Putting Patients First in Organ Allocation

Abstract

This chapter originated in the author’s testimony before a congressional hearing on organ allocation policy. The ethical issues it addresses remain in play, as evidenced in the 2018–2019 debates about liver allocation policy. This chapter defends the fundamental conviction of the report of the Task Force on Organ Transplantation: Donated organs should be viewed as scarce public resources to be used for the welfare of the community. Organ procurement and transplant teams receive donated organs as “trustees” and “stewards” on behalf of the whole community, that is, the national community (with qualifications). Donated organs should be allocated to patients anywhere in the country according to ethically acceptable standards and logistical constraints, thus reducing the relevance of “accidents of geography” except where these are clearly important for transplantation outcomes. In short, patients, not transplant programs, should be put first. In accord with principles of justice and fairness, it is important to specify and balance, through a public process with public input, several criteria in policies of organ allocation: patient need and probability of successful outcome, along with time on the waiting list. Unless the criteria for patient selection are fair and are perceived to be fair, public distrust may hamper organ donation and perpetuate the scarcity of organs for transplantation.