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Prioritize rich and young on organ transplants

It is illegal in the United States to buy a human organ but it seems that some people know how to cut in line to get one quicker as was in the news about Steve Jobs getting his liver transplant in 2009 and Mickey Mantle's liver transplant in 1995.

There have been bioethical debates on how people should be selected to be recipients. Using liver transplants as an example, there are 127 liver transplant centers in the U.S. to which a needy patient's doctor will refer them. There they are evaluated, scored based on illness severity and added to the waiting list if considered a candidate. The center list feeds into the United Network for Organ Sharing (UNOS) national database, a nonprofit that contracts with the federal government. UNOS works with 58 organ procurement organizations (OPOs) who coordinate distribution in their region. The Organ Procurement and Transplantation Network (OPTN) manages U.S. transplant policy.

When a liver becomes available, the OPO looks for a local match based on things like blood type, severity score and time on the waiting list. Neighboring regions are searched if a local match is not found. Since some regions have as many as 15 times more people on their list, patients in smaller OPOs are more apt to get a liver. The national average for a wait is a little over a year but in some it can be over three years.

UNOS does transplant center audits periodically to ascertain that preferential treatment is not happening. However, there are several ways wealth enters into the equation:

  • A liver transplant costs about $519,600 which excludes about a third of Americans because they do not have enough insurance or any insurance to cover that. About five percent of liver transplants are paid for out of pocket.
  • UNOS requires that transplant center tell candidates they can be evaluated to get on the list of more than one center or transfer their care to a different center without losing their time on the waiting list, but to do that people must be able to afford flying around the U.S. to be evaluated. In the case of Jobs, Apple CEO and billionaire, due to heavy competition in his home state of California, he got on a second list in Memphis, rose to the top of the list quickly and could afford to fly on his private jet to Memphis for the transplant.
  • Some insurance companies will not cover these multiple evaluations and at least one company only covers the transplant center it owns.
  • Since being able to afford the transplant is a condition of being evaluated at a center, the preapproved rich can afford to shop the centers to find the one where they have the best chance of getting a liver.
  • The committees who decide if the patient gets on a center's waiting list has full access to financial as well as medical history. In countries with national health-care like Switzerland, finances is not such a priority in organ access.
  • Some physicians of the wealthy may put their patients on the waiting lists before the condition is that severe just to get their place in line early.
  • One teen was turned down for a heart transplant because he had bad grades and been in trouble with the law. The reported concern was that he would not take his meds or come for follow-ups.

Age can be a factor in that recipients under 18 are preferred, making up 16 percent of heart transplants in 2011. But about 12 percent of heart transplants in 2008 went to those over 65 since heart size can mean a child will not be a good fit. Medicare costs were about a million dollars per transplant. A national law that required children under 12 to wait for a pediatric organ resulted in lawsuits by parents wanting their children to be placed on adult lists too in an effort to save their lives. OPTN has opted to allow for case-by-case review.

Not having a job can be a help as in the case of Jim Holahan who in his fifties got a liver transplant in 2012 at Duke University Hospital in N.C. He had no job but had disability payments of $48,000 tax-free yearly and Medicare, could move to N.C., and only had to wait one week on a list.

Some people think social worth should be considered. Some examples are parents with several young children getting preference over single people, an older research scientist prioritized over a high school drop out, and heavy drinkers who damaged their liver possibly even being ineligible for a transplant. Livers are in very short supply with about one-third of the 16,000 people on the liver wait list becoming recipients in a year.

The UNOS board of directors is looking at ways of improving the system, particularly with kidneys where it was proposed that 20 percent of the best kidneys would go to 20 percent of the healthiest patients. The other 80 percent would be based on age and donor and recipient could be no more than 15 years apart. View the details of U.S. Department of Health and Human Services 2013 OPTN proposals. In November 2013, the OPTN/UNOS Board of Directors approved substantial revisions of the national kidney allocation system policies. Read the February 2014 OPTN Transplant Evaluation Plan.

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