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"Something to the tune of 4,000 to 5,000 people a year will die waiting for an organ," says Mark Rosenker, an executive and lobbyist for United Network for Organ Sharing, or UNOS.

In the simplest terms, the transplant fight boils down to this: How should scarce organs, especially livers, be allocated nationwide? Should they be given to people based on where they live, as happens now? Or to the sickest patients regardless of geography, as the Clinton administration has been pushing for two years?

The longer the tug-of-war goes on, however, the messier it gets. It has revived the argument of public vs. private control of health care and bogged down in an argument over states' rights. Several governors have leaped into the fray, unhelpfully, with "hoarding" laws designed to keep organs inside their borders. Beyond politics, the debate has raised touchy questions about how to decide who receives an organ and who is left to die waiting.

Rosenker says the number of deaths will increase if organs are allocated through the federal government instead of through doctors and a private administration system. The administration takes the opposite view -- that more people will die if organs continue to be distributed not necessarily to the sickest patients, but to people who live in a particular region. No plan -- and there are well-meaning proposals floating around as well as mean-spirited ones -- is likely to solve the real problem: There aren't enough donated organs for all the people who need them.

Earlier this month, the House of Representatives voted 275-147 to effectively kill the attempt by the Department of Health and Human Services to exert more control over transplantation. Co-sponsored by Rep. Michael Bilirakis, R-Fla., and Commerce Committee Chairman Tom Bliley, R-Va., the bill would have given even more control over transplant policy to the already powerful United Network for Organ Sharing, a private not-for-profit firm headquartered in Bliley's backyard. UNOS, which administers the national network for procuring and monitoring transplants, says the bill puts medical decisions where they belong -- in the hands of doctors.

"UNOS is made up of the entire transplant community," Rosenker says. "We have followed every transplant and what in fact happens during transplantation. The professionals and the guys who do this for a living make the best judgments."

But John Nelson, director of the Office of Special Projects at Health and Human Services, questions whether broad health decisions should be made by a private, nonprofit organization.

"It's a public health issue determining who receives a transplant," Nelson says. He bristles at the suggestion that Health and Human Services should stay out of the matter. Nelson is the department's point man on organ transplantation and has, along with Health Secretary Donna Shalala, been attacked heatedly by people in the transplant establishment.

"To protect a particular contractor through a statute is not in the best interest of the public," says Nelson, who contends that HHS simply wants to fix inequities in the current organ allocation policy.

Next page | Do current policies "waste" valuable organs?