Over the past few years, there has been growing criticism of the performance record of the U.S. organ transplant system.
The number of people on the national transplant waiting list remains persistently high – over 100,000 – with an average of thirteen people who die every day waiting for an organ, according to the Health Resources Service Administration (HRSA), an agency of the U.S. Department of Health and Human Services (HHS). Is this number high because there are not enough donors willing to commit to organ donation? The answer is surprising.
The Donor Alliance Foundation reported that170 million American adults (approximately 60%) are registered as organ donors. With this number of registered donors, more organs should be recovered and more lives saved. But this is not the case.
One of the most serious criticisms of the U.S. transplant system is the number of recovered organs that are discarded. A 2025 CBS news investigation found that 64,000 organs were recovered in 2024, but 11,853 organs were discarded. The investigation also revealed that 31,000 kidneys were recovered from deceased donors in 2024, but 9,200 were discarded.
HRSA reported that the organ in greatest demand is the kidney, with 86% of patients on the organ transplant list in need of a kidney. Over the last decade, kidney discard rates have risen in the U.S. Data published on the HRSA Scientific Registry of Transplant Recipients’ website shows that 27.9% of recovered kidneys from deceased donors were discarded in 2023.
The U.S. discard rate for recovered kidneys is more than double the discard rate for other developed countries, according to reporter Lenny Bersntein, who published his findings in a March 2023 article in The Washington Post.
In the article, he also noted that European countries have a lower discard rate for kidneys: a 9.1% discard rate in France and a 10% -12% discard rate in the United Kingdom. Eurotransplant, a consortium of eight countries including Germany, reported a rate of about 8%.
How the U.S. Organ Transplant System Works
In his Washington Post article, Lenny Bernstein explained that the U.S. organ transplant system, established by Congress in 1986, is operated by the United Network of Organ Sharing (UNOS), a private contractor.
UNOS has been operating as a monopoly for over 37 years and oversees 56 licensed organ procurement organizations (OPOs) across the U.S. that have contracts to harvest organs and tissues in their operating regions.
UNOS also has a monopoly over the technology that runs the entire system, and system failures have occurred because of its outdated technology.
In his Washington Post article, Lenny Bernstein reported that UNOS holds a $6.5 million contract with HRSA and has been the only entity operating the transplant system in the U.S. since its inception.
HRSA manages the organ procurement and transplantation network, which oversees the 56 organ procurement organizations throughout the country and determines which patients have priority for life-saving organs. The system includes 250 hospitals that perform transplants, labs that test organs for disease and compatibility with recipients, and auxiliary service providers.
Organ procurement organizations (OPOs) are monopolies within their geographic regions. They are reimbursed for all costs, largely by Medicare, including for costs not directly related to organ recovery. They are paid even when they fail to successfully harvest and transport an organ to a waiting recipient, and they report their own compliance data to UNOS.
How Does the Organ Donation Process Work?
The 56 OPOs around the country arrange organ procurement from deceased donors, transport of recovered organs, and transplantation of organs and tissues within their operational area.
People can sign up to be an organ donor on the National Donate Life Registry. They can also enroll in a state registry.
When a death occurs, a potential donor is referred to a regional OPO. A transplant coordinator from the OPO completes a medical evaluation of the patient, including information about the patient’s current and past medical history.
Then consent for organ donation is obtained from the patient’s family or from documents signed by the patient prior to death; the UNOS transplant database is used to identify organ recipients who are good matches for the donor organs; the donor’s death is verified by cardiac or neurological criteria, and the donor is transported to the operating room where the organs are harvested and preserved for transportation to the recipient.
Failures in the Donation and Transplant Process
In a paper published in BU Today, policy analyst Katherine O’Malley of Boston University’s School of Public Health identified the failures of OPOs, including mishandling of recovered organs, rendering them unsterile and unusable; organ retrieval from donors who showed circulatory signs of life or signs of neurological activity when organ retrieval surgery began; understaffing and poor staff training; poor coordination with hospital medical teams, and conflicts of interest in relationships with third-party entities and human tissue product manufacturers.
A total of 28,000 donated organs go unmatched each year, which translates to missed opportunities to save lives that generous donors intended.
