One of my professors in medical school frequently described ethical issues in terms of some things being unfair and some things being unfortunate. A report in this month’s Liver Transplantation (2013: 19: 1330-42; editorial 1287-88) indicates that sometimes an individual does not receive a liver transplant due to an unfair allocation policy. One potential problem with the current UNOS distribution is the use of exception points. Because the Model for End-Stage Liver Disease (MELD) score does not work well for all patients, there are both recognized exceptional diagnoses (REDs) (eg. hepatocellular carcinoma) and non-REDs (eg. cholangitis). The purpose of these exception points is to account for some conditions that may increase the risk of dying on the transplant list in which the MELD score is not an adequate predictor.
In this study of adult liver transplant candidates between 2002-2011, the authors examined non-REDs; among a cohort of 58,641, 7.4% applied for a non-RED. The number of non-REDs increased over the course of the study. In addition, approval rates which were <50% in 2002 increased to nearly 75% in 2010. Candidates with approved exceptions were more likely to undergo transplantation (68.3% vs. 53.4%, P <0.001).
There was significant variability among transplant centers with regard to requesting exception points. Centers with higher median MELD score at transplantation were more likely to have candidates with non-RED applications. The net result was that women, African-Americans, Hispanics, and patients with Medicaid insurance were statistically less likely to have an exception application.
In pediatrics, non-RED applications are more common. Thus, the problem of equitable distribution could be even greater among pediatric patients.
Bottomline: While physicians have a duty to their patients, it is vital to make sure that every effort is made to allocate organs in a fair manner. Since the use of non-RED applications is inconsistent, it suggests that some transplant centers are utilizing this tool inappropriately (?too often, ?too few). This report indicates that more work is needed to have a fair transplant allocation system.
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