As of 7:51 a.m. Tuesday, the method for distributing donated organs to dying patients became a bit more equitable. Or at least, that's what the United Network for Organ Sharing intended when it crafted new distribution rules.
The new plan, years in the making, moves from a system based roughly on geography to one weighted more on the severity of the patient. But major transplant centers in the South and Midwest have resisted, even filing a lawsuit in late April to block implementation.
A federal judge in Atlanta granted a few week delay but ultimately late Monday night dismissed the request to keep the policy from taking effect. The collective transplant centers — which include Emory, Vanderbilt and Indiana University — plan to continue their court challenge. But that will now happen while the new policy is in effect.
"This is good news for the sickest candidates waiting for livers," says Brian Shepard, CEO of UNOS, which predicts 100 additional lives will be saved. "Targeting the livers towards those folks who are really the most critically ill will result in fewer people dying on the waiting list."
But the benefits won't be evenly spread.
Karen Wells drove her husband from their home in Lexington, Tenn., to the busy emergency department at Vanderbilt University Medical Center in Nashville last year, praying for a miracle. He was so jaundiced he was almost unrecognizable.
"He was dark, very dark," she says. "There was no whites to his eyes. They were orange."
The doctors said it was time to make funeral arrangements. His body was rejecting his first liver transplant from 2013, and he needed a second.
"To get one, it's a miracle, honestly. To get two?" she asks. It was a long-shot.
But fortunately, Wells lives in Tennessee, where the waiting list is notably shorter than big cities on the coasts. For comparison, this week the waitlist at the University of California's San Francisco Medical Center numbered 761. Vanderbilt was at 171. But both perform roughly 140 liver transplants each year.
For decades, livers were donated to patients nearby according to a national map — no more than a state or two away. But under the new rule, a liver must be matched with the most critical patient within 500 miles. That means an organ donated in Nashville could end up in Chicago.
That seems unfair to transplant centers in the South and Midwest, where organ donation rates are higher. More people sign up to donate in the region. But transplant experts also point out that residents of both regions are more likely to die in ways that allow their organs to be used, such as from a stroke.
Those old regional discrepancies meant some patients could game the system. When he needed a transplant, Apple founder Steve Jobs even bought a house in Memphis so he could be listed in Tennessee.
"He didn't do anything illegal...but he took advantage of a system because he was able to financially," says Sandy Florman, transplant director at Mount Sinai Hospital in New York City.
Mount Sinai's waitlist is among the longest in the country. And Florman says he's been disappointed to see the debate turn into a "turf battle."
"These are very profitable hospitals, and people are afraid that their programs will not do well," he says.
By one estimate from Milliman, each liver transplant results in more than $800,000 in billed charges. If Vanderbilt, for instance, loses a considerable number of procedures, transplant director Seth Karp says downsizing may have to be considered.
But Karp worries more about smaller centers.
"If the program in Mississippi closes, if the program in Iowa closes because of this, that's a real national public health problem," he says.
Karp doesn't buy that more lives will be saved. He predicts more livers will go to waste.
Every minute counts when deciding where to send a liver, which can only last outside the body 10 to 12 hours. More hospitals will now have to weigh in when a liver becomes available.
"The more complex the distribution scheme is, the more chances you have of not using the liver," Karp says.
The transplant centers that sued plan to keep up their fight in the courts. UNOS says it will monitor the policy and "make adjustments if there are unintended consequences."
For patients and donors, the question is more straightforward. Is an organ donated for someone nearby or anyone who could use it?
Jeffrey Wells, the patient who was near death at Vanderbilt last year, received his second liver transplant, benefiting from the shorter waiting list. But he also supports the new rule.
"When a person decides to be a donor, I don't feel like they're becoming a donor to save one particular person's life."