Transplants: Is system fair?

ST. LOUIS — The group that controls the nation's organ-transplant system is debating a rule to keep patients who advertise for organs from gaining unfair advantage over others. The rule would restrict who could receive organs from a deceased donor.

Amid an explosion in public appeals, a committee of United Network for Organ Sharing is considering ways to make sure every potential transplant patient has an equal shot at getting an organ.

United Network for Organ Sharing manages the nation's transplant lists and oversees distribution of deceased-donor organs.

As wait times grow, more and more patients are asking the public for organs — in newspaper ads, on billboards and on the Internet. Those pushing for restrictions fear a free-for-all, with transplant candidates scrambling to avoid the waiting list, soon to top 90,000.

Some transplant professionals say public appeals give patients who advertise an unfair advantage and are attempts to circumvent a system designed to provide transplants to the sickest and most medically eligible patients first.

The debate over solicitations has been heating up over the past year, fueled by several highly publicized appeals.

Last month, a group working on behalf of a New York City public-relations executive was accused of using questionable tactics in their search for a deceased-donor liver. The tactics included posting fliers in hospitals, allegedly tracking trauma patients in emergency rooms and urging police and emergency-medical workers to identify accident victims who might serve as donors.

United Network for Organ Sharing issued a statement assuring the public that the executive did not get preferential treatment when she got a transplant Aug. 6.

In the current American Journal of Bioethics, Sheldon Zink and colleagues at the University of Pennsylvania Center for Bioethics said recent appeals highlight the potential for exploitation.

State and federal laws permit families to name a specific person to receive their loved one's organs, a process known as "directed donation." Typically those organs go to relatives. Most transplant professionals say designating organs to immediate family members is acceptable.

But over the years, questions have arisen about where to draw the line.

If United Network for Organ Sharing decides to establish limits on who can get a directed organ, a change in federal law would be required.

Some ethicists and others worry that allowing people to designate organs to strangers based on a public appeal sets the stage for unfairness and discrimination.

"Solicitation favors those who have a compelling story, and those who have financial resources and the opportunity to get the word out," said Dr. Douglas Hanto, who is in charge of transplants at Beth Israel Deaconess Medical Center in Boston.

Transplant professionals have been divided about how to handle public appeals.

Dr. Mark Fox views it as a double-edged sword.

"Public solicitation puts a human face on the need for organs in a way that abstract data never can," said Fox, co-chair of the public-solicitation panel and associate director of the bioethics institute at the Oklahoma College of Medicine.

Fox said directed donation threatens the integrity of the system because "it is an effort to circumvent the priorities of the allocation system, which is based on clinically relevant considerations."