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Should human organs made available for donation be distributed on a nationwide basis to patients who are most critically in need of organs rather than favoring people in a particular region

Should human organs made available for donation be distributed on a nationwide basis to patients who are most critically in need of organs rather than favoring people in a particular region?

Viewpoint: Yes, a nationwide system—made possible through advances in the transportation and storage of organs—would be the most equitable method to distribute human organs.

Viewpoint: No, a nationwide distribution system would introduce new inequities to organ donations. The current system of regional and local distribution is superior.

During the second half of the twentieth century, surgeons developed procedures for transplanting kidneys, livers, and hearts into patients whose own organs were failing. The American physician Joseph E. Murray performed the first successful human kidney transplantation in 1954. In this case, Murray was able to take a kidney from the patient's healthy twin brother, but transplantation largely depended on the use of organs from those who had recently died. Liver transplants for patients with end-stage liver disease were performed in the 1960s, but all these early procedures ended in failure. Public excitement about organ transplants, however, was raised when South African surgeon Christiaan Barnard performed the first human heart transplant operation in December 1967. Ten years later, the heart transplant field experienced a wave of disappointment and disillusionment, primarily because the immune response invariably led to the rejection of foreign organs.

Optimistic surgeons nevertheless predicted that organ transplants would one day be as commonplace as blood transfusions. During the 1980s, drugs like cyclosporin, which suppresses the immune response, transformed organ transplants from experimental procedures into routine operations. In the 1990s increasingly complex multiple organ transplants were performed, such as kidney-pancreas, heart-lung, and kidney-liver combinations. The success of transplant operations continued to improve, as measured by the survival rates of organs and patients. Health-care prophets warned that in the not too distant future the supply of money rather than the transplantable organ might become the rate-limiting factor. By the end of the twentieth century, despite the enormous costs involved, the demand for organs continued to exceed the supply.

As surgeons began their dramatic attempts to save lives by means of organ transplants, U.S. federal government efforts to regulate organ and tissue donation led to the passage of the Uniform Anatomical Gift Act (UAGA) of 1968. By 1972 every state had adopted the provisions of the UAGA. This legislation established the legality of donating a deceased individual's organs and tissues for transplantation, medical research, or education. Another important goal of UAGA legislation was to protect health-care personnel from the potential liability that might arise from acquiring organs for approved purposes. Because uncertainties about determining the moment of death were exacerbated by the need to secure functional organs, the Uniform Determination of Death Act of 1980 was important to advances in transplant surgery. This act recognized brain death, as well as cessation of the heartbeat and respiration, as death. Under the new definition of death, irreversible cessation of all brain function, including the brain stem, was established as a valid criterion for determining death.

Because only a few medical centers performed organ transplants in the 1960 and 1970s, and donor organs could only be kept functional for a very short period, the allocation of organs was generally handled on a local or regional basis. As procedures and outcomes improved, more patients became transplant candidates and the competition for donor organs increased. In 1984, just one year after the FDA approved cyclosporin, the National Organ Transplant Act was signed into law in order to establish an equitable and efficient national system to match organ donors and recipients. The act prohibited the buying and selling of organs. To protect dying patients who might become organ donors, the law prohibited the doctor who determined brain death from involvement in organ procurement. The law also initiated the formation of a veritable alphabet soup of agencies and committees charged with carrying out the nationally recognized goals of organ procurement and allocation. The act also established the Organ Procurement and Transplantation Network (OPTN) in order to provide a system for the equitable allocation of donated organs.

