Demographic Processes in the Syrian Christian Community from the Second Half of the 20th to the Early 21st Century. Part I: How Many Christians Were There in Syria in the 2000s?

Orthodox church law is comprised of elements that regulate the life of the Church at various levels. The theological decisions, oroses, canons and canonical letters, which concern the Church globally, obviously focus on doctrine. Still, they also characterize the theological aspects of ecclesiology, primarily expressed in the Orthodox Church’s fundamental confession of faith – the Nicene-Constantinopolitan Creed. Although a number of the canons of the ecumenical councils and of the Holy Fathers, historical and contemporary resolutions passed by various local Orthodox Churches and other ecclesiastical authorities and institutions pertain to the universal sphere in many aspects, the vast majority of them set specific organizational standards of church life in the local perspective: the local Church, basic administrative units (dioceses, metropolises or exarchates), but above all in basic organizational structures, which include parishes and monasteries. This article presents the problems experienced when systematising contemporary Orthodox church law. This research aims to present a model for systematizing church law and to direct further research towards a comprehensive systemization of church law, including both the universal code and the legislation of specific Orthodox autocephalous churches. The methodology of this work is based on analysing legal acts and analyses already conducted by authoritative canonists. While focusing on the legal code of the autocephalous churches, the following questions were addressed: discrepancies resulting from the source corpuses adopted in various local churches and the lack or omission of information on significant organizational and systemic issues. The difficulties presented in this article provoke further research into organizing Orthodox church law. The fundamental problem is the absence of a standardized legal code for the universal Orthodox Church and a standardized compilation of ecclesiastical laws to be applied in autocephalous churches. The provisions of universal church law do not sufficiently organize issues of mutual intra-church relations, and in particular, the obligations and boundaries of the prerogatives of local autocephalous church structures. This process of systematization should include updating legal provisions by means of recognizing provisions that have been canonically repealed by later canons of the same rank or higher as invalid.

The autocephalous Orthodox Archbishopric of «all the Serbian and Maritime Lands», i.e. Serbia, was founded by two consecutive acts of the Roman-Byzantine emperor and the Ecumenical patriarch of Constantinople in Nicaea, where both these institutions had been re-established after the fall of Constantinople to the Crusaders in 1204. Crucially important for the consecration of the archimandrite Sava of Hagion Oros as archbishop and for the creation of the autocephalous Archbishopric of Serbia was the prominent role of the emperor in the Church, marked by his title of the epistemonarches, which epitomized the different prerogatives the emperor had in the Church in the epoch of the Komnenoi imperial dynasty, such as the appointment of the patriarch and other clerics of the episcopal rank, as well as the limitation of ecclesiastical dioceses. The wider context for the establishment of a new local Church was shaped by the crisis in the Byzantine world and the growing influence of the Roman Catholic Church in Southeastern Europe, before and after the 1204. The jurisdiction of the Roman Catholic and Eastern Orthodox Church partially overlapped in Serbia, both theoretically and practically. Neither the Imperial nor the Patriarchal authority in Nicaea recognized the investiture of the then archbishop of Bulgaria (Ohrid) in 1216, a fact that meant his autocephalous archbishopric, which also included bishoprics in the Serbian state, was not in the liturgical communion with the Patriarchate in Nicaea. The Serbian ruler, Stefan Nemanjić, Sava’s brother, was crowned King by a papal legate in 1217, which opened the prospect of the integration of the regions under his control into the jurisdiction of the Roman Church. In such circumstances the creation of a new local autocephalous Orthodox Church – the widely accepted date is 1219 – was an important confirmation of the Imperial and Patriarchal authority under the conditions of crisis created by their involuntary exile. Their acts had very soon resulted in the creation of a network of Orthodox bishoprics in a new local Church, which was in ecclesiastical communion with the Eastern Orthodox Patriarchate in Nicaea and which established a counterpoint in relation to the ecclesiastical conceptions and policy of the Roman Catholic Church. In this, Archbishop Sava had the support of the local monarchical authority personified in his brother Stefan, whom he consecrated King in 1221 presumably, in the coronation ritual at the monastery of Žiča, the seat of the new archbishopric and the coronation church of the future rulers as well. This act established the foundations of the political system that, in the lands under the dominion of the Nemanjić dynasty, would last for almost a hundred and fifty years.

