a person, This be in situations when a person decisions about him to be made in of his social for such decisions his as a on of in social value or would have reason for that his had been the that one is being not as an in himself but as a means in medical progress or the of a greater social good is with and of this in the which was after the after the first heart The of between the and is not only an value in the of being an in the treatment. It is to be of its as a the related values of individual and are maintained in selection by other the argument for this Which criteria and procedures would men have to a in which several men are to determine for themselves and their the criteria and procedures by which they would to be to and from SLMR if the need need to two and ask which set of criteria and procedures would be as the most and, indeed, the The are The men are are interested in their own that of members of their and of they are not by Furthermore, they are of their own and to the social do not how they would in a the for SLMR in of social these which would be all or the use of Which would seem the most The By which set of criteria would they to be in or from the of those who will be The choice in this and of would be selection or since this of A possible is that one would to a and choose the I think especially since I that the in this are for their as well as for selection or could be more to the It would make more for men who are self-interested but about their to society to a set of criteria which would in of would selection by as relatively just and for or The and those who are would be greater if the is on social than if it is on and be in these situations, but they would be by the of being relatively by makes this A to would make for the and those who have a specific in It would be for them to his by relatively of criteria in is involved. the of life have us to the of and to the of or human life is an after has an absolute to most of us would that we have as much to it as in Although it is as selection by is in in I am not of any which some of its patients from kidney in to make for later who are better in of social Furthermore, few would it. few would a person from a kidney on the that a person better had just In a of the of by at the of from to patients but were not the had its of in and is at least certain is that we extend this principle first to determine who the patients shall live or that we artificial such as a or first would be more than a since the make their over a of time rather than as a group at one This procedure would be in with at least one principle in our and with our of individual and in to these values can be by how the can be to the one easy way of this task is to maintain the of which to a patients are not that they are being for SLMR in to the treatment. whether is or not is not the significant it is rather for would be most to the is that can be more if of and are and that they are by selection by or has another since it would the need for a committee to examine in of their social This responsibility can be there is a possible of use of selection which is interesting to although I do not it as a good reason for It can be as of the of has that SLMR cases would if these scarce resources were rather than on social would no be a the of and would make certain that they would not be by a selection they would help to or so that medical would be and the that I have are the of to be without If we would we not just after we had in it The direction of argument has been against any and I would this as the way to me one possible way of while at the same time them so that they would be of the approach is that which make it necessary to that one man is indispensable for a society in view of a particular set of it the when the is a for the argument to this has that the of would on those who think that the social in this is so that they simply by the outcome of a or a first first the reason must be rather than that is, we from in this not we to of this to the of our but his would be the in a social value the should be used as a of exception in for example, only if it would a reason to another person from a kidney if all were this to the has been made to we would be to put this of another for a only if we would be in which all are being to a by from it. would make an exception I do not this procedure of I think that one can it while about selection by or If it is a lay committee would be upon to with the since the or others would in be the outcome of or This lay committee would determine whether this was so indispensable at this time and that he had to be saved by the values by It would make it that exception is if at only as the of two a defense would be only if and so many moral and values in SLMR