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Ruben Korolev
Ruben Korolev

The Crisis of Organ Transplantation in America: How to Fix a Broken System and Save Lives



On the List: Fixing America's Failing Organ Transplant System




Every day, about 20 people die in the United States waiting for an organ transplant. More than 100,000 people are currently on the national waiting list for a lifesaving organ, but only about 39,000 transplants were performed in 2020. The gap between the demand and supply of organs is widening, and the organ transplant system is facing many challenges and barriers that prevent it from saving more lives.




On the List: Fixing America's Failing Organ Transplant System download pdf



In this article, we will explore what organ transplantation is and why it is important, what are the main problems and issues that affect the organ donation and transplantation process in the US, and what are some of the potential solutions and strategies that can help fix the organ transplant system and improve its outcomes.


Introduction




What is organ transplantation and why is it important?




Organ transplantation is a medical procedure that involves removing a healthy organ from one person (the donor) and transferring it to another person (the recipient) who has a damaged or failing organ. The most commonly transplanted organs are kidneys, livers, hearts, lungs, pancreases, and intestines. Some other tissues that can be transplanted include corneas, skin, bone marrow, blood vessels, and heart valves.


Organ transplantation can save lives, improve quality of life, and reduce health care costs for people who suffer from end-stage organ failure. According to the U.S. Department of Health and Human Services (HHS), one organ donor can save up to eight lives, and one tissue donor can enhance the lives of up to 75 people. Organ transplantation can also reduce the need for dialysis or other long-term treatments that are costly and burdensome for patients and society.


What are the challenges and barriers to organ donation and transplantation in the US?




Despite the benefits of organ transplantation, there are many factors that limit its availability and accessibility in the US. Some of these factors include:



  • The shortage of organs: There are not enough deceased or living donors to meet the demand for organs. According to the Organ Procurement and Transplantation Network (OPTN), as of June 2021, there were 107,725 candidates on the waiting list for an organ transplant, but only 14,506 donors in 2020.



  • The inefficiency of organ allocation: The current system of allocating organs is based on geographic regions that vary in size, population, and organ availability. This creates disparities and inequalities in access to organs across different areas. For example, some regions have longer waiting times or higher death rates than others for certain organs.



  • The ethical and legal issues: There are many ethical and legal dilemmas that arise in the process of organ donation and transplantation. For example, how to obtain consent from donors or their families, how to respect the wishes and preferences of donors and recipients, how to balance fairness and efficiency in organ allocation, how to prevent fraud and abuse, and how to protect the rights and interests of donors and recipients.



How can we improve the organ transplant system and save more lives?




There is no simple or easy solution to fix the organ transplant system, but there are some possible ways to address some of the challenges and barriers that it faces. Some of these ways include:



  • Increasing public awareness and education about organ donation: Educating the public about the benefits and risks of organ donation, dispelling myths and misconceptions, and encouraging people to register as donors or discuss their wishes with their families can help increase the number of potential donors and reduce the gap between the demand and supply of organs.



  • Implementing opt-out or presumed consent policies for organ donation: Changing the default option for organ donation from opt-in (where people have to explicitly express their consent to donate) to opt-out (where people are automatically considered as donors unless they opt out) can increase the rate of organ donation and reduce the need for family consent. Some countries that have adopted opt-out policies, such as Spain, Belgium, and France, have higher rates of organ donation than the US.



  • Reforming the organ allocation system and reducing geographic variation: Revising the criteria and methods for allocating organs based on medical need, urgency, compatibility, and expected benefit rather than geographic location can improve the efficiency and equity of the organ transplant system and reduce the disparities and inequalities in access to organs across different regions.



  • Promoting living donation and providing incentives and support for donors: Encouraging more people to donate organs while they are alive, especially kidneys, can help alleviate the shortage of organs and save more lives. Providing financial compensation, tax credits, insurance coverage, or other benefits for living donors can help reduce the barriers and costs of donation and increase the motivation and willingness of donors.



  • Developing new technologies and innovations for organ preservation and regeneration: Advancing the science and technology of organ preservation, such as using machine perfusion or cryopreservation, can extend the viability and quality of organs and reduce the wastage and loss of organs. Developing new methods of organ regeneration, such as using stem cells or bioengineering, can create new sources of organs and tissues that can overcome the limitations of donor availability and compatibility.



The current state of organ transplantation in the US




The demand and supply gap for organs




The demand for organs in the US has been growing steadily over the years, driven by factors such as aging population, chronic diseases, improved survival rates, and increased awareness. According to OPTN data, the number of candidates on the waiting list for an organ transplant has increased by 42% from 75,759 in 2010 to 107,725 in 2021. However, the number of donors has not kept pace with the demand. The number of donors has increased by only 26% from 11,477 in 2010 to 14,506 in 2020.


