## Facts

- Sarah Murnaghan was a 10-year-old girl with end-stage cystic fibrosis and was hospitalized in the intensive care unit at the Children’s Hospital of Philadelphia while awaiting a lung transplant.
- Donated lungs are allocated through the Organ Procurement and Transplantation Network (OPTN), operating under federal statutes and regulations, including the National Organ Transplant Act of 1984 (NOTA), which requires equitable organ allocation.
- OPTN lung allocation Policy 3.7 (the “Under-12 Rule”) placed candidates under age 12 behind all adolescents and adults for lungs from adult donors, without regard to the child’s medical urgency.
- OPTN used a Lung Allocation Score (LAS) system for adults and adolescents but did not apply the LAS to children under 12, stating it lacked sufficient data to do so reliably.
- Evidence presented to the court indicated adult lungs can be transplanted into some children under 12, including by surgical size-reduction, and that children waiting for lung transplants were dying at higher rates than adults on the waiting list.
- Sarah’s treating physician, Dr. Stuart Goldfarb, testified that the Under-12 Rule was developed years earlier and that medical experience since then showed children ages 5–11 with conditions like Sarah’s could receive adult lungs with survival rates and longer-term outcomes essentially comparable to adults.
- Sarah’s parents, Janet and Francis Murnaghan, sued the United States Department of Health & Human Services and the Secretary of HHS (in her official capacity), seeking judicial review and emergency relief to stop continued application of the Under-12 Rule to Sarah.
- At the hearing, the government disclosed that OPTN had scheduled an emergency meeting shortly after the hearing to consider whether to suspend or revise the Under-12 Rule.

## Issues

1. Whether the court should grant emergency temporary restraining relief preventing continued application of OPTN’s Under-12 lung allocation policy to Sarah while the case proceeded.
2. Whether plaintiffs satisfied the requirements for a TRO—likelihood of success (or serious legal questions), irreparable harm, balance of equities, and the public interest—given the asserted inequity of a categorical age cutoff and Sarah’s risk of death.

## Decision

- The court granted a Temporary Restraining Order (TRO).
- For the limited duration of the TRO, Sarah was to be treated for lung allocation purposes as if she were age 12 or older, allowing her to be ranked under the adult/adolescent LAS-based allocation system rather than being placed behind all adults and adolescents solely because of her age.
- The court emphasized the narrow scope of the order: it did not direct that Sarah receive a transplant and did not award her any lung; it only changed how she would be considered and ranked during the TRO period.
- The court credited testimony and record evidence that medical knowledge and practice had changed since the Under-12 Rule was adopted, raising serious questions about the fairness and legality of continuing to apply a categorical age rule to children like Sarah.
- The court relied in part on the government’s disclosure that OPTN was convening an emergency meeting to reconsider the policy, which supported the conclusion that legitimate questions existed about the rule’s validity and that temporary relief would not disrupt a settled policy judgment.
- The court found irreparable harm because Sarah faced a real risk of death during the short period before OPTN’s meeting and any later proceedings; it would be irreversible if she died before becoming eligible to be evaluated under the adult allocation method.
- The court concluded that the balance of harms and the public interest favored allowing Sarah to compete under the same scoring system as older candidates during the TRO period and set further proceedings on an expedited schedule.

## Legal Principles

- A temporary restraining order may issue when the movant shows (1) a likelihood of success on the merits or serious legal questions, (2) irreparable harm absent relief, (3) that the balance of equities favors relief, and (4) that relief serves the public interest.
- Irreparable harm is satisfied where the threatened injury is immediate and cannot be remedied later, including a credible risk of death during the pendency of litigation.
- Under NOTA and implementing regulations, federally supervised organ-allocation policies must be equitable; a categorical rule that subordinates one group regardless of medical urgency can raise substantial legal concerns when medical evidence indicates the rule may no longer be justified.
- Courts may grant narrowly tailored, time-limited relief that changes interim consideration or ranking rules without dictating the ultimate medical outcome (such as ordering that an organ be provided).
- An agency-related policy that is already set for imminent reconsideration by the responsible network may support interim judicial relief where the plaintiff faces immediate life-threatening consequences before that reconsideration occurs.

## Conclusion

The Eastern District of Pennsylvania issued a TRO requiring OPTN to treat 10-year-old Sarah Murnaghan as age 12 or older for lung allocation purposes, temporarily setting aside the Under-12 Rule as applied to her so she could be ranked under the adult/adolescent LAS-based system; the court based the relief on the imminent risk of death, evidence that medical practice supported use of adult lungs in certain children, serious questions about the equity of a categorical age cutoff under federal organ-allocation requirements, and the fact that OPTN itself was about to reconsider the policy.


Murnaghan v. United States Department of Health & Human Services, 2013 WL 3363500 (E.D. Pa. June 5, 2013)