In 1986, the OPTN awarded a contract to the United Network for Organ Sharing (UNOS) to manage organ allocation and facilitate communication and cooperation among members of the transplant community. One year later, UNOS was also given responsibility for maintaining the national Scientific Registry for Organ Transplantation, to facilitate the compilation and analysis of data about solid organ transplants (kidney, kidney-pancreas, liver, pancreas, heart, heart-lung, lung, and intestinal transplant procedures). To coordinate organ sharing throughout the United States, UNOS established 11 geographic regions and established professional standards for transplant centers, organ procurement organizations (OPOs), and tissue-typing laboratories involved in transplantation. Policies formulated in accordance with the National Organ Transplant Act call for the equitable allocation of organs to patients who are registered on waiting lists on the basis of medical and scientific criteria, without regard to race, sex, financial status, or political influence. Efforts to establish a national distribution system have been opposed by state governments and those organizations that believe such a system will have an adverse effect on their own transplant candidates and OPOs.

The ever-increasing disparity between the supply of and demand for organs continues to create tensions within the transplant community. Despite decades of appeals for organ donations, the need for organs continues to grow about twice as fast as the supply. In 1990, about 15,000 organs were transplanted, but about 22,000 people were listed as in need of an organ. Almost 23,000 organs were transplanted in 2000. By the end of 2001, there were about 79,000 people on the national transplant waiting list for a kidney, liver, heart, lung, pancreas, or intestine.

Attempts to balance the goals of achieving optimum patient outcome, equitable distribution of organs, and decreased organ wastage have generated often bitter controversies because of the scarcity of transplantable organs. Members of the transplant community are divided on the issue of establishing a nationwide list for organ distribution, but all agree that recruiting more organ donors is the key to resolving the debate about organ allocation. Alternatives to donor organs, such as xenotransplantation (using organs from pigs or other animals), artificial organs, and growing or repairing organs through the use of stem cells, are remote and still uncertain measures. Recognizing the importance of increasing organ donation, on his first day as Secretary of Health and Human Services in April 2001, Tommy G. Thompson urged all Americans to "Donate the Gift of Life." Through a national campaign called "Workplace Partnership for Life," Thompson urged employers, unions, and other employee organizations to join in a nationwide network to promote organ donation. The goal of Thompson's Gift of Life Donation Initiative is to encourage Americans to donate blood, tissue, and organs. The secretary also directed the Health Resources and Services Administration to organize a national forum to study organ registries and policies in all states.

—LOIS N. MAGNER

Viewpoint: Yes, a nationwide system—made possible through advances in the transportation and storage of organs—would be the most equitable method to distribute human organs.

In the black-and-white, heavily political world of the debate about organ allocation, there exists the perception that "sickest first" and "geographical boundaries" are mutually exclusive terms. From a purely medical point of view, that is not always the case. When a donor organ is removed, it is put into a cold nutrient solution and transported to the hospital that will perform the transplant. Different organs have different "endurance limits," the length of time they can exist without blood supply in cold temperatures before they are damaged and become unusable. There are some circumstances in which long-distance transplant is not feasible, because transporting the organ will exceed this "endurance limit," and any organ-allocation policy must take into account the medical limits on organ transportation. These limits, however, keep changing with development of faster airplanes and the availability of more private charters for transport. No allocation policy should limit, in advance, the area in which an organ must remain. As the American Medical Association stated, donated organs "should be considered a national, rather than a local, or regional, resource."

The term "sickest first" is inaccurate in the context of organ transplantation; a more accurate term would be the patient "with the greatest medical urgency." What opponents of the "sickest first rule" justifiably claim is that the sickest people are not good transplant candidates. The bodies of these patients will most likely be unable to cope with the trauma of transplant surgery and its aftermath. The realistic "sickest first" rule actually favors patients who are in the most urgent need of transplants, but are still viable candidates. An allocation policy favoring these patients should be based on medical criteria, agreed upon by transplant surgeons and other experts in the field. In addition, any organ-allocation policy should apply different standards for different organs. Liver patients in complete liver failure need immediate transplants. Patients with what is known as end-stage kidney disease can be sustained for a time on dialysis treatments. Obviously, the definition of, and criteria for, "greatest medical urgency" in a liver patient will be differ from the that of a kidney patient.

