Marcus Edsall-Parr, a 15-year-old kidney patient from Michigan, endured years of dialysis while waiting for a transplant. After nearly a decade on the waiting list, he received news of a match, only for the kidney to be given to a man 3,557 spots lower on the list. This case highlights a disturbing trend in the U.S. organ transplant system, where fairness is compromised as many patients are skipped in favor of others, often healthier candidates. A New York Times investigation revealed that nearly 20% of organ transplants involve skipping patients, leading to disparities and a loss of trust in the system’s integrity.
Marcus Edsall-Parr, a young kidney patient from Michigan, has been undergoing dialysis treatments for several years.
Alyssa Schukar for The New York Times
By the age of 15, Marcus Edsall-Parr had spent nearly his entire life waiting for a new kidney, fully aware of the routine: three exhausting dialysis sessions each week, restrictions on playing sports, avoiding his favorite foods, and nearly ten years on the transplant list with no success.
However, last spring, he received a call from his doctor with surprising news: a perfect match had been found.
For many years, the principle of fairness has underpinned the American organ transplant system. Central to this is a national registry, which functions under stringent federal regulations aimed at ensuring that donated organs are issued to patients based on their medical needs, in a carefully organized manner.
However, recent trends indicate that officials often overlook these rankings, bypassing numerous individuals to allocate kidneys, livers, lungs, and hearts to recipients who may not be as ill or have been waiting for as long. An investigation by The New York Times has uncovered these troubling practices.
In the previous year, officials skipped patients on the waiting lists in nearly 20 percent of organ transplants from deceased donors, a significant increase compared to just a few years earlier. This represents a notable transformation in a system that has been founded on principles of equality, yet is now increasingly swayed by urgency and partiality.
Faced with governmental pressure to increase organ placements, the nonprofit organizations responsible for donation management are frequently prioritizing convenience over fairness. They often resort to shortcuts to direct organs to particular hospitals vying for better access than their rivals.
These hospitals wield significant power over which patients receive transplants, regardless of their ranking on the waiting lists. Some have even created private “hot lists” of preferred recipients.
“They are undermining the integrity of the allocation system,” remarked Dr. Sumit Mohan, a kidney expert and researcher from Columbia University. “It’s alarming. And it threatens to erode trust in the system.”
Patients await organ transplants for months or even years while their health declines, often unaware of their status on the waiting list or whether they have been skipped. They simply do not receive the life-saving call when it matters most.
Over the last five years, more than 1,200 individuals that were nearing the top of a waiting list were skipped, leading to their eventual deaths, as reported by The Times. Their medical teams may have ultimately deemed the organ unsuitable, but those patients were deprived of the chance to find out.
Among these individuals was Corey Field, a grocer from Minnesota who was 10th on the liver transplant list when he was bypassed in 2023. He was given a mere two months to live thereafter. His wife, Laura Field, was devastated to discover from The Times what had occurred. While she felt her husband didn’t have an innate right to an organ, she believed he deserved a fair opportunity.
“Corey wasn’t just a line item in a database,” Ms. Field stated. “He meant the world as a husband, father, grandfather, son, brother, and friend. His life held value.”
In the U.S., over 100,000 individuals are currently in need of an organ transplant, depending heavily on nonprofit organizations known as organ procurement organizations. Each state has at least one, and these bodies are contracted by the government to identify potential donors, retrieve organs, and distribute them to those in need.
To illustrate their function, let’s consider the example of kidney transplants:
The procurement organizations are meant to offer the organ to the doctor of the first patient on the list. Typically, doctors may decline, citing reasons such as the donor’s age or the patient’s status.
In such cases, the organization should move down the list until the organ is accepted. This process occurs approximately 200 times daily throughout the nation, with each donated organ requiring a new list to be created.
Previously, organizations adhered closely to these lists. When out-of-order allocations did occur, they were reviewed by the United Network for Organ Sharing (UNOS) and an oversight committee. Going against the list was permissible solely in exceptional situations to prevent organ wastage.
Currently, however, bypassing patients has become so routine that UNOS and the committee are unable to monitor each instance effectively.
Leaders of procurement organizations have admitted to The Times that they occasionally deviate from waiting lists, justifying it as a means to save lives.
They acknowledge an inherent tension exists within the transplant system. Pressured by the government to increase organ placements, organizations depend on algorithms that often yield inaccurate match results. Meanwhile, hospitals, evaluated based on patient outcomes, frequently reject potential matches, leading to wasted organs while doctors continue to deny them.
