Once it appears, it's a difficult image to shake: The friendly skies filled with thousands of iced kidneys, livers, hearts and lungs crisscrossing the country on red-eye shuttles. It's more than just a reason to hope for a turbulence-free flight, though.

A group of the country's largest surgical centers recently pushed for wider sharing of precious bodily organs among hospitals nationwide. They charge that the way transplantable organs are distributed is unfair--and occasionally deadly--to patients.

The current system dictates that most organs be transplanted close to where they were donated. This might work fine if a handful of medical centers didn't do the majority of the country's transplant operations. Because of the regional system, however, these centers can suffer a severe organ shortage while others are flush.

In addition, there is no official mechanism to marry perfectly matched organs and patients nationwide. There is no guarantee that even though a Colorado liver is ideal for a California patient, the two will ever meet.

"The organs belong to the patients and not to us," says Goran Klintmalm, director of transplantation services at Baylor University Medical Center in Dallas, one of the seven busiest centers in the country and a strong proponent of wider organ sharing. "Each patient should have the same access, regardless of where they live."

Yet the idea is strenuously opposed by the country's smaller transplant centers, including the University of Colorado Health Sciences Center. Igal Kam, the hospital's chief of transplantation, says that putting Colorado patients who need transplants on a larger list could result in locals getting inferior replacements.

"If this happens," he warns, "Colorado will still get its share of organs. But they will be the worse organs, the borderline organs. Organs should stay close to their recipients."

Most transplant specialists concede that the disagreement over how to disperse the valuable replacement parts is partially a turf war over a scarce resource. Yet it also cuts to some of the industry's most vexing ethical questions.

A system in which hospitals pulled organs off a national list, for instance, would force surgeons to come up with universally accepted guidelines--and then follow them--as to who appears on the waiting list, and when. The debate also raises the question of which patients should be candidates for transplants: Those most likely to survive, or those whose need is most urgent?

The way organs are now distributed favors smaller, local centers. For transplant purposes, the country is divided into eleven regions. Each region has several organizations that gather livers, kidneys, hearts and lungs. The organs are first made available to local patients. If no one can use them, they go into a regional pool and then into a national one. It is a system that critics contend doesn't work, simply because some regions do disproportionately more transplant operations than others.

"The small size of the regions provides for inequities in sharing," complains Baylor's Klintmalm. "Because of these artificial boundaries we have set up, patients may have to wait a disparate amount of time. In one part of the country, they might wait eighteen days, and in another, 260 days. Patients right now aren't being treated equally."

A study completed by the United Network of Organ Sharing (UNOS)--a Virginia organization that coordinates organ distribution throughout the country and also functions as a sort of transplant-issues clearinghouse--confirms Klintmalm's point. Waiting times in 1992 for a liver range from a median of about fifty days in the southeast United States to nearly a year in the state of New York, which operates as its own region. (In Colorado, the median wait was 73 days.)

CU's Kam responds that such inequities are not a glitch in the regional organ distribution system but rather a result of stresses caused by managed health care. He points out that when insurance companies shop nationally for good deals, they frequently end up sending patients to the country's largest centers. (Klintmalm says that's partially because patients in larger centers have better outcomes, which Kam disputes.)

The result is an imbalance between a region's supply and demand. For example, even though the University of Pittsburgh Medical Center is supplied with organs primarily from the mid-Atlantic region, many of the patients on its waiting lists are from other parts of the country. If insurers would allow people to stay put, Kam says, most regions could adequately supply their transplant centers with enough organs.

Kam adds that it makes good medical sense to let people receive their transplants close to home. Fifty percent of a transplant's success revolves around a patient's care after the actual operation. So it follows that if a patient stays closer to home, he will recover better, Kam says.

In addition, Kam points out that transplant patients are always better off using fresh, local organs. A liver arriving in Colorado by Learjet twelve hours after being pulled from a car fatality in Atlanta is inferior to one that can make it to a CU operating room just a couple of hours after being harvested from a farm accident outside of Greeley.

Others cite arguments against national organ-sharing that are more parochial than medical. In Colorado and Wyoming, organ collection and distribution falls to Colorado Organ Recovery Systems (CORS). According to Director Jim Springer, the organization has been comparatively successful in convincing residents of the two states to donate their organs to others.

One reason, he believes, is that people believe they are performing a community service. "We feel a strong tie to our local community," he says. "We're trying to help people close to home." He hypothesizes that if Coloradans knew their organs were going to be used in, say, New York City, they might not be so eager to donate.

The issue of wider organ-sharing began in August 1993, when a group of physicians representing the country's largest centers sent a letter to Congress advocating a revision of the regional system. Yet one year later, it is far from clear how the debate will be resolved. Even supporters of national organ-donor lists (or simply larger regions) concede that many thorny issues remain.

For instance, at what point should a transplant patient go on a list? UNOS spokesman Joel Newman says that even if surgeons, a notoriously hardheaded lot, agree on a set of rules, hospitals must agree to follow them. As it stands now, he says, the heated competition for organs leads some institutions to place patients on a waiting list before they belong there. The reason: The longer a person waits, the better chance he (and the hospital, of course) has of getting an organ.

Even more basic is the question of who should appear on the waiting lists. Newman points out that some hospitals will accept people carrying the hepatitis B virus for a liver transplant; others won't. "There are no hard-and-fast guidelines," he says. "The individual transplant centers set their own protocols on who they accept and who they won't."

Whatever changes emerge from the fracas, nearly everyone agrees that a system in which seven people die every day waiting for a transplant organ could stand some re-examination. Even CORS's Springer concedes, "We've got to look beyond our own patients at times.

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