An alarming New York Times report this week revealed that several organ procurement attempts proceeded despite signs that the donors were not yet brain dead or had not received adequate neurological testing. These cases primarily involved donation after circulatory death, where organs are retrieved shortly after the heart stops but before full brain death is declared. This troubling episode highlights that the transplant industry – a critical, lifesaving system of medical coordination and innovation – is also flawed, and in need of reform. 

The U.S. organ donation and transplantation system is an incredibly complex care continuum: More than 50 organ procurement organizations (OPOs) operate with geographic monopolies, more than 250 transplant hospitals operate under the Centers for Medicare and Medicaid Services’ (CMS) oversight, the Organ Procurement and Transplantation Network (OPTN) writes policy, the United Network for Organ Sharing manages operations, the Scientific Registry of Transplant Recipients (SRTR) evaluates performance and provides advanced statistical and epidemiological analyses related to solid organ allocation and transplantation, and the Health Resources and Services Administration (HRSA) provides general oversight. The Department of Health and Human Services (HHS) is charged with governing the transplant system, as well as its participants.  

This vast network has well-known positives and negatives. The United States leads the world in both number and rate of transplants, with more than 48,000 transplants performed in 2024. Yet, as with most complex networks, issues abound. These include inadequate oversight and accountability, data integrity and metric manipulation, organ wastage and inefficient utilization, and equity and access disparities. 

There are several things HHS can do not only to rectify these issues but also to promote improvement in the organ donation and transplant system. For one, there is a desperate need to modernize opaque OPTN governance. OPTN is a unique public-private partnership that links all professionals involved in the U.S. donation and transplantation system, run by a single entity that has held the reins for decades. Following a 2023 bipartisan law, HHS was directed to decentralize portions of the OPTN, such as IT infrastructure, data analysis, and policy development. Breaking up these responsibilities could reduce conflicts of interest and introduce competition into the system for the first time in decades. This ongoing process is slow, however, and resources must be dedicated to speeding up implementation.  

There’s also the complicated issue of performance metrics. These data are generated to provide objective assessments on quality that multiple participants in the transplant industry use to make patient and donor care decisions. There are concerns, though, that the current metrics are not reflective of actual transplants, instead including other non-transplanted organs. Eliminating incentives to recover organs unlikely to be transplanted – especially under the guise of research, which is an avenue sometimes used to procure organs – would reduce the gaming of federal performance standards. Policymakers must focus on closing loopholes that result in performance padding, such as building on the updated guidance narrowing the definition of “research-use” organs. Even metrics that aim to improve care – such as CMS’ “expected vs. observed” survival benchmarks – can have unintended consequences. Efforts should continue to focus on expanding measurements of actual organs donated for transplantation.

Some advocates have proposed redesigning the metrics system into risk-adjusted transplant performance benchmarks. Currently, transplant centers may avoid accepting organs from high-risk or older donors, fearing the higher likelihood of poor outcomes that would hurt their ratings. But this practice leads to viable organs going unused, and patients remaining on waitlists. Hospitals should be encouraged to accept organs from donors with comorbidities or complex medical histories if those organs are otherwise viable. Doing so would both expand transplant access and reduce waste. 

The U.S. organ and transplant system is a miracle of modern coordination. Yet the incident cited in The New York Times follows a long trail of criticism about its greatest challenges – most notably inefficiency, inequity, and opaque governance. With an average transplant waitlist of 100,000 Americans, every wasted organ, every procedural failure, and every governance misstep comes at a human cost. The administration and Congress should seize this moment to tighten oversight, modernize governance, and realign incentives so this critical system can provide the highest standards of care for a public that places extraordinary trust in this system.