The scramble for organs

How common are organ transplants?

About 25,000 organ transplants are performed annually in the U.S.—including kidneys, livers, hearts, lungs, and pancreases. As these once-perilous operations become more common, they’ve also become safer. The survival rate in the first year for kidney transplants is now 95 percent; for liver transplants, 87 percent; and for heart transplants, 86 percent. But success has created a greater demand for these life-saving procedures. Today, 82,000 critically ill Americans are currently on various waiting lists for organs. On average, they must wait nearly three years before they move to the front of the line and receive a transplant. Last year, more than 6,500 people on the list died, and the gap between supply and demand is actually widening.

Why aren’t there enough organs?

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Only 10,000 to 14,000 of the 2.4 million Americans who die each year meet the criteria for organ donation. Organ donors have to have relatively young, strong bodies and be free of serious disease. That’s why accident victims left brain-dead by head injuries are ideal donors. But more stringent public-safety measures—such as seat-belt and helmet laws—have reduced their numbers. The rise of infectious diseases like AIDS and hepatitis C, as well as diabetes and hypertension, has also rendered many potential donors unsuitable. But the biggest problem remains that most of us cannot bring ourselves to think about our own mortality.

Why is that an issue?

If you don’t leave some record that you want to donate your organs, hospitals won’t touch them. When asked by pollsters, 85 percent of Americans say they favor organ donation. But only 28 percent have signed a donor card. (The cards are available from donor agencies and are on the back of some states’ driver’s licenses.) Even these cards do not guarantee that your organs will be harvested in the event of your untimely demise. Virtually no hospital will act on a donor card unless the family also gives its consent; the fear is that aggrieved survivors will sue. Only about half of the families who are approached will allow their loved ones’ organs to be harvested.

How are organs doled out?

The United Network for Organ Sharing is the government-authorized contractor that oversees all organ transplants. The network divides the country into 11 administrative regions, serviced by 59 regional “procurement centers.” UNOS matches patients with organs based on medical urgency, blood and tissue type, and time spent on a waiting list. But while UNOS sets the standards, the procurement centers make the actual decisions. When an organ becomes available, the relevant procurement center offers it first to the sickest patients in the immediate area. If no match is found, the organ is then offered regionally, and, finally, nationally. For years, a host of critics have complained that the system is inherently unfair.

What’s their complaint?

Geography, and sometimes income, often trumps need. If, say, a liver becomes available in Cincinnati, it usually goes to the sickest person on the liver list in that region, even if someone in Los Angeles has a more urgent need and may die without an immediate transplant. Under current rules, people get organs more quickly if they happen to live in states with high organ-donation rates—such as Wisconsin, which averages 30 donors per million residents per year, compared with the national average of 21 per million. Some desperate people have also figured out a way to increase their odds of getting an organ, by flying around the country and registering on the waiting lists at different procurement centers. Called “multiple listing,” the practice is perfectly legal and, in the view of many medical professionals, totally unethical. The current system also makes no provision for the 43 million Americans without health insurance, leaving them little chance of getting a transplant. Transplanting a major organ can easily cost you $150,000 or more.

So why not change the system?

It’s been tried. But states that are relatively rich in organs, like those in the Midwest, don’t want them shipped across their borders. In 1998, then–secretary of health and human services Donna Shalala ordered that organs should go to the nation’s sickest patients, regardless of geography. That triggered a fight with Congress, which said that Shalala didn’t have the authority to change the system. The two sides fought to a stalemate. UNOS says it is trying harder to take medical need into account, but the status quo remains in effect.

What are the alternatives?

The best alternative is to increase the donor pool, so people wouldn’t have to fight over available organs. One controversial proposal is to pay the families of organ donors from $3,000 to $10,000. Another is to adopt a system of “presumed consent.” In this system, everyone would be presumed to be a willing organ donor, and you’d have to file paperwork to opt out. In countries that use the presumed-consent system, such as France, Poland, Portugal, Austria, and Belgium, the organ-donation rate is about 15 percent higher per capita than in the U.S. But it’s highly unlikely that presumed consent would ever take hold here. Americans, says bioethicist Arthur Caplan, “are far more distrustful of doctors and of central governments” than Europeans. For now, the best hope is that more Americans will sign donor cards and inform their families of their wishes.

Buying the gift of life