The dramatic success of organ transplantation in the last 20 years has led to a growing imbalance in the number of patients awaiting transplantation and the number of organs available for that purpose. As a result, the prioritization of individual recipients for organ allocation, especially for vital organs such as the heart, lung and liver, has become the subject of heated debate. Nowhere is this issue more pressing than in the discussion of the appropriate allocation of vital organs to patients with a failed first graft.

The decision to retransplant a critically ill patient, who will almost surely die rapidly without such intervention, touches on many controversial aspects of modern medicine. Is it ethical to provide one individual with a second opportunity for a life-saving therapy when others will die awaiting their first? Is it appropriate to expend a precious health care resource on an individual whose outcome is known to be inferior and more costly than if used in a patient receiving a first time transplant? The reduced efficacy of retransplantation, in conjunction with the increased cost relative to a first graft, is magnified as the financial constraints of health care provision continue to grow. How to balance these concerns with the obligation of physicians to provide maximal care to their patients is a complex and unresolved issue. Is it really appropriate to consider depriving a critically ill patient a proven therapy simply because their medical history includes prior similar resource utilization?

What is clear is that the scarcity of organs mandates difficult decisions regarding their rational use. This duty currently falls on UNOS (the United Network for Organ Sharing). This organization supervises the procurement and allocation of organs —compiling patient waiting lists and formulating list priority — ranking patients while attempting to balance fairness, efficacy, and medical urgency. The waiting list, for some organs such as kidney and pancreas, gives priority to time on the list and to better donor-recipient histocompatibility (a factor which has been shown to improve survival for these grafts). In contrast, for vital organs, for practical reasons, allocation is based predominantly on the time waited and medical urgency. Thus, even if one puts the issue of retransplantation aside, inherent in the system is the prioritization of those who are the most critically ill and the most likely to die soonest. As a result the system gives preference to individuals likely to benefit the most even though the average graft survival in these patients is less

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