In 1965, NBC-TV did a documentary entitled, “Who Shall Live.” It covered how areas of the country had set up “God Committees” with local citizens who decided which patients with kidney disease would get a scare resource: a dialysis machine. The committees’ decisions indeed meant life for some––and death for others––based on criteria that include strong family connections, employment, and being a contributor to society.

In 1972, Congress and, subsequently, the dialysis industry, responded to that need and today over 400,000 patients are being treated with dialysis. But if you want what many believe is the optimal therapy for kidney disease––a transplant––get in line. A selection committee is still making those decisions for you.

And it is a tough job for the United Network for Organ Sharing (UNOS). Like the early days of dialysis, donated organs cannot keep up with the demand. There are currently 121,678 people waiting for an organ transplants in the U.S. (including fictional U.S. president Frank Underwood in the Netflix television series House of Cards, after being shot during an assassination attempt. He needs a liver transplant to survive). Of these, 100,791 are awaiting a kidney transplants (as of 1/11/16). The median wait time for an individual’s first kidney transplant is 3.6 years and can vary depending on health, compatibility, and availability of organs.

There was some good news in 2015. More than 30,000 transplants were performed annually for the first time in United States. For the year, 30,973 transplants were reported, representing an increase of nearly 4.9% over 2014. Approximately 81% of the transplants (24,982), however, involved organs from deceased donors. Nineteen percent (5,986) were made possible by living donors, a slight increase of nearly 2.9% over 2014. The proportion of living donors older than 50 increased slightly, with a slight decline in the proportion of living donors between the ages of 18 and 34.

Is asking to donate enough?

The odds of getting an organ could improve if, of course, there were more people willing to donate their organs, whether as a deceased donation or a living-related or unrelated donation. But is altruism alone enough to solve the shortage? Should we “sweeten the pot” with a federally-regulated payment system for organs? How about paying for the funeral expenses of a loved one who agreed to donate their liver, kidneys, and skin tissue? Or funding their child’s college education? If I am a living kidney donor, should the government share with me some of the money they are saving when taking someone off dialysis? Who will pay for my medical care if there is a complication after the surgery, or when I lose time at work?

Those in attendance at the American Society of Transplantation’s Cutting Edge of Transplantation program, a special summit held Feb. 26-28 in Phoenix called “Resolving the organ shortage: Practice, policy, politics” grappled with those issues. It was a continuance of the AST’s efforts over the past couple years to improve organ donation, particularly living donors. A summit was held in 2014  looking at non-financial ways to improve living donation, and a series of articles were published from the summit’s findings.

Living donations usually have the best organ survival rate for the recipient; the organs have not been exposed to trauma and the individual donor’s overall health can be more closely evaluated.

Some key points from the Phoenix conference:

  • Attendees and speakers agreed that using compromised organs––perhaps some from older individuals or some that had been procured from individuals with a checkered medical history––should be given more consideration. Many organs are discarded because surgeons are concerned the transplant will not be successful.
  • If compromised organs are used and their rate of success is lower, transplant centers should not be penalized by payers, like Medicare, who evaluate and monitor transplant centers partially based on organ survival rates. In an audience poll at the conference, people said they were concerned that their transplant programs would be punished if marginal donors don’t generate good outcomes.
  • All agreed that providing more financial support and meeting the medical needs for the living donor should be a priority. Lost wages, the cost of travel and testing for donation, and other expenses should not be borne by an individual willing to undergo surgery to help another. Congress recently introduced a bill to address some of those issues, and a federally-funded program to provide financial assistance to those who donate helps cover some costs (although the funding is limited to those who meet certain low income levels). Many felt more needed to be done, and financial assistance should not be based on income levels.
  • Clearly, the most controversial idea would be creating a federally-run exchange for the buying and selling of organs. Such systems exist in other countries. An audience poll indicated that most were in favor of the idea if pricing and procuring the organs could be controlled by the federal government.