States Square Off Against Each Other in Allocation of Livers for Transplant

Rarely does the law of supply and demand have a sadder application than in the world of organ donations, and the latest case of too much need and too few resources has states doing battle with each other.

According to a story on TheHill.com, “A heated redistricting battle has gripped the nation’s heartland this fall, but instead of votes, the debate has centered on livers.” Many congressional representatives from Midwestern and Southern states are disputing how the United Network for Organ Sharing (UNOS) wants to allocate livers.

UNOS is a private nonprofit outfit that manages the nation’s organ transplant system under contract with the federal government.

Shortages of transplantable organs are an enduring problem, and transplant surgery is complicated by the need to identify suitable donor-recipient matches quickly and transport organs efficiently. Also, who’s a higher priority recipient is a determination fraught with medical and ethical considerations.

As The Hill recalled, in 2009 then-Apple CEO Steve Jobs traveled to Tennessee from California to receive a liver transplant, raising objections that he had “cut the line.”

According to the Department of Health and Human Services, (HHS), about 15,600 people are awaiting a liver transplant, including 3,000 in California and 1,300 in New York. In Kansas, the waiting list has 129 names, and 252 in Georgia.

As The Hill noted, rates of organ donation vary widely depending on location. The highest rates are in the Southeast and Midwest, which also have the nation’s highest death rates.

“That disparity can lead to vastly different outcomes for patients,” the story said. It referred to a report last year published in the American Journal of Transplantation that death rates for people awaiting liver transplants range from 14 in 100 to 82 in 100, depending on their state.

Currently, the organ network is composed of 11 districts; the new plan could re-map it into as few as four.

Under the UNOS plan, The Hill explained, states with larger supplies of livers, such as Kansas and Tennessee, would share their donations with states with fewer donations, including California and New York.

UNOS claims the plan would “increase equity to access” for people across the country.

Some representatives in states where relatively more people donate organs have called the UNOS plan “political gerrymandering.” (Elected officials see everything in political terms.) They say the reallocation would punish thousands of people in donor-rich states, and some have wondered if these areas would become “organ farms” for coastal states.

A bipartisan group of 52 congressional representatives of Texas, Tennessee, Kansas, Mississippi, Iowa, Ohio, Wisconsin and Indiana signed a letter last week condemning the plan, and 11 representatives from Georgia made their feelings known several months ago. The redistricting, they said in a letter to HHS, “would single out the state of Georgia, making it the only southern state in a region comprised of northeastern states.”

Scores of transplant doctors, mostly in the Southeast and Midwest, also oppose the plan, expressing their feelings in a letter to HHS over the summer calling the plan “the most drastic change in liver allocation ever.”

The realignment would boost the average travel time for a liver from five to eight hours. The Georgia lawmakers said that would increase risks and transportation costs for each transplant. Once harvested, a liver is viable before being transplanted for about 12 hours.

Dr. David Mulligan, a transplant surgeon and UNOS official, said the plan would ensure that people with the greatest need would be the first to receive an organ, and told The Hill that if people with less-urgent needs “just wait a little longer, they’ll be a hero and literally save the life of someone who doesn’t have that extra day.”

That’s reasonable, but “being a hero” probably isn’t foremost on the minds of people who are feeling overlooked and taken advantage of.

Last week, the leader of the multi-state objectors, Rep. Kevin Yoder, (R-Kan.), issued a statement that the solution to the organ shortage isn’t shipping them out of the Midwest or South. “[UNOS] should not adopt proposals that punish successful programs and decrease access to organs where donation rates are highest.”

His solution was to increase donations “where disparities in wait times are the greatest.”

Easy to say, hard to do. Donation rates in coastal states have been about the same for a decade.

Mulligan said the conversation is ongoing, and that nothing will change immediately. “It’s kind of nice to say, ‘Oh, all we’ve got to do is make them donate more in the Northeast or Northwest,'” he told The Hill. “But I don’t know how we’re going to do more than what we’re already doing.”