The Inequity of Geographical Boundaries

A system based on solely geographical boundaries calls for organs available in one zone to be offered to patients in that zone first, regardless of medical urgency. Some zones, for a variety of reasons, have a higher organ-donation rate than others, or better transplant programs. When patients become aware of these zones, financial status comes into play. Patients who can afford to travel for medical treatment can list themselves in one—or more—transplant centers outside their area of residence. To be listed in a center, doctors at the center must examine the patient in person. The patient must then be able to travel on a moment's notice if an organ becomes available. The net result is that more affluent people, or people with better insurance coverage, can often get an organ transplant far more quickly than those who have to rely solely on their local organ-procurement system.

Allocating transplant organs on the basis of geographic boundaries can create absurd situations. An organ can be transplanted into a patient who could still be sustained by medical treatment, while a patient in the next state who could have been saved by the very same organ will die, simply because he or she lived in the wrong zip code, so to speak. In 1998, 71% of liver transplants were carried out on patients in the least urgent category, while 1,300 people died that same year waiting for a liver. Three Institute of Medicine (IOM) experts, working on their own "as an intellectual exercise," found that 298 of these 1,300 patients would have received a transplant under a broader sharing policy.

The Department of Health and Human Services (DHHS) presented data it collected on liver and heart transplants that were done under the geographic boundaries system. These results were presented at a congressional hearing on the proposed "Final Rule" that would change the organ-allocation system in the United States. The department looked at rates of transplant within a year of a patient being listed as a candidate, the one-year survival rates following transplants, and the risk of dying while on the waiting list in the various transplant programs across the country. The results were adjusted to account for differences in patients' health status (risk adjustment). The risk-adjusted differences in rate of transplants within a year ranged from 71% of liver patients transplanted in some programs, as opposed to less than 25% patients transplanted in others. In patients with heart disease, the range of transplants within a year was 36% to 72%. The risk of dying while on the waiting list was less than 8% in some liver-transplant programs, and more than 22% in others. The numbers in the same category (risk of dying while on the waiting list) in the heart-transplant programs ranged from 9% to 23%. The one-year survival rates after transplants ranged from 65% to 86% in liver-transplant programs, and 67% to 84% in heart-transplant programs. Obviously geographical boundaries create a staggering inequality in access to transplants, and in the outcome of these procedures.

Does Sharing Beyond Geographic Boundaries Work?

Many opponents of the "sickest first" rules fear that broader sharing will lead to the closing of many small transplant centers. If the small centers close, they say, access to transplants may be restricted for those patients who live in rural or remote areas, or have limited means of travel. In fact, according to transplant experts, a broader sharing will benefit the small centers, which will receive more organs for their patients. An independent review of the IOM agreed that broader sharing would not have an adverse effect on small centers.

The organ at the center of most debates about allocation policy is the liver. With most other organs, severely ill patients can be assisted by methods such as dialysis and ventricular assist devices. However, there are, to date, no available options for patients whose livers stop working. As a result, those who discuss organ allocation policies use the liver as a key component in the debate. In computer modeling done by the United Network for Organ Sharing, broader sharing of livers reduced the number of deaths in patients with liver disease. This opinion was confirmed by the IOM's independent analysis of liver-transplant data across the country. The IOM recommended, based on this analysis, to change the allocation policy for livers, and establish broader sharing areas. The Campaign for Transplant Fairness, a lobbying group in Washington, DC, claims that even this recommendation does not go far enough, since it maintains regional boundaries, albeit larger ones. In a November 2000 interview, Dick Irving, then president of the National Transplant Action Committee, said: "There is plenty of evidence that the current system of organ allocation is not fair and that patients are needlessly dying because they are being overlooked in favor of healthier patients."

Kidney Allograft Survival Rates

But could the shipment of an organ across wider geographic areas damage the organ to the point where it would become useless to the recipient? Although every organ has different survival time outside the body, a recent study published in the New England Journal of Medicine on October 25, 2001, is worth mentioning.

