Rethinking the Fairness of Organ Transplants

Because of an organ shortage, hundreds or even thousands of people miss out on needed organ transplants each year. Business researchers at Harvard and MIT are rethinking how kidney transplants are allocated to give patients longer lives. An interview with professor Nikolaos Trichakis. Key concepts include:
  • A new empirical model for allocating available kidneys to patients provides the potential for a system with greater fairness and longer life outcomes for those who receive transplants.
  • The method—the work of Nikolaos Trichakis of Harvard Business School and Dimitris Bertsimas and Vivek F. Farias, both of MIT's Sloan School—can help policy designers create the most equitable point system based on their chosen constraints and criteria.
  • In early simulations, the model suggests that life-year expectancies for the program can be increased by up to 8 percent, depending on variables plugged into the process.
by Dennis Fisher

A proposal out of Harvard and MIT to rethink how kidney transplants are allocated could result in a fairer system giving patients longer lives.

The new empirical model, which is intensely data driven, would provide a flexible framework to policymakers responsible for deciding which potential recipients get organs as they become available—decisions that must be based on various priority and fairness criteria.

“The new system will explicitly give points based on the likelihood of survivability.”

The method—the work of Nikolaos Trichakis of Harvard Business School and Dimitris Bertsimas and Vivek F. Farias, both of MIT's Sloan School—can help policy designers create the most equitable point system based on their chosen constraints and criteria. They detail the proposed model in a new paper, Fairness, Efficiency and Flexibility in Organ Allocation for Kidney Transplantation.

In early simulations, the model suggests that life-year expectancies for the program can be increased by up to 8 percent, depending on variables plugged into the process.

As with the "Moneyball" metrics movement in baseball, the goal of the model is to use the best available data to make the best possible decision in each individual case. But here, the ultimate objective is adding years to patients' lives, not just points to the team's winning percentage.

"Because of the organ shortage, you want a system that is transparent and perceived as fair by the candidates," says Trichakis, an assistant professor in the Technology and Operations Management Unit. "If you're one of them and you're not getting a kidney, you should be able to understand why and what the criteria are."

A Long Line

About 500,000 people in the United States suffer with terminal end-stage renal disease. The only treatments are maintenance dialysis and kidney transplantation. The former requires visits to a treatment center for at least 12 hours a week, while a transplant—from either a living family member or a matching deceased donor—can have the recipient soon resuming regular life activities. In mid-November, the active waiting list for a kidney stood at 72,845. Once an organ is available, there can be thousands of compatible recipients queuing up.

In the time since the US Congress passed the National Organ Transplant Act in 1984, organ allocation has been handled by the Organ Procurement and Transplantation Network (OPTN). This national registry and waiting list is managed by the private nonprofit United Network for Organ Sharing (UNOS), which has the unenviable task of making priority and allocation decisions for each new organ that becomes available.

Currently, this is done under a point system that takes into account a number of factors including the potential recipient's proximity to the available organ, blood type, life expectancy after a transplant, and various fairness criteria such as time waiting on the list.

Those decisions can be complicated by cold realities. Organs typically need to be transplanted within 36 to 48 hours, otherwise they begin to deteriorate, so recipients who live close to the source of the donated organ often are logistically preferable. Another difficulty: waiting lists can be much longer in some areas of the nation than in others.

But one particular concern has policymakers rethinking the current kidney-allocation process, a problem ironically created by improved medical treatments for renal disease. "Because patients are living longer, more and more of them are accumulating points just for being on the list a long time, which dwarf the points accumulated for a matching profile," says Trichakis. The end result: the allocation process "no longer meets the needs of the patients."

So, despite the best efforts of those involved, the current transplant point system is in need of fine-tuning. OPTN is developing a new policy and has put out a formal request for information to help guide that decision-making process, to which Trichakis, Bertsimas, and Farias are contributing.

Their key idea is to propose a new way of thinking about the problem. So far, OPTN has been conceiving the new process as an allocation system to provide good matches so patients survive longer, but with fairness. By contrast, rather than designing a policy and then looking at what the outcomes are, Trichakis and his coauthors allow policymakers to start with desired outcomes and then work backward using historical and other data to create a policy.