Consequently, bypassing patients is viewed as a necessary, albeit flawed, solution.
“Expedited placement is problematic because it diverges from the list that patients and the public assume we are following, yet it highlights the urgency of ensuring that organs are transplanted,” stated Dorrie Dils, president of the association representing most of the 55 procurement organizations across the country.
Both she and others claim they only deviate from the lists to allocate lower-quality organs that have been persistently rejected. However, data indicates otherwise.
The Times examined over 500,000 transplants conducted since 2004 and revealed that procurement organizations often ignore waiting lists when distributing even higher-quality organs. In the last year, 37 percent of kidneys allocated outside the usual procedure rated as above average. Though not all organs are scored similarly, donor age frequently serves as a quality indicator, and the data shows minimal age difference between typically allocated organs and those allocated differently.
Moreover, while many in the transplant community contend that disregarding lists reduces organ waste, an unreleased report commissioned by the transplant system last year insufficiently supports such claims.
In response to The Times’s findings, the federal Health Resources and Services Administration (HRSA), overseeing UNOS, has instructed the contractor to cease allowing organizations to ignore waiting lists and called for increased supervision.
Additionally, The Times found that ignoring patients exacerbates health disparities. When waiting lists are disregarded, transplants disproportionately favor white and Asian patients, as well as college graduates.
“We have strayed from our core principles. Transparency and trust in the system have been compromised,” stated Dr. Nicole Turgeon from the University of Texas at Austin, during a discussion at the most recent American Transplant Congress.
“While I truly believe everyone’s intentions are good, we are facing chaos within the system.”
A donated kidney can remain viable outside the body for as long as 48 hours.
Alyssa Schukar for The New York Times
How a rare shortcut became routine
In 2020, procurement organizations felt cornered. Congress called them out for allowing too many organs to go unused. Regulations were established to rate each organization, with the threat of firing the lowest performers starting in 2026.
In response, they mobilized. More staff were assigned to hospitals to identify donors, becoming more assertive with families, and recovering more organs from older or sicker donors.
This approach led to record highs in both donations and transplants, with 2022 witnessing 41,115 transplants.
Simultaneously, organizations began using a shortcut called an open offer more frequently. This method allows a designated hospital to place an organ into any patient.
For instance, in 2023, OneLegacy, the Los Angeles procurement organization, arranged the allocation of a donated heart and began ranking potential recipients.
Directly following on that list was Damon Gault, a 55-year-old brewery owner in Northern California, who had been battling cardiac issues for decades and had spent months hospitalized, eagerly awaiting a new heart.
Mr. Gault passed away six weeks later.
His fiancée, Jennifer Sakai, was taken aback when informed by The Times that he had been skipped. “How is that just?” she expressed. “A system has been established to guarantee everyone has a chance, and it is clearly failing.”
In a statement, OneLegacy indicated it did allocate the other organs from the donor and had under 12 hours to find a recipient for the heart before the planned removal. The decision was made to send the heart to Keck, as that hospital was already dispatching a surgeon for the lungs. Keck contended that patients higher on the list from their facility were not suitable matches for the heart.
Historically, the use of open offers occurred in approximately 2 percent of cases, but The Times discovered that nearly all organizations now bypass patients a minimum of 10 percent of the time, with some exceeding 30 percent.
Line-skipping has increased for every organ provider
Out-of-sequence allocation rates by procurement organization
Source: Based on Organ Procurement and Transplantation Network data as of Jan. 17.
By The New York Times
Some procurement organizations are bypassing the list, believing it enables them to allocate more organs. However, it can also have financial implications for them.
In 2021, the South Carolina procurement organization eliminated its allocation team, delegating the responsibility to staff already managing donors, testing organs, and assisting with surgeries. Former employees reported that a workaround appeared, with executives establishing a spreadsheet containing preferred doctors’ phone numbers.
If employees were too busy for allocation tasks, they were instructed to extend open offers to those doctors.
“They told me to expedite the process for organ placements, so I could move on,” recounted Aron Knorr, a former employee who found the directive concerning.
David DeStefano, chief executive for We Are Sharing Hope SC, stated that the spreadsheet was only used when an organ was at risk of being wasted. “We strive diligently to follow sequencing for allocation,” he emphasized.
Data indicates that Sharing Hope bypassed patients more than 20 percent of the time last year.
