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Mulling Options to Fix an Ailing Organ Transplant System

Hospital confirmation that the late Steve Jobs, the legendary founder of Apple, received a liver transplant faster by getting placed on a transplant list in Tennessee—instead of enduring a longer wait in his home state of California—underscores the geographic inequities regarding liver-donation allocation in the United States.

Distributive justice regarding organ-transplant allocation has been a highly contested topic over the last decade. According to UCSF Medical Center, there are more than 17,000 patients on the nationwide liver-donation waiting list, yet only 5,000 will get livers each year. More than 1,700 patients each year die while waiting. The current system, established by the United Network for Organ Sharing (UNOS), is based on regional waiting lists. Organs are allocated to the region in which they were donated in order to minimize the amount of time that the organ is sitting without a direct blood source.

Within a given region of the United States, UNOS prioritizes the sickest patients based on the severity of their condition. This is determined using a Model for End-Stage Liver Disease scoring system, which measures the urgency of the patient’s need for transplantation. It is logistically much better for an organ to stay within its own region. Because organ transplantation is coordinated within regions, however, a patient’s need for a liver transplant does not always correlate with his or her likelihood of getting one. Waiting lists tend to be longest in regions with large cities, especially New York, Los Angeles and San Francisco.

In 2011, USA Today profiled 21-year-old Matthew Rosiello, who needed a liver transplant and was advised by his doctors to move from New York to Ohio, where his chances of getting a liver were better. The ability to relocate in order to “cut the line” is a privilege that many patients cannot afford to indulge in. Some insurance programs, such as Medicaid, are state-based, and will not cover out-of-state procedures.

Many people, however, argue that the real problem lies in the lack of motivation for registered organ donors in these regions, which also contributes to the disparity. New York State has the third lowest percentage of organ donors in the country. Should financial compensation be provided to organ donors or their families? Perhaps. But that raises ethical concerns about bodily commodification and the potential for an unregulated market.

Greater investment in preventive care for liver disease and new technological methods to increase organ-preservation time are longer-term solutions that have been suggested. While there are different viewpoints about the source of the problem and how to fix it, there appears to be wide agreement that something radical needs to be done to change the current system, so that everyone, despite income and geography, has an equal chance to survive.

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Kelly Walters

Kelly Walters

Kelly Walters is an intern at the Montefiore-Einstein Center for Bioethics. She is a recent graduate of Wellesley College, where she studied mathematics, pre-medical sciences, and women's and gender studies. She is most interested in health disparities, feminist bioethics, and global health, and is considering a career in medicine and/or public health.

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