Former Texas Congressman Charlie Wilson used to describe himself as “a poster boy” for heart transplants, but when he died of cardiopulmonary arrest last week at 76 it called into question the nation’s organ allocation system.
Wilson, whose transplant was performed at Methodist Hospital in October 2007, had quickly moved up the national waiting list not because of any celebrity status but because the agency that matches donor organs to recipients prioritizes sickest patients highest of all. That spring Wilson’s doctors had told him he’d die soon without a transplant.
Charlie Wilson benefitted from a national allocation system that prioritizes that available donor organs go to the sickest patients.
Wilson, only five years younger than the all-time oldest heart transplant recipient, lived 2 1/3 years after the transplant, undoubtedly special time to him and his loved ones. But given that the average survival time after a heart transplant is 10 years, some in the transplant and ethics communities are increasingly asking whether a higher priority for organs whose demand exceeds the supply should be the likely outcome. That is, should the probable success of a transplant be the greatest consideration?
“I think it’s time to reassess the criteria and give more weight to transplants that result in longer and better quality lives,” says Art Caplan, director of the University of Pennsylvania’s Center for Bioethics. “Certainly, that’s nothing outlandish — that’s the principle that informs triage, vaccine distribution, ICU beds.”
The optimal use of organs is of paramount importance. Eighteen Americans die every day waiting for an organ transplant, a total of 6,700 in 2008, according to the Department of Health and Human Services. There are currently more than 105,000 people on the United Network for Organ Sharing‘s waiting list for a donation, most of them kidney patients, more than 3,000 of them heart patients. Many won’t get a donation in time.
To be sure, the allocation of donor organs is guided by a formula that takes many factors into account — matches of tissue and blood type, immune status, geography and the patient’s length of time on the waiting list. But UNOS spokeswoman Anne Paschke acknowledges that medical urgency is typically the No. 1 consideration, a preference that goes back to transplants’ experimental days, when it was logical to test the procedure on people with no other hope.
Paschke says that expected outcomes are slowly becoming more of a component of allocation formulas. There’s been no change in the heart allocation formula, but a committee recently reworked the lung allocation policy so a candidate’s transplant rating now reflects whether the transplant will be successful, in addition to the other considerations.
Still, it remains to be seen what sort of formulas ultimately emerge. Dr. Charles Van Buren, director of the division of immunology and organ transplantation at the University of Texas Medical School at Houston, says a committee he recently served on was excited about its consensus that kidney allocation should take into greater account the candidate’s likely outcome, only to have it rejected by two groups to which it was submitted.
“Both the public and the Department of Justice didn’t like the age implications of our recommendation that kidneys go to people likely to benefit the longest,” says Van Buren. “The public didn’t like it because the average age of kidney transplant recipients is 57 and the Department of Justice had concerns it would amount to age discrimination.”
So who do you side with?