The study examined the survival rates of kidney allografts, organs transplanted from another person who is genetically different from the recipient. Survival rates were compared between local and distant transplants. The study looked at pairs of kidneys from the same donors, where one kidney was transplanted locally and the other was shipped to a different area of the country. The results (adjusted for factors such as age, race, etc.) showed that locally transplanted kidneys fared better (fewer were rejected) in the first year in individuals that did not have a complete antigen match with the donor. There was no difference in the survival rates of locally transplanted and shipped kidney allografts after the first year. We must bear in mind that, since 1990, priority in kidney transplants (from cadaveric donors, which the study looked at) is given to individuals who have a complete antigen match with the donor. Antigens are responsible for invoking the body's immune responses, and certain group of antigens called HLA plays an important role in the rejection of transplanted organs. When the study looked at the rate of allograft survivals for the first year in HLA-matched individuals, there was no difference between locally transplanted and shipped kidneys. In addition, the study found that shipped kidneys transplanted in HLA-matched individuals fared better than kidneys transplanted locally into mismatched individuals.

This study illustrates a few important points. The first (and obvious) point is that the success of an organ transplant depends on many factors. In this study, a complete antigen match (the preferred situation) offsets the adverse effects of long travel time for a shipped kidney. The study does not prove that geographic boundaries are better for transplant patients. What the study does prove is that if organ-allocation policy is amended based on sound medical criteria—for instance, kidneys will be shipped only to completely matched individuals, with few exceptions—shipped kidneys can be as useful to transplant candidates as locally available ones, and sometimes even more useful, depending on the degree of antigen matching.

The other point this study illustrates is the inflammatory nature of the organ-allocation debate. When the study was published, a headline in the mainstream media proclaimed, "Shipping Kidneys Elsewhere Raises Failure Risk, Study Says." Actually, the study stated that there was no significant association between one-year allograft survival rates and shipping status in completely matched individuals. Yet according to the Associated Press story, the conclusions of the study support the argument that organ should be kept locally.

Public Perception

Proponents of allocating organs based on geographical boundaries say that broader sharing would lead to decreased organ donation, as people would want to benefit their community first. This claim has been disproved in several surveys. A survey reported in Transplantation, the official journal of the Transplantation Society, found that "responders were willing to allocate a portion of organs to older and sicker patients even when they felt that, overall, the allocation system should direct organs to patients with the greatest potential to benefit." In 1998, Peter A. Ubel of Philadelphia Veterans Affairs Medical Center and Dr. Arthur Caplan of the University of Pennsylvania Center for Bioethics quoted studies that found that the public does not see maximizing outcome as the sole goal of transplantation, but rather prefer "to distribute resources to severely ill patients, even when they benefit less than others." Moreover, the IOM report found that in areas of broader sharing, donations actually increase.

The problem of organ allocation is so hugely controversial because we are faced with a very small supply and a very great demand. Clearly the biggest help to patients needing organ transplants would be to increase the number of donated organs. States with aggressive "Donate for Life" campaigns have seen the numbers of organ donations increase dramatically. However, a change in federal donor policy might be called for. In Belgium, citizens have to "opt-out" of being organ donors, as opposed to the "opt-in" requirement in the United States. In the first ten years of the opt-out program in Belgium, only 2% of the population chose to opt out, and donation increased by 183%. A survey done in the United States in 1993 shows that 75% of the eligible population would want to donate organs. Many, however, never discuss their wishes with their families, and fail to otherwise indicate that they wish to become donors. If we would simply ask the 25% to opt out, we would automatically eliminate the missed opportunities and greatly increase the supply of badly needed organs. We may not be able to resolve the debate about organ-allocation policy, but we can greatly alleviate the problem that led to the debate in the first place.

Interestingly enough, the "sickest first" rule has always been applied in the United States under the regional boundaries system. Under that system, the most medically urgent patients in the region where a donor organ was available were offered the organs first. If the most urgent patient was ruled out as a candidate, the organ was offered to less urgent patients in the same region, even if more urgent patients were dying elsewhere in the country. One has to wonder whether the current debate over organ-allocation policy is motivated more by territorial or financial concerns than by altruism.