The article examines the views of one of the outstanding Greek theologians, Metropolitan Hierotheos (Vlachos), as part of the “Theory of Primacy of Power” of the Patriarch of Constantinople in connection with the so-called Ukrainian question. After the Russian Orthodox Church broke off Eucharistic communion with the Patriarchate of Constantinople in October 2018, Metropolitan Hierotheos outlined his theory on granting autocephaly from the position of the Church of Constantinople. This theory, in essence, is a distortion of Orthodox ecclesiology, since the institution of primacy violates equal relations between Local Orthodox Churches. At the beginning of the article, Metropolitan Hierotheos’s theory of an autocephalous Church is examined. His confidence in the special right of Constantinople to grant autocephaly is unfounded, since one Local Church is granted an excessive privilege that goes beyond its honorary rights and obligations. The Metropolitan’s theory of the gradual granting of autocephaly is examined in detail: 1) “by oikonomia” by the Patriarch of Constantinople, and then 2) “by akrivia”, by the All-Church Council. In any case, the Metropolitan supports the Patriarch of Constantinople in his actions leading to a schism, which complicates the possibility of restoring peace between the Local Orthodox Churches. In conclusion, the author summarizes: the anti-Russian rhetoric of Metropolitan Hierotheus testifies to his biased and unscientific approach to the history of Russia and the Russian Church. His distorted understanding of history allows him to “justify” the decisions of Constantinople, which radically violated peace and harmony in the Ecumenical Church.

The missionary ethos of the Orthodox Church reflects the character and message of Christ and, broadly speaking, remains constant in all Local Orthodox Churches. However, there can be subtle nuances of differentiation between the various Local Churches and in different time periods, depending on the current context and challenges, as well as the priorities they address.

The primary purpose of this paper is to present the post-council theology in terms of theology of primacy of the most important theologians and in the most important documents in the period after the Second Vatican Council. Based in its documents, the Council made a huge turn in the Roman Catholic ecclesiology. However, although the Ecumenical Council did not give any final solutions, documents about the most important issues remain open for further reflection and contemplative upgrading. The Council only laid the foundations on which such an undertaking could begin. The paper focuses on theology of primacy that evolved from the Council?s documents during the period after the Second Council. The focus will be on subjects that had an impact not only on the Roman Catholic, but in particular on the Orthodox and other churches as well. The author of the paper will say more about the infallibility of the Pope, the primacy of the Roman bishop, about the relation of the Pope with other bishops, and about the relation of local and universal Church in the light of the post-council theology. Particular attention will be paid to the New catechism, a statement of the Congregation for the Doctrine of the Faith Mysterium Ecclesiae, and the dispute between cardinals Joseph Ratzinger and Walter Kasper about the relation between the universal and local Church, with special reference to the letter from the Congregation for the Doctrine of the Faith Communionis Notia, written by Cardinal Ratzinger.

In the early 21st century, Christianity in China is a diverse, growing, and small but resilient force. Estimates vary, but one informed report speculates that the number of Christians is perhaps 5 percent of the population, in any case giving China one of the largest Christian populations in the world. Historically, like Buddhism in earlier times and Marxism in the 20th century, both of which also came from outside China, Christianity has become Chinese in many forms: as doctrine and theology, as institutions, as communities, and as spiritual experience. In the 16th century, the Jesuit missionary Matteo Ricci argued for a Sino-Christian synthesis based on the natural theology that God had placed in Confucian classics as well as the Bible. After the emperor proscribed Christianity and expelled foreign missions in 1724, Catholic village communities grew by melding Christianity into local Chinese religions. In the century after the Opium Wars of the 1840s, Protestant and Catholic missionaries and Chinese Christians established a network of churches, seminaries, schools, universities, hospitals, and publishing houses, which all made key contributions to the emerging Chinese nation. At the same time, independent Chinese evangelicals attracted large followings based on their own readings of the Bible. After 1949 the new People’s Republic of China once again expelled foreign missions and campaigned to suppress or control all religions except officially sanctioned groups. Yet the number of Christians still rose, mainly in the countryside. When the post-1978 reforms brought a loss of faith in Marxism and a spiritual crisis, Catholic and mainline Protestant churches thrived, as did “underground churches,” but the fastest growing groups were independent evangelicals and Pentecostals, again especially in the countryside. In short, over the centuries there have been many and often competing Chinese Christianities. For many millions, Christianity was a spiritual experience and daily practice which gave meaning to life. Doubters saw Christianity as a foreign religion incompatible with Chinese culture, while China’s rulers, both before and after the 1949 revolution, assumed that it was their responsibility to regulate all religions, especially ones they saw as foreign. Nationalists charged that Christianity entered China by what they called imperialist “gunboat diplomacy,” accused converts of being “rice Christians,” and charged that “one more Christian is one less Chinese.” In recent decades, perhaps no other field in Chinese studies has changed more than the study of Christianity. The earliest scholars, often missionaries or their sympathizers, wrote reverentially of struggles to create a Chinese church and plant the seeds of Christianity. Recent scholarship centers on Chinese Christianities as independent and authentic entities, not as versions of western Christianity; on missions as part of Chinese society; on grassroots communities that practice Christianity as a Chinese folk or popular religion; on Christianities which enlarge rather than replace Chinese identities; and on lived experience as much as on orthodoxy and doctrine.

