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ONCE CONSIDERED experimental, transplantation for end-stage cardiac disease has now achieved accepted status. Survival rates of 70% to 80% for one year and 50% for five years are routine. Medicare has announced that it will cover heart transplants at selected centers. Many public and private insurers already extend this coverage. As heart transplantation matures medically, a second generation of ethical and policy issues demands attention. The concerns about safety and efficacy, which led to a moratorium of the procedure in the 1970's, have given way to questions about increasing organ supply and developing fair systems for allocating and distributing the hearts that become available. While these questions are typical of later stages of biotechnological development, they present a new challenge to further progress in cardiac transplantation. Scarcity as the key issue. A central fact about organ transplantation, and heart transplantation in particular, is the scarcity of organs for transplant. Only a minority of patients who would benefit receive transplants. Although twice as many people (719) received heart transplants in 1984 as in 1983 (365), more than 1000 patients died awaiting a donor heart.' Many more who would benefit had not even been referred for evaluation. The National Heart Transplant Study found that 14,000 to 15,000 people a year could benefit from the procedure under current criteria for heart transplantation.2 Relaxing the criteria would make the gap between supply and demand even greater. Yet donor supply is also limited by medical, social, moral, and legal factors. An estimated 17,000 to 26,000 persons annually become brain dead while maintained on respirators, a situation that makes them potential organ donors.3 (Changes in speeding, seatbelt, helmet, gun, and other laws could affect this number in either direction). It has been estimated that

Supply and distribution of hearts for transplantation: legal, ethical, and policy issues.