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Editorial: Livers and lives UNOS resists a 'sickest-first' transplant policy Tuesday, July 27, 1999
A long-awaited report by the Institute of Medicine recommended changes in the nation's organ distribution system that would significantly enhance fairness and save lives.
The United Network for Organ Sharing, a private organization that runs the allocation system, read the report, focused on the assessment that the current system works reasonably well and claimed vindication.
That defensive and shortsighted reading is evidence enough that a systemic change is desperately needed. An organization committed to providing the best and most effective service to transplant patients would be scouring the report looking for ways to improve. Instead, UNOS ran for cover.
It's depressing but not terribly surprising. If organs were directed to the sickest patients first, smaller transplant centers that handle less complex and less serious cases would see their supply of organs dwindle. Since a disproportionate number of UNOS board members represent those small transplant centers, UNOS has been fighting such a system tooth and nail.
But provincialism and self-perpetuation should not be the driving forces behind organ allocation. The Department of Health and Human Services, which contracts with UNOS, has pushed for a straightforward sickest-first allocation system. Unfortunately, last fall that proposal was put on hold for a year by congressmen acting at the behest of UNOS and their local transplant centers.
Congress commissioned the Institute of Medicine report in the interim. The study is finally over and the evidence in support of change is increasingly compelling. But rather than respond responsibly, UNOS continues to try to spin the results and sidestep real reform by offering cosmetic alterations.
At the moment, patients are ranked according to how ill they are, within 62 local geographic distribution areas ranging in population from 1 million to 12 million. And those local areas are divided up among 11 regions. Organs are first offered for transplant patients within the locality, then within the region. If a match still isn't found, it is then offered nationally. As a result, a less seriously ill patient can get an organ, while just across the border, a much sicker person waits. The policy leads to an enormous disparity in how long people wait for organs, and many die waiting.
The change that was recommended by HHS, or some variation on that theme, should be implemented as soon as the congressional waiting period is over. But that is not enough. The Institute of Medicine strongly recommends that the federal government create an independent agency to oversee the system, so that transplant surgeons are not regulating themselves. UNOS' reaction to the institute's study simply makes the case for such external authority.
Tragedies will be part of the process as long as organs remain in such short supply. Nationally, 64,450 people are on the waiting list for all organs. Last year, 20,961 transplants were performed, using organs from about 10,000 donors. But that very shortage makes it critical that the organ distribution system be as fair and efficient and effective as possible. UNOS has not been up to that task.
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