Lung transplantation and organ allocation in Brazil

Abstract

The philosophy of organ allocation is the result of two seemingly irreconcilable principles: utilitarianism and distributive justice. The process of organ donation and transplantation in Brazil reveals large inequalities between regions and units of the Federation, from the harvesting of organs to their implantation. In this context, lung transplantation is performed in only a few centers in the country and is still a treatment with limited long-term results. The allocation of the few organs harvested for the few procedures performed is defined mainly by chronology, a criterion that is not linked to necessity, which is a criterion of distributive justice, and neither to utility, a criterion of utilitarianism. This article reviews the organ allocation philosophy focusing on the case of lung transplantations in Brazil.

Clinical characteristics and outcomes in adult cystic fibrosis patients with severe lung disease in Porto Alegre, southern Brazil

“…Patients who receive an organ that does not function within the first 48 h are an exception to the criteria above. In these situations, these receptors can be listed to receive another organ with urgency, being automatically placed at the top of the list [20]. The mean time on the waiting list for lung transplantation during the period of the study was approximately 18 months [21].…”

Thoracic surgery in Brazil: an overview

“…To date, there are eight active lung transplantation programs in Brazil, four located in the southeast states (three in São Paulo and one in Rio de Janeiro), three in south states (two in Rio Grande do Sul and one in Paraná), and one in the northeast (in the state of Ceará). Beginning in 1989 as the first lung transplantation in Latin America with the pioneering of Prof. Dr. Jose Jesus Camargo in the state of Rio Grande do Sul, the total cumulative number of lung transplants performed accounts for more than 1,300 procedures according to the 2021's Brazilian Organ Transplantation Association (ABTO) report, initiated in 1997 (19) Distinct from North America and some countries in Europe, Brazil's lung allocation system respects the chronological listing time, not specific prognostic scores such as Organ Procurement Transplantation Network (OPTM) Lung Allocation Score (20). On the other hand, similarly to the worldwide tendencies, Brazilian programs are performing progressively more bilateral transplants with increasing use of ECMO technology, with comparable survival results to those reported in the international literature (21).…”

“…Distinct from North America and some countries in Europe, Brazil’s lung allocation system respects the chronological listing time, not specific prognostic scores such as Organ Procurement Transplantation Network (OPTM) Lung Allocation Score ( 20 ). On the other hand, similarly to the worldwide tendencies, Brazilian programs are performing progressively more bilateral transplants with increasing use of ECMO technology, with comparable survival results to those reported in the international literature ( 21 ).…”

Lung transplant—shifting sands!

“…The chronological criteria put certain pathologies like pulmonary fibrosis at a disadvantage, because these patients may deteriorate suddenly and catastrophically on the wait-list. ‘In a health system based on universality and equity, the application of the criterion of necessity, based on distributive justice, is ideal’ [ 2 ]. However, the relative merits of the philosophies of ‘utilitarianism’ and ‘distributive justice’, based on ‘maximum good of the maximum people’ versus the need based on the severity of illness respectively, can be debated.…”

“…The latter, though may be needing urgent transplantations, lest they risk death on the transplant list, are avoided at the altar of superior results. However, with this need to treat ‘the unequal unequally to promote equity’ [ 2 ], ‘distributive justice’ seems right to be gaining in India.…”