The Ethical Lessons of the
Scarce Vital Organs
Peter A. Ubel, Robert M. Arnold,
and Arthur L. Caplan
Vital organ transplantation has captured the attention of the medical community and the public in part because of the tragic choices the transplant community must make every day. The demand for vital cadaver organs far exceeds the supply, forcing the transplant community to decide who should get available life-saving organs. At the end of 1991, over 1,500 people were on waiting lists seeking cadaver livers and over 2,000 were seeking hearts'; of those patients, 9.9 percent awaiting livers and 16.7 percent awaiting hearts were removed from the waiting lists because they died before transplant organs be came available. 1 Because of this unavoidable shortage, the transplant community has had to literally decide—by choosing who gets an organ—who lives or dies.
Despite the great amount of attention focused on transplant allocation, few have remarked at length about the special issues raised by the allocation of organs to retransplant candidates. This made some sense initially, both because retransplantation was a rapidly progressing field, with uncertain efficacy in many patient groups, and because many were hopeful that enough organs could be procured to reduce the scarcity of available organs. 2,3,4,5 But this inattention is no longer justifiable. The shortage of cadaveric transplant organs has grown with time rather than decreased.' Meanwhile, retransplantation has become a large part of transplant practice, accounting for 20 percent of all liver transplants (written communication, Steven Belle, PhD, United Network for Organ Sharing [UNOS]/ University of Pittsburgh [ Pa] Liver Transplant Registry, December 14, 1992) and 10 percent of heart transplants, excluding heart-lung transplants (written communication, Tim Breen,____________________