—ADI R. FERRARA

Viewpoint: No, a nationwide distribution system would introduce new inequities to organ donations. The current system of regional and local distribution is superior.

Throughout most of the twentieth century, advances in medicine—in vitro fertilization, frozen embryos; surrogate childbearing, whereby a fertilized human ovum is implanted in the womb of a third party; human cloning; human gene therapy; and genetic engineering—outstripped the ability of laws to meet the challenges created by these advances. However, in one area, lawmakers and the government seemed to have moved swiftly. With the enactment in 1984 of the National Organ Transplant Act, the United States moved to introduce order and fairness into a patchwork system of transplant centers, organ-procurement organizations, and associated transplant laboratories clustered in some major cities and scattered around the country. Above all, the new law sought to ensure that citizens would be able to receive transplants of organs based on medical need rather than on wealth, status, and other accidents of birth or fortune. The law sought to encourage donation of organs by individuals and their families when a tragic sudden and unforeseen death occurred. Individuals were encouraged to clearly indicate their desire to will organs to recipients with medical need; families were urged to cooperate when the possibility of recovery from an accident was no longer even a slim hope.

These efforts have been successful in many ways. Medicine and surgery have made enormous strides in perfecting transplant techniques and the improving the continuing care of individuals who receive the organs. Campaigns to promote and encourage greater involvement of the general public in agreeing to donate organs upon death have been less successful. By early January 2002, nearly 80,000 individuals were waiting for an organ to become available. In 2000, the number of donors reached only 11,684, and some 13 people die each day while awaiting organ transplant. In the face of this disappointment, the public, the government, the U.S. Congress, the organizations that provide the organs and carry out the transplants, experts in the field and, above all, the individuals (and their families) whose lives could be saved by a transplant, demand more. Legal and regulatory reforms over the past two decades have been launched to remedy factors in the Organ Procurement and Transplant Network that interfere with the focus of the original legislation—saving and improving lives. However, legal and regulatory reforms alone may not be the best way to make the system work.

Neither may nationwide distribution of organs based on medical need be the answer. Many of the impediments to making organs available to anyone with an urgent need wherever they are in the United States have been overcome. There are systems to register patients and to contact the transplant centers when organs do become available. Improvements in the testing of organs and recipients to determine suitability of the organs to be transplanted have reduced the chance of mismatches or unsuitable transplants. In the past, the rejection of organs by the new recipients was a problem in all but the most genetically similar individuals, such as identical twins. Now, powerful new immunosuppressive drugs reduce the likelihood of rejection. Other advances in medical technology permit organs to be preserved without the deterioration that might jeopardize the success of transplantation, prolonging the time available to transport the organs from place to place. Laws and regulations demand improvements in the standards of medical criteria for placing patients on transplant lists and for determining medical need, so that subjective or nonmedical factors are eliminated from decisions when registering patients for transplants.

Ideally, patients with the most critical need, those facing imminent death, would be the top candidates for receiving organs as soon as organs become available, as long as there was an appropriate match. However, a number of voices have advocated that preference be given to specific regions in allocating scarce organs, particularly livers from cadavers, and allocations on the basis of medical need have not always prevailed. For example, the 1996 Code of Medical Ethics of the American Medical Association states: "organs should be considered a national, rather than a local or regional, resource. Geographical priorities in the allocation of organs should be prohibited except when transportation of organs would threaten their suitability for transplantation." This same position is embodied and endorsed in final regulations issued by the U.S. Department of Health and Human Services (DHHS) that govern the Organ Procurement and Transplantation Network (OPTN). The DHHS has been given authority by the U.S. Congress to exercise oversight of the OTPN. As amended, the Organ Transplant Act makes clear that its principal aim is to ensure a nationwide system that fairly distributes organs for transplant based on need and not location. However, local priorities often undermine the intent of the law.

