ORGAN ALLOCATION: Geographic System ‘Indefensible’

The current geographic distribution of "cadaveric livers for transplantation" is "ethically indefensible" and no longer justifiable for medical reasons, according to an essay in the current New England Journal of Medicine. University of Pennsylvania Center for Bioethics' Arthur Caplan and Dr. Peter Ubel of the Philadelphia Veterans Affairs Medical Center argue that the U.S. Department of Health and Human Services proposal to shift the current regional allocation system to a national one "is laudable and overdue." Blasting the current system for creating geographic inequities in liver transplant waiting lists, they write: "The geographic inequities are especially troubling because they create advantages for patients who are informed and wealthy enough to place themselves on multiple waiting lists." In their essay, Caplan and Ubel counter criticisms of the HHS plan:

Discouraging Donations: While opponents contend that a national distribution system would discourage the public from donating organs, the authors say they "are unaware of data to support this claim." They add that "studies of donors' motivation show no evidence that donors or their families ask whether organs will be distributed locally or nationally."
Small Transplant Programs: Opponents also argue that smaller transplant programs would suffer. Caplan and Ubel agree, saying such an outcome might be preferable. They note that "there were 124 liver-transplantation programs in the" U.S. as of August 1998, of which 26 centers "performed five or fewer transplantations in 1997."
Favoring The Sickest: Critics also charge that a national system will favor the sickest patients over those who have a better likelihood of living a long time with a transplanted liver. Caplan and Ubel say this is a "disingenuous" argument, noting that the "process of granting priority to severely ill patients has been built into the existing allocation system for many years."

The two authors make clear that they "are not suggesting that livers should be distributed without regard to the results of transplantation." In the absence of "a statistically sound system to determine how to maximize the benefits of transplantation," Caplan and Ubel urge the development of "acceptable allocation criteria for a single national list, with an emphasis on identifying categories of patients who are unlikely to benefit from the procedure." They add, "Once forced to accept the idea of such a list, transplantation specialists will have every incentive to maximize the efficient use of organs." This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.