Responses and Dialogue Response to “ A Critique of UNOS Liver Allocation Policy

The critique of the United Network for Organ Sharing (UNOS) liver allocation policy by Kenneth Himma has flaws related to the complexities and evolutionary nature of the field. Recent improvements in transplantation have achieved national attention of this sort. There has been an evolution, unequaled elsewhere in medicine, of a national data set and national rules. The transplant community might have been more effective in communicating the details of this, and the problems associated with organ allocation policy. The novelty and complexity of the new rules understandably can produce misleading conclusions. Mr. Himma’s article suffers in the first place from inaccurate conceptual premises. These incorrect premises lead to incorrect outcomes of his reasoning. Equally important, for practical implications in the field of transplantation, there are critical medical facts underlying the evolution of national allocation rules that are not accurately represented by him. It is important to note at the outset that transplantation is distinguished from the rest of medicine, ethically and practically. Because there are not enough donated organs, all patients and practitioners are bound together by a community of medicine principle: whenever a patient receives a transplant, it diminishes the chance that other potential recipients will be able to receive this gift of life in time to save them. In this response, I summarize the development and current status of UNOS policy, and point out the errors in Himma’s reasoning due to the above issues. The conclusion that UNOS policy is unethical is flawed by premises and facts on which that reasoning is based.