Secretary Shalala Proposes Revising Priority for Recipients of Donated Organs

By S. Van McCrary, Health Law & Policy Institute

The Clinton Administration, through a letter from Donna E. Shalala, Secretary of Health and Human Services, has proposed to replace the current regional system for distributing donor organs and replace it with one where the sickest patients would receive priority for the organs regardless of where in the country they reside. The letter was an attempt to resolve a contentious, long-standing dispute about ways that organs should be distributed. The debate has focused primarily on livers because they are in especially short supply, and because unlike kidney transplant patients, persons in acute liver failure cannot be kept alive for significant periods of time while awaiting a donor organ. Secretary Shalala wrote the letter to 89 members of Congress who had written to her expressing concerns about the issue.

In response, the United Network for Organ Sharing, the independent agency that controls the current system, immediately criticized the plan, stating that the transplant community strongly supports the idea of regional organ allocation because each geographic area has a shortage and people are dying everywhere in the country. However, the Network conceded that the wait for organs is much longer in some regions than in others. For example, in the region including Michigan, Indiana and Ohio, the average wait for a liver was 370 days in 1995, while in the region containing Florida, Georgia, and Alabama, the wait was 96 days. Thus, under the regional system, patients who live in areas where the wait is shorter may receive organs even if they are not as critically ill as patients who live in areas with longer waits.

Dr. Shalala wrote, "In the worst case, patients die in areas where waiting times are long while at the same time organs are being made available to less ill patients with shorter waiting times" (New York Times, Feb. 27, 1998). In addition, the Secretary observed that although current technology allows organs to be preserved long enough to be transported across the United States, the existing allocation system has failed to take advantage of that opportunity to date.

Dr. Shalala said that in 1996 over 60 percent of livers were used in the local area from which they were obtained. However, over 50 percent of those livers went to recipients who were not sick enough to be hospitalized. In contrast, during the same year almost 400 of the 953 patients who died while waiting for transplants were hospitalized. The proposed program is intended "to develop the specific, medically sound policies" for achieving the Administration's goal of equitable distribution of available organs. The debate over proper distribution of donor organs has been ongoing in the bioethics community for some time. It appears that the Administration's proposed policy change may foster an increased level of public and professional discussion about this difficult issue.