Current rules established by UNOS specify that donated livers must stay within a particular region and go to the sickest patients first. But a “sickest-first” policy is myopic, because it ignores the impact that today’s decision has on the number of deaths over time. The two-year organ-graft survival rate for patients who are in intensive care before their transplants is approximately 50 percent, compared to a whopping 75 percent for transplantees who are still relatively healthy. Given those differences, it makes sense to perform transplants on patients before they become critically ill.
UNOS’s rules, however, reflect an attempt to balance the competing concerns of equity and efficiency. The cost in terms of efficiency (that is, the number of lives lost) is mitigated by the regional nature of the system, which often results in healthier patients receiving transplants. New regulations threaten to skew the balance. A national distribution system coupled with a sickest-first allocation policy would dramatically increase these inefficiencies; the average liver patient would be in even worse health at the time of transplant and have an even lower chance of survival.
The crucial question of how this mandate would affect other organs has been lost in the debate. In deciding who receives a given kidney, for example, a patient’s health is rarely considered because patients can live with dialysis treatments. Instead, the primary factor is the quality of the biological match between donated organ and prospective patient. Unlike a sickest-first policy, allocating organs to those with the best biological match is extremely efficient: the one-year kidney-transplant survival rate for well-matched kidneys jumps 13 percentage points above that for poorly matched ones.
Given the mandate for a national distribution of kidneys, however, UNOS is discussing de-emphasizing biological matching in favor of waiting time, a seemingly more equitable allocation method. This is because, although a nationwide matching system would save additional lives, its impact would further widen the disparity between blacks and whites — since a national system would indirectly place greater emphasis on biological matching. Already, blacks wait twice as long as whites for kidney transplants.
The longer waiting time is due to the disproportionate number of blacks suffering from hypertension and diabetes — the major causes of kidney failure — and not to discrimination. Furthermore, the quality of the biological match is usually better when donor and recipient are of the same race. The fact that blacks as a group demand more kidneys than they supply largely explains the discrepancy between waiting times. To minimize the importance of biological matching because of its racial impact would, in effect, place a higher value on the lives of some patients than others.
Organ transplants have saved countless lives, but the severe shortage of transplantable organs has required some tough decisions. The debate needs to be refocused. A squabble about winners and losers has intruded on what we should be discussing: how to design an efficient system that best uses our extremely scarce and valuable supply of organs. While fairness is an appropriate concern when discussing organ transplants, we must guard against the unfairness of a transplant policy that allows needless deaths and focuses on less relevant concerns. A national transplant policy should have exactly one goal — saving as many lives as possible.