This mismatch between the demand and supply of organs has resulted in a large and persistent gap that cannot be filled by the current system. As of June 2021, there were more than six times as many candidates on the waiting list as there were donors in 2020. The gap is especially pronounced for certain organs, such as kidneys, livers, hearts, and lungs. For example, there were more than 90,000 candidates waiting for a kidney transplant in 2021, but only about 23,000 kidney transplants were performed in 2020.


The gap between the demand and supply of organs has serious consequences for patients who need a transplant. Many patients face long waiting times that can range from months to years depending on the organ type and region. For example, according to OPTN data from 2018-2020, the median waiting time for a kidney transplant was 3.6 years nationally, but it varied from 1.5 years in Oregon to 6.3 years in California. The longer patients wait for a transplant, the higher their risk of dying or becoming too sick to receive a transplant. According to HHS estimates, about 20 people die every day while waiting for an organ transplant in the US.


The regional disparities and inefficiencies in organ allocation




This regional system of organ allocation has been criticized for creating disparities and inefficiencies that affect the outcomes and fairness of the organ transplant process. Some of the problems and issues that have been raised include:



  • The variation in organ availability and waiting times across regions: Some regions have more donors and organs than others, resulting in shorter waiting times and higher transplant rates for candidates in those regions. For example, according to OPTN data from 2018-2020, the median waiting time for a liver transplant was 5.4 months nationally, but it ranged from 2.7 months in Region 3 (Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, and Puerto Rico) to 14.6 months in Region 1 (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont). This means that candidates in some regions have a lower chance of receiving a transplant than candidates in other regions with similar medical need.



  • The inefficiency and waste of organs due to geographic constraints: The regional system of organ allocation limits the pool of potential recipients for each organ and reduces the likelihood of finding the best match for each organ. This can lead to longer cold ischemia time (the time between organ removal and transplantation), lower organ quality, higher rejection rate, and lower survival rate for transplant recipients. It can also result in the loss or discard of organs that could have been used for candidates outside the region. According to a study by researchers at Columbia University, about 20% of donated kidneys were discarded or not used in 2016, and about 7% of those kidneys could have been transplanted if they were offered to candidates nationwide rather than regionally.



  • The lack of transparency and accountability in organ allocation: The regional system of organ allocation relies on the discretion and judgment of OPOs and transplant centers to determine the criteria and methods for allocating organs within their regions. This can create inconsistency and variability in how organs are distributed and who gets priority for organs. It can also create conflicts of interest and incentives for OPOs and transplant centers to favor their own candidates or regions over others. There is also a lack of oversight and evaluation of the performance and outcomes of OPOs and transplant centers by OPTN or other authorities.



The ethical and legal issues in organ donation and transplantation




Organ donation and transplantation involve many ethical and legal questions and dilemmas that challenge the principles and values of medicine, society, and individuals. Some of these questions and dilemmas include:



  • How to obtain consent from donors or their families: Consent is a key requirement for organ donation, but there are different ways to obtain it. In the US, most states use an opt-in system, where people have to register as donors or express their consent to donate their organs after death. However, some states use an opt-out system, where people are presumed to be donors unless they opt out or their families object. There are also different types of consent, such as informed consent, presumed consent, mandated choice, or family consent. Each type of consent has its advantages and disadvantages in terms of respecting autonomy, maximizing donation rate, reducing family conflict, and ensuring legal validity.



  • How to respect the wishes and preferences of donors and recipients: Donors and recipients may have different wishes and preferences regarding organ donation and transplantation, such as religious beliefs, cultural values, personal motives, or medical conditions. For example, some donors may want to specify which organs they want to donate or which recipients they want to receive their organs. Some recipients may want to choose or reject certain donors or organs based on their compatibility or characteristics. How to accommodate and balance these wishes and preferences without compromising the efficiency and equity of the organ transplant system is a difficult issue.



such as the sickest first, the best match, the net benefit, the fair innings, etc. Each model and method has its pros and cons in terms of maximizing utility, saving lives, reducing harm, respecting rights, promoting justice, etc.


  • How to prevent fraud and abuse in organ donation and transplantation: Organ donation and transplantation are vulnerable to fraud and abuse by various actors and stakeholders, such as donors, recipients, OPOs, transplant centers, brokers, intermediaries, etc. Some examples of fraud and abuse include falsifying or manipulating medical records or tests, violating consent or allocation rules or policies, exploiting or coercing donors or recipients, trafficking or selling organs or tissues, etc. These practices can undermine the trust and integrity of the organ transplant system and harm the interests and welfare of donors and recipients.



