When the phone rings at LiveOnNY, death turns to opportunity. The organisation fields calls from 100 or so hospitals in and around New York City about every dead or dying person on a ventilator: stroke patients, gunshot victims, car-crash fatalities. Their organs might save sick people’s lives. But most are not registered donors, so staff at LiveOnNY must persuade their families to donate, then rush the organs to transplant centres. Time is precious: a heart can go no more than six hours outside the body. Kidneys last longer, and can fly commercial.
LiveOnNY is one node in a network that gets organs from dead bodies into sick patients. America has more deceased donors, relative to its population, than any other country, but that does not adjust for type of death. Take into account America’s surfeit of drug overdoses, car crashes, suicides and shootings—which tend to be more conducive to donation—and America probably looks less exceptional.
Indeed, the system could work better: last year more than 36,000 organs from deceased donors were transplanted, though the pool of unrecovered, potentially usable organs is estimated to be at least double that. Tapping that supply would help meet a vast demand: 103,000 people are waiting for an organ. Last year about a tenth died while waiting or were delisted for being too sick. Ignoring the “gap between the donors that we know are out there and the donors that we’re actually finding”, says Seth Karp, director of Vanderbilt University’s transplant centre, is “kind of unconscionable”. Modest increases could eliminate heart, lung and liver waiting-list deaths, and reduce the wait for a kidney, which averages four years.
More than four-fifths of all donated organs and two-thirds of kidneys come from dead people (who must die in hospital); living donors can only give a kidney or parts of a lung or liver. Whereas some countries, such as England, France and Spain, have an opt-out model, in America donors must register or their families agree. Persuading them will always be hard: Dr Karp’s hospital gets consent from about half of potential donors. Elsewhere rates are much lower owing to the fact that those responsible are not trying hard enough, or at all. The Veterans Health Administration—the country’s largest health-care provider—yielded just 33 deceased donors out of roughly 5,200 donation-consistent deaths between 2010 and 2019.
Responsibility lies partly with some of the 56 nonprofit Organ Procurement Organisations (OPOs), like LiveOnNY, that do the legwork. Brianna Doby, a researcher and consultant, advised Arkansas’s OPO in 2021 and was astounded to learn that most calls about potential donors went unanswered outside the nine-to-five workday and on weekends. Other OPOs, by contrast, sent staff to hospitals within an hour of an alert about a prospective donor.
Each OPO has a monopoly in the region in which it operates: the idea was that they should not jockey with each other at a deathbed. But none has ever lost its contract, removing incentives to improve. Performance varies hugely. If the bottom three-quarters of OPOs matched the top performers’ recovery rates in 2021, there would have been about 6,000 more organs transplanted, or 17% of the total from deceased donors that year.
At last, reform is on the way: laggards will be decertified in 2026 and taken over by high-performers that bid for them. The group responsible for monitoring the OPOs is also due for a shake-up. In July Congress passed a law to open bidding for parts of that job, which has been held exclusively for decades by the United Network for Organ Sharing (UNOS).
Tossing too many years away
Yet unrecovered organs are not the only reason America could do more transplants. A surprising number of organs from deceased donors end up in the trash: more than a quarter of kidneys and a tenth of livers last year. In the past few years UNOS expanded the geographic area over which organs could be allocated, increasing travel times and discard rates. The system is “groaning under this new complexity”, says Peter Reese of the University of Pennsylvania’s medical school.
Hospitals’ own risk aversion is another factor. Discard rates are higher for organs of lower quality. Olivier Aubert at the Necker Hospital in Paris and his colleagues found that between 2004 and 2014 America’s kidney-discard rate was twice that of France, which makes greater use of older kidneys. During that time three in five kidneys binned in America would have been transplanted in France. Extrapolation from French recipients’ survival rates yielded more than 132,000 unrealised life-years in America had those kidneys not been tossed.
For elderly recipients, getting older or otherwise risky kidneys generally means better odds of survival than staying on dialysis. But hospitals are disincentivised from using them for two reasons. First, they can lead to more complications and thus require more resources, eating into margins. Second, if the recipient dies soon after the transplant, hospitals suffer—a key metric used to evaluate them is recipients’ survival rate a year after transplant. Hospitals succeed by being excessively cautious and keeping patients with worse prospects off waitlists, says Robert Cannon, a liver-transplant surgeon at the University of Alabama at Birmingham.
Meanwhile, usable organs are going to waste. Sumit Mohan of Columbia University found that kidneys of the same quality were 25% more likely to end up in the trash if procured on a Friday or Saturday. That would mean operating on a weekend. ■
