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FORUM
Troubleshooting Allocation of Transplant OrgansIn a 1975 article in the New England Journal of Medicine, then-dean of HSPH, Howard Hiatt, introduced the concept of the "medical commons," drawing an analogy between the problems faced by herdsmen sharing a field to the challenge of allocating scarce medical resources. "...There is a limit to the resources any society can devote to medical care.... The dilemma confronting us is how we can place additional stress on the medical commons without bringing ourselves closer to ruin." The challenge of allocating scarce resources is ever present in the medical field--choices abound between prevention and curative medicine, between the young and the old, and they infuse the politics and policies of health care. The area of organ allocation brings many of the issues presaged by Hiatt into sharp focus. Currently in the U.S., 81,000 people are waiting for organ transplants, and in 2002, more than 6,000 people died for lack of a suitable organ. A Mismatch TragedyThe pitfalls of allocating scarce organs were thrust into the spotlight in February with the failed transplant that left 17-year-old Jesica Santillan dead at Duke University Hospital after receiving mismatched organs. A second transplantation was unable to save her life. The Santillan case raises many questions about the allocation process: how is it possible that incompatible organs were transplanted and what safety mechanisms failed? Was this a personal failure on the part of particular individuals, or a systems failure? Why is there an organ shortage? Why was a second set of organs transplanted when the failure rate from second transplants is extremely high?The organ allocation system in the U.S. is coordinated by a not-for-profit entity, the United Network for Organ Sharing (UNOS), under contract since 1984 with the Health Services and Resources Administration of the U.S. Department of Health and Human Services. UNOS maintains a centralized computer network that links organ procurement organizations and transplant centers. When a doctor recommends a patient for organ transplantation, the individual is evaluated by the transplant center. If eligible for a transplant, the patient's medical profile is added to the national patient waiting list, which is categorized by organ type and geographic area. When a donor becomes available, UNOS scans the database to produce a list of potential recipients, ranked by best match. This process is repeated for every organ that becomes available. The characteristics that generate the ranked matching include tissue match, blood type, length of time on the waiting list, immune status, and how far away the recipient is from the donor. The organ is then offered to the highest-ranked patient on the list. If that person is not available or becomes ineligible, the next person on the list is evaluated. Dr. Susan Saidman, chair of the UNOS histocompatibility committee, is director of the histocompatibility lab and an HMS assistant professor of pathology at Massachusetts General Hospital. As committee chair, she is responsible for considering issues relating to donor and recipient histocompatibility, organ allocation, tissue typing consistency, and histocompatibility laboratory and personnel qualifications. "Given the shortage of donor organs," she said, "there is a great deal of controversy related to the need to balance medical utility with equity when developing these policies." How the transplant community can prevent errors like the Santillan case is now foremost in the minds of those at UNOS. According to Saidman, it is difficult to answer the question of what steps transplant centers need to take, since every center has its own protocols for verifying information about donors before proceeding to transplant. "They need to have protocols to ensure that information about donors is received by all appropriate members of the transplant team and verified prior to a transplant," she said, adding that UNOS has organized a task force to review these procedures. Bioethicist Arthur Caplan pointed to another area of debate--retransplantation--which he sees as generally unethical and done at the expense of another potential recipient. "It is very understandable that the Duke transplant team did not want to abandon their patient," he said. "They must have felt tremendous guilt about the errors that had happened which caused her organ to fail and to imperil her life. They may also have felt that their legal liability might be exacerbated if they did not do everything possible to try and repair their mistake. But success of heart-lung retransplant is very poor, and retransplant post a mismatch to a hypersensitized immune system is zero." Allocation AlternativesSome have argued that setting up a market for organs would serve patients better than the current system. Caplan disagrees. "Markets will not work. They lower the quality of organs available by giving sellers a motive to lie. Those who do not want to donate do not want to do so for religious and aesthetic and equity reasons, and few will be moved by money. Markets will also turn off the minority poor for whom a market will become exploitative with strong echoes of slavery and the sale of bodies."Caplan believes a national policy of "presumed consent" would improve the shortage. The idea behind this policy is that society would assume that deceased individuals are organ donors unless otherwise specified. Advocates of this policy point to the more than 85 percent of Americans who support organ donation, even though at the time organs can be harvested, family members of the deceased often do not know the express wishes of their dead relative, are too distraught to make the decision, and sometimes override the express wishes of the deceased to become a donor. The American Medical Association opposes the presumed-consent policy. Saidman suggests that a better alternative to ease the organ shortage might be further development of artificial organs and refinement of xenotransplantation, taking organs from other animals for transplant into humans. --Erica Seiguer, a fourth-year MD-PhD student at HMS Some Websites of InterestUnited Network for Organ Sharing (UNOS)The Organ Procurement and Transplantation Network (OPTN) U.S. Department of Health and Human Services Organ and Tissue Donation website |
