Organs for TransplantationOrgans for Transplantation

In the US today, we allocate organs In the US today, we allocate organs for transplantation from cadavers (a for transplantation from cadavers (a scarce resource), scarce resource), notnot according to according to social utility, but by factors that social utility, but by factors that (more or less) depend on luck.(more or less) depend on luck.

The key factors: The key factors: medical medical suitability, geography, and time suitability, geography, and time on the waiting list.on the waiting list.

The allocation of cadaver organs for The allocation of cadaver organs for transplantation is coordinated by the transplantation is coordinated by the United Network for Organ United Network for Organ SharingSharing (UNOS), located in (UNOS), located in Richmond, VA. UNOS has a contract Richmond, VA. UNOS has a contract with the US government.with the US government.

Web site: www.unos.orgWeb site: www.unos.org

If an organ (e.g., a liver) is procured If an organ (e.g., a liver) is procured from a newly deceased, it is from a newly deceased, it is “offered” first to a person on the “offered” first to a person on the locallocal waiting list. If the organ is not a waiting list. If the organ is not a match for anyone on that waiting list, match for anyone on that waiting list, then they look to pts in the then they look to pts in the samesame regionregion. If no one in the region is a . If no one in the region is a match, then it is offered match, then it is offered nationallynationally..

At the At the locallocal level, organs are supposed level, organs are supposed to be distributed to candidates based to be distributed to candidates based on on urgency of medical needurgency of medical need (sickest first, “rescue rule”).(sickest first, “rescue rule”).

Among those with Among those with equalequal medical medical urgency, the distribution is supposed urgency, the distribution is supposed to be based on to be based on matching factorsmatching factors (blood type, etc) and (blood type, etc) and time on the time on the waiting listwaiting list..

Why geographical arrangements?Why geographical arrangements? Reasons of efficiency (organs Reasons of efficiency (organs

deteriorate rapidly)deteriorate rapidly) Giving preference to locals makes it Giving preference to locals makes it

more likely that locals will donatemore likely that locals will donate Some believe that we should take Some believe that we should take

care of “our own” first (constituency care of “our own” first (constituency factor)factor)

Critics object to the current system of Critics object to the current system of geographical preference in geographical preference in allocation; they favor a allocation; they favor a nationalnational waiting list (based on matching waiting list (based on matching factors, medical urgency, and time factors, medical urgency, and time on the waiting list).on the waiting list).

Critics have Critics have twotwo specific objections. specific objections.

ObjectionsObjections

1.1. Time on the waiting list varies Time on the waiting list varies radically from region to region.radically from region to region.

2.2. Geographical inequities create Geographical inequities create advantages for pts who are advantages for pts who are informed and wealth enough to informed and wealth enough to place themselves on place themselves on multiplemultiple waitingwaiting listslists..

Though many in the transplant Though many in the transplant community favor the current community favor the current geographic basis for distributing geographic basis for distributing organs, not all do. This is one organs, not all do. This is one controversy. controversy.

There is also some controversy about There is also some controversy about whether whether medicalmedical urgencyurgency should be should be given the weight that it is because given the weight that it is because severely ill patients have worse severely ill patients have worse outcomes (i.e., they do not live as outcomes (i.e., they do not live as long after receiving a transplant) long after receiving a transplant) than those who are less severely ill.than those who are less severely ill.

Doubts and questions about the Doubts and questions about the current system of allocating organs current system of allocating organs in the US:in the US:

1. Do celebrities/public persons get 1. Do celebrities/public persons get preferential treatment? Examples:preferential treatment? Examples:

Mickey MantleMickey Mantle Robert Casey (gov. of Pennsylvania)Robert Casey (gov. of Pennsylvania) Dick CheneyDick Cheney

2. Should personal responsibility for 2. Should personal responsibility for one’s medical problems (e.g., one’s medical problems (e.g., alcoholics who need liver alcoholics who need liver transplants) place one at the bottom transplants) place one at the bottom of the waiting list? There is of the waiting list? There is disagreement about this.disagreement about this.

3. Persons receiving second, third, and 3. Persons receiving second, third, and fourth transplants. Fair? [Example: fourth transplants. Fair? [Example: case of Danny Canal.]case of Danny Canal.]

Questions of justice (fairness) raised Questions of justice (fairness) raised about the allocation of organs in the about the allocation of organs in the US:US:

Waiting time in different regions Waiting time in different regions varies widely.varies widely.

Multiple listings by some people.Multiple listings by some people. Preferred treatment for celebrities?Preferred treatment for celebrities?

Questions of FairnessQuestions of Fairness

Self-induced problems?Self-induced problems? Individuals with “retardation”?Individuals with “retardation”? Receipt of 2Receipt of 2ndnd, 3, 3rdrd, 4, 4thth transplants? transplants? Racial and ethnic inequalities.Racial and ethnic inequalities.