In this book, David Weimer brings his considerable expertise in policy analysis to an extensive, original study of the private rulemaking that governs organ transplantation in the United States. A widely published public policy scholar, Weimer explores the rationale for government delegation of governing authority for organ transplantation to a network of private organizations and experts. He assesses the relative value of this governance approach across a range of cases, drawing on a comprehensive data set that includes federal congressional hearing testimony and decisions, expert stakeholder and public comments on proposed and final rules, the federal regulatory docket, formal positions and decisions of private network organizations, and state regulatory and political responses. This thorough and accessible study makes the case that governance through private rulemaking can provide advantages to government and to the public in addressing complex, value-laden policy questions, in comparison to markets, bureaucratic supply, or other rulemaking variations.

In making the argument that governance by private rulemaking offers comparative advantages, Weimer synthesizes a range of literature, including public policy, economics, political science, public administration, and law to create an original framework for description and analysis. Central concepts include the competing values in which all policy judgments are grounded, and the expertise that is common to groups given delegated responsibilities. The author establishes the tacit knowledge of professionals (p. 28) as both an information base and a normative platform for communication that is critical to identifying, understanding, and framing the questions that are addressed across the policy process. To contrast private with other rulemaking approaches, he creates an original array of regulatory governance arrangements and assesses each according to its opportunity for stakeholder involvement and its incorporation of expertise in rulemaking (p. 30). The author argues that private rulemaking can provide the relative comparative advantages of technical efficiency, blame avoidance, and a cooperative stakeholder framework that encourages participation in exchange for considerable control over substance (p. 32).

To assess the relative merit of private rulemaking in contrast to other governance approaches, the study presents a nuanced account of specific organ transplant rules and the customs and values that shape current practice. The interior chapters of Medical Governance delve rigorously into the formation and operation of the government-sponsored organ procurement and transplant network (OPTN) and related nongovernmental entities.

Chapter 3 briefly describes the evolution of the OPTN and its companion organizations, as well as their relationships to one another and to government overseers. Chapters 4 though 7 consider cases that illustrate the process of private rulemaking against other alternatives; an important dimension of these studies is that each case illustrates different but common policymaking conditions or constraints. Chapter 4 examines the role of the OPTN in making decisions that would have the effect of expanding the pool of eligible organ donors. These decisions include death criteria for organ harvesting, classes of eligible organ donors, and guidelines and data requirements for live organ donation. Chapter 5 focuses on formal rulemaking and government oversight in the development of new liver allocation rules. The chronology illustrates the continuing tensions among the OPTN, the federal government, and the states in achieving national consensus within the constraints and opportunities for policymaking under American constitutional federalism and delegated power. Chapters 6 and 7 present, respectively, cases of incremental and nonincremental policymaking in kidney allocation. The realities of incrementalism and competing values are demonstrated in fairly stark terms, through discussion of an iterative process in which countless studies were generated and assessed in order to establish the need for new allocation protocols and evaluate alternatives. To accomplish policy change, the OPTN examined such factors as waiting times for organs, permissible blood type matches, priority ranking criteria including new cost–benefit criteria, and evidence of racial disparity.

Chapter 8 examines the general hypothesis that governance by private rulemaking would produce a different type of policy change than would other forms. Weimer carefully notes the impossibility of perfect comparison and concludes that the OPTN appears to be a more effective arrangement than other alternatives. Chapter 9 offers an assessment of private rulemaking in general and of the OPTN in particular as an appropriate institutional arrangement that could be applied in medical contexts beyond organ transplantation; electronic medical records and a Medicare surgery budget are two examples. Weimer argues that the viability of private rulemaking as an institutional arrangement for policymaking in a representative bureaucracy will be influenced by a range of factors, including strong professional norms linked to important social values, continuous engagement by stakeholders, meaningful stakes for participants, group decision by voting, specialization by committee balanced with consultation across committees, transparency, data collection, and strategic oversight that fosters cooperative decision processes between government and the private rulemaking network.

The book makes a unique contribution to our understanding of the mechanics of government delegation; institutional arrangements that place some measure of delegated authority into organizations such as OPTN are remarkably common and yet have not been studied systematically in this context. The book also makes several contributions to the study of public policy and to a wide range of other literatures, including public administration, law, and political science. A particular strength is its synthetic discussion of multiple literatures throughout; another is its methodological road map for examining complex and changing institutional environments. Weimer's approach demonstrates the level of detail that is necessary to develop findings that allow for meaningful interpretation and that facilitate future comparisons. One example is the carefully specified definition of private rulemaking; another is the comprehensive chronology of the OPTN activities across multiple policy dilemmas.

The rigorous examination of the interior dimensions of delegated authority and the administrative processes employed by a private network also makes a significant contribution to the emerging interdisciplinary scholarship on collaborative governance. Through the cases, the book translates abstract institutional arrangements into tangible, detailed interactions within the OPTN and between the OPTN and government proper. The distinction between de jure and de facto rulemaking and the continuum of rulemaking arrangements provide a new platform for future research. The conditions for successful governance via private rulemaking provide new avenues for theory building, as well as a series of testable hypotheses for future research in multiple disciplines.

Medical Governance also contributes to the normative conversation about the interaction of nongovernmental (typically nonprofit) organizations with government and the respective roles of each sector. The cases articulate the essential contribution of private nonprofit organizations and professionals to the public policy process, made possible by sustained participation, common experiences and expertise, and reservoirs of trust accumulated through myriad personal and professional interactions over time. Weimer acknowledges the unique stakeholder relationships in the organ transplant network and does not advocate that private rulemaking provide a universal governance solution. Rather, he suggests that government itself has an important role to play as the architect of governance through the careful design of institutional arrangements to foster policy decisions that are productive, responsive, and accountable. In this blend of theory, practical understanding, and methodological sophistication, Weimer has produced an important set of ideas that can be applied to at least some of today's health-care policy challenges and perhaps beyond.