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Continuously Balancing the Ethics of Organ Allocation

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Abstract

Purpose of Review

In 2018, the US Organ Procurement and Transplantation Network (OPTN) approved a continuous distribution model as a framework for developing future organ allocation policy. This review assesses the ethical underpinnings and implications of the OPTN’s transition to the continuous distribution of organs.

Recent Findings

Continuous distribution is as much a change in how organs are allocated as it is a change in how organ allocation policies are developed. The OPTN is transitioning all organ allocation systems to this new framework.

Summary

The OPTN changed its policy development process to distinguish ethical issues from operational and clinical decisions. Changes have been made to include more of the transplant community in the policy development process, solicit more specific feedback about value prioritization, understand the ethical tradeoffs in allocation, optimize policies to maximize the community’s ethical goals, and provide a more consistent experience for transplant candidates.

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Abbreviations

AHP:

Analytic Hierarchy Process

DSA:

Donation Service Area

MCDM:

Multicriteria decision making

NOTA:

National Organ Transplant Act

OPTN:

Organ Procurement and Transplantation Network

References   

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. •• Snyder JJ, Salkowski N, Wey A, Pyke J, Israni AK, Kasiske BL. Organ distribution without geographic boundaries: a possible framework for organ allocation. Am J Transplant. 2018;18:2635–40. https://doi.org/10.1111/ajt.15115. This paper served as the primary inspiration for the continuous distribution of organ framework.

    Article  PubMed  Google Scholar 

  2. Veatch RM, Ross LF. Transplantation ethics. 2nd ed. Washington D.C.: Georgetown University Press; 2015. p. 302.

    Google Scholar 

  3. National Organ Transplantation Act, Pub. L. No. 98-507 (1984) (codified as amended at 42 U.S.C. §§ 273-274g). Available from https://uscode.house.gov/view.xhtml?path=/prelim@title42/chapter6A/subchapter2/partH&edition=prelim. Accessed 1/7/2024.

  4. Weimer DL. Medical governance. Washington D.C.: Georgetown University Press; 2010. p. 117–34.

    Google Scholar 

  5. Robinson DG. Voices in the code. New York: Russell Sage Foundation; 2022.

    Book  Google Scholar 

  6. Massie AB, Luo X, Lonze BE, Desai NM, Bingaman AW, Cooper M, Segev DL. Early changes in kidney distribution under the new allocation system. J Am Soc Nephrol. 2016;27:2495–501. https://doi.org/10.1681/asn.2015080934.

    Article  PubMed  Google Scholar 

  7. OPTN. Briefing paper: elimination of DSA and region from kidney allocation policy. Richmond; 2019. Available from: https://optn.transplant.hrsa.gov/media/3366/kidney-bp_112219.pdf. Accessed 1/7/2024.

  8. Bertsimas D, Papalexopoulos T, Trichakis N, Wang Y, Hirose R, Vagefi PA. Balancing efficiency and fairness in liver transplant access: tradeoff curves for the assessment of organ distribution policies. Transplantation. 2020. https://doi.org/10.1097/TP.0000000000003017.

    Article  PubMed  Google Scholar 

  9. OPTN. Continuous distribution of livers winter 2023 values prioritization exercise community results. Richmond; 2023. Available from:https://optn.transplant.hrsa.gov/media/0g5l3qpa/05122023_vpe_researchreport_final.pdf. Accessed 1/7/2024.

  10. OPTN. Mini-brief: broader sharing of adult donor lungs. Richmond; 2017. Available at: https://optn.transplant.hrsa.gov/media/2314/broader_sharing_lungs_20171124.pdf. Accessed 1/7/2024.

  11. OPTN. Briefing paper: enhancing liver distribution. Richmond; 2017. Available at: https://optn.transplant.hrsa.gov/media/2329/liver_boardreport_201712.pdf. Accessed 1/7/2024.

  12. Kizer KW, English RA, Hackmann M (eds) (2022) Foundations for a trustworthy deceased donor organ transplantation system. In: Realizing the promise of equity in the organ transplantation system. National Academies Press, Washington, D.C., 61–84. https://doi.org/10.17226/26364

  13. OPTN. Briefing paper: frameworks for organ distribution. Richmond; 2018. Available at: https://optn.transplant.hrsa.gov/media/2762/geography_boardreport_201812.pdf. accessed 1/7/2024.

  14. White DB. Who should receive life support during a public health emergency? Using ethical principles to improve allocation decisions. Ann Intern Med. 2009;150:132.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Kasiske BL, Pyke J, Snyder JJ. Continuous distribution as an organ allocation framework. Curr Opin Organ Transplant. 2020;25:115–21.

