In light of the great shortage of transplantable organs in the United States, the transplant community has been faced with many seemingly unanswerable questions. In the first chapters of this book, we looked at supply-side questions of organ procurement; from whom can we retrieve organs? and How can we maximize the efficiency of organ collection? Yet, some of the most complex issues in transplantation ethics surround the distribution and allocation of the organs that are available. The resolution of the terrifying dilemma of who lives and who dies when shortage is a reality is an omnipresent ethical challenge in transplantation. It also means that transplantation has much to teach about how Americans respond to situations where rationing is inevitable as well as about how we might defend certain policies and practices when not all lives can be saved.
Two prevailing principles of organ distribution divide the transplant community. The first, maximize efficiency, would favor recipients for whom a transplant would ensure the highest chance of living a long and high quality life. The second, urgency of need, favors allocating organs to those who are the sickest and most likely to die. Both systems represent ethical positions but they lead to very different consequences in terms of who ultimately would live. Those who are younger, relatively healthier, have fewer complicating diseases and conditions and who have not undergone a transplant would be favored by a policy driven by efficiency in the use of donor organs. Those who are older, are at death's door due to the failure of a previous transplant or artificial organ or even a previous xenograft would go to the head of the waiting list on a policy sensitive to medical urgency and patient need.
Our current system relies more on medical urgency then it does efficacy—a system supported by members of the Pittsburgh Transplant Institute.