To correlate international official data on Cesarean delivery rates to infant and maternal mortality rates and low weight-at-birth rates; and to test the hypothesis that Cesarean rates greater than 15% correlate to higher maternal and infant mortality rates. Analyses were based on the most recent official data (2000-2009) available for 193 countries. Exponential models were compared to quadratic models to regress infant mortality rates, neonatal mortality rates, maternal mortality rates, and low weight-at-birth rates to Cesarean rates. Separate regressions were performed for countries with Cesarean rates greater than 15%. In countries with Cesarean rates less than 15%, higher Cesarean rates were associated to lower infant, neonatal, and maternal mortality rates, and to lower rates of low weight-at-birth. In countries with Cesarean rates greater than 15%, Cesarean rates were not significantly associated with infant or maternal mortality rates. There is an inverse exponential relation between countries' rates of Cesarean deliveries and infant or maternal mortality rates. Very low Cesarean rates (less than 15%) are associated with poorer maternal and child outcomes. Cesarean rates greater than 15% were neither correlated to higher maternal nor child mortality, nor to low weight-at-birth.

Much of the social science literature pertaining to the development of civil society in post-communist Eastern Europe focuses on the issue of religious pluralism, especially the relationship of religious minorities and new religious movements (NRMs) to the state and their established Orthodox churches. Their findings suggest that the equation of ethno-religious nationalism, cultural identity, and the state becomes a hindrance to religious pluralism and the development of civil society in these nation-states. As a result, social scientists depict these national churches, and in most cases rightly so, as being the caretakers and fomenters of ethno-religious nationalism in their particular states. A factor in this debate that is often overlooked, however, is the role of the local church in intra-ecclesial relations. Is the concept of the “local church,” which developed in the time of the Roman and Byzantine Empires, to be identified with the modern national church? If this is the case, these churches may be guilty of the sin of ethno-phyletism, which the Council of Constantinople condemned in 1872 in regards to the Bulgarian schism. Additionally, while the development of religious pluralism in post-communist society with the proliferation of Protestant Christian sects and NRMs challenges the religious hegemony of the national churches, even more problematic has been the issue of inter-territorial Orthodox churches in Eastern Europe. The existence of a plurality of national Orthodox churches in the same territory violates the ecclesiological principle of the “local church” as well as perpetuates the sin of ethno-phyletism. While some social scientists may laud the development of a multiplication of churches in the same territory, from an ecclesiastical standpoint such a multiplication denies the unity and identity of the Orthodox Church as the one, holy, catholic and apostolic Church, which it confesses to be. What social scientists have failed to discuss is this important self-understanding of the Orthodox churches, especially as it pertains to inter-Orthodox ecclesial relations. Only with this self-understanding of the church blended with the issue of ethno-nationalism can the problems pertaining to the relations and development of ethno-national churches be properly understood.

