BackgroundThe allocation of any scarce health care resource, especially a lifesaving resource, can create profound ethical and legal challenges. Liver transplant allocation currently is based upon urgency, a sickest-first approach, and does not utilize capacity to benefit. While urgency can be described reasonably well with the MELD system, benefit encompasses multiple dimensions of patients’ well-being. Currently, the balance between both principles is ill-defined.MethodsThis survey with 502 participants examines how urgency and benefit are weighted by different stakeholders (medical staff, patients on the liver transplant list or already transplanted, medical students and non-medical university staff and students).ResultsLiver transplant patients favored the sickest-first allocation, although all other groups tended to favor benefit. Criteria of a successful transplantation were a minimum survival of at least 1 year and recovery of functional status to being ambulatory and capable of all self-care (ECOG 2). An individual delisting decision was accepted when the 1-year survival probability would fall below 50%. Benefit was found to be a critical variable that may also trigger the willingness to donate organs.ConclusionsThe strong interest of stakeholder for successful liver transplants is inadequately translated into current allocation rules.

The German Transplant Law is the legal basis of the liver allocation system in Germany and is specified by the guidelines of the German Medical Association. These guidelines are based on current medical knowledge. The procedure of developing these guidelines was formalised and made transparent.This survey with 502 participants examines how four current aspects of the allocation system are perceived by different stakeholders (medical staff, patients on the liver transplant list or already transplanted, medical students and non-medical university personnel and students). A great majority of respondents considered the current organ allocation system to be fair. Physicians were given a great say on allocation rules. Most respondents assessed the chances of a patient on the transplant list to receive a donor organ over time as being worse than it really was. The respondents supported six month alcohol abstinence before patients with alcohol-related liver cirrhosis are listed for liver transplantation. The findings suggest that people trust that physicians develop fair allocation rules and appreciate the current liver allocation system.