ORGAN TRANSPLANTS: New Guidelines For Allocations Announced

      Capping a "nasty, three-year political fight over the rules governing the nation's organ sharing program," the Department of Health and Human Services yesterday issued new organ allocation guidelines stipulating that donated livers must be offered to the sickest patients first. The AP/Cincinnati Enquirer reports that the move "promis[es] to overthrow a system that gives priority to patients who live closest to the donor." It also promises to ignite a battle in the organ-transplant community over how to distribute organs in the U.S. Dr. Doug Hanto, director of the adult liver transplant program at the University of Cincinnati Medical Center, said, "This decision will precipitate a revolt from 90% of the organ transplant centers in the country." On one side of the battle is the United Network for Organ Sharing, the agency that established the current rules. The UNOS "is controlled by transplant centers, most of which benefit from the policy that assures smaller programs will be offered organs locally." On the other side are larger organ transplant centers, such as the University of Pittsburgh, that contend "they care for the sickest patients and have the longest waiting lists" (Bonfield, 2/27).

Close To Home
      Some smaller organ transplant centers -- "including those at UC-Davis Medical Center and Sutter Memorial Hospital -- say new federal rules about how to distribute scarce organs could put them out of business," the Sacramento Bee reports. Sutter Memorial heart transplant surgeon Dr. Michael Ingram said of the new procedure, "It would close our doors." Dr. David Follette, medical director of UC-Davis Medical Center's transplant program said, "If you allocated all organs to all patients on the list based on waiting time and status, programs like those in Sacramento would be put out of business." The Bee reports this is because large cities such as San Francisco have "far more very sick patients on waiting lists than in communities such as Sacramento, which has relatively small programs and fewer critically ill patients." Follette added that transplant centers that "do not perform a certain number of transplants annually" stand to "lose their state and federal accreditation" (Griffith, 2/27).

Chronic Need
      Under current regulations adopted in 1984, donated organs must be first offered to a patient in the area where the donation was made. If no patients are in need, the organ is then to be offered to a patient in a "surrounding region," with the nation "divided into 11 regions," the New York Times reports. If no regional patients are in need, the organ is offered to anyone in the country (Stolberg, 2/27). The result of this system, the Washington Post reports, is "great disparities in how long patients in different parts of the country must wait for an organ" (Weiss, 2/27). For example, in Michigan, Indiana and Ohio, the wait for a liver was more than 370 days in 1995, while in "Louisiana, Mississippi, Florida, Georgia and Alabama, the wait was 96 days." HHS Secretary Donna Shalala said, "In the worst case, patients die in areas where the waiting times are long, while at the same time organs are being made available to less ill patients with shorter waiting times" (New York Times, 2/27). Shalala said the problem "could be resolved in part by a broader sharing of organs around the country."

Local Power
      Some transplant experts express concern that "people may be less wiling to donate if organs will not be used locally" (Washington Post, 2/27). In addition, many local transplant centers said the new policy would primarily benefit the major centers. Dr. Roger Evans, head of health care evaluation at the Mayo Clinic, said the policy would result in organ transplants going to patients in large transplant centers, "whose odds of long-term survival were poor and whose costs of treatment were high." However, Dr. Jorge Reyes, director of pediatric transplantation at Children's Hospital in Pittsburgh, said that argument was unsubstantiated. He said, "The purpose of this operation is to help the sickest patients. That's why we're doctors and that's why we take care of patients" (New York Times, 2/27).

Legal Battles Ahead?
      The Washington Post reports that the HHS decision "may set the stage for a legal battle between HHS and the United Network for Organ Sharing" because "UNOS has argued that the government lacks the legal authority to dictate the rules of organ allocation, which the group says should remain in the hands of the 'transplant community,' including the centers that UNOS represents." Lawmakers are divided over how to run the organ transplant network. A group led by Sen. Bill Frist (R-TN) has "cautioned Shalala against micromanaging UNOS and the transplant business," while another camp, led by Sens. Arlen Specter and Rick Santorum, both Pennsylvania Republicans, have pushed for HHS intervention. Santorum and Specter are from the home state of the University of Pittsburgh, which "stands to gain millions of dollars in business from a change to a broader sharing of organs" (Weiss, 2/27).