The UNOS scoring system

Mark S. Nadel & Carolina A. Nadel, Commentary, USING RECIPROCITY TO MOTIVATE ORGAN DONATIONS, 5 Yale J. of Health Pol., L. & Ethics 293 (2005).



The allocation of organs among those on the UNOS waiting is based, to a large degree, on compatibility.
[FN37] For example, for kidneys, a standardized formula awards points to potential recipients based on factors like tissue type, immune status, time on the waiting list, and distance from the donor. [FN38] For most organs, consideration is first given to recipients located within the same donation service area (DSA) as the donor. Nationwide, there are fifty eight DSAs, which are regional combinations of organ procurement organizations (or OPOs) and their transplant center networks. The organ is given to the person in the DSA with the highest UNOS score. [FN39] If there are no suitable recipients in the donor's DSA, the organ is offered next to the candidates in the donor's OPO region (there are eleven OPO regions nationwide), again, based on their scores. If there are no suitable recipients in that region, then the organ is offered nationwide based on those UNOS scores. [FN40] This “local first” policy has been *301 widely criticized. [FN41]. Id. at 300-01.


[FN37]. See Munson, supra note 15, at 47-51. OPOs, however, cannot consider an organ seeker's ethnicity, gender, or religion, and some OPOs also have policies against discrimination against prison inmates. See, e.g., James Sterngold, Inmate's Transplant Prompts Questions of Costs and Ethics, N.Y. Times, Jan. 31, 2002 at A18.

But is "Native American" an "ethnicity"?

[FN38]. UNOS Organ Distribution Policies § 3.5-3.9 (July 2004) (rules for kidneys, livers, and hearts), http://www.unos.org/policiesandbylaws/policies.asp?resources=true; see also Marlies Ahlert et al., Kidney Allocation in Eurotransplant, 23 Analyse & Kritik 156 (2001); Johan De Meesters et al., The New Eurotransplant Kidney Allocation System, 66 Transplantation 1154 (1998).

[FN39]. With some exceptions (e.g., special priority is given to O-type recipients, see Galen, supra note 20, at 357-58), the organ is offered first to the transplant team of the person on the top of the list from the DSA. Meanwhile, doctors of the patients scoring highest will decline an organ when their patient is not willing and healthy enough to undergo major surgery immediately or insufficiently compatible with the donor.

[FN40]. See 1993 GAO Report, supra note 27, at 18-19.

[FN41]. The justification given for the “local first” policy is that organs deteriorate rapidly and that the policy
encourages local donors. Livers, however, are generally offered to the medically suitable patient with the most
urgent need nationwide, rather than local, subject to travel time constraints. See infra notes 139-142 and accompanying text.


[FN139]. The maximum allowable transport time for organs removed for transplant (also known as cold ischemic time) limits how far they can be sent to recipients. See Introduction to Transplants, at http://
www.ustransplant.org/primer_intro.php (last updated July 9, 2004). There is also a cost advantage to minimizing transport time. See Mark A. Schnitzler et al., The Economic Impact of Preservation Time in Cadaveric Liver Transplantation, 1 Am. J. Transplantation 360 (2001).


[FN142]. See 1999 IOM Report, supra note 136, at 52-53 (1999) (reporting that both a 1998 Gallup poll and a 1995 Southeastern Inst. of Research poll found little patient preference for local recipients over more needy patients in the nation). On the other hand, a local preference probably serves to improve the morale and motivation of those involved in encouraging organ donation in each community. See Koch, supra note 36, at 74, 97-99. This policy also reflects the efforts of smaller, local transport centers to protect themselves and their patients. See Jeffrey Prottas, The Politics of Transplantation, in Organs and Tissue Donation, supra note 27, at 3, 17.