    Article  PubMed  Google Scholar 

  16. •• OPTN. Briefing to the OPTN board of directors on establish continuous distribution of lungs. Richmond; 2021. Available at: https://optn.transplant.hrsa.gov/media/esjb4ztn/20211206-bp-lung-establish-cont-dist-lungs.pdf. Accessed 1/7/2024. This paper was one of the first papers from the OPTN explaining the continuous distribution framework.

  17. • Stewart D. Moving toward continuous organ distribution. Curr Transplant Rep. 2021;8:301–13. This paper, written by one of the architects of the continuous distribution framework, was one of the first published articles explaining the transition to this new framework.

    Article  Google Scholar 

  18. The Organ Procurement and Transplantation Network Final Rule, 42 C.F.R. §§ 121.1-121.14. Available from: https://www.ecfr.gov/current/title-42/chapter-I/subchapter-K/part-121. Accessed 1/7/2024.

  19. •• OPTN. Ethical considerations of continuous distribution in organ allocation. Richmond; 2021. Available at: https://optn.transplant.hrsa.gov/media/5ywggnez/20211206-bp-ethics-ethicl-cnsdrtns-cntnus-dstrbtn-orgn-allctn.pdf. Accessed 1/7/2024. This whitepaper provided ethical guidance to the OPTN committees on developing the continuous distribution policies, whereas this article expands upon these concepts and reviews how well these ethical issues have been addressed in developing the continuous distribution policies to date.

  20. OPTN. Ethical principles in the allocation of human organs. Richmond; 2015. Available at: https://optn.transplant.hrsa.gov/professionals/by-topic/ethical-considerations/ethical-principles-in-the-allocation-of-human-organs/. Accessed 1/7/2024.

  21. Veatch RM. Generalization of expertise Stud Hastings Cent. 1973;1:29–40. https://doi.org/10.2307/3527511.

    Article  PubMed  Google Scholar 

  22. Childress JF (2001) Putting patients first in organ allocation: an ethical analysis of the U.S. debate. https://doi.org/10.1017/S0963180101004054

  23. OPTN Lung continuous distribution policy toolkit. https://optn.transplant.hrsa.gov/professionals/by-organ/heart-lung/lung-continuous-distribution-policy/. Accessed 12 Dec 2023

  24. Bunnik EM. Ethics of allocation of donor organs. Curr Opin Organ Transplant. 2023;28:192–6. https://doi.org/10.1097/mot.0000000000001058.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Elalouf A, Pliskin JS. Balancing equity and efficiency in kidney allocation: an overview. Camb Q Healthc Ethics. 2022;31:321–32. https://doi.org/10.1017/s0963180121001018.

    Article  PubMed  Google Scholar 

  26. Caplan A, Purves D. A quiet revolution in organ transplant ethics. J Med Ethics. 2017;43:797–800. https://doi.org/10.1136/medethics-2015-103348.

    Article  PubMed  Google Scholar 

  27. OPTN. Committee update: Continuous distribution of kidneys and pancreata. Richmond; 2023. Available at: https://optn.transplant.hrsa.gov/media/a5glt304/continuous-distribution-of-kidneys-and-pancreata-committee-update_pc-winter-2023.pdf. Accessed 1/7/2024.

  28. Saaty TL. How to make a decision: the analytic hierarchy process. Eur J Oper Res. 1990;48:9–26.

    Article  Google Scholar 

  29. Dolan JG. Multi-criteria clinical decision support. The Patient: Patient-Centered Outcomes Research. 2010;3:229–48. https://doi.org/10.2165/11539470-000000000-00000.

    Article  PubMed  Google Scholar 

  30. Lin CS, Harris SL. A unified framework for the prioritization of organ transplant patients: analytic hierarchy process, sensitivity and multifactor robustness study. Journal of Multi-Criteria Decision Analysis. 2013;20:157–72. https://doi.org/10.1002/mcda.1480.

    Article  Google Scholar 

  31. Stewart D (2023) Artificial Intelligence (AI) should be used to match appropriate organs to recipients. Controversies in Transplantation. https://usbjob.com/ebooks/controversiesintransplantation23/8/ Accessed 12 Dec 2023.

  32. Alcorn J (2023) Continuous distribution of pancreas, kidney-pancreas, and pancreas islets. In: Tableau Public. https://public.tableau.com/app/profile/optn.committees/viz/ContinuousDistributionofPancreasKidney-PancreasandPancreasIslets/Home. Accessed 12 Dec 2023

  33. OPTN. A guide to calculating the lung composite allocation score. Richmond; 2022. Available at:https://optn.transplant.hrsa.gov/media/jhcppfnd/guide_to_calculating_lung_composite_allocation_scorepdf.pdf. Accessed 1/7/2024.

