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WASHINGTON — Spoiler alert: President Frank Underwood needs a liver transplant in this season of “House of Cards.”

He’s been shot through the abdomen, and a transplant is the only way he’ll survive. Luckily, “House of Cards” is the sort of program that trades in ethical compromise, and so Underwood’s chief of staff strong-arms a cabinet secretary into moving the president to the top of a waiting list for a transplant. The president gets his liver, and a man he leapt in line dies.

Like other storylines in the hit Netflix series, this one has a touch of the absurd. But for STAT, it also begged the question: Could the real president jump the line to get an organ?


According to the rules: no.

In real life, the ploy would be highly illegal and, more to the point, should be impossible, according to the nonprofit that coordinates transplants across the United States.


The process by which patients are chosen for transplants is actually determined by a computer algorithm. That system has no idea whether the recipient is the president of the United States or a schoolteacher — and it’s designed to be impenetrable to tampering.

“The computer would have no idea that he was the president, just like it has no idea how rich and famous someone else is,” said Anne Paschke, a spokeswoman for the group, the United Network for Organ Sharing. “Nobody can rig the system to make it different in one case or not.”

The waiting list is also under intense security. UNOS has an in-house IT security team. Doctors can only input data for their individual patients. The agency audits every single transplant performed to make sure the proper procedures were followed.

That’s how the system is set up, to be totally ignorant of anything but medical viability and need — to avoid exactly the kind of situation envisioned in “House of Cards,” in which the secretary of the Health and Human Services Department makes a call to move Underwood up the roster.

But those in the transplant world routinely contend with the myth that the rich and powerful get preferential treatment.

“We would never listen to anybody, including the president of the United States themselves,” said Dr. Ryutaro Hirose, a liver transplant specialist at the University of California, San Francisco, who sits on the UNOS liver committee. “This is how our allocation works.”

And so the system uses a series of objective variables to determine who gets a transplant. For a liver, the biggest is medical urgency: How likely is a patient to die without a transplant? The system also considers the compatibility of the donor and recipient, and their proximity to each another.

Right now, there are more than 15,000 people in the United States waiting for a liver transplant.

Of course, it’s easy to say power and status don’t matter when the most powerful person in the world’s life is not actually in jeopardy. But is there a contingency plan in case the president needs a life-saving transplant?

STAT couldn’t find anyone who could say for sure. Paschke wasn’t aware of any such contingency. Neither could a senior administration official. Two former White House physicians didn’t return requests for comment.

“We would never listen to anybody, including the president of the United States themselves.”

Dr. Ryutaro Hirose, liver transplant specialist, UCSF

The anonymous donations that the UNOS facilitates and the show portrays aren’t the only option, though.

A donor, living or dead, could dictate that he or she wants to donate organs to a specific person. It’s easy to imagine the president of the Unites States being the recipient of such a sacrifice — in fact, in “House of Cards,” Underwood’s chief of staff, Doug Stamper, tries to offer his own liver but is told he can’t because the president needs a full, not partial, organ. (Stamper is also a recovering alcoholic.)

That little detail, true to life, was one of several that Dr. Joel Adler, a general surgery resident at Massachusetts General Hospital, said he appreciated.

Adler, who described himself as “a pretty big fan” of the show, said the showrunners got some of the other little things right: Underwood’s yellowing skin, for instance, and the incision that the surgeon makes when the transplant finally gets underway.

But even a fan like Adler couldn’t get around the climax of the waiting-list subplot.

“Everything up until the skipping-the-line thing was pretty right as far as I know,” Adler said. “That’s the grossest inaccuracy.”

Despite the sensationalism of having Stamper threaten the HHS secretary’s job to get Underwood a transplant, Adler and others did want to make something clear: There are inequalities when it comes to transplants. They just aren’t so Machiavellian in nature.

The problem is that transplants are geographically based. Wealthier people can afford to travel across the country if it will help them get a transplant.

Hirose cited the example of former Apple CEO Steve Jobs relocating to Tennessee for a liver transplant in 2009.

That option wouldn’t be available to the less fortunate.

“There’s a lot of geographic disparity,” Hirose said. “That’s the two-tiered thing that does exist right now.”

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