One of transplantation's biggest problems is its own success. Dramatic progress in transplanting human organs -- from kidneys and hearts to skin and bones -- has worsened the shortage of donor organs and raised troubling questions about how they should be rationed.

"It's almost succeeding too well, and putting pressure on the system," Dr. Jimmy Light, director of transplantation services at Washington Hospital Center said last week at a conference at the hospital. "Now the main problem in transplantation is that someone has to die first."

Improved surgical techniques, better methods of preserving transplantable organs and the legal acceptance of brain death have all contributed to the proliferation of organ transplants. But perhaps the biggest boost of all came from the drug cyclosporin, which suppresses the immune system's natural tendency to reject "foreign" organs transplanted from another person.

"The drug has made an incredible difference," Light said. "It's the next best thing to cotton candy, for the transplant surgeon and the transplant recipient."

"The effects of cyclosporin have been nothing short of explosive in terms of the need for additional organs," said Donald Denny, director of organ procurement at the University of Pittsburgh Medical Center.

More than 75 medical centers now do heart transplants, compared with a mere handful 10 years ago. But growth will level off in the next two years because of a "drastic" shortage of donor hearts, said Dr. Bruce Reitz, director of cardiac surgery at Johns Hopkins University Hospital.

About 500 heart transplants were done last year, and 200 heart patients are on the waiting list. But a report by the Battelle Institute, a Seattle think tank, estimated that 14,200 Americans fit the medical criteria for a heart transplant. That number would rise sharply if Medicare extended coverage to heart transplants.

"But before that happens we're going to have drastic competition and shortages in organ donors," Reitz said.

Such shortages raise the specter of rationing and other agonizing ethical dilemmas. "No matter what we do, there will always be a shortfall of organs," said Ronald Bayer, codirector of a project on organ transplantation at the Hastings Center, a New York institute devoted to the study of ethical issues. "Physicians and other clinicians will sooner or later have to face the question: Who gets the organ when not everyone who needs an organ can get it?"

Indirect rationing of health care is widespread already, Bayer said. No one, in effect, throws a patient overboard. But patients are often denied treatment because transplant programs may require advance payment or insurance coverage.

"We have decided in this country that you may not sell organs," Bayer said. "We have not, however, decided that it is against the law to charge $150,000 for the surgery."

About 25,000 Americans received a corneal transplant last year, but another 20,000 are on waiting lists for a cornea. About 6,000 received a kidney last year, but 8,000 are on waiting lists.

The total pool of potential organ donors, the Hospital Center's Light said, includes about 20,000 Americans a year who are pronounced brain dead. They are otherwise healthy people who, because of a gunshot wound or traffic accident or other trauma, have lost all brain function.

A brain-dead person can be kept breathing on a ventilator, so that other bodily organs remain "alive" and can be surgically removed for transplantation. But organs are retrieved from only about 3,500 of the 20,000 potential donors.

"If we got organs from half of the pool -- from 10,000 donors -- we would have more than enough organs for transplant," Light said.

Transplant and organ procurement teams at medical centers around the country have promoted organ donation as the "gift of life" in an effort to narrow the gap between supply and demand. One problem, they say, is a reluctance of Americans to face their own mortality. Another is that doctors often are hesitant to broach the question with a family in the midst of grief over the loss of a loved one.

A 1983 Gallup poll found that 72 percent of Americans were "very likely" to want to donate their relatives' kidneys after death, but only 24 percent said the same about their own organs.

And while 94 percent of 1,500 Memphis doctors surveyed in 1983 recognized kidney transplants as a successful procedure, only 43 percent said they would be willing to discuss organ donation with a patient's family.

"It really doesn't matter who sits down with the family," Light said. "The important thing is that someone does -- at the right time, in the right place and with the right kind of sensitivity."

Fewer than 25 percent of Americans carry a donor card or driver's license indicating willingness to be a donor. But between 60 and 80 percent of families approached at the time of a relative's death agree to donate organs, Light said. Dealing with such families and brain-dead "patients" can be disconcerting to hospital staffs, said Dr. Stuart Youngner, codirector of the center for biomedical ethics at Case Western Reserve University Medical School.

"We have created a new class of dead patients who have a considerable amount of life in them," Youngner said.

It is even possible, he said, for an intensive care unit staff to have to use cardiopulmonary resuscitation (CPR) to "revive" a brain-dead patient -- a potential organ donor -- while a patient under a do-not-resuscitate order lies awake in the next bed.

Youngner suggested that "we may have to develop new rituals" to help doctors and nurses deal with brain-dead patients, who often appear as healthy as a living patient would under anesthesia. For example, they could observe a moment of silence when the respirator finally is turned off -- a moment that is emotionally troubling for many doctors and nurses.

Language itself is a problem. No one knows just what to call a person who is brain-dead. Terms such as "corpse," "neo-mort" or "beating-heart cadaver" are inaccurate or offensive, or both, to many people.

"Perhaps we will only be able to give these artificially maintained organ donors an appropriate name," Youngner wrote in The New England Journal of Medicine recently, "when we ourselves have made the necessary emotional and cultural adjustments."

Resources

Many organizations offer organ donor cards and information on organ donation and transplants, including:

American Council on Transplantation, 652-0994.

George Washington University Medical Center. Call the page operator at 676-3321 and ask for the surgical transplant coordinator.

Georgetown University Hospital Division of Transplantation, 625-2445.

Howard University Hospital Transplant Center, 745-1443.

Walter Reed Army Medical Center, 576-3250.

Washington Hospital Center, 541-6301.