Organ allocation: What is just and fair?
By Dorothy L. Tengler

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The Cleveland Clinic will be holding a conference on Emerging Issues in Organ Transplantation on Sept. 23-24 at Kiawah Island, S.C., focusing on current issues that are in various states of transition. One such issue is organ allocation, a topic that raises some serious questions about ethics and best practices in a field that is already fraught with tension over life-and-death decisions.


Do you feel that the organ allocation criteria need to be revised?
  • 1. Yes
  • 2. No

Generally speaking, in the United States alone, nearly 100,000 people are on waiting lists for organ transplants. About a dozen of these people die each day because of a lack of organs. In fact, according to the United Network of Organ Sharing (UNOS), 17,086 people were waiting for organ transplants in February in the U.S.; 23,360 transplants occurred January to October 2012 from 11,663 donors.

In 2010, a total of 6,521 patients died while waiting for organ transplants. This demonstrates that the need for organs is far greater than the quantity available and that complex decisions must be made as to who receives available organs.

Although rationing is unavoidable in organ transplantation, the system for allocating organs must be just and fair. The UNOS, which is governed by state and federal laws, federal regulations and UNOS policies, attempts to guarantee fairness in distributing donated organs.

Currently, to be added to the UNOS waiting list, a person (U.S. citizens, non-US citizens who are U.S. residents, and non-U.S. citizens who are not U.S. residents) must be in end-state organ failure and seen by a physician at a U.S. hospital where transplants are performed.
Issues Surrounding Organ Transplantation

  • Who should get transplants first, those first on the list or those in greatest need?
  • Should illegal aliens, foreigners, or addicts be excluded from organ waiting lists?
  • Should organ donators be paid?
  • Should people be legally permitted to buy and sell organs?

  • Once a person is entered into the database, the computer generates a prioritized list of those suitable to receive organs, matching candidates to donors. Factors affecting ranking include the following:
    • tissue match
    • blood type
    • length of time on the waiting list
    • immune status
    • distance between the potential recipient and the donor
    • degree of medical urgency (for heart, liver, lung and intestines)
    However, there are justified questions about the current system. Transplant centers usually make decisions about who they will and will not admit as transplant candidates, and the policies of these transplant centers vary. Whether the nonmedical values that shape some of their decisions are just and fair may be subject to serious discussion. Consider the following:
    • Many transplant centers will not accept those without insurance
    • Candidates over age 75 are rarely considered
    • Those with mental retardation, HIV, a history of addiction or a long criminal record are often excluded
    • Foreigners can only comprise 5 percent of any center's list
    • Although some transplant center accept illegal aliens into their program, most are children
    • Some transplant centers have refused to replant a failed organ in an adult whose initial transplant was received during childhood
    On the other hand, if policymakers relax the criteria for organ transplants, then transplant lists may quickly triple or quadruple the supply of available organs, thereby making increasing the supply of donated organs essential.

    Dorothy L. Tengler, MA, is a freelance medical writer/communication specialist with nearly 20 years of experience in the pharmaceutical and medical communication industries. She has developed educational and medical marketing materials, including monographs, slide kits, health articles, primary and review manuscripts, and pharmaceutical sales training materials.