The waiting game

Jonathon Rosen


Question: I’ve read that transplant candidates wait longer for organs in some cities than others. Is that true?

Answer: It’s not fair, but yes, it’s true. The nation’s wait list for organs is over 94,000; there simply aren’t enough to go around. This means that the fairness of the way we give out such life-saving treatments is paramount.

The United States is divided into 58 service areas, each operated by a local organ procurement organization. The OPOs evaluate potential donors, facilitate family discussions about donation and coordinate the removal and distribution of organs. Many of the factors that go into determining who gets an organ have to do with medicine and fairness — how good is the biological match, how sick is the patient, how long has he or she been on the waiting list — but geography also plays a dominant role.

The OPO typically offers organs to individuals within its own area. This puts candidates living in regions with large poor populations at a great disadvantage because poverty is associated both with diseases that lead to the need for organs and with lower donation rates. The result is wait times that greatly vary from area to area. The San Francisco Bay Area OPO (with Oakland, San Francisco and San Jose) has many more people who need kidneys and livers than the Sacramento OPO. As a result, wait times for kidneys are typically twice as long in the Bay Area as the Sacramento area, and Bay Area patients who need livers have to be much sicker to receive one than those being transplanted at UC-Davis — the only transplant center in the Sacramento region. Similar problems arise throughout the country. Wait times are much higher in New York City than across the river in New Jersey. New York, San Francisco and Los Angeles have the nation’s longest waiting lists for livers.

Candidates can essentially buy themselves a better shot at a transplant. Most insurance plans cover transplant care at just one center at a time but those who can pay out of pocket can be listed in multiple OPO areas. Patients with the means can also move to areas of the country (e.g., Florida) with shorter wait times. Most ethicists agree that this bias toward wealthy patients is unjust. A more equitable system would distribute organs throughout wider regions and would limit candidates to a single wait list. Since livers can survive for up to 12 hours after procurement, arbitrary geographic boundaries should not dictate patients’ care.

So why don’t we change the system? One downside would be that transplant programs in less populous regions might have too few procedures to stay afloat. Programs like these have largely opposed what I believe would be a more just allocation system. The resulting change would certainly be inconvenient for patients in Sacramento who would have to travel to the Bay Area for treatment. But the benefit would be a system that no longer bases candidates’ chances for a transplant on their wealth or the ZIP code of their hospital.

David Magnus, PhD, directs the Stanford Center for Biomedical Ethics. Send your questions to or Ask the Bioethicist, Stanford Center for Biomedical Ethics, 701 Welch Road, Suite 1105, Palo Alto, CA 94304

Comments? Contact Stanford Medicine at

 Back To Contents