Doctors Face Scrutiny Over Alleged Manipulation of Organ Waitlist

The organ transplant system in the United States is under renewed scrutiny following allegations that some doctors may be manipulating the waitlist to prioritize certain patients over others. In September 2023, the Trump administration announced investigations into state organ procurement organizations, particularly focusing on serious safety lapses, including incidents where attempts were made to remove organs from terminally ill patients who were still alive. While accountability for such errors is essential, the discourse is shifting to a more systemic issue that undermines fairness in organ allocation.

Since the introduction of a new heart allocation system in 2018, concerns have arisen about practices that some describe as “gaming” the system. The new six-tier framework was established by the nonprofit organization United Network for Organ Sharing (UNOS) to better assess patient urgency and ensure that the sickest individuals receive transplants more quickly. This replaced an older three-tier system that had been in place since 2006. The aim was to save lives by expediting transplants for the most critically ill patients.

Despite these intentions, the system has led to unintended consequences. Reports indicate that some patients are receiving invasive treatments to enhance their position on the waitlist, even when such interventions may not be medically necessary. These so-called exception requests to boost transplant status have surged, as doctors appear to be incentivized to use aggressive treatments to escalate patients’ severity ratings.

A pivotal study published in Transplantation Direct in 2020 revealed a significant increase in the use of intra-aortic balloon pumps among waitlisted patients. The percentage rose from just 3% in 2017 to 45% under the new allocation system. Notably, there is no evidence to suggest that patients requiring these devices were any sicker than those treated with medications alone. This raises critical questions about the motivations behind such treatment escalations.

The current allocation system bases disease severity primarily on the therapies employed, rather than an objective assessment of a patient’s condition. This has created an incentive for physicians to adopt more invasive approaches, potentially leading to waitlist manipulation. The ethical implications are profound; with a finite number of donor hearts available, boosting one patient’s status can detrimentally impact another.

Moreover, a growing number of healthcare professionals have expressed concern that they feel pressured to engage in these practices to avoid disadvantaging their patients. The financial implications are also significant, as an increase in transplant volume can enhance a medical center’s reputation and revenue stream.

The ethical dimensions of this situation are further complicated by the potential for doctors to prioritize their centers’ transplant numbers over patient wellbeing. Escalating treatments not only waste resources but can also harm patients, creating complications that could have been avoided.

To address these issues, the transplant community must focus on restoring equity and fairness within the organ allocation system. Standardizing criteria for exception requests could be a crucial first step, ensuring that all patients have equal access to the resources needed for their treatment, regardless of their healthcare provider’s capabilities.

There is also a call for the development of a new assessment system that evaluates medical urgency independently of treatment interventions. Transplant doctors, working alongside UNOS, have been exploring a scoring system based on objective test results, which could help eliminate the incentives for manipulation seen in the current framework. This scoring method has already successfully reduced gaming in lung transplant allocations.

Currently, however, federal agencies have instructed transplant organizations to pause this development to focus on investigating rare organ procurement mistakes. This decision is viewed as a significant misstep, as addressing the issue of waitlist manipulation is crucial for ensuring safety and equity in the organ transplant system.

As the debate continues, the medical community must grapple with the ethical responsibilities involved in organ allocation practices. The integrity of the transplant system is at stake, and the lives of countless patients depend on its fairness.