LIVER TRANSPLANT PRIORITIES CHANGED.

Byline: Gina Kolata The New York Times

An organization that controls the allocation of organs for transplant voted Thursday to change substantially the rules for determining which dying patients get livers, giving those with the best prospects of survival top priority. In doing so, the group made a rationing decision that has been shunned by most of American medicine.

The decision, made by the board of the United Network for Organ Sharing, a private group of transplant experts overseen by the Department of Health and Human Services, revises the longstanding policy of putting the sickest patients at the top of the waiting list for new livers, no matter their chances for survival.

People who suffer liver failure because of a sudden illness do much better when they receive a transplant than people who have been ill for a long time. The new rules apply only to people who are already at the top of a transplant list and who are expected to die within days.

From now on, anyone who faces imminent death because of an unexpected liver failure - from mushroom poisoning, for instance, or a rampant viral infection - will have priority over those who are just as ill but who have a chronic disease, like cirrhosis of the liver caused by years of alcoholism or hepatitis C or B infections, viral diseases that damage the liver over decades. Hepatitis A, which can be contracted from eating contaminated shellfish, usually does not cause permanent liver damage or terminal illness.

About a quarter of adults who receive liver transplants have alcoholic cirrhosis. Others have chronic diseases including liver tumors, nonalcoholic cirrhosis and several inherited disorders.

Although the new rules could make it harder for some alcoholics to receive liver transplants, there is no moral judgment involved, said Dr. William Payne, director of the liver transplant program at the University of Minnesota and a board member of the United Network for Organ Sharing.

The organ-sharing network took its action on liver transplants and not on other organs because there is a significant shortage of livers for transplanting, and because for someone suffering liver failure, there is nothing comparable to kidney dialysis, which can keep someone in need of a kidney transplant alive indefinitely.

For instance, the change in rules would not have affected former baseball star Mickey Mantle's liver transplant in 1995, although he had both hepatitis and cirrhosis of the liver, because there was no one ahead of him on the regional liver transplant waiting list.

Joel Newman, a spokesman for the network, based in Richmond, said the publicity given the Mantle case had nothing to do with the group's decision. ``There's been considerable discussion about liver allocation that began before Mickey Mantle and continues to this day,'' Newman said.

Both transplant surgeons and ethicists said the significance of Thursday's decision went far beyond deciding which dying patient received a liver.

``The decision has been made to say, let's ration to the ones with the greatest chance of being helped,'' said Dr. Richard Thistlethwaite, a surgeon who is chief of transplantation at the University of Chicago. Although Thistlethwaite said he agreed with the change, ``that's not the way American medicine has been done.'' Until now, he said, ``American medicine has looked at each patient individually and tried to do what's best for the patient.''

Dr. Arthur Caplan, the director of the Center for Bioethics at the University of Pennsylvania, has studied organ transplant policies for 15 years and sees the liver decision as a test case for medical rationing in general.

``This isn't of interest only to people who need livers,'' Caplan said. ``It is a case study of rationing. It is of fundamental interest to every American. All of us will have to confront the decision of what is fair in the allocation of scarce resources. This is a canary in a mine that all of us will have to enter.''

With liver transplants, all agree that the issue of rationing is urgent. Last year, 7,279 people put their names on waiting lists for a liver, but only 3,922 liver transplants were performed. In general, patients move up the list according to how sick they are and how long they have waited.

``The real issue is that there are not enough organs and that people are going to die waiting for livers,'' Thistlethwaite said.

So who lives and who dies?

``It's truly a dilemma,'' said Payne, the board member of the United Network for Organ Sharing. The group struggled to make its rules, he said, ``trying desperately to balance justice and utility.'' It decided that since the acutely ill did best with liver transplants, they should be moved to the top of the list.

Also moved to the top for the same reasons were those who just had a liver transplant that failed within seven days. And since children also do well, those children who would suffer damage to their nervous systems if they did not immediately get a liver were also given priority, even if they were not terminally ill.

``If I had alcoholic liver disease, I would think this is unfair,'' Thistlethwaite said. ``There's no right answer. The right answer is to have more organs.''

Some ethicists say rationing should apply to everyone on a transplant list, not just the most desperately ill.

``It seems to me you ought to extend it all the way,'' said Dr. Stuart Youngner, the director of the clinical ethics program at University Hospitals of Cleveland. ``If somebody who isn't at death's door would do better with a transplant than somebody who is, why wouldn't you give it to them?''