Foreign Candidates on the Transplantation Waiting List: An Ethical Dilemma G. Sahar, M. Berman, H. Shmuely, T. Ben-Gal, E. Sahar, A. Kogan, R. Michowitch, G.P. Georghiou, V. Bobovnikov, A. Sagie, D. Aravot, and B.A. Vidne I T IS NOW well recognized that the gap between the supply of available transplantable human organs and the need is constantly increasing. Medical suitability is the basis of organ allocation, although the social, economic, psychologic, and demographic situation of each potential recipient represents important considerations. The ethical dilemma that we face is whether foreign, nonresident candidates should be placed on a national waiting list, and, if the answer is positive, under what terms? Organ trans- plantation, especially heart or lung, requires not only a well-trained group, but also an extensive infrastructure, which does not exist in each country. The lack of organs in the one hand and the lack of infrastructure in other countries on the other hand lead to the need for a mutual partnership among nations. Among the 100 organs transplanted in our center, 3 were donated by nonresident Palestinians who were treated in Israeli hospitals, 1 of whom was a victim of a violent act during the “Intifada.” The Palestinian population, although being provided with diverse medical services, is not entitled to be on the Israeli national waiting list. The ethical question that the medical community faces in these circum- stances is whether to accept a family request to donate the organs to a close relative of the donor instead of offering them to all patients on the list. The other debate is whether the waiting list should be equally open to residents and nonresidents, now that they have became part of the potential population to donate. As Kleinig 1 suggested, there are three possible options concerning a system of organ allocation to nonresidents: (1) a single-list equal access system, in which residency plays no role; (2) a dual-list differential access system, based on resi- dency, in which members of the resident list have right of first refusal; and (3) a single-list differential access system, in which non- residents are subject to a quota. Kleinig believes that fairness should be the strongest argument in favor of the third option due to a moral obligation for international sharing. Prottas 2 express a different point of view which is supported by The Euro- transplant International Foundation 3 favoring a two-list system. In a two-list system, those on the first list would have first refusal on any organ. No physician would be asked to transplant any organ not found suitable, but neither would any be denied an organ he or she wished to trans- plant because it was going to a nonresident alien. At the same time, no organ would be wasted, and someone on the second list would receive a transplant. The Middle East makes the task of sharing even harder due to the political debate. We believe that peace will offer, among other benefits, the option to open regional and national waiting lists to nonresidents thereby expanding the potential organ pool. In time, the virtues of a dual-list system versus a quota sytem will be discussed among nations, assessing the European and US approacher. REFERENCES 1. Kleining J: Transplant Proc 21:3430, 1989 2. Prottas JM: Transplant Proc 21:3426, 1989 3. Haase-Kromwijk B, du Pre F, Cohen B: J Health Serv Res Policy 2:168, 1997 From the Department of Cardiothoracic Surgery, Heart-Lung Transplant Unit (G.S., M.B, H.S., A.K., R.M., G.G., V.B., D.A., B.A.V.), and Department of Cardiology, Echocardiographic Unit (T.B-G.), Rabin Medical Center, Beilinson Campus, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Address reprint requests to Dr Marius Berman, Department of Cardiothoracic Surgery, Rabin Medical Center, Campus Beilin- son, Petah Tikva 49100, Israel. E-mail: mariusby@yahoo.com 0041-1345/03/$–see front matter © 2003 by Elsevier Science Inc. doi:10.1016/S0041-1345(03)00023-X 360 Park Avenue South, New York, NY 10010-1710 650 Transplantation Proceedings, 35, 650 (2003)