The question of the biblical bases for a feminist and participatory theology of mission takes us back to the beginnings of Christianity in the first and second century, when the first Christian communities were starting to develop their religious and cultural identity and to gain an understanding of themselves as the church of Jesus Christ. Just as the idea of being church was still in a state of flux, so too was the idea of what we today call What this concept comprised, who could participate in mission and help decide how it was to be done, differed according to the thinking of different local churches and itinerant ascetic apostles. The biblical foundations for mission are difficult to ascertain, because the relevant concepts (1) appear in the New Testament in connection with a variety of activities and groups of people. For example they include such disparate things as the work of itinerant apostles among Gentiles in the known world at that time, as well as leadership tasks within local churches such as proclamation, teaching, responsibility for the sacraments, as well as caring for the needy and for prisoners. But they also include standing up for one's faith under persecution, holding fast to the true faith, and transmitting the legacy of the faith to the next generation. (2) The public dimension is the one characteristic that does stand out in the multi-faceted subject of mission, in all the forms mentioned. Mission, at its core, urges Christians towards public activity, anchored as it is in the gospel of Jesus Christ. Jesus' own understanding of the purpose for which he was sent was that it was a public action which he carried out in the public sphere, in the streets, market squares and in the temple. Called to account for it by the high priest at the beginning of his passion, Jesus said: have spoken openly (parrhesia) in the world; I have always taught in synagogues and in the temple, where all the Jews come together. I have said nothing in secret (en krypto) (John 18:20). From the beginning the mission of Jesus' disciples involved active participation of church members in public tasks, in worship, communication within and beyond the congregation, as well as in public work outside the church among people of other faiths (ethne). Did women take part in this? Could they actively and publicly participate in missionary tasks, and be involved in decision-making, in view of the fact that in the Mediterranean world at that time, offices and functions in the public sphere (polis) were generally the affairs of men? (3) What follows is an exploration of women's role in mission in the early church, by asking whether, in what ways and to what degree women participated in the public work of the early church. On this basis, the biblical premises for women's involvement in mission will be established, in the context of a feminist and participatory theology of mission. The scope for women's mission activities basically depended on whether local churches, in ordering the way they operated within and beyond the congregation, held to androcentric and consequently unbalanced gender images, of whether and to what extent they thought up and realized alternative forms of community life. As a first step, I will sketch out the different ways in which Christian communities dealt with this issue (1). An outline of an understanding of mission beyond established gender models will be given on the basis of Galatians 3:26-28 (2). Then I will explore the beginnings of gendered missions, typified by hierarchical gender role stereotyping within the New Testament canon (3), and from there proceed to develop some perspectives, on the basis of four key biblical passages, for a feminist and participatory theology of mission (4). Finally, whether and how women took responsibility for mission beyond New Testament times will be shown by a few examples from the early church (5). I. Women's opportunities for participation in the early Christian communities In the period between the ministry of Jesus and the finalization of the Old and New Testament canons at the end of the second century, the degree to which women were able to participate in mission and the forms that this participation took were exceedingly varied. …

Based on the principle of health equity, the Italian National Health Service is known worldwide for being a universalistic system that guarantees healthcare services for all its population, among which there are undocumented migrants. A commitment for their health needs is further motivated by their lower utilisation rates of healthcare services, which becomes even more crucial when considering chronic conditions such as diabetes that require adherence and continuity of care. However, the need for more official data has resulted in little research documenting these healthcare usage patterns. For this reason, our objective has been to deepen, from the Italian NHS perspective, the quantity, costs, type, preventability and organisation of healthcare services directed to undocumented migrants. We used official healthcare data from the Lombardy Region, which enable the identification of people receiving the STP code (undocumented migrants) and of people with foreign citizenship (documented migrants). After quantifying the average annual amount and expenditure for healthcare services grouped by Italian citizens, documented migrants and undocumented migrants for all clinical conditions (quantity and costs), we performed three primary investigations where we enlightened differences between the three mentioned groups focusing on the diagnosis of diabetes: (i) mapping the types of healthcare services used and their characteristics (type); (ii) quantifying the impact of preventable hospital admissions (preventability); (iii) examining the healthcare patterns linking pharmaceutical prescriptions with hospital accesses (organisation). Our results reveal significant differences among the three groups, such as more urgent hospital admissions, more preventable complications, and a higher recurrence in terms of access and costs to hospital services rather than pharmaceutical prescriptions for undocumented migrants. These findings can represent the leverage to raise awareness toward the emerging challenges of the migrant health burden.

