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Ethical Evaluation of Multiple Listing

eye iconAt a glance

Current policy

Currently, OPTN Policy 3.4 Multiple Transplant Program Registrations allows patients to be registered for an organ transplant at more than one transplant hospital. This policy also allows transplant hospitals to decide whether or not to accept a candidate who is listed at more than one transplant hospital. Additionally, OPTN Policy 3.2 Notifying Patients on their Options requires transplant hospitals to let patients know that the patient is allowed to be registered at more than one transplant hospital. This practice is known as “multiple listing” within the transplant community.

Although current policy allows multiple listing, there have been several different attempts to remove the policy in previous decades. The primary ethical concerns are equitable access to transplantation and whether multiple listed patients have an advantage over patients listed at only one transplant hospital.

Supporting media


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  • Ethical analysis of allowing patients to list at more than one transplant hospital and accept organ offers at more than one transplant hospital simultaneously
  • Applies the ethical principles of organ transplant to the multiple listing topic – these principles are: equity (which includes distributive justice and procedural justice), utility, and autonomy
  • Includes sociodemographic data on the use of multiple listing
  • Considers disparities in patient access and recommends how to promote equity in access for patients

Anticipated impact

  • What it's expected to do
    • Provides an ethical analysis of multiple listing through the ethical principles that apply to organ transplant
    • Recommends to the transplant community that multiple listing should apply and be used to increase equitable access to transplantation for medically complex or otherwise hard to match patients
    • Recommends that transplant hospitals should not be allowed to deny medically complex patients from multiply listing at their hospital
    • Recommends that transplant programs give extra support to medically complex patients
    • Recommends that support and transparent information is given to patients to aid them in choosing a primary transplant program that is the best fit for the patients’ needs, preferences, and values
  • What it won't do
    • There are no changes to policy
    • There are no changes to allocation
    • There are no changes to data collection

Terms to know

  • White paper: A white paper considers a complex issue and develops a position.
  • Ethics Committee’s Scope: The Ethics Committee makes recommendations to OPTN Board of Directors for changing, creating, or eliminating policies if warranted by ethical concerns.
  • Multiple listing: being on the transplant waiting list for the same organ type at more than one transplant hospital
  • Equity: The ethical principle of equity, in organ transplant, refers to removing barriers in access to transplant so that those with fewer resources still have equal access to information on transplant programs.
  • Distributive justice: The ethical principle of distributive justice dictates fairness in the distribution of scarce resources so that similarly needy patients have an equal opportunity to benefit from transplantation.
  • Procedural justice: The ethical principle of procedural justice, in organ transplant, ensures a commitment to treat cases similarly, transparently, and predictably.
  • Autonomy: The ethical principle of autonomy, in organ transplant, refers to one’s ability to be self-directing, decide what happens to oneself in the future, and the ability to be a part of decisions regarding one’s own medical treatment.
  • Utility: The ethical principle of utility, in organ transplant, refers to creating the most benefit to the transplant community (i.e. promote graft survival, reduce waste, improve efficiency).

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matthew mulloy | 02/03/2023

I am frankly saddened that valuable time and resources were spent on the ethics white paper concerning multiple listings. There have been very few things to come out of UNOS/OPTN that I have ever disagreed with more. I understand that there is a problem that is trying to be addressed. However, I have never had a single patient ask me to make the transplant system in this country one that is more restrictive and provides them with less access. There are a wide number of valid reasons a person may seek to dual list other than simply trying to "game the system". The solution proposed seems borderline socialist and I would think, if enacted, would create a large number of valid legal challenges across a wide number of states. Rather than restrict the autonomy of one group of patients to provide a paternalistic benefit to another I would propose that we continue to educate patients as to their options and see if the are other ways to fix the inequities. If there was a proposal to limit the number of centers an individual could be actively listed at to 2 or 3, I could see where that may improve things slightly and still leave patients with an ability to have options. Maybe this an option that could be considered. I would have to ask the ethics committee how many patients waiting for transplant did they talk with before reaching these conclusions? As I previously stated, I have never encountered a single patient awaiting transplant who has asked that we as a community restrict access to transplantation. Academic exercises are great in theory, but it seems that the committee may have lost sight of the forest from the trees while debating ethical definitions and applying them to the transplant community as a whole. I completely disagree with the concept of limiting an individuals right to be listed at multiple centers. American healthcare has been based on access and choice and limiting this for many in order to attempt to help a few doesn't seem the best way to go about solving the problem, but feels more like a cop out.

Lorrindas Gray-Davis | 02/02/2023

This will cause even more issues because it does not address the cost associated with evaluation, travel, lodging, etc. Scholarships are recognized as needed but nothing as to how that can happen.

Andrew Courtwright | 02/01/2023

I appreciate the committee’s comprehensive approach—both normative and epidemiological—to this topic. The data on time to transplant among multiply listed candidates was unexpected and captures some of the tensions between high visibility cases and the more mundane utilization of multiple listing. Two comments: 1) Preserving access to multiple listings for highly sensitized candidates is not merely a matter of utility or fair equality of opportunity. Highly sensitized candidates are more likely to be non-White women, a population that already has reduced access to transplant. A commitment to addressing inequalities in transplant gives particular moral weight to policies such as multiple listings that ameliorate pre-existing disparities. The committee’s argument here could be strengthened with reference to the sociodemographics of sensitized candidates (1-3). 2) In practice, there are several reasons why multiple listings may benefit candidates aside from their being intrinsically difficult to match because of, for example, sensitization. Older candidates who are at risk of “aging out” of a program’s age cutoff have a short time window to transplant, even if they are otherwise not a difficult match. Similarly, candidates who have diseases (e.g. pulmonary veno-occlusive disease; combined pulmonary fibrosis and emphysema) that are at risk for rapid acceleration but have low prioritization scores would also benefit from multiple listings given their short time window before disease progression. Finally, changes in program staff such as the loss of a transplant surgeon or program willingness to take on transplant risk as a result of CMS flagging can change a candidate’s ability to access transplant at a center. In this setting, the ability to access multiple listings would be appropriate, independently of the difficulty that any specific patient may have finding a match. Candidates may, for example, prefer to maintain listing at the original center while programmatic challenges are being resolved but also being listed at another regional center to maintain access to transplant. 1. Higgins RS, Fishman JA. Disparities in solid organ transplantation for ethnic minorities: facts and solutions. Am J Transplantation. 2006;6:2556-2562. 2. Tambur AR, Campbell P, Claas FH, et al. Sensitization in transplantation: assessment of risk (STAR) 2017 working group meeting report. Am J Transplant. 2018;18:1604-1614. 3. Tambur AR, Campbell P, Chong AS, et al. Sensitization in transplantation: assessment of risk (STAR) 2019 working group meeting report. Am J Transplant. 2020;20:2652-2668.

Steven Weitzen | 01/29/2023

The system should be made to allow for multiple listing. If there are inequities, the system should be reorganized or update to make it work, because it is so important. Educating all that are involved would be a big step toward success.

Melanie Everitt | 01/25/2023

Please also address any ethical issues related to patients who can be multiple listed as pediatric and as an adult due to their 18th birthday; and, therefore, have potentially different advantages over other patients with similar acuity who are singly listed.