The Geography of Life and Death: Evidence and Values in the Evolution of U.S. Liver Transplant Rules

Abstract

For a quarter‐century, the Organ Procurement and Transplantation Network (OPTN) has confronted the role of geography in the allocation of deceased‐donor livers for transplantation. An historical legacy of a geographical hierarchy giving priority to patients within the same local Donor Service Area (DSA) as the donor gradually evolved to give some regional and national patients priority. However, in 2020, an eight‐year process resulted in the allocation system being revised to centralize the granting of exemptions to the quantitative severity index and eliminate the DSA and region as relevant geographic units in favor of direct distance measures called acuity circles. In this account, we focus on the roles of expertise, values, and interests during this development to assess the OPTN as a form of stakeholder rulemaking. We find extensive use of medical evidence that may make such stakeholder rulemaking worthy of consideration as a governance alternative in evidence‐rich applications.