Transplant Tribulation

Photographer Bryan Lee, 28, of Ottumwa, Iowa, entered a living nightmare last spring. His daughter Makenzie, 4, had developed liver cancer, and the only thing that could save her was a new liver. Since the demand for transplantable organs is always greater than the supply, Makenzie had gone on a waiting list--but high up, due to the severity of her condition.

Then doctors told Lee that the list would soon have to be rejiggered and that Makenzie would be dropping toward the bottom. Reason: the Federal Government was planning to institute a new system for organ allocation. Makenzie would have to compete for an organ with not only patients in her local area but liver patients all across the country as well. She might have been one of the sickest in Iowa, but in that larger population, she would have been considered relatively well off. Fortunately, Makenzie got her transplant last May.

But this week doctors must begin figuring out precisely how the new system will operate. Will there be a national database, for example, and what criteria other than location will be used to decide who gets an organ?

The idea of the new rule--that the most gravely ill should be first in line for scarce medical resources--sounds like the essence of fairness. Yet the new organ-allocation system has ignited one of the most bitter and divisive controversies to hit U.S. medicine in decades. Hospital officials are charging one another with dishonesty and greed. Old friends have become enemies. Says Mayo Clinic health-policy analyst Roger Evans: "It's shocking. There is so much personal animosity, it's almost hatred, and it will only deteriorate over time."

The battle began last April when the federal Department of Health and Human Services proposed a regulation stating in part that decisions about the allocation of organs should "give priority to those whose needs are most urgent." Currently, an organ is offered first to the neediest person in one of 63 organ-procurement areas. If no one in the area qualifies, then it is offered to one of the 11 multistate regions and finally to the rest of the nation.

Under this system, though, accidents of geography can create dramatic inequities. A patient who could afford to wait in, say, Dallas might get an organ that could have gone to someone on the brink of death in nearby Fort Worth, Texas. Varying patterns of supply and demand can create tenfold differences in waiting times. According to computer models cited by the government, these inefficiencies cost as many as 300 lives each year. Says John Fung, transplant director at the University of Pittsburgh: "There's no justification to keep the current system the way it is."

Sounds virtuous, but opponents of the rule say the equity argument is a smoke screen for a baser motive. They point out that transplants are down dramatically in big centers as smaller regional centers have proliferated. The University of Pittsburgh, for example, did 540 liver transplants in 1991, but only 200 last year. The cost per patient can be as high as $300,000. "You're talking millions and millions of dollars lost to those big transplant centers," says Iowa surgeon Maureen Martin.