In 1998, Dr. Arthur Caplan, a prominent philosopher in the field of bioethics (the area of ethics that helps unravel complex life-and-death issues emerging from scientific advances) spoke out in support of the DHHS position in the New England Journal of Medicine : "The federal government's tough stance against geographic favoritism should be embraced. It is inherently unfair to give priority to some patients merely because of where they live…. The geographic basis of the allocation system … is ethically indefensible." Underlying this philosophical view is the notion that the best way to allocate a scarce resource is to save a life in immediate danger.

Why, then, in the face of such a strong ethical imperative, have a number of states enacted laws to prohibit the transport of organs out of the state? In fact, the states have been responding to another perceived unfairness. Waiting lists for organs in some areas of the United States show clear disparities; in some regions, patients wait a median of 30 days for a liver, in others the median is over 200 days. Many patients in areas with long waiting lists will die before they receive a liver. Faced with the prospect of its own citizens and residents being deprived of life-saving intervention, is it any wonder that the state lawmakers have responded by putting the interests of their own residents first? Organs are in short supply—each year need exceeds supply by a factor of 5 to 10. Although it seems fair to treat the sickest patient first, that reasoning assumes that patients who are not as ill will be able to receive treatment later. However, this is not the reality in the case of liver transplants. When one patient receives a liver, that means another may never receive one. Patients could wait years, becoming increasingly ill and even risking death until they were at a critical point, and there is no guarantee that a suitable liver would become available even then.

Another way of looking at the ethics of allocating scarce resources is to consider how to bring about the best overall result for everyone. From this perspective, a number of factors come into play, as patients who are close to death do not respond well to new organs. Frequently the donated organ fails, and the patient requires a fresh transplant to survive, but even when the organ functions, the patient's general health is so poor that he or she may survive for only a year or less. These sick patients may never regain a satisfactory quality of life, they are hospitalized and require expensive care. Consequently, in 75% of the cases the result of the transplant is only a postponement of death and the loss of an organ for someone else, and even, at times, the need for another organ transplant to try to save the life of the individual who received the organ. From this perspective, does it make sense to risk "wasting" organs on the most ill when a greater overall benefit can result from a successful transplant?

Under mandatory liver sharing, when the geographic region is expanded, the waiting time for the gravely ill is reduced, although even then some of the gravely ill do not receive a liver. But the overall net effect is even more discouraging. In one study, the overall wait for the gravely ill was cut from five to three days. But the cost was significant. Twenty-one of the gravely ill did not receive a transplant even with a greater geographic pool. Of those further down the waiting list, 132 died. Thus, for a shortened waiting time, the tradeoff was increased mortality for a larger number. The remedy of mandatory wider geographic or nationwide sharing saves only a small number of lives, mainly in the short term, and results in prolonging morbidity and ends in death for a greater number. The shortage of organs is so great that any improvement that might be achieved through a nationwide sharing is cancelled out. The numbers of transplants in some areas may increase, but there is no increase in the number nationwide nor in nationwide survival numbers.

Some types of liver failure can only become worse due to the longer waiting times that result from mandatory nationwide sharing. For patients with liver cancer, the average waiting time is only about a year, but during the wait the cancer grows, perhaps spreads, rendering the tumors incurable. However, evidence shows that tumor-free survival rate over five years for patients who have an organ transplant at an early stage of liver cancer are remarkably high—over 90 to 100%. Even in more advanced cases, this is a better survival rate than that of the sickest patients who received liver transplants near the point of death.

Economic benefits also support the view of earlier transplant, even if nationwide sharing might help save the lives of the gravely ill. Earlier transplants can eliminate the expense associated with nationwide availability to the most seriously ill, those of lengthy hospitalization and the recovery and transport of organs from and to distant locations. Furthermore, early transplants mean that patients are able to return to normal and productive lives. These individuals contribute to the economy, pursue career goals, and are there to provide loving support to their families. Patients who receive transplants near death seldom return to normal life, and caring for them drains the financial and emotional resources of their families.

