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Ethical Considerations of Continuous Distribution in Organ Allocation

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Current policy

The Organ Procurement and Transplantation Network (OPTN) is working to develop a system of allocating deceased donor organs called Continuous Distribution. This new approach will consider many factors that contribute to a successful transplant. In this new approach, patients will be ranked with an overall score that is determined by considering multiple patient factors, which are called “attributes”.

The purpose the OPTN Ethics Committee’s White Paper is to serve as a reference tool for organ specific committees to use as they develop ethically sound policies using the Continuous Distribution framework.

Supporting media


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  • Reference tool for organ specific committees to utilize as they move forward developing an ethically sound continuous distribution framework
  • Highlights possible areas of discussion and aims to assist organ specific committees in closing potential gaps in equity, utility, transparency and autonomy
  • Aims to contribute to the development of the best possible continuous distribution system
  • Furthers discussions within the community of what makes up an ethical organ allocation framework
  • This document should be viewed broadly and considered during the development of each organ system’s allocation framework

Anticipated impact

  • What it's expected to do
    • The paper is expected to discuss and expand upon ethical principles that organ specific OPTN committee members should consider when making changes to their respective organ’s policy and allocation process
  • What it won't do
    • The paper will not provide required criteria for how organ specific OPTN committees are supposed to change policy and allocation


  • Ethical considerations
  • Utility
  • Equity
  • Transparency and autonomy

Terms to know

  • Ethical Principle of Utility: The greatest benefit for the entire community.
  • Ethical Principle of Equity: The fair pattern of distribution of benefits.
  • Ethical Principle of Transparency and autonomy: Association with the ethical principle of respect for persons, and holds that actions or practices tend to be right insofar as they respect individual’s independent choices, as long as the choices do not impose harm on others, and the ability to easily understand any new allocation rules and processes.
  • Continuous Distribution: The name of the new approach the OPTN uses to develop a more equitable system of allocating organs.
  • Composite Allocation Score: The number used in Continuous Distribution that will be assigned to waiting list patients. This score is determined by using several patient factors.

Click here to search the OPTN glossary

Provide feedback

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Region 1 | 09/24/2021

Region 1 sentiment: 1 Strongly Support, 7 Support, 0 Neutral/Abstain, 0 Oppose, 0 Strongly Oppose. No comments.

OPTN Pancreas Transplantation Committee | 09/24/2021

The Pancreas Committee thanks the OPTN Ethics Committee for the opportunity to review their public comment proposal. The Committee provides the following feedback: Members expressed appreciation for the work the Ethics Committee has done in tandem with the Kidney and Pancreas Committees as they work on the Continuous Distribution project. A member noted that the weighting of the attributes is where they see most of the value based judgements coming into play. By not just relying on the modeling and instead gathering feedback on the communities values of different attributes through the analytical hierarchy process (AHP) exercise, this creates an allocation system that more easily identifies areas where certain groups may be disadvantaged and is more responsive.

American Nephrology Nurses Association (ANNA | 09/23/2021

ANNA supports


Region 6 | 09/23/2021

Region 6 sentiment: 4 Strongly Support; 16 Support; 4 Neutral/Abstain; 0 Oppose; 0 Strongly Oppose. Comments: One attendee noted a potential recipient being listed one day before their 18th birthday versus a patient listed on their 18th birthday would dramatically change their scores. Another commenter recommended the committee assess the overall impact of continuous distribution on kidney discard rates. A third attendee expressed appreciation for the attention given to pediatric considerations in the ethics of continuous distribution in organ allocation, and noted special attention should continue to be given to pediatrics across all organs in the development of continuous distribution.

Region 8 | 09/22/2021

Region 8 sentiment: 5 strongly support, 14 support, 3 neutral/abstain, 0 oppose, 0 strongly oppose. Comments: Region 8 supports this proposal. A member provided support for the paper, and stated that overall he thinks the paper is well written and informative. But he did question whether the OPTN will review the current lung allocation proposal in the light of the included recommendations prior to making a final decision on its adoption and implementation. A member questioned whether continuous distribution is truly an ethical issue. He stated that as long as disparities remain in supply/demand, as well as other issues such as health care insurance, race, etc. there will be issues of allocation. Further, there will always be an unresolvable ethical debate of trying to balance different aspects.

Region 7 | 09/15/2021

Region 7 sentiment: 3 strongly support, 11 support, 3 neutral/abstain, 0 oppose, 0 strongly oppose. Comments: One attendee commented that protection for pediatric candidates should be underscored.

Region 9 | 09/14/2021

Region 9 sentiment:  1 Strongly Support; 6 Support; 1 Neutral/Abstain; 0 Oppose; 0 Strongly Oppose. No comments .

Region 3 | 09/10/2021

Region 3 sentiment: 3 strongly support, 5 support, 6 neutral/abstain, 0 oppose, 1 strongly oppose. Region 3 supported this proposal. One attendee expressed appreciation for the work of the ethics committee.

Region 2 | 09/10/2021

• Region 2 sentiment: 7 Strongly Support, 16 Support, 2 Neutral/Abstain, 0 Oppose, 0 Strongly Oppose • Comments: This was not discussed during the meeting but OPTN representatives were able to submit comments with their sentiment. Members of the region supported the white paper, and one member stated that there needs to be consideration regarding significant increases in costs and staffing as these will further challenge organizations coupled with imminent changes to reimbursement. Another member noted that while evaluating the various attributes, it would be helpful to also consider other items that may impact the Continuous Distribution allocation system, such as the ability to handle an increased volume of organ offers. Due to the increased volume many OPOs are moving away from facilitating import offers for their local transplant centers. There are also financial implications to consider like increased transportation costs. As the community moves to a Continuous Distribution allocation system, will it decrease organ discards? Lastly, a member noted that it would be more equitable to reconsider the pediatric designation across all organ types to a youth designation and that for certain very young adults the allocation should gradually move down a scale as they age into more mature adulthood, perhaps with the scale ending at 25 years old

Region 5 | 08/30/2021

Region 5 sentiment: 7 strongly support, 16 support, 2 neutral/abstain, 1 oppose, 0 strongly oppose. Region 5 supported the white paper for Ethical Considerations of Continuous Distribution in Organ Allocation. A member stated that this is an important consideration during the transition to continuous distribution. Another member commented the regional impact of continuous distribution must occur and that there should be consideration of ethics in continuous distribution decisions.

Region 4 | 08/27/2021

1 strongly support, 9 support, 1 neutral/abstain, 0 oppose, 0 strongly oppose. Region 4 supported this whitepaper.