Maximizing in Scarcity: How To Improve Organ Donation

Authored by: Isabella Fiutak

Art by: Kenneth Li

Organ transplantation is a marvel of modern medicine, offering patients a second chance at life. To consider it miraculous, however, is to underappreciate the complexities of the United States organ transplant system— known as the Organ Procurement and Transplantation Network, or OPTN. Following the passage of the National Organ Transplant Act in 1984, the OPTN was established as a public-private partnership under the authority of the United Network for Organ Sharing (UNOS). The OPTN collaborates with 56 regional Organ Procurement Organizations, or OPOs, to coordinate the allocation, transportation, and transplantation of available organs [1].

Yet at the center of this system is an ethical dilemma: in a world with too many patients and too few organs, who gets to receive an organ, and who doesn’t [2]? This question underscores the necessity of a system that acts as fairly, transparently, and efficiently as possible— one that has yet to come to fruition. In 2024, for example, 103,000 patients were on the organ transplant waitlist, where the average waiting time was 3–5 years. That year, 17 people died every day without an available transplant [1]. This scarcity exacerbates existing inequalities, as racial and ethnic minorities, women, and patients of lower socioeconomic status are less likely to be added to the organ waiting list and less likely to receive organs than those of more privileged groups with similar need [1,3]. 

What exactly is going wrong? One issue is a shortage of donors, who must meet strict medical and health criteria to donate organs and who may be discouraged by the ethical and psychological challenges that come with such a complex procedure— not to mention the ongoing lack of transparency between health professionals and potential donors [4]. Another even more frustrating issue is how many donated organs are wasted. Traditionally, organs were mostly accepted from young, otherwise healthy donors who succumbed to brain death. Although the donor pool has expanded beyond these old parameters, new organs are only useful if they are actually transplanted. The nonuse rates for organs in the U.S. is high: 25% for kidneys and pancreas, 40% for livers, and 70% for thoracic organs like hearts and lungs [5]. Finally, there is controversy surrounding UNOS, whose performance overseeing the OPTN is marred by outdated information technology infrastructure and logistical challenges [1].  

The progress made on these issues cannot go unnoticed. The Health Resources and Services Administration launched the OPTN Modernization Initiative in 2023, following an inquiry by the Senate Committee on Finance in 2022 and a report released by the National Academies of Science, Engineering, and Medicine. The initiative aims to eliminate the use of outdated data that places certain populations at a disadvantage; improve efficiency in donation, procurement, and transportation; and increase accountability by evaluating performance across the system. In that same year, then-President Biden signed into law the Securing the U.S. Organ Procurement and Transplantation Network Act, which authorized the potential for multiple entities to support the operation of the OPTN. For example, UNOS now shares the responsibility of overseeing the network with the American Institutes Research [1].

However, much more can be done. To decrease the nonuse rate of viable organs, OPOs can promote donation after circulatory death (or DCD) rather than only after brain death. While the final decision to use DCD organs lies with hospitals, OPOs can play a significant role in raising awareness among healthcare professionals and investing in new technologies to improve DCD organ quality. In addition to DCD organs, HCV-positive (HCV +) kidneys, or kidneys from donors with the viral infection hepatitis C, are another example of transplants historically viewed as suboptimal. They are less commonly accepted than HCV- kidneys, even though the two are associated with similar survival rates after transplantation. The OPTN and its OPOs can increase hospitals’ willingness to accept these organs and consequently decrease wait times by making antiviral medications to cure HCV infections more available. Research on the relevance of HCV positivity for organ donation should also be furthered to allow for a comprehensive understanding of this procedure for both health professionals and patients [5].

Additionally, it is imperative that potential donors and their families feel confident in their decision to participate in the donation process. Strengthening public education campaigns to dispel myths about organ donation, providing incentives for registration, and increasing communication, support, and transparency between doctors and donors are all steps the OPTN, its OPOs, and the federal government can take to increase the number of donors and thus the availability of critical organs [4, 6]. 

The OPTN is an incredible tool that has and will continue to benefit the health of the population. It has its weaknesses, but improvements to the rate of organ usage and donor registration can strengthen its life-saving capacity.

References

1. Adashi, E. Y., & O’Mahony, D. P. (2024). The US Organ Transplantation System: HRSA’s Modernization Initiative. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-024-09210-x

2. Experts Discuss Organ Transplant System Reform With Focus on Racial Equity | Yale Law School. (2024, February 7). Law.yale.edu. https://law.yale.edu/yls-today/news/experts-discuss-organ-transplant-system-reform-focus-racial-equity

3. Park, C., Jones, M.M., Kaplan, S., Koller, F.L., Wilder, J.M., Boulware, L.E., McElroy, L.M. (2022). A scoping review of inequities in access to organ transplant in the United States. International Journal for Equity in Health, 21:22. https://doi.org/10.1186/s12939-021-01616-x

4. Olawade, D. B., Marinze, S., Qureshi, N., Weerasinghe, K., & Teke, J. (2024). Transforming organ donation and transplantation: Strategies for increasing donor participation and system efficiency. European Journal of Internal Medicine, 133. https://doi.org/10.1016/j.ejim.2024.11.010

5. Stewart, D., Hasz, R., & Lonze, B. (2023). Beyond donation to organ utilization in the USA. Current Opinion in Organ Transplantation, Published Ahead of Print. https://doi.org/10.1097/mot.0000000000001060

6. Vanholder, R., Domínguez-Gil, B., Busic, M., Cortez-Pinto, H., Craig, J. C., Jager, K. J., Mahillo, B., Stel, V. S., Valentin, M. O., Zoccali, C., & Oniscu, G. C. (2021). Organ Donation and Transplantation: A Multi-Stakeholder Call to Action. Nature Reviews Nephrology, 17(8). https://doi.org/10.1038/s41581-021-00425-3