The group's proposed method determines how many life years can be added by looking at the expected survivability for every case. "The new system will explicitly give points based on the likelihood of survivability," says Trichakis. Fairness is measured by looking at the distribution of recipients across different groups by age, race, diagnosis, and blood type.

"This gives policymakers the ability to focus on what's important and relevant," he adds. "Right now, they focus more on what the policy should be and then the outcomes."

Putting It To The Test

In order to test their methodology, the research team performed a series of case studies on policies with different criteria for matching. In the first instance, using the criteria and constraints of the current dominant policy, their method produced a program with life-year gains of 3 percent over the existing one. The results were significantly better—life-year gains of 8 percent—in a second study for policies that could be based on all score components considered by policymakers, while continuing to meet the fairness properties of the dominant proposal.

The model also allows policy designers to consider fairness factors not used before in the allocation process. "For instance, what is the impact of reducing the percentage of transplants to patients on dialysis for greater than 15 years by 1 percent?" their paper puts forward. "In the case of some constraints, relaxations of fairness constraints can result in life-year gains on the order of 30 percent. As such, we believe this is a valuable tool in the policy-design process."

The authors are preparing a new version that is specifically aimed at the medical community. The ultimate goal is to bring this work to the attention of the United Network for Organ Sharing and the Organ Procurement and Transplantation Network, allowing it to be considered alongside other proposals.

"The first step is for UNOS and OPTN policymakers to make a proposal, which would go to Health and Human Services for approval," Trichakis says. "The Office of Civil Rights is involved too. Everyone is still in the loop of thinking about how the system should look: how many points for dialysis time, waiting time, things like that.

"I wouldn't say there's going to be a proposal in the next month or so," he continues. "There are different proposals on the table. But we will start talking with policymakers about what we can offer."

Interestingly, Trichakis is not the only HBS professor playing a significant role in development of organ donor programs. Alvin E. Roth, cofounder of the New England Program for Kidney Exchange, is a pioneer in creating a system that allows living donors to exchange with others. So far, the program has been responsible for over 70 successful exchanges.

Kidney exchange programs are organized on the regional level, but the OPTN recently started a pilot program to test the concept on a national scale, where Roth's work is likely to prove equally influential. "Al's work has already influenced local policies and is perhaps about to go national," Trichakis says.

About the Author

Dennis Fisher is a writer based in Plymouth, Massachusetts.
    • David J Undis
    • Director, LifeSharers
    Your story about Organ Donation highlighted the tragic shortage of human organs for transplant operations.

    There are now over 112,000 people on the National Transplant Waiting List, with over 50% of these people dying before they get a transplant. Most of these deaths are needless. Americans bury or cremate 20,000 transplantable organs every year.

    There is a simple way to put a big dent in the organ shortage - give donated organs first to people who have agreed to donate their own organs when they die.

    Giving organs first to organ donors will convince more people to register as organ donors. It will also make the organ allocation system fairer. Everyone who is willing to receive should be willing to give.

    Anyone who wants to donate their organs to others who have agreed to donate theirs can join LifeSharers, a non-profit network of organ donors who agree to offer their organs first to other organ donors when they die. Please contact me - Dave Undis, Executive Director of LifeSharers - if your readers would like to learn more. My email address is
    • MPatel
    • Analyst
    Why not create a law where by default any mortal is automatically elegible to donate their organs unless they opt out by signing a document when they are alive if they do not want to donate their organ. That way it would cost less time, money and effort to market of organ donation. And instead create market full of potential donors unless opted out. This would make sense even more because for those who wish not to donate will learn about the law out of personal or selfish reasons. Others by default are expected to be good and donate.
    • Paul Nicholas
    • Director, Soul-Chaplain Consultancy
    How interesting, how necessary, and unfortunately how tragic - a calculus that ascribes values to determine the fate of individuals. Such a development is not only essential, but also a heavy moral responsibility, and I admire the strength of those who must bear it.
    • Anonymous
    I agree that highest preference should be given to exact matches rather than longest wait on the list; I've also seen success with kidney exchanges. However, I'd also like to see advances in dialysis, where smaller machines could be kept at home and patients dialyze themselves daily using a gentler process than every other day, which patients say is very debilitating; by dialyzing daily or even several shorter times each day this more mimics the natural kidney function which is constantly filtering. I believe this is a very do-able solution for the near term. I also strongly advocate for paying donor families for organs; when there is a financial incentive, and many families are cash-strapped regardless of the circumstances they find themselves in vis a vis an accident that brings a loved one to life's end, you'd see the number of families donating go up...there is nothing wrong with that-- and since doctors make those decision
    s of when someone's life is truly at it's end (without financial incentive to the doctor) I don't believe monetary payment would drive decisions such as "pulling the plug too soon."
    • Ron muhlenkamp
    The basic problem remains a lack of organ donors, which means a lack of incentives for organ donors.
    The comments from David Undis are a first step in addressing the shortage - giving donated organs first to those who have agreed to donate their organs when they die - but it needs one more step. your place in line to receive an organ should be heavily influenced by the date on which you signed the donor card. This gives you an incentive to sign TODAY. the best source of donated organs is from the young, who die accidently. They currently have no perceived urgency in signing a donor card, even if they're willing. A date priority rule would supply the incentive.

