EXACTLY HOW do you place a
UNOS is a nonprofit group tasked with setting national organ distribution policy under government contract. As a recent Wall Street Journal article about kidney transplants pointed out, in general the patient whose name has been on the list the longest in each region of the country gets dibs on the next available organ.
But what if the recipient list is topped by an elderly patient nearing the end of his life, while a 20-something with plenty of years left languishes near the bottom? Is giving the kidney to the older patient the best use of a scarce resource?
Today, more than 70,000 people await new kidneys (by far the most common form of transplant). About 4,000 die each year without receiving an organ. In 1999 the Department of Health and Human Services ordered UNOS to restructure its allocation modality, placing more emphasis on "best use" criteria and de-emphasizing simple length of time on waiting list. This prospect has left older patients concerned.
The rationale is simple. The success of an organ transplant is generally measured in terms of "life years gained." With research showing that recipient age is the major factor in the success of kidney transplants, UNOS has targeted that factor as a primary "best use" criterion. For example, according to the Scientific Registry of Transplant Recipients, a typical 25-year-old diabetic will gain an extra 8.7 years of life from a kidney transplant, while a 55-year-old diabetic will reap only 3.6 years. Therefore, according to the "best use" concept, the kidney should go to the younger recipient.
But what if the 55-year-old is the president of the United States? Or a world-class surgeon? Or a child's beloved grandfather? How exactly do you figure in those factors?
It gets worse. Some people say that if a patient's organ has been damaged by lifestyle choices like alcohol, drug use, obesity, or smoking, that patient isn't worthy of a transplant. More objectively, African-Americans do better on dialysis than other ethnic groups, meaning their net gain from a kidney transplant is automatically less. (Wisely, UNOS decided to exclude race as a factor.)
And then there is that old bugaboo, ability to pay. Transplantation and follow-up care are very expensive. And while UNOS is the organization that maintains the organ transplant list, who gets onto the list to begin with is decided by 256 organ-transplant centers around the United States. Here, what some call a "wallet biopsy" often weeds out those with fewer means.
The bottom line is there are just too few organ donors, requiring mere mortals who lack omniscience to make life-and-death decisions regarding who should get transplants. But assessing the value of a life based strictly on age seems a slippery slope. "In UNOS We Trust"? Not yet. The "time on the list" approach seems more fair.