Dr. Alghidak Salama, former head of the South Florida organization, pointed out that open offers turned out to be financially advantageous: organizations are compensated with a standard fee by the hospitals receiving organs, regardless of their incurred costs. Accelerated allocation saves money on staffing.
While Dr. Salama expressed discontent with skipping patients, he noted, “It’s effectively sidelining a human being who is in dire need of an organ, and they’re high on that list for a reason.”
Organizations locate recipients for hearts, lungs, and livers before they are retrieved from the donor’s body, while kidneys are usually extracted and tested prior to allocation. They remain viable on pumps for up to 48 hours, with the average transplant conducted within 20 hours.
Recently, however, several organizations have established short, seemingly arbitrary countdowns for allocation.
Mid-America Transplant in St. Louis currently enforces open offers whenever kidneys reach 12 hours outside the donor’s body, a timeframe employees deemed excessively short. Subsequently, leaders reduced this threshold to eight hours, then six.
At LiveOn NY in New York City, staff indicated that after five hours, they extended open offers to favored hospitals to identify their most suitable patient for the kidney. The highest offer succeeded.
In discussions, heads of both organizations justified their policies by asserting that recent regulatory changes requiring organ offers to patients nationwide imposed additional time constraints.
However, the system continues to prioritize patients closer to hospitals. Analyses conducted by UNOS have indicated that new regulations have not drastically altered the distances organizations must travel for organ transport.
Lenny Achan of LiveOn, which has among the highest rates of patient bypassing, noted that his organization’s methods had been examined and approved by regulators.
Surgeons conducting a liver transplant within a Texas hospital.
Alyssa Schukar for The New York Times
Why some hospitals get preference
Among all procurement organizations, Lifebanc in Northeast Ohio has recorded the highest rates of patient bypassing over the last two years.
According to ten current or former employees, Lifebanc employs open offers to direct organs toward the nearby Cleveland Clinic, a respected hospital.
This strategy reportedly emerged after Lifebanc recruited senior management from the Cleveland Clinic and established contracts paying the hospital for medical advisors. Employees have claimed that directions were given to prioritize open offers to the hospital.
“We were expected to assist the clinic,” reflected Monalyn Kearney, who resigned from Lifebanc last year over ethical issues. “There were instances when we wouldn’t pursuit an organ unless they expressed interest.”
Katie Payne, Lifebanc’s chief executive, stated that all procurement organizations operate similarly by bypassing patients to provide organs to centers they believe will most likely accept them. When informed that the University Hospitals, another nearby transplant center, has better organ acceptance rates than the Cleveland Clinic, Ms. Payne defended Lifebanc’s practices, stating that they too extend open offers out of sequence.
The Cleveland Clinic maintained that it does not control organ allocation processes.
Legacy of Hope, the sole procurement organization in Alabama, frequently provides open offers to the University of Alabama at Birmingham. Though the hospital boasts an esteemed transplant program, two physicians there alleged it pressures Legacy of Hope for more organs.
Both Legacy of Hope and the hospital refuted claims of pressure, emphasizing that open offers are made to numerous other facilities.
Last fall, The Times observed a Gift of Life Michigan worker offering an open bid to a Canadian hospital, Trillium Health, prior to involving any American facility. The employee indicated this was standard practice for recovering lungs that might be troublesome to place. However, UNOS regulations stipulate that organs must first be offered to patients in American hospitals.
In response, Gift of Life asserted that the worker had misunderstood their practices and no such policy existed.
Hospitals are engaged in competition to curry favor with procurement organizations. One doctor mentioned that a superior had visited every organization on the East Coast to establish relations. Another colleague claimed their hospital consented to accept lower-quality organs. An administrator recounted negotiating terms regarding organ transportation fees.
These discussions were shared under conditions of anonymity due to apprehensions about jeopardizing open offers.
Who is benefiting
Open offers favor particular hospitals, leading to more transplants, increased revenues, and reduced waiting times.
When hospitals receive open offers, they frequently provide organs to healthier patients compared to others needing transplants, as revealed by The Times. For instance, data indicates that 80 percent of donated hearts in recent years were allocated to patients sick enough to be hospitalized; however, that figure drops to under 40 percent when lists were bypassed.
Healthier patients are more likely to enhance transplant centers’ performance metrics, particularly the one concerning one-year post-surgery survival rates. Government agencies and insurers monitor this crucial rate, and those with low performance may face payment denials.
