Crisis in U.S. Organ Transplant System Intensifies

Article excerpt

More than 10 Americans die each day while awaiting organ transplantation. The U.S. organ transplant system has been in "crisis" for decades, but recently its systemic failures have become more glaring. Indeed, the crisis has worsened since I wrote "Organ Donations: The Failure of Altruism" (Issues, Fall 1994), in which I argued that voluntary organ donation should be replaced with a system of compensated presumed consent. Although continuing advances in transplant technology have made it possible for many people to benefit from transplants, the number of organs available for donation has remained stubbornly insufficient. In 1997, only 9,235 donor organs were recovered. Yet since 1994, the number of individuals waiting for an organ has risen from 36,000 to 59,000. In addition, the limited number of organs that are available are not always allocated equitably. A recent study in the Journal of the American Medical Association reported that "blacks, women, and poor individuals are less likely to receive transplants than whites, men, and wealthy individuals due to access barriers in the transplantation process." These twin problems of organ scarcity and inefficient, inequitable organ allocation are, in part, a result of the largely private and unregulated system of organ transplantation that the United States has chosen. Until the American people and the U.S. government develop the moral and political will to deal decisively with the structural flaws in the U.S. organ transplant system, many individuals who could benefit from organ donation will die needlessly.

In December 1997, the U.S. Department of Health and Human Services (HHS) proposed a new National Organ and Tissue Donation Initiative, with the goal of increasing organ donation by 20 percent within two years. This national partnership of public, private, and volunteer organizations will provide educational materials and hold workshops to promote public awareness about donation and to encourage people to donate their own or loved ones' organs. In addition, on April 2, 1998, HHS issued a final rule under the National Organ Transplant Act of 1984 (NOTA) to improve the effectiveness and equity of the nation's transplantation system. NOTA established a national system of organ transplantation centers with the goal of ensuring an adequate supply of organs to be distributed on an equitable basis to patients throughout the United States. NOTA created the Organ Procurement and Transplantation Network (OPTN) to "manage the organ allocation system [and] to increase the supply of donated organs." OPTN is operated by the United Network of Organ Sharing (UNOS), a private, nonprofit entity under contract with HHS to develop and enforce transplant policy nationwide. All hospitals performing organ transplants must be OPTN members in order to receive Medicare and Medicaid funds.

Under the new rule, which was four years in the making, an improved organ transplantation system with more equitable allocation standards will be developed to make organs "available on a broader regional or national basis for patients with the greatest medical need consistent with sound medical judgment." Under the rule, three new sets of criteria for organ allocation would be developed by OPTN: 1) criteria to allocate organs first to those with the greatest medical urgency, with reduced reliance on geographical factors; 2) criteria to decide when to place patients on the waiting list for an organ; and 3) criteria to determine the medical status of patients who are listed. These criteria will provide uniform national standards for organ allocation, which do not currently exist. …