When a liver becomes available, the nearest of the 49 national Organ Procurement Organizations (OPO) will run a database search and algorithm to match the liver to people on all the transplant centers within that OPO's designated local and regional area.
"The local area is not a state, it's that donor service area of that OPO," explained Anne Paschke, spokesperson for the United Network of Organ Sharing (UNOS). "For a liver, they're going to look in the local and regional areas before they look nationally."
According to the Organ Procurement and Transplantation Network, 15,771 people are currently waiting for a liver in the United States. Last year, 1,481 people died waiting for a donor liver, almost all of which come from the recently deceased. The national average waiting time for a transplant is about a year, but it can average as little as a few months at some centers, organ experts said.
Paschke said UNOS requires transplant centers to inform patients that they are allowed to do "multiple listings" at transplant centers in multiple geographic areas to increase the odds of being matched to a liver. The only catch, Paschke said, is that health insurance policies often cover only one medical evaluation to get on one transplant center list. Most people simply don't have the money to pay for multiple extensive evaluations at far-flung locations.
"[Multiple listing] is not common. I think you have to have the means to do it and most centers are looking for patients that have a support system within the area," said Dr. Michael Porayko, medical director of Liver Transplant at Vanderbilt University in Nashville, Tenn.
"So, most people don't travel all around the country to get on a liver transplant list," he said.
The fact that anyone with Steve Jobs' level of wealth could use money to get a numerical advantage within the national system irks ethicists like Caplan. According to Caplan 3 to 5 percent of the names on organ waiting lists are "multiple listing," including U.S. citizens and wealthy foreigners who moved to the United States for medical treatment.
"Obviously the supply of organs is controlled as a public resource by UNOS," said Caplan. "Multiple listing undermines the fairness of the listing, in my opinion."
While Jobs and Apple have refused to speak about the matter, doctors say what Jobs has publicly revealed about his health makes his case more unusual in the organ donation system.
Jobs stated in 2004 that he was diagnosed with an uncommon islet cell neuroendocrine tumor in the pancreas. Doctors say under some circumstances the islet cell tumors cancer can metastasize to the liver, thus necessitating the need for a transplant. However, Apple has not commented on whether Jobs' cancer ever metastasized.
"Islet cell tumors are an unusual but an accepted indication for liver transplantation when the primary tumor has been addressed and the metastatic disease is limited to the liver," said Dr. Michael Millis, chief of transplantation at the University of Chicago Medical Center.
In years past, a person needing a liver transplant from islet cell cancer would have to join a local waiting list with patients suffering liver failure from multiple reasons from alcohol abuse to hepatitis C. For years, the liver recipient lists were managed by wait time and other factors such as age.