    Ron Muhlenkamp
    • Anonymous
    I am afraid the allure of "scientific" life-year optimization methods may obscure the more fundamental moral issues. Developing scientific sounding methods, backed up with policy, reinforced with whisker tugging members on an appointed panel...will lead - as it always does - to heat and debate and new problems.

    Dignity of the individual, sanctity of every individual life (vs. the "collective"), natural death...these are the principles that will get swept aside by quasi-science.
    • Neil Wood
    I received a kidney from a family member, I am a lucky one. But the conversation should be about permitting purchase of kidneys, not about allocation of the short supply. The benefits of increasing supply in this way are overwhelmingly greater than the possible detrimental effects. The current situation in this respect is ridiculous. It's akin to the stemcell foolishness.
    • Anonymous
    I think Europe is the model for organ donation. They have an "opt-out" system as opposed to our "opt-in" system. They have about 40% more people donating. Most people will not take the time to change their status, meaning more people would be in. If they want to opt out, they can. This simple change would save live and take advantage of human nature.
    • Joseph Kelly
    • AVP-Risk Management, CSX Transportation
    I donated a kidney to my brother-in-law in 2010. One of the doctor's involved in the screening told me that if my remaining kidney failed that I would be placed at the top of the waiting list for a new kidney. I hope that is considered by the research team. My brother-in-law lives in Michigan and I live in Florida so I flew up to his choice of hospitals for the transplant. I think I would have accepted the kidney exchange program, but since there is a likelihood that I could have given my kidney to someone and the kidney that was suupposed to go to my brother-in-law failed to materialize, I would be devastated.
    There needs to be greater education to the public about how relatively easy it is to donate a kidney, and the minimal adverse affects on the donor. My patient advocate explained the risks, but really, I was safer being off the highways for the period I was recovering than the risks I faced donating the kidney.
    Prior to starting the process of testing to become a donor I had never heard anything about the living donor possibilities. Also, I was a little afraid of listing on my driver's license that it was okay to harvest my organs in case of my death in case the decision was made too hastily. After seeing how much concern the medical staff had for my health and well being, I now have absolutley no concerns about premature harvesting of my organs prior to my death.
    Education is sadly lacking and could go a long way to alleviating the organ shortage.
    • Jon Womersley
    • Principal, Private Consultancy
    This is an interesting piece of work. While it may tick all of the boxes for operations research it does not address two fundamental issues.

    The first is referred to in the first comment on this article. As with the USA, those awaiting transplants in Australia face long waits because of a lack of organ donors. Investment in changing the views of family members about the desirability and benefits that flow through the donation of organs will significantly reduce this dilema, though not completely because of the issues involved in the cross matching of tissue and logistics.

    The second issue is that the research appears not to have evaluated the ethical issues associated with organ transplantation. While it is well established that medical practitioners use a points based system for assisting in determining the allocation of organs, there are significant ethical issues involved in the choices made in the allocation model. Why has the research team in this case given priority to life expectency over the quality of life that a recipient might enjoy? Is this simply a choice driven by concepts of efficiency and economy? The bottom line is that there can be no application of any model unless there is consent to the donation of organs by the next of kin, and it is unlikely that consent will be given based on concepts of efficiency and economy, much more likely that utility will be pursuasive.

