"We're trying to best utilize the gift of the donated organ," said Kenneth Andreoni, an associate professor of surgery at Ohio State University who chairs the committee that is reviewing the system for the United Network for Organ Sharing (UNOS), a Richmond-based private nonprofit group contracted by the federal government to coordinate organ allocation. "It's an effort to get the most out of a scarce resource."
The ethically fraught potential changes, which would be part of the most comprehensive overhaul of the system in 25 years, are being welcomed by some bioethicists, transplant surgeons and patient representatives as a step toward improving kidney distribution. But some worry that the changes could inadvertently skew the pool of available organs by altering the pattern of people making living donations. Some also complain that the new system would unfairly penalize middle-aged and elderly patients at a time when the overall population is getting older.
"The best kidneys are from young adults under age 35 years. Nobody over the age of 50 will ever see one of those," said Lainie Friedman Ross, a University of Chicago bioethicist and physician. "There are a lot of people in their 50s and 60s who, with a properly functioning kidney, could have 20 or more years of life. We're making it harder for them to get a kidney that will function for that length of time. It's age discrimination."
More than 110,000 Americans are listed as waiting for organs, including more than 87,000 who need kidneys. Only about 17,000 Americans get kidneys each year, and more than 4,600 die because they did not get one in time.
"It's a big shift," said Arthur C. Caplan, a University of Pennsylvania bioethicist. "For a long time, the whole program has been oriented toward waiting-list time. This is moving it away from a save-the-sickest strategy to trying to get a greater yield in terms of years of life saved."
If adopted, the approach could have implications for other decisions about how to allocate scarce medical resources, such as expensive cancer drugs and ventilators during hurricanes and other emergencies, Caplan said.
"This is a fascinating canary-in-a-cave kind of debate," he said. "We don't want to talk about rationing much in America. It's become taboo in any health-care discussion. But kidneys reminds us there are situations where you have to talk about rationing. You have no choice. This may shine a light on these other areas."
An evolving system
The current system, which dates to 1986, was first based largely on giving kidneys to the patients who matched the organs best, but it evolved to take a first-come, first-served approach made possible by safer, more powerful anti-rejection drugs. Today, the UNOS's Organ Procurement and Transplantation Network (OPTN) gives priority to patients seeking organs from someone who dies based mostly on who has waited the longest.
"It was just a fairness issue," Andreoni said. "You're next in line. It's your turn."
The problem is that, in some cases, elderly recipients get organs from much younger donors whose kidneys could have provided far more years of healthy life to younger, heathier patients. Younger patients can receive older or less-healthy organs that wear out more quickly, forcing them back onto the transplant list in a few years.
The 30-member UNOS Kidney Transplantation Committee, which has been reviewing the system for about six years, last week quietly began circulating for public comment a 40-page document outlining possible revisions.
Under one scenario, for 80 percent of kidneys, patients 15 years older or younger than the donor would get higher priority. The remaining 20 percent of organs - those deemed to have the best chance of lasting the longest based on the age and health of the donor and other factors - would be given to recipients with the best chances of living the longest based on criteria such as their age, how long they've been on dialysis and whether they have diabetes.
M. Jill McMaster, a UNOS board member representing the public, acknowledged that the new system would put older people at a disadvantage, but she argued that it is necessary.
"I'm 60 years old, and I have a transplant. But if I were to need a second transplant, I wouldn't have a chance of getting the best organs, whereas in the past I did have a chance," McMaster said. "What we're asking those on the list to do is hard when you are sick, which is to look at the needs of everybody. I think it's the right thing to do."
Although many of the details about how the new concept would be implemented still have to be worked out, McMaster said it is likely to be adopted.
Public comments invited
The public has until April 1 to comment on the idea, which would make the kidney system more similar to those used to allocate livers, hearts and lungs. The committee will take those comments into account before formally proposing the specific changes, which will be open to public comment again before going to the UNOS board of directors. The board could approve final changes by June 2012.
"I strongly endorse this," Robert M. Veatch, a bioethicist at Georgetown University, wrote in an e-mail. "I think it is defensible on both fairness and efficiency grounds."
But others worry that the changes could reduce the overall number of organs available for transplants or inadvertently further shift the matches between organs and recipients by affecting living donors, who are not regulated by UNOS. Some relatives who would have donated a kidney to a young patient might now decide not to, for example, putting pressure on other relatives to donate kidneys to older family members. In addition, the changes would do nothing to address the wide variation in waiting times in different parts of the country.
"If we really want to improve things, we need to address the variation in access to transplants based on geography," Ross said. "This factor, more than any other, would increase the overall number of life years gained from kidney transplantation."
Some argued that a better solution would be to give recipients the option of choosing what donor kidneys to accept.
"Some younger people may accept a donor that is higher risk and may not last as long if they could get it sooner," said Richard Freeman, chairman of surgery at Dartmouth Medical School. "It should be more patient-based and less driven by absolute gain in life years."
Others questioned the formula that would be used to match patients and organs. Because the system would be more complicated, it could backfire by creating suspicions of cheating, eroding confidence and reducing organ donations.
"It works well enough the way it is, and everyone understands it, which is important to maintain the public trust," said Benjamin Hippen, a kidney specialist at Metrolina Nephrology Associates in Charlotte.