At least 16 hospitals have reportedly developed discreet “hot lists” of patients to contact when they receive open offers. One list reviewed by The Times, compiled by UVA Health, featured the top candidate for a kidney being a well-conditioned woman in her 60s, superior to many other kidney patients at the hospital.
Eric Swensen, a spokesperson for UVA Health, stated the list comprised patients willing to accept organs of lower quality.
In other discussions, doctors referenced various reasons that patients appeared on hot lists, including proximity for quick summons, fewer health complications that could complicate a transplant, or greater age, leaving them less time to wait for an organ.
The transplant field has long posed ethical challenges and tough decisions. Even when lists are adhered to, biases can influence medical choices.
Ignoring waiting lists has intensified existing disparities: data shows that while white individuals constitute 39 percent of the organ registry, they received 46 percent of transplants in the normal process last year; this number increased to 50 percent when lists were ignored.
Other demographics have also gained from this trend, including Asian patients, men, college graduates, and candidates from larger hospitals.
Dr. James Wynn, a surgeon and former president of the transplant system, commented that unconscious bias undoubtedly impacts the process. “We implement protocols for valid reasons,” he noted.
A Gift of Life Michigan employee preparing a liver for transport.
Bryan Denton for The New York Times
Where watchdogs fall short
Since 2022, federal regulators have been aware of the increase in patients being bypassed, according to meeting notes obtained by The Times. Yet, until recently, little action was taken.
The U.S. Centers for Medicare & Medicaid Services oversees both hospitals and procurement organizations while the Health Resources and Services Administration monitors the system in general. For years, however, they deferred responsibility to UNOS.
Documentation shows that when the oversight committee evaluates instances of patient bypassing, it dismisses over 99.5 percent of cases without action, often concluding the organ risked going to waste. In five years, the committee has never pursued actions beyond issuing “notices of noncompliance,” which represent the mildest response available.
“The oversight is essentially nonexistent, a sentiment that has persisted for quite some time,” stated Dr. Seth Karp, a surgeon at Vanderbilt University involved with the committee, which largely consists of transplant physicians and procurement officials who are essentially self-policing.
Dr. Richard Formica, a Yale University surgeon who serves as president of the transplant system, remarked that volunteers on the committee strive to do their utmost, but assessing motivations behind out-of-sequence allocations poses challenges.
Certain procurement organizations contribute to the challenge of oversight by concealing their use of open offers, according to current or former employees from 14 organizations.
Numerous employees reported that they directly contacted physicians, which meant open offer details were not logged in a centralized system. Many stated they would only record entries when an organ resulted in placement, painting a misleadingly effective image of their practices. Others indicated a tendency to default to a “time constraints” reason when skipping patients, even if that was inaccurate.
Therefore, it’s impossible to ascertain whether skipping patients effectively prevents organ waste — although data indicates it does not. Despite the rise in this practice, rates of organ discards are also escalating.
Skipping patients has not improved organ discard rates
Source: Based on Organ Procurement and Transplantation Network data as of Jan. 17.
By The New York Times
“If this approach was yielding a decreasing discard rate, we could argue: ‘There are trade-offs to consider. There may be racial and socioeconomic disparities, but we should weigh those against the outcomes,’” said Dr. Stephen Pastan, a transplant medical director at Emory University Hospital. “However, that’s not what’s taking place.”
Marcus, pictured with his mother Kath Edsall, was the top candidate for a kidney when he was skipped last spring.
Alyssa Schukar for The New York Times
Marcus’s lost match
The kidney that could have benefited Marcus Edsall-Parr was donated by a young man in his 20s who passed away in Texas last April. Records show the organ was in excellent condition.
Marcus’s physicians at the University of Michigan Health, Dr. Michael Englesbe and Dr. Meredith Barrett, were thrilled. They had established a rapport with Marcus and his parents, Drs. Kath Edsall and Alice Parr, both working in veterinary medicine. Since adoption at age five, Marcus had dealt with kidney issues and developmental challenges.
Due to testing complications, Marcus was infrequently a suitable match for transplants as his antibodies were likely to reject almost any donor organ. His doctors had declined previous kidneys, identifying them as poor matches. But this was the most promising opportunity to date.
Initially, the University of Illinois Hospital Transplantation Program held priority for the kidney for a multi-organ transplant. However, such specialized operations often do not occur, leading to the assumption that allocation would revert to the regular list, with Marcus at the top.
