Pennsylvania Gov. Robert P. Casey is a doubly lucky man.

Lucky first of all to be alive, with a 34-year-old heart beating inside his 61-year-old chest. Casey is the seventh person in the world, and by far the oldest American, to receive both a heart and a liver from another human being -- in a transplant operation that took 13 1/2 hours last Monday at Presbyterian University Hospital in Pittsburgh.

But Casey, who suffers from a rare hereditary liver disease called amyloidosis, was lucky even to be in a position to receive his unusual transplant.

How many patients dial the world's foremost liver transplant surgeon, Thomas E. Starzl -- and get through directly -- as Casey did on May 24? How many could get a personal consultation from Starzl at the Westin Hotel, as Casey did June 8 while on a business trip to Pittsburgh? How many, once on the transplant waiting list, find a donor overnight?

For patients on the waiting list for a heart transplant, the average wait is 198 days. For liver transplant patients, the average wait is 67 days. For Casey, a suitable donor of both organs was found in less than 24 hours.

Favoritism for a prominent politician? Or, as one Pittsburgh official put it, "the luck of the Irish"?

Double Priority

At the time he went into surgery, there were six patients ahead of Casey on the waiting list for hearts and two ahead of him on the waiting list for livers. But since he was the only known patient waiting for both organs at once, he was given priority over patients waiting for one or the other.

Casey's name was placed on both the heart and liver waiting lists on Saturday night June 12 after tests revealed that the build-up of an abnormal protein produced by his liver was attacking his heart and other vital organs. His heart was in fibrillation, beating irregularly and pumping ineffectively, according to Starzl. He was listed as "stat 1" on the heart list -- the highest-priority ranking of medical urgency. On the liver list he was a "stat 3," the second-highest rank.

"It was clear that he was dying," Starzl said in an interview.

The next day the Pittsburgh organ procurement team located a possible donor: a 34-year-old man who had been fatally beaten a week earlier and was still on a respirator in nearby Allegheny General Hospital. The donor and Casey were of comparable size and identical blood type (type O) -- two of the prerequisites for a transplant match. Casey received the double transplant the following day.

"That's the paradox of transplantation: It takes a death to save a life," said Roger W. Evans, head of health services evaluation at the Mayo Clinic and a leading researcher on transplants. And because of lengthening waiting lists, "every time you do a transplant, someone's going to be elated to have that extra chance at life -- and someone else is going to be disappointed."

There is no national policy for heart-liver transplants, because they are so rare. United Network for Organ Sharing (UNOS), the national transplant clearinghouse that sets voluntary rules for most other organ matches, including heart-lung transplants, has no rules for heart-liver operations.

"That is something we probably will have to clarify," a UNOS spokesman said.

The University of Pittsburgh, one of the few medical centers in the world that have even tried such a transplant, does have a policy. The Pittsburgh rule is to give the person who needs a heart-liver combination priority over people waiting for a heart or a liver alone.

"We're not saying the policy's right," said Brian Broznick, executive director of the Center for Organ Recovery and Education, the agency that coordinates organ donation in the Pittsburgh area. "But we at least have a policy, and we followed that policy."

Casey got the organs because of that rule, not because of his political position, Broznick said. "That {preferential treatment} didn't happen."

Complicated Rules

Broznick acknowledged that the policy was open to criticism from those who say the same donor's organs could have been better used to save two lives -- if they had been given to top-priority patients from both the heart and the liver waiting lists. But he defied anyone to come up with a criticism-proof guideline.

"We're saying to the public: If you don't like the policy, then you come in and make the decision because it's not easy," Broznick said. "No matter what you do you're affecting someone's life. I really wish he {Casey} would have been the coal miner from West Virginia or the steelworker from {Monongahela} Valley, and we wouldn't be having this discussion."

Had there been any other candidate besides Casey for a heart-liver transplant and that person had waited longer, then Casey "would not have gotten it," Broznick said, adding, "I'm not sure we'll ever convince anybody of that."

Ironically, if the donor had had healthy lungs, Casey probably would not have received his transplant. That is because at least two Pittsburgh patients were waiting for a heart-lung transplant, and they would have come before Casey because they had been waiting longer, Broznick said. But the donor's lungs were not suitable for transplant because he had been on a respirator too long.

Starzl said the priority for double-organ recipients makes medical sense. "It's just foolish to put a heart in first and then a liver later," he said. "The outcomes are much better when both organs come from the same donor."

Starzl found it "hard to believe" that the issue of favoritism was raised after Casey's transplant. "I really believe he was the sickest of any heart candidate on our list."

Starzl said he found out about the donor Sunday evening when he was telephoned at home by a colleague during the second overtime of the Bulls-Suns pro basketball championship series game. "Look, can you give me five minutes,? " Starzl told his caller -- and then, after the game, he drove to the hospital and spoke with Casey and his family. "Maybe somebody up there is watching," he said he told them in reference to the sudden discovery of a donor.

