Zehn Skin and Health

A summary of the recent NY times report by Rosenthal, Hansen, and White.

For decades, the American organ transplant system has been guided by the principle of fairness, with a national waiting list designed to ensure organs go to the sickest patients first. However, a recent investigation by The New York Times has uncovered a troubling shift: organ allocation is increasingly bypassing the sickest patients, raising serious questions about equity and trust in the system.

Skipping the Line: A Growing Trend

The investigation found that transplant officials are now regularly ignoring the established waiting lists, skipping patients in nearly 20% of transplants last year. This is a six-fold increase compared to just a few years ago. These organs often go to patients who are less ill, have waited less time, or are not even on the standard waiting list. Over the past five years, more than 1,200 people died after being skipped on the waiting list, just as they were nearing the top.

Why is this happening?

Several factors are contributing to this alarming trend:

• Pressure to Increase Transplants: Under pressure from the government to increase the number of transplants, organ procurement organizations (OPOs) are prioritizing speed and efficiency.
• “Open Offers”: A Shortcut Favoring Hospitals: To quickly place organs, OPOs are increasingly using “open offers.” This means they offer an organ to a specific hospital, allowing that hospital to choose any of its patients to receive it, regardless of their position on the national waiting list.
• Hospital Competition: Hospitals compete to be favored by OPOs because open offers increase their transplant numbers and revenue. Some hospitals have even created “hot lists” of preferred patients to quickly access organs offered through this shortcut.
• Lower Quality Organs Not the Only Factor: While OPOs claim line-skipping is necessary to place lower-quality organs that might otherwise go to waste, data shows this isn’t always the case. Even high-quality organs are being allocated outside the standard waiting list process.

Consequences of Line-Skipping

This shift away from the established system of fairness has serious consequences:

• Erosion of Trust: Experts warn that these practices are “making a mockery of the allocation system” and will “destroy trust in the system.” Patients waiting for life-saving transplants are left in the dark, unaware of their true position or if they have been unfairly bypassed.
• Ethical Concerns: Prioritizing expediency over the established fairness principles raises significant ethical questions about who gets a second chance at life.
• Exacerbating Disparities: The investigation revealed that when waiting lists are ignored, transplants disproportionately go to white and Asian patients. For example, while white individuals make up 39% of the organ registry, they received 50% of transplants when lists were ignored, compared to 46% in the standard allocation process. Line-skipping also favors college graduates, men, and patients at larger hospitals, further widening existing healthcare inequities.

Lack of Oversight and Accountability

Federal regulators have been aware of the increasing trend of line-skipping since 2022 but have taken limited action. The oversight committee responsible for reviewing bypassed cases rarely takes meaningful action, often citing the risk of organ wastage as justification, even when evidence suggests otherwise. In fact, despite the rise in line-skipping, organ discard rates are also increasing, indicating the practice is not achieving its stated goal of reducing waste.

A Call for Change

Following the New York Times investigation, the federal Health Resources and Services Administration has ordered increased oversight of organ procurement organizations, signaling a potential shift towards addressing these concerning practices. Whether this will be enough to restore fairness and trust in the organ transplant system remains to be seen.

This situation highlights the urgent need to re-evaluate and reform the organ transplant system to ensure it truly lives up to its guiding principle of fairness and provides equitable access to life-saving organs for all patients in need, regardless of their background or hospital affiliation.