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Elalouf, A.Y. Preferences regarding Organ Allocation. Encyclopedia. Available online: (accessed on 19 June 2024).
Elalouf AY. Preferences regarding Organ Allocation. Encyclopedia. Available at: Accessed June 19, 2024.
Elalouf, Amir Yosef. "Preferences regarding Organ Allocation" Encyclopedia, (accessed June 19, 2024).
Elalouf, A.Y. (2022, June 20). Preferences regarding Organ Allocation. In Encyclopedia.
Elalouf, Amir Yosef. "Preferences regarding Organ Allocation." Encyclopedia. Web. 20 June, 2022.
Preferences regarding Organ Allocation
Allocating organs is a societal undertaking, as preferring a particular patient always implies deselecting others who may not be eligible for future organ transplants. The priority-setting and decision-making depend on various stakeholders, including the general public (who are the potential organ suppliers who influence the availability of organs for transplantation), medical professionals (who are responsible for patient care), and the patients (who will receive the new organs) 
medical experts’ opinion organ allocation

1. Introduction

Advancements in medical knowledge have developed the trust of end-stage organ failure patients in organ transplantation. The success rate of organ transplantation has significantly intensified the confidence that also increased the demand for vital organs [1]. According to the U.S. Organ Procurement and Transplantation Network (OPTN), 39,000 organs were transplanted in 2020. Still, 106,708 are waiting for an organ [2][3]. Organ shortage kills three Americans every day, and up to one in six of those waiting for a heart, liver, or lung transplant die or are too ill to be given organs. As the number of patients adds day-by-day on the waiting list for organ transplantation, the organ allocation procedure becomes more challenging. Different organ allocation policies are present but finding the most appropriate recipient is challenging. For kidney allocation, various policies have tried to balance utility (kidneys should be used as efficiently as possible) and equity (waitlisted patients have an equal chance of receiving kidneys) [4]. Nonetheless, substantial debates have raised many questions to balance the utility and equity, such as “Should we discriminate between patients while considering their medical conditions?” [5], but no one reported a definite settlement [6].
Transplantation represents a unique challenge for clinicians as they tend to care for many patients who could benefit from a similar donated organ. Donated organs must be deliberated as a national resource, and all the listed patients have an equal opportunity to receive the donated organ. Therefore, donated organ allocation and rights of competing recipients need to be clearly defined, focused, and evidence-based to merely benefit the patients [7]. Currently, organs from deceased donors are allocated based on criteria such as the likelihood of success, medical urgency, time on the waiting list, or pediatric status [8]. In the case of heart and liver transplants, clinicians’ decisions and centers’ policies prefer to allocate the organ to the most appropriate recipient. Some patients are listed as super-urgent; if they do not obtain the urgent transplant, it may lead to death so that patients receive the available donated organ with clear justification. Further, cold ischaemic time (CIT)—the interval between the cooling and implantation of an organ- is also considered in the organ allocation process. Organ allocated to patients with short CIT nearly available or present in a similar center [7].
Various organizations are managing organ transplantation in different countries, for instance, Euro-transplant in Europe, United Network for Organ Sharing (UNOS) in the U.S. [9], and Israel National Transplant Center (INTC) in Israel [10]. In leading countries, a point scoring system is practiced to allocate the kidneys. The patient who secures maximum scores, the available organ would be allocated to him/her. In this context, researchers have tried to improve the organ allocation system to make it transparent and effective. In 1990, David and Yechiali optimized the organ allocation model with different criteria to allocate various organs to recipients [11]. In 2001, Yuan et al. introduced a fuzzy logic-based kidney allocation system to deal with complexity and ambiguity near expert opinion [12]. Gundogar et al. (2005) established a kidney allocation system known as fuzzy organ allocation system (FORAS) and claimed it was better than other allocation systems [13]. Later, in 2008, a utility-based system was developed by Baskin and Nyberg to balance the demand and supply of kidney transplantation [14].
For liver allocation, a rule-based decision-making system was proposed by Cruz-Ramirez in 2013 [15]. In parallel, linear regression of score weights [16], fuzzy lung allocation system (FLAS) [17], Data Envelopment Analysis (DEA) [18], Delphi method, Analytic Hierarchy Process (AHP) [19][20][21], and Mamdani Style Fuzzy Inference System (MSFIS) [22] were developed and practiced for allocating organ in different regions at different time. Altogether, AHP and Delphi have been extensively used for developing the organ allocation system [19][20][21]. Recently, Taherkhani et al. used the Intuitionistic Fuzzy AHP method for weighting kidney allocation criteria to remove the uncertainty in decision making [9]. Related studies pointed out that sometimes, more deserving candidates for allocation are inappropriate, such as those with alcoholism, HIV, suicidal tendencies, or drug addiction [23]. Therefore, medical factors such as inoperable coronary artery disease, active systemic lupus erythematosus, and diabetes are also considered as transplantation contraindications [24].