  • How to protect the rights and interests of donors and recipients: Donors and recipients have certain rights and interests that need to be protected and respected in the process of organ donation and transplantation. For example, donors have the right to decide whether to donate their organs or not, to receive information and counseling about the risks and benefits of donation, to withdraw their consent at any time, to be treated with dignity and respect, to have their privacy and confidentiality protected, etc. Recipients have the right to receive fair and equal access to organs, to receive information and counseling about the risks and benefits of transplantation, to accept or decline an organ offer, to be treated with dignity and respect, to have their privacy and confidentiality protected, etc. How to ensure that these rights and interests are upheld and enforced is an important issue.



The potential solutions to fix the organ transplant system




Increasing public awareness and education about organ donation




One of the possible ways to increase the number of organ donors and reduce the gap between the demand and supply of organs is to increase public awareness and education about organ donation. Many people are not aware of the benefits and risks of organ donation, or have misconceptions or fears about it. For example, some people may think that organ donation is against their religion or culture, that it will affect their appearance or funeral arrangements, that it will compromise their medical care or cause pain or suffering, that it will cost them money or burden their families, etc. These myths and misconceptions can deter people from registering as donors or expressing their wishes to their families.


Educating the public about the facts and realities of organ donation can help dispel these myths and misconceptions and encourage more people to become donors. Some of the strategies for increasing public awareness and education include:



  • Using mass media campaigns, social media platforms, websites, apps, etc. to disseminate information and messages about organ donation.



  • Using celebrities, influencers, role models, testimonials, stories, etc. to promote organ donation and inspire people to donate.



  • Using educational programs, materials, curricula, etc. to teach students and young people about organ donation.



, events, activities, etc. to engage and educate different groups and populations about organ donation.


  • Using behavioral nudges, incentives, rewards, recognition, etc. to motivate and persuade people to register as donors or discuss their wishes with their families.



Implementing opt-out or presumed consent policies for organ donation




Another possible way to increase the number of organ donors and reduce the gap between the demand and supply of organs is to implement opt-out or presumed consent policies for organ donation. Under these policies, people are automatically considered as donors unless they opt out or their families object. This is different from the current opt-in system in most states, where people have to explicitly express their consent to donate their organs after death.


Opt-out or presumed consent policies can increase the rate of organ donation by changing the default option and reducing the need for family consent. Some studies have shown that countries that have adopted opt-out policies, such as Spain, Belgium, and France, have higher rates of organ donation than countries that use opt-in policies, such as the US, Germany, and Japan. Opt-out policies can also reduce the psychological and emotional burden on families who have to make a decision about organ donation at a time of grief and stress.


However, opt-out or presumed consent policies also have some drawbacks and challenges. Some of these include:



  • The ethical and legal implications of assuming consent without explicit expression or verification.



  • The potential backlash or resistance from the public or groups who oppose or distrust organ donation or the government.



  • The practical difficulties of implementing and enforcing opt-out policies in a large and diverse country like the US.



  • The possible unintended consequences of opt-out policies, such as reducing the quality or suitability of organs, increasing the risk of coercion or exploitation of donors or families, undermining the altruism or voluntarism of donation, etc.



Reforming the organ allocation system and reducing geographic variation




, and expected benefit rather than geographic location can improve the outcomes and fairness of the organ transplant process and reduce the variation and waste of organs across different regions.


Some of the strategies for reforming the organ allocation system and reducing geographic variation include:



  • Using national or broader criteria and methods for allocating organs rather than regional ones.



  • Using mathematical models or algorithms to optimize organ allocation and match organs with recipients.



  • Using performance metrics or indicators to evaluate and compare the outcomes and efficiency of OPOs and transplant centers.



  • Using incentives or penalties to motivate or compel OPOs and transplant centers to improve their performance and compliance with organ allocation rules or policies.



Promoting living donation and providing incentives and support for donors




A fourth possible way to increase the number of organ donors and reduce the gap between the demand and supply of organs is to promote living donation and provide incentives and support for donors. Living donation is when a person donates an organ or part of an organ while they are alive, usually to a relative or friend who needs a transplant. The most commonly donated organ by living donors is the kidney, but other organs that can be donated by living donors include the liver, lung, pancreas, and intestine.


Living donation can help alleviate the shortage of organs and save more lives by increasing the pool of potential donors and reducing the waiting time for recipients. Living donation can also improve the quality and compatibility of organs and reduce the risk of rejection or infection for recipients. Living donation can also benefit donors by enhancing their psychological well-being, self-esteem, or sense of purpose.


However, living donation also has some risks and costs for donors. Some of these include:



  • The medical risks of surgery, anesthesia, complications, infection, etc.



  • The financial costs of travel, lodging, lost wages, medical bills, etc.



  • The emotional costs of stress, anxiety, guilt, regret, etc.



  • The social costs of family conflict, relationship strain, discrimination, etc.



Providing incentives and support for living donors can help reduce the barriers and costs of donation and increase the motivation and willingness of donors. Some of the incentives and support that can be offered include:



, tax credits, insurance coverage, or other benefits for living donors to cover their expenses or losses.


Providing medical care and follow-up for living donor


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