In July 2025, HHS announced its decision to overhaul the U.S. organ donation system after an investigation by HRSA identified operational problems within regional OPOs that affected dozens of transplant cases, according to CNN. Staffing shortages, inadequate staff training, mishandling of recovered organs, and organ shipping errors were among the issues identified in the investigation reported by the news organization.
In a 2025 New York Times article, reporters Rosenthal and Tate wrote that alarming incidents of organ harvesting from patients who showed signs of life triggered investigations and examination of the organ transplant process.
Their article explained that cardiac death or neurological death criteria must be used to determine if a potential donor is dead. When a patient is on life support and the machines are disconnected, the patient’s heart must stop beating within 60 minutes before organs can be harvested. A neurological exam must be performed by physicians to determine brain death, the New York Times reporters noted
Neurological or brain death is irreversible. The patient is disconnected from the ventilator for 8 -10 minutes to determine if breathing will resume without the ventilator. If the patient fails to initiate breathing, a declaration of brain death is made and organ harvesting can proceed.
Alarming Incidents of Harvesting Organs From Live Patients
According to the New York Times article, OPOs have been aggressively pursuing organ harvesting from patients declared to be in circulatory death and there has been an increase in the number of cases in which patients showed signs of life and where patients’ hearts began beating while they were being prepared for organ harvesting.
The Association of Organ Procurement Organizations (AOPO) published a March 2025 article in which they claim to be under increased pressure from HRSA, an agency within HHS, to harvest more organs and their contracts with the government are under threat based on their performance.
These claims by the AOPO don’t excuse the recent incidents of attempts to harvest organs from patients who showed signs of life, mishandling of harvested organs, increased organ discard rates, and a host of other failures. HHS Secretary Robert F. Kennedy Jr. and Congress are moving to reform the US transplant system.
Most recently, in a written statement, the HHS announced the decertification of Life Alliance Organ Recovery Agency because of patient safety concerns.
In September 2025, the Miami Herald reported that this is the first time in the history of the U.S. transplant system that an organ procurement organization has been decertified and shut down.
The newspaper quoted Secretary Kennedy as saying that Life Alliance “…may have caused as many as eight missed working recoveries each week, roughly one life lost each day.” Life Alliance, a division of the University of Miami Health System, will not be allowed to bid on a new contract.
Outdated Central Computer System
UNOS considers the technology used in its operating system to be its own. However, the system’s technology is outdated, sometimes nonfunctional, and responsible for missed opportunities to recover organs and deliver them to matched recipients. There have been unacceptable computer system failures causing the system to crash for hours at a time, which translates to lost lives.
HRSA is reforming the current system by opening the contract bidding to other entities, creating more transparency, and modernizing the outdated technology used for organ tracking and allocation.
Changes in the US Transplant System
Jennifer Erickson, a senior fellow at the Federation of American Scientists, reported in a radio interview on WBUR’s On Point show that the entire U.S. transplant system, with its monopoly-related functioning problems, is being overhauled to modernize its operations, open it up for bidding and competition, and save more lives.
Erickson noted in the interview that 74% of OPOs don’t meet standards of organ recovery and only recover 80% of donated organs. UNOS is supposed to be overseeing the OPOs, but there has been a lack of accountability. Additionally, there has been a lack of oversight and accountability by HHS, the government agency that oversees UNOS.
Erickson added that when UNOS was first established, it was the sole contractor who bid on the U.S. government contract to operate the system. No other contractors qualified because bidders had to demonstrate that they had three years of experience performing the functions of the system.
The 56 OPOs around the country also have contracts with the U.S. Government to harvest organs from donors in their geographic operating areas. They retain their contracts because competing entities can’t meet the contract requirements.
The bidding requirements for the government contracts eliminated competition for 37 years. Without competition, the existing OPOs continue to operate in spite of their underperformance and failures in harvesting organs and transporting them successfully to waiting recipients
The new HRSA reforms to the transplant system include breaking up the monopoly by separating functions and opening the contract bidding to experienced contractors, removing anti-competitive restrictions, and adding transparency and accountability to new contracts. We can only hope that a modernized organ transplant system happens sooner rather than later and that more lives can be saved.
About the Author
Elaine Bossik is an editor, medical writer, screenwriter, and author of Body Merchants, a novel about human organ theft. Visit her website at www.elainebossik.com.