Waiting in line: should selected patients ever be moved up?

Assuring equitable access of patients to needed organ transplants is a responsibility that must be shared by transplantation teams, the patients, their families, referring physicians, and society as a whole. Barriers of major proportion still exist that strongly bias the initial selection of patients for placement on waiting lists and adversely affect the rates of transplantation among the older age groups, nonwhites, and the poor. The very issue of making up the waiting list is fundamental to the development of fair and equitable distribution of the national resource of organs for transplantation. Actual organ allocation must involve medical judgment and must strive to achieve the maximal benefit to patients. Despite dangers of paternalism and bias masquerading as medical criteria, to overlook outcome predictions in selecting the recipient of a scarce resource is to be irresponsible toward the donor and society as well as to the patients on the list. Insofar as benefit and need can both be served, as in the case of liver transplantation for fulminant liver failure or kidney transplantation in a well-matched recipient, these considerations should far outweigh the poor criterion of length of time on the waiting list. In many instances, it will be the most appropriate choice to give the organ to a patient waiting on the list at home rather than to a desperately ill patient who will doubtlessly die without the operation but whose risks of failure are significantly higher. As difficult as these decisions are, especially in life and death situations, a system of organ allocation based on medical judgment, with appropriate safeguards and thorough monitoring, eventually will prove to be the fairest method.