The article analyzes the process of system formation of the structure of Ecumenical Orthodoxy at the current stage. Church life is a dynamic process. The Church is constantly moving forward and has to respond to social demands and problems. It is determined that the institution of autocephaly went through a difficult path of formation, however, even today there is no clear regulated mechanism for the acquisition of autocephalous status by the new Local Church. It has been proven that a number of national churches, such as Montenegro, Macedonia and Belarus, have been defending their own church independence for a long time. However, due to external political-ecclesiastical pressure and the lack of an algorithm for the autocephalization process, they cannot acquire an independent status. In addition, it has been established that such "daughter" churches as Macedonian and Ukrainian are much older than their own kyriarchal patriarchates (Serbian and Moscow). The study found that an obvious violation of canonical rules is the presence of two jurisdictions (two canonical bishops) in the same territory. It has been proven that such a situation exists in a number of countries, such as the United States, where a number of churches in the diaspora of different jurisdictions operate in parallel. A similar situation has already formed in Ukraine. Two significant church organizations operate simultaneously. It has been proven that due to the pressure and reluctance of the mother churches to release the subsidiary churches from the field of influence and their own canonical territory, a similar situation could potentially occur in Montenegro, Macedonia and Belarus. As in Ukraine, some of the parishes will move to the newly created autocephalous church, for example, the Belarusian one, and some will remain loyal to the Russian Orthodox Church. However, it has been established that the coexistence of different mutually recognized Local Churches on the same territory contradicts a number of canons and traditions of the Orthodox Church. The article proves that the Conciliar fullness of the church does not justify such a status of churches, however, in general, the phenomenon of parallel jurisdictions is justified by the time and public demand of the population of different countries, as well as by the political situation. The Grand Council of Crete has not found a compromise solution for an authorized resolving of the problem of the diaspora and "parallel jurisdictions". The article establishes that institutional disputes between Local Churches related to borders and "canonical territory" and the proclamation of new Local Churches in autocephaly status can be resolved only by a conciliar way and with the participation of all Orthodox hierarchs. Existing approaches to solving the "temporary" problem of "parallel jurisdictions" have led to the incorporation of existing non-canonical entities into recognized churches. It has been proved that only the autocephalous system is a unanimously accepted version of the existence of Ecumenical Orthodoxy. Thuse, the striving of a number of national churches for their recognition and independence is just. Therefore, further scientific explorations of autocephalous topics and the canonical work of the holy fathers will complement the study.

Autocephaly independence and self-government is an attribute of the major Orthodox Churches. Theoretically it offers no scope for isolationism or exclusivism. John Meyendorff traces its origin to the arrangements whereby local communities of believers in the early church came into association with each other. The initiative was with the local church. Pluralism was maintained; it was necessary, however, for all local churches to remain part of the Universal Church. This contact and communion was facilitated by the bishops who were in this sense the servants of the local church rather than representatives of some central authority. 'The full integrity and catholicity of each local church required its communion with all the churches,' explains Meyendorff. 'The initial form of this communion was normally realized with neighboring churches in the framework of existing political structures. These canonical groupings were meant to serve unity, not create divisions.' 1 It was the local church community that was of fundamental importance; the bishops of local churches were equal in status and they met regularly in provincial synods under the authority of the bishop of the local provincial capital, or 'metropolitan' .2 'There were no canonical obstacles to the existence of this patriarchal pluralism. On the contrary, the ancient canons of Nicaea and subsequent councils ... sanctioned ecclesiastical regionalism in the framework of a universal unity of faith, secured by councils.'3 These fundamental principles of autocephaly remain valid today. 'The eucharistic assembly, presided by the bishop, is the fullest manifestation of the Church catholic, although it is always a local event. It gathers all the Orthodox Christians living in a given place.' One of the factors which determines its authenticity is 'unity with all the other Orthodox communities of the present.' 'If there is no concern for horizontal unity in truth with the entire Church universal, there is only congregationalism.'4 Autocephaly, then, affirms the integrity of each 'local' church community while asserting that each such community achieves its validation only within the Universal Church. Such continues to be the teaching of those with the profoundest insight into Orthodox ecclesiology. The Russian Orthodox priest Fr Aleksandr Men' was once