    Organ donation is an altruistic expression of a sense that we have that what we have ceased to use or depend on may be of value to someone else. Increasing the pool of those who share that altruistic view needs to be the primary focus of research effort.
    • Mario
    • Founder, Musul International
    It is interesting what this case is about. It is hard to give an objective opinion. I am sure there are many different sides in this kind of topics. We should make sure every side has the right to give an opinion before deciding a final new way of working it. Other than that it sounds fair. Though I am sure there are some other points of view to analyze.
    • Victoria Hummel
    • Student, Lane Community College
    I do see the ethical issues, from all points of view. Some recipients feel as if they have been left to die waiting on lists. If they could only get their new organ all would be well for them, but many don't make it for their call. While others receive their new organs who have nearly no chance of survival, and transplants aren't always successful and they suffer the same fate. Parents standing over their children are being asked by doctors if donation is acceptable because they are clinically dead and time is critical for those organs. The views from each angle of this issue are incredibly subjective, and to have a fair and objective approach might be the only solution. My thought is, has there been any advancement in artificial organs? Essentially that's what dialysis machines are, and if we've made advancements in pacemakers and cochlear implants, why aren't there devices installed, where only intake and output are necessary wit
    hout the 12 hours or more each week of being tied down. I might be far ahead of my time, but instead of being so dependent on the tragic death, or sacrifices why not put this energy into reproductions; I do understand the ethical issues that is involved with that issue as well.
    • Anonymous
    Perhaps this is insensitive of me, but many of the people with kidney failure are obese and diabetic through no reason other than their own choice. They also experience a much higher rate of post-transplant complication and mortality. When considering priorities for transplant, shouldn't these factors be taken into consideration? I know it is complicated somewhat by the fact that the urban poor live in food deserts, which is a legitimate concern. But I live in a rural area where real food is plentiful and cheap at the farmers market, and still I see obese people at the supermarket with their baskets loaded up with sugar, fats, and starch.
    • D W Brooks
    • ESRD Patient
    As a 68 year old white male who has been on dialysis almost 4 years and on the transplant list for almost that long, I can see the emotional side and the precious commodity side of kidney donations. Even though I do everything I can to maintain and improve my health and treatments, I do not expect (based on my experiences and observations) to ever understand how the system works now much less a new, improved version. I only wish I could have some encouraging follow-up if a transplant is a possibility or some candor if it is not. I believe most patients could embrace facts regarding matches without having to wonder if there is some subtlety in the decision making process that is not necessarily older age friendly.
    • Kapil Kumar Sopory
    • Company Secretary, SMEC(India) Private Limited
    Much time is also lost in locating a donor who satisfies compatibiility requirements. I know of a few cases where transplantation did not serve the purpose of enhacing life span of recepient simply because donors' details were casually matched (if at all) with the recepients'.
    Kidney transplant is a racket and the gullible are making big money at the risk of others' lives. There has to be a strict legal machinery to curb such activities.
    Logically, you can't make donations mandatory and only human feelings of an extraordinary order can make people " live and let live".
    • livingdonor101
    • Independent Living Donor Activist,
    The first obvious change that must be made is eliminating death by geography. This occurs because allocation is first local, than regional and finally national. In the 80s this was necessary - now it is not. However, too many transplant centers benefit from the current system and will not approve any change.

    The biggest focus should be on reducing demand for organs rather than increasing supply. The biggest kidney killer in the US is diabetes, and most cases can be prevented or treated. If we concentrated on education, prevention, diagnosis and treatment, our need for kidneys would be greatly reduced.

    In addition, the average age of end-stage renal disease onset is 64.4 years old. We probably should be asking ourselves if it is beneficial to transplant a 75 year old person.

    Unfortunately, what Joseph Kelly reported is incorrect. A prior living donor is given four points of allocation - s/he does NOT go to the top of the list. The points themselves are only for regional allocation and provide no benefit on the national level.

    It is very important that we distinguish between deceased donor organs and living donors. Despite public perception, living donation is not safe, and we have NO comprehensive or reliable short or long-term data on living donors' health or well-being. It simply isn't ethical to continue to harvest kidneys from healthy members of the public while the industry fails to protect and care for them.