It's fairly hard to find a heart-and-liver donor of Casey's blood type and size -- he's 6 feet 2 inches tall and weighed 190 pounds before his health failed. Of the 139 organ donors in the Pittsburgh area last year, Broznick said, only eight would have been a suitable match for Casey's transplant. That is an average of one every six-and-a-half weeks.

"He's very lucky," Starzl said.

Renowned transplant pioneer Starzl, 67, is director of the Pittsburgh medical center's Transplantation Institute, but did not directly observe Casey's heart-liver transplant. "I don't operate anymore," he said. "The guys tell me that my watching them makes them nervous."

Six days after the transplant, Casey was transferred out of the intensive care unit and was listed in "fair" condition yesterday, a hospital spokeswoman said.

Four of the six previous heart-liver transplants were performed at Pittsburgh. None of those patients is alive, though one lived six years before her body rejected the transplant. The two other known cases -- one transplanted at the Mayo Clinic in Rochester, Minn., and one in England -- are alive after nearly a year.

UNOS regulations govern the way organs from the nation's 69 local organ procurement agencies are allocated and the way wait-listed recipients are ranked. The rules are complicated -- the rules for allocation of kidneys alone run more than seven pages. Essentially, donors and recipients are matched on the basis of blood type, body size (a heart from a 150-pound donor will not support a 250-pound patient), length of time on the waiting list and medical urgency. That last criterion, urgency of need, is intended to give priority to the sickest patients, those most likely to die soon if they don't get a transplant. It also makes every transplant a medical judgment call.

Despite the national computerized list, UNOS' voluntary guidelines leave medical decision-making largely to the 268 medical centers in the country that do transplants and to the 69 local organ procurement agencies.

"We don't really have a transplant policy. We've got a concatenation of organ-by-organ decisions," said Ron Milhorn, program analyst in the federal Health Care Financing Administration, which reviews applications for Medicare certification of heart and liver transplant centers.

"Had he {Casey} been Joe Schmo the truck driver, I don't know. He might have died," Milhorn said. "But the governor of the state in which your hospital is located? Get serious. What the hell are you going to do?"

The larger point, Milhorn said, is that this is exactly the kind of impossibly thankless decision that transplant centers and "the system" face every day in less publicized cases.

"Basically, you're on the Titanic. You got 500 people. You got 200 life jackets. The boat's going down, and you don't have a lot of time to think about it.

"And it happens every day." Series of Hurdles

Another way to think about the agonizing dilemma the transplant system routinely faces, Milhorn said, is to imagine a room with 300 people in it. One hundred are the donors, who must die -- usually in tragic and violent circumstances -- in order to become organ donors. The other 200 are terribly sick patients who are waiting for a chance at the donor's hearts and will die if they don't get it.

If everything goes "perfectly" -- if all 100 potential donors become donors and all their hearts are successfully transplanted -- Milhorn noted that "you're still left with a room full of 200 dead bodies."

And that is before anybody even raises the question of cost. "It's not a fun job around here," Milhorn said.

Organ transplants are among the most expensive operations in medicine, often reaching between $100,000 and $300,000 for hospital costs alone, not to mention the follow-up care and medications that recipients must take for the rest of their lives.

The dilemma starts -- but does not end -- with the shortage of organs. While the supply of organ donors has remained nearly stable at about 4,500 a year since the mid-1980s, waiting lists have swelled. More than 31,000 Americans are on waiting lists for vital organs, according to UNOS.

"No matter how many organs you come up with, there will always be a shortage," said George Annas, professor of health law at Boston University and former chairman of the Massachusetts Task Force on Organ Transplantation. "Every time you get more organs, the doctors put more people on the waiting list, so you'll never meet the demand with human organs."

In the meantime, transplant medicine must try -- through a combination of quiet triage, waiting lists and computerized matchups -- to make the best of an inherently unfair system. Potential organ transplant recipients face a series of hurdles.

"The first thing you have to do is get referred to a specialist by a primary care doc who thinks you're a good candidate to be considered for a transplant," Annas said. "Most people never get referred into the system."

Casey "probably did get preferential treatment," Annas said. "But that shouldn't surprise anybody."

Making it onto a transplant waiting list involves a series of judgments about medical and social factors thought to make a person more or less worthy of a chance at a transplant. These include not only medical need but age, personality, social support system and health habits. A person living alone without family support, or a smoker, for example, would likely be excluded. A few years ago, Casey's age (61) would have disqualified him from the waiting lists at most transplant centers.

Inability to pay also keeps a patient off the waiting list. Every patient on a Pittsburgh waiting list, for example, must be financially cleared. If the patient is not covered by private insurance, Medicare or Medicaid, a down payment is required: $208,000 for a liver transplant, $200,000 for a heart transplant, $118,700 for a kidney transplant.

For a leading transplant center like Pittsburgh -- and its patients -- decisions about how to distribute scarce organs are not an abstract ethical question but a daily ordeal.

In the five days after Gov. Casey's heavily publicized heart-liver transplant, Pittsburgh doctors performed 27 other organ transplants, Broznick said. In every case, a donor had to die before the operation could take place -- and other desperately ill recipients had to keep waiting in line.

"I always think I've heard the most tragic case -- until I see the next one," Broznick said.