It is not altogether comfortable to place a dollar value on human life, and the economic issues should be subordinated to the goal of saving lives and restoring health. However, economic considerations are part of the equation of making the best use of scarce resources—organs to be transplanted. Even some who have argued against the apparent benefits of geographic organ allocation have acknowledged that a decreased emphasis should be placed on giving organs to the most severely ill patients.

Under the present system, although 98 to 99% of patients are listed in only one place, the alert or more affluent can arrange to place themselves on more than one list to increase their chances for a transplant. A system of mandatory nationwide sharing could eliminate this source of unfairness. However, the problems created in centralizing to a "national list" would prove logistically and administratively out of proportion to the problem of multiple listing.

The Organ Procurement and Transplantation Network is a patchwork system. Although they aspire to do an outstanding job and gain satisfaction from success, organizations in the network do not always have clear or rational lines of jurisdiction or responsibility, and there are rivalries and areas of personal and professional involvement. But that is not to belittle the energy that goes into local operations. These organizations take on the task of encouraging and promoting organ donations and conduct delicate negotiations to obtain family agreement under the most challenging of circumstances. Many represent families of persons who need a transplant or have received one. Transplant physicians and surgeons in the network are dedicated to saving and improving lives. Therefore, the whole system is not a feat of "engineering," but of intensely involved stakeholders. One could not expect many of the "local" energies and commitments that make the operation successful to be as effective if the organs donated and procured were "placed" in some other location.

The arguments for a nationwide listing often cite surveys of potential donors and families of donors, in which they express no desire to restrict the use of the organs to a specific location or region when urgent need exists elsewhere, and one would expect this altruistic view. But we should be skeptical of surveys of donors or potential donors, indeed of surveys in general. What attitudes do the professionals and volunteers who are involved in securing agreement to donation hold? It is their energies that stand to be undercut by a system that diminishes their immediate investment in the outcome. One hesitates to speculate that the enthusiasm and commitment of these organizations might be impaired by a nationwide mandatory listing and availability. Likely it would not. But the many voices who have expressed concern that limiting or diminishing local energies can affect the overall system need to be acknowledged.

In the end, the arguments are a matter of consensus and sound negotiation. What is working well does not have to be totally revised. However, a mandatory nationwide sharing of organs will not address the scarcity. The real issue is not local or geographic favoritism, the use of that description has only served to obscure the real issue. We need more societal investment to encourage organ donation, and funding to insure greater access and availability to underserved groups and areas. Simply redrawing maps is not the answer.

—CHARLES R. MACKAY

Further Reading

Bonfield, Tim N. "The Wait for Organs ToChange." Cincinnati Enquirer (November 24, 2000).

Committee on Organ Procurement and Transplantation. Assessing Current Policies and the Potential Impact of the DHHS Final Rule. Washington, DC: Policy Institute of Medicine National Academy Press, 1999.

Hostetler, A. J. "Organ-Sharing Changes Urged Study Supports Move to Need-Based System." Richmond (Virginia) Times-Dispatch (August 2, 2000).

Kahn, Jeffrey P. "States' Rights Or Patients'Rights? The New Politics of Organ Allocation" CNN. <http://www.cnn.com/2000/HEALTH/04/17/ethics.matters/>.

"Reorganizing the System." The NewsHour withJim Lehrer. <http://www.pbs.org/newshour/bb/health/jan-june98/organ_3-27.html>.

"Background and Facts/Liver Allocation and Transplant System." University of Pittsburgh Medical Center. http://www.upmc.edu/NewsBureau/tx/hhsfact.htm .

Ubel Peter A., and Arthur L. Caplan. "Geographic Favoritism in Liver Transplantation: Unfortunate or Unfair?" New England Journal of Medicine 39, no. 18 (1998): 1322-25.

KEY TERMS

ALLOGRAFT:

Organ transplanted into an individual from another person who is genetically different from the recipient.

ANTIGEN:

Any molecule that, when encountered by the body's immune system, will invoke an immune response.

HLA:

Human leukocyte antigens. A group of six antigens that play an important role in tolerance or rejection of a transplanted organ.

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