The Organ Transplant System
Well, my good buddy, Steve Jobs, (NOT! I hate the man...) recently emerged from a liver transplant procedure and he is doing very well all things considered. While I hate the man with a passion that can't be comprehended by mortals, even I will admit that I am glad that he is doing well. I know that going through such a thing is hell, its risky, and it can destroy a person. I know that many people aren't aware of how the organ transplant process works in how it finds and matches donors, so I figured that I would shine some light on this subject.
Livers are a scarce resource. In any given year, only about one-third of the people on the national transplant waiting list receive one, and as of late June, more than 16,000 people were on the list.
Yet it sometimes seems that celebrities in need end up at the front of the line when they need a transplant, and people often assume they get preferential treatment. (Rumors about special treatment circulated after baseball player Mickey Mantle's liver transplant in 1995, for example.)
The truth is more complicated. No one can actually buy an organ in the United States (legally, that is). But getting a liver transplant, it turns out, is a lot like getting into college. Once you're on the waiting list, your chances of getting off it depend largely on your personal circumstances -- how sick you are and whether you are a good donor match. But getting on the list in the first place -- or on more than one list, as the case may be -- requires resources and know-how that most people don't have.
There are 127 centers in the U.S. that perform liver transplants. If you need an organ transplant, your doctor will refer you to one of these centers, where you will be evaluated, given a score based on the severity of illness, and placed on the center's waiting list, if you are indeed a candidate for transplant.
The center's waiting list feeds into a national database managed by the United Network for Organ Sharing (UNOS), a nonprofit organization that contracts with the federal government to manage the nation's organ transplant system.
UNOS works with 58 organ procurement organizations (OPOs) that coordinate organ distribution in their region of the country. When an organ becomes available, the OPO in that region searches the UNOS database for a local match using blood type (and other biological considerations), the patient's severity score, and the time spent on the waiting list. If a match can't be made within that region, the organization expands its search to neighboring regions.
The problem -- or the advantage for some patients -- is that not all OPOs are created equal. Some regions contain nearly 15 times as many people as others, and their waiting list times vary widely. Patients in the smaller OPOs tend to be less sick and experience shorter wait times before getting an organ. In the Tennessee OPO where Jobs received his transplant, the median wait for a liver between 2002 and 2007 was just over four months. The national average was just over a year, and in some OPOs it was more than three years.
Though there is always the possibility of preferential treatment once a patient is on a waiting list -- UNOS conducts periodic audits of transplant centers for exactly this reason -- it is unlikely that someone like Steve Jobs can "cut the line" of the transplant waiting list.
The reason that some people might be able to get transplants more quickly is that they're standing in more lines. Nothing prevents someone from being evaluated and listed at multiple transplant centers. As long as a patient has the wherewithal to fly around the country -- and be available at the drop of a hat if a liver becomes available (this is where the private jet comes in handy) -- a patient can, in theory, be evaluated by all the transplant centers in the country.
"The system works at two levels," explains Arthur Caplan, Ph.D., the chair of the department of medical ethics at the University of Pennsylvania. "One, who gets in to a center. Two, who gets transplanted off a particular center's list when an organ becomes available. Most of the attention goes to stage two, but the biggest ethical challenges are really at stage one."
Since 2003, UNOS has required that transplant centers inform all candidates that they can be evaluated and listed at more than one center, and that they can also transfer their care from one center to another without losing the time they have accrued on the waiting list. However, not everyone can afford to fly around the country and be evaluated at more than one transplant center. In fact, many people can't afford a liver transplant, period.
According to the most recent estimates, the cost of a liver transplant is $519,600 -- a price tag that excludes roughly one-third of Americans because they don't have sufficient insurance (or any insurance), Caplan estimates. According to data collected for UNOS, only about 5 percent of liver transplants are paid for out of pocket.
"What your insurance covers is very different from everyone else's," says Anne Paschke, a spokesperson for UNOS. Some insurance companies won't cover evaluations at multiple transplant centers, Paschke explains, and in at least one case, an insurance company has restricted its coverage to a single transplant center that the company itself owned.
Obviously, the system is flawed and favors those with the means to work the system. There have been attempts to reform the system, but they have all met their end in Congress. Politicking has left the larger transplant centers against the smaller ones. The larger ones wish to maintain the larger pool of available organs in their region, whereas the smaller ones were concerned that in a national organ allocation system, they would receive fewer transplants and be driven out of business.
There is work to be done in this area. No matter what side you fall on.
Source: CNN Health
Source: Health.com: The real gift of life: How medical donations help
