Gatekeeping and Bias Against Pediatric Risk in Solid Organ Transplant

We present the case of a three-year-old boy with an inherited progressive liver disease who developed liver failure and required a liver transplant to survive into adulthood. The child had a second medical condition that increased his risk of poor outcome during a liver transplantation, but the absolute risk was unknowable. Newer regulations, including the 2007 Centers of Medicare & Medicaid Services (CMS), which published the Conditions of Participation (CoPs) for United States transplant centers, fostered a new environment that created incentives for transplant centers to be more conservative in the selection of candidates and altered the traditional role of gatekeeping performed by the transplant team.1 After reviewing the relevant U.S. transplant policies and their impact on transplant centers, this review seeks to provide ethical arguments related to justice, fairness, and utility in the distribution of scarce organs in this more risk-averse environment. The net effect of the changes in transplant regulation appears to be exclusion of potential candidates for whom solid organ transplant is clearly in their best interests. The change in the nature of gatekeeping may also undermine the trust of both patients and the public in transplantation.