The mathematics and politics of allocation of organs for transplant

We have a problem in this country with how precious organs for transplant are allocated. The problem has been brewing for years, and is well recognized in the transplant community, the physicians and institutions that perform them. Two recent opinion pieces review the issue well — here and here. Since PICUs such as mine are closely involved in the practice of organ transplant, both from the donor and the recipient sides, pediatric intensivists like me have a great interest in the process. Above all else, we want it to be fair, because the supply of organs always falls short of the need. Many patients die on the waiting list.

The way the system works now is “locals first.” The country is divided into 58 geographical zones called donation service areas, which are in turn grouped into 11 regions. When an organ becomes available, the system called the United Network for Organ Sharing (UNOS) first tries to match the organ with the most needy person in first the service area and then the zone. Transplanted organs need to match the recipient in several key ways or they will be rejected. If there is no patient match in either of these, the organ can be listed nationally for a match. If there is one, we have a sophisticated system in place to scramble the team at the distant facility to fly to the place where the donor is to pick up the organ and get it back in time to transplant it, although there are some constraints to timing depending upon the particular organ.

The boundaries of these zones and regions were drawn decades ago. The problem is that some geographic areas have longer lists of patients waiting for organs than do others, and different places also vary in how many organs for transplant they produce. So, even though there is a “sickest first” priority system, a less sick patient in a region with a shorter list and for whom an organ matches may get that organ ahead of a much sicker patient in a less fortunate region. Patients can also choose to be listed in a region where they don’t live, as long as they can be at the hospital within several hours. Steve Jobs, for example, chose to be listed for a liver transplant in Tennessee rather than where he lived in Northern California, which has an average waiting time 6 years, because he was more likely to get a new liver in Memphis, which has an average waiting time of 3 months. When the call came, he chartered a jet to fly him there in time.

This doesn’t seem fair. But there are strong political reasons for the debate going on in the transplant community over the issue. If the system is changed, some smaller transplant centers might close down and some regions could become net exporters of organs. For example, the head of the transplant program at the University of Kansas estimates that his institution would lose 30-40% of its transplant practice.

There are some ethical issues to consider, too. For one, an individual physician is responsible for the care of his or her patient. It’s personal. How can a surgeon say to one them that, although there is a match for an organ in the same city, that organ is going to go half-way across the country to a recipient to whom the surgeon has no medical duty other than the abstract social principle of fairness? (To be fair, though, justice is one of the four principles of medical ethics.)

From the ongoing debate it seems clear that the system will be revised. For institutions, there will be winners and losers. But for patients, which is after all why we do transplants, it will be fairer. From one of the essays:

One way or another, I believe, the U.S. organ-transplantation system needs to change. The availability of the benefits of organ transplantation should depend neither on a patient’s ability to charter a private jet nor on whether he or she is lucky enough to live near a hospital that, thanks to our “local first” system, has a relatively short waiting list. When it comes to lifesaving transplants, geography should not be destiny.


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