Organ transplant rules should have a certain type of patient hierarchy but it should be very specific.The sickest patients should of course have first priority.Of course it should not be based on ability to pay but in this day and age it sometimes comes down to that but in a formal system that wouldn't apply.
A hierarchy should be established to determine who is next in line for transplants, if for no other cause to make order out of the system. This could be done on a needs based system, a locality/availability based system, or some other method of fairly distributing goods and services to as many people as possible, without preference to something like skin color or personal financial situation.
I believe the current system where the patient who is most tissue matched gets the organ is the only way. If you had a system where patients where ranked on anything else, then someone has to make the decision. This could lead to unfairness in the system, the person choosing being accused of favoritism, or taking bribes, etc.
I think the patients who are the most in need of the transplant must be able to get it before somebody who needs it but can survive for a period of time without getting it, I think it's only fair to give that person a chance to survive over just giving the organ on a first come first serve basis.
The term hierarchy implies that there is a more deserving or advanced group of people waiting for organ transplants, if we abide by the U.S. Constitution and its premise that all are created equal, then this is extremely false. The only considerations that should be made in determining the ‘list’ of patients for organ transplants are those factors that are present when physicians look at the likelihood of survival, the lifestyle of the person that may or may not have led consciously to such a terrible need to begin with (such as smoking, excessive drinking, or dangerous sexual practices), and age as it pertains to the size and usefulness of an organ or the recipient. There is already a method of determining the way of placing patients on the list (which also includes geographical location as well) that, while it has a few flaws like issues with young patients being denied immediate transplants simply because they are younger and not because the organ will be refused or there is another person immediately nearby in need of it first. In the medical world, where all practitioners should be concerned with the Oath of Hippocrates who swore to preserve life and comfort, not the trivialities of something as divisive as a hierarchy in a country already struggling for equality in medical care.