Actual situation in Eurotransplant regarding high urgent heart transplantation.

A century ago, the Royal Mail Ship Titanic fatally struck an iceberg and descended into the Atlantic Ocean. To reduce clutter on deck the number of lifeboats on board was brought down from 64 to 20. Each class of passengers had access to their own decks and allocated lifeboats, although crucially no lifeboats were stored in the third class sections of the ship. Third class passengers had to find their way through a maze of corridors and staircases to reach the boat deck. When the lifeboats were finally lowered, officers gave the order that women and children should go first, with the threat of shooting those who disobeyed [1]. Official reports later showed that the percentages of lives saved across the different passenger categories differed from 100% for children in first class to 8% for men in second class (Table 1) [2]. The tragedy with the RMS Titanic is a school example of resource allocation, albeit unequal access and allocation by social worth are certainly not praiseworthy, because it illustrates quite clearly a rationing setting, the allocation policy and its consequences. In times of abundance no resource allocation policy is needed; everyone will get his or her share. But in several countries in Europe, as well as in the USA, there are so many high urgent transplant candidates competing for the few scarce donor hearts that the transplant community is showing a new openness to changing the heart allocation system [3–5]. The current heart allocation systems in Eurotransplant, France and in the USA are all urgency tier systems, where within the same tier a first-come, first-served principle is applied. Eurotransplant is an organ exchange organization in which eight countries collaborate and who all subscribe to the solidarity principle of exchanging donor hearts for the high urgent patients within the Eurotransplant area (www.eurotransplant.org). However, as the heart donation rates are widely different between the individual countries [2.3 donors per million population (pmp) for Netherlands and 8.8 heart donors pmp for Croatia] this exchange is governed by a strict country exchange balance. In each of the Eurotransplant countries a transplant law has been enacted, where these laws form the framework within which all transplant-related activities must take place.