Despite the apparent problems with the transplant system, past efforts at reform have generally failed.
In the late 1990s, the U.S. Department of Health and Human Services issued new regulations that would have given priority to the sickest patients, regardless of region. This would have eliminated the geographic disparities that make approval at multiple transplant centers advantageous, but Congress blocked the regulations and instead asked the Institute of Medicine (IOM), an advisory organization that belongs to the National Academy of Sciences, to consider the issue.
The IOM’s proposal was less far-reaching, but they did recommend standardizing the size of the organ donor pool for the sickest patients. Congress failed to implement this measure as well, however.
Some transplant centers advocated the shift away from the OPO system, but others vigorously lobbied Congress to oppose the new policy. The smaller transplant centers were concerned that in a national organ allocation system, they would receive fewer transplants and be driven out of business. The larger transplant centers, meanwhile, wanted to maintain the size and geographical reach of the OPOs in their areas.
“There was a huge split in the transplant community,” says Paschke. “It was very territorial at the time, and there was a lot of maneuvering going on. There were a lot of business interests on the part of the transplant centers.”
UNOS itself has been split on the issue of multiple listing. The organization’s board of directors has voted on whether to restrict multiple listing three times in the past 15 years; the first vote resulted in a tie, and in the others the proposal was rejected by a divided vote.
The inequity revealed in the liver transplant process is symptomatic of the larger inequalities in the American health-care system, says Caplan, who also cochairs a UN task force on organ trafficking. In countries such as Canada or Switzerland that have national health-care systems, a patient’s finances don’t influence access to organs to the same extent, he says.
“Money doesn’t play such a big role in entry into the system,” he says. “Steve Jobs’s transplant is relevant to why we need some health reform.”