    Google Scholar 

  34. OPTN (2023) OPTN system tracking: Lung monitor. In: OPTN. https://optn.transplant.hrsa.gov/data/dashboards-metrics/optn-system-tracking-lung-monitor/. Accessed 12 Dec 2023

  35. •• Papalexopoulos TP, Bertsimas D, Cohen IG, Goff RR, Stewart DE, Trichakis N. Ethics-by-design: efficient, fair and inclusive resource allocation using machine learning. J Law Biosci. 2022. https://doi.org/10.1093/jlb/lsac012. This paper explains the use one of the key methodologies in the development of continuous distribution of organs, the use of mathematical optimization.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Freedman R, Borg JS, Sinnott-Armstrong W, Dickerson JP, Conitzer V. Adapting a kidney exchange algorithm to align with human values. Artif Intell. 2020;283:103261. https://doi.org/10.1016/j.artint.2020.103261.

    Article  MathSciNet  Google Scholar 

  37. Babic B, Cohen IG, Evgeniou T, Gerke S, Trichakis N (2020) Can AI fairly decide who gets an organ transplant? In: Harv Bus Rev. https://hbr.org/2020/12/can-ai-fairly-decide-who-gets-an-organ-transplant. Accessed 12 Dec 2023

  38. Mankowski MA, Wood NL, Segev DL, Gentry SE. Removing geographic boundaries from liver allocation: a method for designing continuous distribution scores. Clin Transplant. 2023. https://doi.org/10.1111/ctr.15017.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Bonner K, Hirose R, Heimbach JK. The evolution of the national liver review board. Curr Transplant Rep. 2018;5:7–13. https://doi.org/10.1007/s40472-018-0176-y.

    Article  Google Scholar 

  40. Ladin K, Hanto DW. Rationing lung transplants — procedural fairness in allocation and appeals. N Engl J Med. 2013;369:599–601. https://doi.org/10.1056/nejmp1307792.

    Article  CAS  PubMed  Google Scholar 

  41. Hsu E, Perito ER, Mazariegos G. Save the children: the ethical argument for preferential priority to minors in deceased donor liver allocation. Clin Liver Dis. 2021;17:312–6. https://doi.org/10.1002/cld.1039.

    Article  Google Scholar 

  42. OPTN. Ethical principles of pediatric organ allocation. Richmond; 2014. Available at: https://optn.transplant.hrsa.gov/professionals/by-topic/ethical-considerations/ethical-principles-of-pediatric-organ-allocation/. Accessed 1/7/2024.

  43. Reese PP, Caplan AL, Bloom RD, Abt PL, Karlawish JH. How should we use age to ration health care? Lessons from the case of kidney transplantation. J Am Geriatr Soc. 2010;58:1980–6. https://doi.org/10.1111/j.1532-5415.2010.03031.x.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Wainright JL, Kucheryavaya AY, Klassen DK, Stewart DE. The impact of the new kidney allocation system on prior living kidney donors’ access to deceased donor kidney transplants: an early look. Am J Transplant. 2017;17:1103–11. https://doi.org/10.1111/ajt.14102.

    Article  CAS  PubMed  Google Scholar 

  45. Gershun M (2023) Living kidney donors rely on a promise to protect our future health. We’re scared it will go away. In: Stat. https://www.statnews.com/2023/03/22/living-organ-donors-priority-status-transplant-waiting-list/. Accessed 12 Dec 2023

  46. Lentine KL, Lam NN, Segev DL. Risks of living kidney donation: current state of knowledge on outcomes important to donors. Clin J Am Soc Nephrol. 2019;14:597–608. https://doi.org/10.2215/cjn.11220918.

    Article  PubMed  PubMed Central  Google Scholar 

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Funding

This work was funded by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), Health Systems Bureau, Division of Transplantation under contract number HHSH250201900001C, and was conducted under the auspices of the United Network for Organ Sharing (UNOS), the contractor for the Organ Procurement and Transplantation Network (OPTN).

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  1. United Network for Organ Sharing, 700 N. 4 Street, Richmond, VA, USA

    James Alcorn

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JA wrote the manuscript text.

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Correspondence to James Alcorn.

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James Alcorn works for the United Network for Organ Transplantation, the OPTN Contractor, and has been involved in the development of the continuous distribution of organs.

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Alcorn, J. Continuously Balancing the Ethics of Organ Allocation. Curr Transpl Rep 11, 7–14 (2024). https://doi.org/10.1007/s40472-023-00423-3

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