Dr. Englesbe advised Marcus to hurry to the hospital. He notified the Texas procurement organization, LifeGift, and the Illinois hospital of his intention to accept the kidney, even offering to collect it personally.
Shortly after the kidney’s arrival in Illinois, the multi-organ surgery was canceled. According to UNOS policy, LifeGift was obliged to offer the kidney to Marcus, and ample time remained: the organ had spent only ten hours outside the donor’s body. Instead, it extended an open offer to the Illinois hospital.
This diversion was not uncommon; records indicate that LifeGift bypassed patients 29 percent of the time in the previous year.
Dr. Englesbe discovered this several hours later, by which time surgeons were already completing the kidney transplant for a man in his 40s who had been on the list for less than six months.
The doctor conveyed the news to Marcus and Dr. Edsall, who both broke into tears. They had to drive home defeated.
Months later, Dr. Edsall learned the complete story from The Times. She felt relief that the kidney had been utilized but could not shake her anger.
“What criteria led them to conclude Marcus wasn’t worthy of that kidney?” she asked. “What was the rationale that prompted someone to claim, ‘This man deserves it more’? ”
In an interview, LifeGift’s CEO, Kevin Myer, claimed that the organization acted with good intentions to allocate the kidney effectively. “It’s tragically unfortunate that Marcus missed a genuine opportunity because of the system, rather than due to our negligence or any intentional bypass,” he said. “Do I regret that he lost his chance? Yes, frankly.”
The University of Illinois stated that it was LifeGift’s responsibility for allocation decisions.
Marcus did eventually receive a transplant from a donor who passed away in Arizona last June. Yet, the kidney was less compatible and of inferior quality compared to the one he had previously missed. He still endures dialysis sessions twice a week, where a machine cleanses toxins from his bloodstream.
Should his kidney functioning fail to improve, he might find himself reinstated on the transplant list. His parents realize that he cannot rely on dialysis indefinitely.
His medical team remains outraged. “We’ve created a system with the intent of being fair, and yet this exemplifies profound unfairness,” stated Dr. Barrett, adding, “We adhered to the protocols, yet the rules seemingly didn’t apply to him.”
The doctors submitted a complaint regarding the situation but did not receive any feedback.
Methodology
The New York Times analyzed two anonymized databases from the United Network for Organ Sharing, the entity responsible for overseeing the U.S. transplant system. The first, the Standard Transplant Analysis and Research (STAR) File, contains information on every transplant since the system’s inception in 1984. The second database, the Potential Transplant Recipient (PTR) File, has all entries from 2000 onwards related to organ procurement organizations’ documentation of organs retrieved from deceased donors, the creation of potential recipient lists, and patient offers.
The Times relevantly assessed all transplant categories in the program: kidney, liver, heart, lung, pancreas, intestine, or combinations of heart-lung, kidney-pancreas, or simultaneous kidney transplants. Other multi-organ transplants, living-donor transplants, and transplants before 2004 are cataloged differently and were excluded from the analysis.
The databases do not explicitly document instances where organs were allocated out of sequence, thus The Times collaborated with various medical research experts to appropriately identify these cases. Journalists searched allocation records for cases where procurement organizations recorded at least one “bypass code,” which indicates a patient was skipped. The analysis quantified these codes — 861, 862, 863, or 799 — only if they were applied to patients higher on the list than the eventual transplant recipient.
To analyze those patients who died after nearing the top of a waiting list but were skipped, The Times designated “near the top” as being ranked higher than the median acceptance threshold for that organ type. (For instance, last year this threshold meant the top 12 for a kidney, top 10 for a liver, top 6 for a heart, and top 14 for a lung.) Journalists identified patients who were bypassed within that range, didn’t receive a transplant, and were later noted in the databases as having died. This total is likely an undercount as databases often lag in updating after patient deaths.
The Times also conducted interviews with over 275 individuals involved in the transplant ecosystem, including current and former employees of procurement agencies, transplant hospitals, regulatory bodies, and waiting patients. Additionally, the journalists scrutinized documents, including organizational policies regarding patient bypassing, private physician complaints, and internal discussions amongst transplant system leaders.
The Times actively embedded with procurement organizations in two states, witnessing firsthand the efforts to persuade families to consent to donations, the allocation and transport coordination, and the surgical procedures involved in organ retrieval and transplantation.
In the graphic representing allocations by Lifebanc, each depicted organ corresponds to one transplant.