Partly as a result of the controversy surrounding the new UNOS liver allocation policies, some have questioned whether a private sector agency (i.e., the OPTN contractor) can or should set policy for a system that has such a profound effect on life-and-death decisions (DHHS, 1998b).

In comments provided on the Final Rule, a number of individuals and organizations argued that the approval of a flawed liver allocation policy in November 1996 and the failure to improve current policy in more fundamental ways illustrate systemic flaws in the current governance structure, specifically the structure of the UNOS Board of Directors. Some assert that the OPTN is dominated by hospitals (large and small) and transplant surgeons and physicians, and that the greater public interests—the altruistic motives of donors and their families and the health and survival of potential recipients—are not given adequate attention. Still others claim that hospitals, physicians, and payers can manipulate the current system of organ allocation and listing by excluding highrisk patients from the list, listing patients early to gain waiting time points, listing patients at more than one transplant hospital to increase the chance of getting an organ, and referring high-risk patients to other hospitals to avoid adverse performance outcomes.

Criticisms and concerns have also been raised about the role of the federal government in the oversight and regulation of decision making with respect to organ procurement and transplantation.


The discrepancy between the number of donated organs and the need for organ transplants has called into question current policies and practices regarding allocation and distribution of organs, particularly livers. There is ongoing controversy about the uniformity of listing criteria, referral practices, donation rates, access, and the effects of these factors on waiting times. The committee concludes that although controversy may continue regarding many of these issues, the objectives of uniform minimal listing criteria, better data collection, and greater accountability on the part of the organ transplant system, seem reasonable and should be pursued with vigor.

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