W dniach 18-26 czerwca 2016 r. na Krecie miało miejsce ważne wydarzenie dla Kościołów prawosławnych. Uczestniczyły w nim oficjalne delegacje dziesięciu lokalnych Kościołów prawosławnych. Z udziału w soborze wycofały się cztery lokalne Kościoły prawosławne, a mianowicie: Patriarchat Antiocheński, Patriarchat Moskiewski, Patriarchat Gruziński oraz Patriarchat Bułgarski. Niepełna reprezentacja Kościołów prawosławnych na Soborze świadczy o nierozwiązanych problemach oraz różnicach w podejściu do kwestii kanonicznych i teologicznych. W artykule została syntetycznie przedstawiona historia działań, mających na celu zwołanie wszechprawosławnego Soboru oraz problemy eklezjologiczne, które spowodowały wycofanie się z soboru na Krecie czterech lokalnych Kościołów prawosławnych. Przedstawiona argumentacja może być pomocna w zrozumieniu istniejących obecnie rozbieżności teologicznych oraz napięć we wzajemnych relacjach lokalnych Kościołów prawosławnych.

Population as an element of regionalization of Serbia

INTRODUCTION HCC is the fifth most common cancer in the US, and with a 5-year survival rate of 18%, the second most lethal tumor after pancreatic cancer.1 Liver transplantation (LT) is a remarkable therapeutic option for patients with liver cancer. In addition to removing the tumor, LT has the advantage of curing the underlying liver disease. LT within Milan criteria is associated with 60%–80% survival at 5 years and 50% at 10 years.1 For patients with more aggressive disease, however, the treatment options are much more limited and survival time drastically decreases. In an effort to optimize patient selection and allocation policy, the Organ Procurement and Transplant Network (OPTN)2 and United Network for Organ Sharing have developed multiple policy changes in regard to liver transplant for patients with HCC. On February 4, 2020, OPTN/United Network for Organ Sharing implemented a new organ distribution system called the "acuity circles" (AC) model. With this policy change, AC are used where the median Model for End-Stage Liver Disease (MELD) at Transplant (MMaT) is calculated for transplant centers within a 250 nautical mile radius around donor hospitals, and patients with HCC are listed for transplant with a MELD exception score of MMaT-3. Although the policy change is still new and recent, the current available official data released by the OPTN suggest that this new policy places patients with HCC at a disadvantage for 2 main reasons: an increase in the number of liver cancer patients removed from the list due to death or becoming too sick for transplant and fewer patients with HCC receiving transplants after policy. Increased waitlist removal Once a patient is listed for transplant, he or she may be removed for 1 of 3 reasons: transplantation, death, or change in clinical status.3 Waitlist removal is thus an important metric to gauge whether a transplant policy is appropriately providing patients with life-saving organs before their disease progresses to a point beyond transplant or even death. Before the policy change, patients qualifying for HCC exception points comprised 2.5% of those who were removed from the waitlist. Postpolicy overall, that percentage increases to 3.1%. Meanwhile, the waitlist removal rate for patients without HCC exception status remained unchanged.4 In a 2021 retrospective analysis, Bernards and colleagues demonstrate that transplant candidates with HCC were 344% more likely to be removed from the waitlist in the post-AC policy era compared with the prepolicy era in longer waitlist regions (cause-specific hazard ratio (CHR), 1.31, p=0.001). Meanwhile, in shorter waitlist regions, candidates with HCC were 10% more likely to dropout postpolicy compared with those without HCC (CHR, 1.10, p = 0.24).5 Furthermore, while there was concern that compensated patients with HCC were placing decompensated non-HCC patients at a disadvantage with the prior allocation policy systems, the MMaT-3 has now placed decompensated patients with HCC at a significant disadvantage. HCC patients with a MELD-Na score of 21–25 at the time of listing were at higher risk of waitlist dropout compared with those with MELD-Na<15 (CHR, 2.26, 95% CI, 1.99–2.57, p<0.001). Those with a MELD-Na score of >25 were at even higher risk of being removed from the waitlist (CHR, 8.55, 95% CI, 7.54–9.70, p<0.001).5 Decreased liver transplant rates Overall, across all MELD scores, patients with HCC exception points are now being transplanted at a lower rate compared with preceding policy eras. There was a notable drop in transplant rate from the National Liver Review Board system, which immediately preceded the AC model, from 79/100 active person-years (95% CI, 74–85) to 57 (95% CI, 53–61). This point is further solidified with the release of the 12-month report, which