Shalala Calls For Organs To Be Given To The Sickest Transplants Now Often Determined By Where Patient Lives

Injecting itself into one of the thorniest issues in medicine, the Clinton administration Thursday ordered the private network that distributes donated organs to replace its current system with one that gives priority to the sickest patients, no matter where in the country they live.

But the architect of the controversial order, Donna Shalala, the secretary of Health and Human Services, did not offer any specifics about what the new system should look like. Shalala left it up to the network, the nonprofit United Network for Organ Sharing, giving it five months to devise a plan that will even out waiting times for donated organs across the nation.

“People are dying unnecessarily, not because they don’t have health insurance, not because they don’t have access to care but simply because of where they happen to live in the country,” Shalala said in announcing a new regulation. “We need a level playing field for patients.”

In effect, her decision means the end of what one surgeon called “the crazy patchwork quilt” in which donated organs remain within narrow geographic boundaries, with the result that waiting times vary greatly from one region to another.

It also means that for the first time in its 12-year history, the organsharing network must submit to government oversight; if the group does not devise a system Shalala likes, she plans to present her own.

The network intends to fight the new regulation.

“They’re saying something like ‘Bake a cake and it needs to taste good. Submit it to us and we’ll tell you if it’s OK,”’ said Walter Graham, executive director. “They are moving the decision-making out of the hands of doctors and into the hands of the federal government.”

An estimated 54,500 Americans are now waiting for hearts, lungs, livers, kidneys and pancreases, and demand far exceeds supply. According to the government, about 4,000 people each year - or more than 10 a day - die while waiting for donated organs. The shortage of livers is especially dire, and much of the current dispute centers on liver transplant patients.

Under the current system, patient are ranked according to the severity of their illness. The nation is divided into 63 local areas and 11 regions. When an organ becomes available in one local area, it is offered locally to the sickest patient first. If there are no local patients, it is offered regionally, then nationally.

The result, said Dr. John Roberts, professor of surgery at the University of California at San Francisco, is that adjacent cities can have vastly different waiting times.

“Our waiting times run two to three years,” Roberts said, “but in Sacramento, which is right next door to us, they run on the order of months.”

As an alternative, Roberts has devised a system that would “lose all the geographic boundaries” and instead assign organs based on three factors: how far the patient lived from the donor, how sick the patient was and how long the patient had been waiting.

“You would use points to rank the patients,” he said, “and give the organ to the patient that comes out on top.”

The organ-sharing network rejected the plan, but one administration official said Thursday that Roberts’ idea was one that might meet the criteria Shalala set out.