Transplantation is the accepted treatment for patients with end stage liver disease, and because of an increasing number of patients being referred for transplantation, the gap between donate livers and recipients on the waiting list is ever increasing (Neuberger and James (1999). This shortage has encouraged the splitting of livers and the use of marginal organs for transplantation, but the gap still remains significant. There are substantial differences between countries in donation rates. Figures from 1996 show 26.8 cadaveric donors per million population in Spain, 21.2 in the United States, 14.6 in the United Kingdom and Republic of Ireland, 15.1 in France, and 11.0 in Italy. The high rate of donation in Spain is attributed to well-resourced and organized donor awareness programs. The Council of Europe has estimated that as many as 50 donors per million are required to meet the clinical need for liver transplants.
The United Network for Organ Sharing (UNOS) in North America has adopted minimum criteria for patients to be accepted onto the waiting list for a liver transplant because too many patients were being put onto the list at an early stage (Neuberger and James, 1999). The World Health Organization believes that organs should be allocated on the basis of medical need, and UNOS has stated that allocation should balance medical usefulness and justice. The American Medical Association Committee on Ethical Issues has outlined as criteria for acceptance of a patient for liver transplantation: the likelihood of benefit for the patient, importance for improving the quality of the patientÆs life, duration of benefit, urgency for treatment, and amount of resources likely to be required (1636). An intolerable quality of life and a life expectancy without transplant of less than one year are usually indications for liver transplantation.
Unacceptable criteria include ability to pay, patientÆs contribution to society,...