Abstract

In lieu of an abstract, here is a brief excerpt of the content:Kennedy Institute of Ethics Journal 10.1 (2000) 75-80 [Access article in PDF] Bioethics Inside the Beltway: A New Basis for Allocating Livers for Transplant Robert M. Veatch The Department of Health and Human Services (DHHS) and the United Network for Organ Sharing (UNOS), the private organization with the government contract to manage the national organ transplant program, are in the midst of a protracted dispute over how livers for transplant should be allocated. UNOS, which is based in Richmond, Virginia, has for many years set the national policy for allocating cadaver organs. UNOS had a policy that, in effect, gave healthy local recipients priority over much sicker, more urgent cases beyond the local level. In April of 1998, Donna Shalala, the Secretary of Health and Human Services, issued a regulation requiring that organs must be allocated according to uniform medical criteria and that organ sharing must take place over broad enough areas to ensure that organs can reach the patients who need them most. In effect, she sought to overturn the strict local priority in favor of a more uniform national list based on medical need or at least an approach that extended allocation beyond the strict locals-first approach.UNOS has put up great resistance, expressing a strong preference for retaining local priority even though doing so means some desperately sick people at more distant centers almost certainly will die for lack of organs. What sounds at first like a rather esoteric dispute over government regulation turns out to raise some fascinating issues involving questions of ethics and moral epistemology. The Background For several years, UNOS followed a policy of dividing all potential liver transplant recipients into four categories based on how urgently the person needed a transplant. Status 1 patients were the sickest, essentially those in intensive care. Status 2 patients were the next most ill-in the hospital, but not the ICU. Status 3 patients were ill enough to be at home, while Status 4 patients were still up and about. UNOS coordinates 62 local organ procurement organizations (OPOs), each serving a metropolitan area. These are grouped into 11 regions.The long-term allocation rule gave first priority to local Status 1 patients. If no Status 1 patient was available locally, rather than sending the organ to another OPO, it would be assigned to a Status 2 patient in the same OPO where the [End Page 75] organ was procured, then to a local Status 3 patient, and then to one at Status 4. Only if no patients could use the organ locally would it be "exported" to another OPO. It would then be offered to another OPO in the same region, starting once again with patients at the most urgent status. Only if no patients in the region could use the organ would it be offered outside the region. The effect of this policy was that in some cases quite well-off local patients could get priority over more distant patients who only had hours or days to live if they did not get transplanted. (It was because of this policy that Mickey Mantle-who was Status 2-got an organ so quickly. There were no other suitable Status 1 or 2 patients in the Dallas area. He did not have to compete with any of the thousands of liver transplant patients on the waiting lists beyond his local area.)The realization that critically ill patients beyond the local area were dying while healthy local patients got organs even though they still could wait for perhaps months or years led DHHS to issue its mandate. The goal was to get more organs to people who were in desperate need.The response at UNOS has been hostile. UNOS is made up primarily of representatives from the OPOs, which, in turn are often dominated by transplant surgeons. They did not like the idea that locally-procured organs were being shipped to other communities when they had their own patients who needed them.Spokespersons for this position offered two primary arguments. First, they believed that people would be more...