Inequalities on the UNOS Transplant Lists Have Gone On for Too Lung

By: R. Peterken


The Gift of Life by Ada Love

What would you do if a loved one’s only chance at living was getting a high-demand organ that’s in low supply? The lack of supply of organs versus the demand for them is one of the biggest current issues with the United Network for Organ Sharing (UNOS) waitlists (there are separate waitlists for children and adults).

There is much debate about how to ethically rank patients for receiving an organ, especially because different people have varying opinions on what factors are important.  According to the official UNOS website, factors like blood type and age contribute to where a patient is placed on their respective waitlist for all donated organs. However, there are also factors that are specific to the certain organ that is needed.  This piece will focus mainly on those patients who need liver transplants and what factors contribute to their ranking as well as the inequalities that they face.  Important factors specific to liver transplant patients on the UNOS lists include medical urgency and the patient’s Model for End Stage Liver Disease (MELD) score.  According to the journal Annals of Gastroenterology, patients who have a higher MELD score typically are on the wait lists for less time.    

While the UNOS transplant lists have benefits for many liver transplant patients, they also have major pitfalls. The official UNOS website explains that the lists currently are created by a computer that receives both donor and transplant data.  The computer takes the information and makes a ranked list of patients who could potentially get the organ based off general (ex. blood type) and organ specific factors (ex. medical urgency).  One paramount benefit of this system includes that a computer is able to rank the patients, meaning that healthcare and administrative personnel do not have to make the hard decision of how organs are rationed.

Another pro to the UNOS ranking system is that children and adults are each given their own specific list, meaning the organs can be given to the age group/patients that will have the best chance of a successful transplant and recovery.  On the other hand, a pitfall is the apparent inequalities that will later be discussed involving the system of ranking patients/ the UNOS lists.   Inequalities can be shown by investigating which patients get transplants and how this correlates to factors such as ethnicity, socioeconomic status, and age.

Inequalities can quickly become harmful and even deadly for many patients who need liver transplants if they are unable to obtain an organ before succumbing to their illness. A study from Gastroenterology, vol. 154, explored data on patients removed from the UNOS adult wait list in the U.S. from 2006-2016 due to receiving an organ transplant, death, etc. The findings showed that there were several inequalities stemming from influences such as insurance type.

This same journal stated that patients who do not have private insurance are more likely to die while still on the waiting list.  According to a section from a different journal, Gastroenterology and Hepatology, the National Healthcare Disparities Report said that not having insurance was a huge obstacle in getting healthcare for both Asian and African American populations.  Having private insurance makes it much easier to get evaluated for UNOS waitlist candidacy and can even get patients evaluated at multiple centers. While it is beneficial to have, is not always possible to obtain because of the high costs.

Another major inequality discussed in a study in the journal Gastroenterology, vol. 154 was the fact that Black and Asian patients were found to be less likely than whites to die on the waiting lists.  While this may at first seem like an inequality to whites, the official current numbers of each ethnicity on the UNOS waiting lists tell a different story.  The data shows that the number of white patients registered as candidates for a liver transplant is about the same as the number of patients from all other ethnicities combined.  This means that while more whites are dying, there are thousands more of them on the UNOS lists for liver transplants compared to other ethnicities.

One explanation for why there are so few minorities in the U.S. on the list is that liver transplants are extremely expensive, and many patients who are Asian, Hispanic, etc. may not have the means to be able to afford getting evaluated, medical bills or transfers to other centers when organs become available.  Inequalities such as the ones stemming from being a minority cause a large amount of skepticism for UNOS and its current system.

The skepticism previously mentioned means that many people are scared to donate organs, which breeds a cycle of organ shortage.  In fact, in a study from the early 2000’s discussed in the Journal of General Internal Medicine, it was stated that many populations (especially African Americans) were either unwilling to donate or did not understand how great the shortage for livers was.  Many also did not trust the healthcare system in general because of the inequalities present.

According to journals such as the Revista de Bioteca y Derecho, one way to lessen the inequalities on the lists would be to make the UNOS lists public.  This journal explains that doing so would lead to less skepticism in the general public.  This is because if the public was able to see where patients were on the lists, they would be more likely to believe that the lists would not be unfairly changed to help certain races, celebrities, etc.  This would also make it possible to see some of the inequalities that minorities face and could lead to policy changes that help solve these problems.  A build-up of trust and lessening of inequalities would increase the amount of organs being donated, essentially lowering the gap between the supply and demand.

This research shows that while the current UNOS system used does have its pros, it is defined by many to be a broken system.  Without change, there will continue to be a high volume of patients who die without the organ transplant that they need. Making the list transparent is just one way that would likely increase the public’s trust in UNOS, and make many more willing to donate.  This would progressively lessen the cycle of inequality that stems from a lack of organs. Discussions surrounding the issues on the UNOS organ transplant lists and possible solutions need to become more prominent for patients in the United States to have a happier, healthier future.


“How We Match Organs.” UNOS, 10 February 2020.

Kemmer, Nyingi. “Ethnic disparities in Liver Transplantation.” Gastroenterology & Hepatology vol. 7, (2011).

“Organ Procurement and Transplantation Network.” OPTN, OPTN, 11 February 2020.

Shen, Nicole T., et al. “Sa1508 – National and Regional Ten Year Assessment of United Network for Organ Sharing (UNOS) Liver Transplant Data Wait List Removals: Improvement over Time but Inequalities Persist.” Gastroenterology, vol. 154, no. 6, 2018, p. S1137.,

Siminoff, Laura A et al. “Racial Disparities in Preferences and Perceptions Regarding Organ Donation.” Journal of General Internal Medicine vol. 21,9 (2006): 995-1000.

Trieu, Judy A et al., “Factors associated with waiting time on the liver transplant list: an analysis of the United Network for Organ Sharing (UNOS) database.” Annals of gastroenterology vol. 31, 155, 1 (2018): 84-89.

Zúñiga-Fajuri, Alejandra. “The Case for Making Organ Transplant Waitlists Public to Increase Donation Rates: Is It Possible?.” Revista de Bioética y Derecho, Vol 55. (2017): 187-196. Web. 21 Jan. 2020.

Image Credits:

Author: Ada Love

Title of Image: Woman Gives the Gift of Life

Website: Right as Rain by UW Medicine


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