2. Public Preferences regarding Organ Allocation

Transplantation relies on public needs and people’s willingness to donate; hence it is vital to involve the general public preferences in organ allocation decisions [25]. The general public broadly agrees that organs should be preferentially allocated to candidates expected to benefit from them the most regarding life expectancy and quality of life. In numerous studies, maximum benefit caused the slightest moral discomfort among survey respondents and was assessed as the main parameter in selecting transplant recipients. Typically, survey respondents view time spent on the waiting list as an essential criterion in organ allocation. They believed that priority should be given to candidates who have been waiting a long time for a transplant. Noticeably, this factor is more objective and unequivocal than other criteria; hence people feel less ambivalent when integrating it into their decisions [26][27][28][29][30]. Furthermore, time spent on the waiting list is perceived as culturally acceptable and treated as an ‘automatic’ parameter invoking a systematic and mechanical procedure [30].
Regarding age, members of the general public have indicated that, when organ availability is limited, the young should be prioritized over the elderly. The public deemed that younger people should have an opportunity to live and anticipated that they would have a better prognosis than older individuals [26][28][29][31][32]. Nevertheless, a survey conducted in Israel [27] discovered that respondents did not perceive recipient age as a criterion that should be attributed excessive importance. In fact, 24% of the interviewees ranked it as the least essential factor in determining transplantation priorities.
The notion of registered donors’ preferred status gained community members’ support as respondents felt that registered donors’ should be prioritized [29][31]. Nonetheless, Israeli respondents ranked donor status as the least important criterion in allocation decisions despite registered donors’ prioritization by Israel’s organ allocation policies [27]. Moreover, according to survey results, members of the general public feel aversion toward any preferences based on variables such as recipient gender, ethnicity, social utility, employment status, occupation, ability to pay, and socioeconomic status. They believe that these variables should not impact a patient’s access to the waiting list and impede chances of receiving transplantation [29][33][34].
Studies highlighted that some traits impact likelihood and priority ratings due to different social characteristics’ effects (e.g., gender and ethnicity) on values and preferences. For instance, Sears et al. (2000) learned that race has a particular impact on decision-making. They found out that compared with Caucasians, African Americans believe that every person who needs transplantation should be given high priority [34]. Similarly, Clark et al. (2009) noted that preferences slightly varied according to gender; notably differed according to ethnic origin. Caucasians, non-white, and South Asian ethnic minorities were not inclined to give precedence to recipients with a good tissue match and tended not to prioritize younger recipients. Further, non-white and South Asian ethnic minorities were less likely to prioritize people with moderate rather than severe diseases that affect life expectancy [35].
To conclude, studies have proved that the general public holds opinions regarding the prioritization of transplant candidates. These preferences are based on a delicate balancing act of expediency, morality, socioeconomic aspects, justice, and equitable ideals [29]. Decisions and comparative significance of different allocation factors influence equality; therefore, they are constantly debated. Thus, it is interesting to observe the opinions of the crucial players in charge of the transplant process.