demonstrated a clear decrease in number of transplants for HCC patients prepolicy to postpolicy across almost all OPTN regions.6 One particular group of interest is those listed with a MELD/PELD score of 15–28. This population is of utmost importance because it represents the vast majority of HCC patients listed for transplant. The OPTN reports demonstrate that 95% of transplant centers have a MMaT of 31 or less. Therefore, most patients with HCC are listed with MMaT-3 within this 15–28 category. Data from the OPTN again demonstrate a significant decrease in transplant rate from 197 in the National Liver Review Board system to only 126 per 100 active person-years postpolicy without overlapping CIs.4 Although there is a paucity of data available because of the relatively recent implementation of this AC-based allocation policy, the official data presented by the OPTN insofar has demonstrated that this new allocation system clearly puts patients with liver cancer at a disadvantage. But Patients with HCC are already advantaged and overprioritized? Since the onset of MELD exception points for patients with HCC, numerous policy changes have been implemented to appropriately allocate organs for patients awaiting liver transplant. However, the original purpose of the AC policy was not to address any perceived advantages that patients with HCC had in the transplantation allocation process, but rather to respond to concern by the HRSA regarding OPTN Final Rule Section 121.8, paragraph a(8), which states that allocation policies "shall not be based on place of residence or place of listing."7 In addition, the most recent allocation policy change aimed at patients with HCC was the "cap and delay" policy introduced in 2015, and this substantially reduced any advantages that HCC patients previously had over non-HCC patients in regard to access to transplant. As per Ishaque and colleagues, this policy led to comparable waitlist mortality/dropout for both HCC and non-HCC candidates with the same allocation MELD (9.3% vs. 9.6%). In addition, the rate of waitlist dropout was actually higher for HCC candidates, 1.93-fold over 24 months postpolicy (p<0.001).8 In a large single-study cohort of patients with HCC who dropped out of the liver transplant waiting list due to tumor progression between 2000 and 2016, Gorgen et al9 demonstrated that prognosis after dropout is dismal with a median survival after dropout of 3 months. Role of locoregional therapy Although LT is the gold-standard, curative-intent therapy for patients with unresectable HCC meeting Milan criteria, a role for locoregional therapy (LRT) has emerged as a potential bridging therapy with the goal of slowing tumor progression while the patient awaits curative treatment through transplant. In their official HCC guidelines, the American Association for the Study of Liver Diseases does suggest utilizing LRT to bridge to transplant in those within Milan to decrease progression of disease and subsequent waitlist dropout. However, the quality/certainty of evidence for this recommendation is very low and the strength of Recommendation is Conditional.10 In a multicenter study analyzing 3601 patients with HCC who underwent LT, Agopian and colleagues demonstrated that bridging LRT did not improve survival and did not decrease post-transplant recurrence. In fact, those patients who received both transarterial chemoembolization and ablation had a 52% higher rate of recurrence than those not receiving any therapy. Those who received 3 or more treatments had an inferior 5-year recurrence-free survival rate and an increased risk of post-LT recurrence compared with those receiving 2 or fewer treatments. The only benefit of LRT came to those who received complete pathologic response on explant, but those who did not actually had worse outcomes than with no treatment, including a higher rate of HCC recurrence (HR: 1.32, p = 0.044).11 Additional studies from Xu et al12 and Ravaioli et al13 demonstrated similar findings of higher rates of recurrence in those who received LRT and had only partial necrosis.12,13 Although there may still be a role for bridging LRT, these findings simply highlight that tumors are often unpredictable and dynamic and that prolonged waitlist times, not to mention waitlist dropout, are detrimental to patients with liver cancer. CONCLUSIONS A perfect organ transplant allocation policy remains a moving target. However, the most recently adopted AC policy has led to clear disadvantages for patients with HCC because of increased rates of waitlist removal/dropout and decreased rates of transplantation based on official OPTN data. The benefits and success of bridging LRT in decreasing disease progress remains controversial and does not present a worthy alternative to transplantation in patients with liver cancer.