Since 1994, the US Department of Health and Human Services (HHS) and the United Network for Organ Sharing (UNOS) have been locked in a dispute over how best to allocate donor organs in the US, and who is best qualified to set organ policy. Now it seems that the UNOS has gained the upper hand following congressional intervention.

In March, the HHS put into effect what it called a final rule, declaring HHS control over transplant organ allocation policy; the rule is opposed by the UNOS, the non-profit government contractor controlling the medical network that acquires and matches organs to patients. But in April, the House of Representatives passed the Organ Procurement and Transplantation Network Amendments Act of 1999, reserving organ policy decisions to the UNOS.

This is not the first time that Congress has intervened in the dispute. A 1998 attempt by the HHS to change UNOS policies (Nature Med. 4, 376; 1998) was suspended by a congressional moratorium pending requested fact-finding investigations by the HHS and the Institute of Medicine (IOM). An IOM report last year agreed with the HHS that UNOS geographical-preference policies needed to be altered, which led to the HHS' March declaration that it would establish an independent scientific review board to oversee UNOS policies.

The two groups disagree on how to balance conflicting goals—providing fair access to all patients while making best medical use of scarce organs. Ideally, organs should go to the sickest patients; survival rates, however, are best among those who are least desperate. The HHS has complained that the UNOS too often allows patients living nearby transplant surgery centers to receive organs in preference to those in greater need, but living farther away; the HHS contends the ‘locals first’ policy causes unnecessary deaths. Last year, the UNOS did increase the proportion of organs going to the most life-threatened patients, but it is adamant that the medical community it represents is best qualified to set organ policy.

Provisions of the new act must now be reconciled with those of a bill that may eventually emerge from the Senate. That legislation has been influenced by Senator Bill Frist (R-TN), a heart-and-lung-transplant surgeon. Frist proposes that the UNOS set organ policy, but calls for a committee to arbitrate disagreements between the HHS and UNOS. However, voting on the bill has been delayed by Senator Russ Feingold (D-WI), who is concerned about the arbitration committee's makeup. His state is particularly unhappy with the HHS: Wisconsin has taken the HHS to court to maintain its ‘locals first’ preference.