3. Health Care Professionals’ Preferences regarding Organ Allocation

Transplantation and organ donation require organization, coordination, planning, managing registries, waitlists, and effective resource allocation. Health care professionals identify potential donors, seek families’ consent, conduct suitability tests, and coordinate with transplant authorities to find a match. Therefore, medical professionals hold the key to improving the organ transplantation process as they stand on the front line in health care [36].
Previous studies assessed the medical expert’s opinion on organ allocation by agreeing/disagreeing with the statements [37][38] and testing the eligibility of hypothetical patients [39]. Usually, comparing and ranking criteria for allocation eligibility regarding the importance of patients is rarely executed. However, the interviews are often exploratory [40][41]. In this regard, Thamer et al. determined the U.S. nephrologists’ recommendations regarding eight unique hypothetical patient scenarios. Patients with end-stage renal disease who were female, Asian, and not black were more likely to be recommended for renal transplantation. According to some other researchers, the well-documented disparities in kidney transplantation between black and white people may stem from unaccounted-for factors or result from subsequent steps in the transplantation process [39]. Cass et al. elucidated what factors influence medical professionals’ decisions about patients’ suitability for kidney transplants. Experts recommended young and regular weight recipients over smokers, heart disease, and diabetes patients [37].
Tong et al. interviewed the nephrologists of 15 Australian transplant and nephrology centers. They emphasized that the primary responsibility is to give their patients easy access to transplantation (e.g., waitlist of patients and acceptance of individual kidneys), maintain transparency, avoid value judgments, and uphold professional integrity. Furthermore, they stipulated that the allocation system should comprise age compatibility so that younger candidates had a higher chance of receiving a more youthful and better-quality kidney. In addition, nephrologists advocated maximizing transplant survival since it was perceived as the primary community benefit. An interesting finding of the study was that although nephrologists had personal views about societal benefit and equity, they believed that the issue of resolving this equilibrium should be an external responsibility borne by policymakers and the general public [40].
Davison, Kromm, and Currie (2010) [42] found that health care professionals favored a more utilitarian to egalitarian approach in allocating deceased donor kidneys. They preferred match ability to equity (first come, first served), believing that a functional approach is needed to allow maximum flexibility in accommodating advances in renal transplants. On the topic of precedence in organ donation, research which was executed in India by Almeida et al. (2016) [38] discovered that a substantial majority of medical professionals (90.7%), who took part in the survey, upheld giving priority to organ donors in the event of a future need for an organ. Specifically, 47.1% of the participants stated that donors should be rewarded and recognized for their selfless and humane acts.
Differences in priorities among stakeholders, namely, considerable variance in the preferences of members of the general public, family physicians, and hospital clinicians, were presented in a survey by Neuberger et al. [43]. While respondents representing the general public prioritized age, transplant outcome, and time on the waiting list, family physicians maintained that transplant outcome, age, and likely work status after transplantation were the most important criteria. Hospital clinicians evaluated transplant outcomes, work status, and non-involvement of substance abuse as the most critical aspects. Nonetheless, all three groups agreed that anti-social behavior and substance abuse should hinder entitlement to transplantation.
Regarding willingness to donate organs, Bedenko et al. [44] assessed the knowledge and acceptance of the general public and professionals working in intensive care units. Their research results revealed the tendency to donate organs was substantially higher among the health professionals group. Further, in comparison with males, females were more willing to donate. Yet, no significant difference was found concerning religion, education level, or income.
In a survey performed in Germany among intensive care specialists [45], 81% of respondents favor organ donation in the event of brain death. The consent rate in the medical profession was 84% compared to 75% in the nursing profession. However, only 45.3% of the participants (47% of physicians and 44% of nurses) have signed an organ donor card in practice. Merely 45% shared and confided their decision and preference for organ donation with family and friends.
Notwithstanding, some nephrologists believed that they had a duty to protect their centers’ reputations by selecting “good” patients, which caused frustration. The nephrologists preferred to maximize societal benefit while ensuring equity but did not want direct responsibility for this across the entire health care system. In contrast, they were responsible for resolving potential tensions between policymakers and the community [40]. In a related study, health professionals’ attitude was examined regarding the controversial issues of transplantation. Most experts disagreed with giving incentives to donors and allocating organs to HIV/hepatitis carriers. For this purpose, the majority favored allocating organs to donors due to their previous acts [38].
In summary, given that the views of medical professionals largely shape allocation policies, it is of interest to recognize whether their preferences diverge from those of the general public and if different groups of medical professionals hold different opinions.


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