Ethics in liver transplantation.

In little over 30 years, liver transplantation has become the preferred therapy for many forms of end-stage liver disease. Improvements in immunosuppression, management of comorbidities, and surgical techniques have contributed to the spectacular improvement in patient and graft survival. Unfortunately, global application of this lifesaving therapy is limited by the inadequate supply of livers available for transplantation. Therefore, in an effort to minimize the mortality among patients waiting for liver transplantation, allocation based on the model for end-stage liver disease (MELD) has been adopted. Unfortunately, the current allocation system, initially developed to distribute deceased-donor kidneys for transplantation, has many deficiencies when applied to the allocation of deceased-donor livers. One such deficiency is exemplified by the unequal distribution of deceased-donor livers across and within regions with respect to MELD. Consequently, the national directive to transplant the sickest first among those awaiting liver transplantation has yet to be realized among all patients listed irrespective of region.