The State of the Art—The Law, the List, and the Record

Organ Donation in America: Who Gets the Organ, the Law, the Black Market, and What Changed

On Sunday night a network drama put a liver, a computer, and a rich man in one operating room, and on Monday morning the country is asking how an organ is actually assigned. The record answers plainly. In the United States the list is one national list, the order is set by published medical formulas, no hospital runs an algorithm of its own, and no judge has ever ordered an organ to a named patient. What moves a person up the list is documented and narrower: an insurance clearance before the list, a center’s quiet power to refuse an organ in a patient’s name, exception points granted by review boards, and, for those who can pay for duplicate evaluations and a fast flight, a second and third listing. Around that machinery stand the law that makes selling an organ a federal crime, a waiting list of 109,817 people, a black market abroad that the World Health Organization sized once, in 2007, and never sized again, and a quarter-century of invention that has changed what an organ is: pumped on a machine instead of packed in ice, taken from donors dead by a stopped heart, carrying hepatitis C or HIV and cured or managed after the fact, and, in five years of firsts, grown in a pig. The desk files the whole record, attributed and graded, in that order.

By Eunice, the desk · Collected and analyzed at 0805 ET, Monday, November 9, 2026.

The File in Brief

Everybody watched it on Sunday night, and everybody is talking about it on Monday, so the desk brings the state of the art. Cupertino, the CBS legal drama created by Robert and Michelle King and premiered on October 8, 2026, aired its sixth episode, “Harper,” on Sunday, November 8, 2026, in a special Sunday showcase after 60 Minutes; the episode streams on Paramount+ today. The episode was written by Keith Eisner and directed by Rosemary Rodriguez, with Erich Bergen guest-starring as Carl Kenner; Vulture’s Noel Murray rated it four stars. In the episode, as the listings and recaps filed below describe it, the allocation system ranks Harper Gervin, a woman of 27, first for a liver; a human hand overrides the result in favor of Albert Ensler, a wealthy venture capitalist; the intervention is connected to a promised cancer-research donation from the Ensler Foundation to the institution; a fired assistant helps expose the arrangement; and the transplant proceeds for Harper Gervin. The episode sits at the confluence of artificial intelligence, extreme wealth, the law, and health care, and that confluence is why the question is live today. The desk files the episode as the occasion, in this paragraph, and answers its question from the documented record in everything that follows—including, in Section 6, a direct test of the episode’s exact mechanism: whether a donation-linked favor could move an organ in the real system, and whether any documented case matches that shape.

The record’s first answer is that the machine in the episode does not exist. No American hospital runs its own allocation algorithm, AI-generated or otherwise. When a deceased donor’s organs are recovered, the organ procurement organization enters the donor into one national system, the Organ Procurement and Transplantation Network’s matching system, UNet and its DonorNet interface, and the system produces one match run: a ranked list of waiting patients, in an order set by allocation policies adopted in public by the OPTN board and written as fixed, published formulas—a liver score, a lung score, a heart status, a kidney formula—not by a learning machine. The organ is then offered down that list, one transplant center at a time, and the center has one hour to accept or decline for its patient. Artificial intelligence, where it verifiably touches the system at all, touches the decision to accept or decline: a predictive-analytics tool inside DonorNet estimates how long a center’s patient is likely to wait for the next offer and the likelihood of death without this one, and advises the human being deciding. It ranks no one. The ranking is arithmetic, and the arithmetic is public.

The record’s second answer is that the episode’s turn—a human hand, not the computer, moved the queue—is the documented way queues move. A center may decline an organ for its patient, and does: more than 99 percent of kidney offers are declined, in most cases without the patient ever being told an offer existed. A center may ask a review board for exception points the formula did not give, and in heart transplantation the requested status takes effect the moment it is submitted and is reviewed afterward; a quarter of excepted heart candidates in one six-year cohort were transplanted before the board had even received the application. A center may take an organ out of sequence, off the match run entirely, a practice that grew from 2.2 percent of kidney transplants in 2020 to 15.7 percent in 2023 before federal pressure pushed it down. And a patient with money may be listed at several centers at once, which the record associates with higher transplant rates and lower death rates, because each additional listing is bought with a duplicate evaluation, travel, and lodging that insurance does not cover. Wealth in this system does not buy an organ—buying one is a federal crime, five years and $50,000 under the National Organ Transplant Act of 1984—but wealth buys position around the organ, and the record says so in numbers.

The record’s third answer concerns the four hours. The episode gives its liver a four-hour viability window. The documented cold-storage ranges are these: a heart and a lung travel four to six hours, a liver eight to twelve, a kidney twenty-four to thirty-six. Four hours is the heart’s classic clock, not the liver’s; the drama took the tightest window in the building and put it on the wrong organ. The window itself is also being rewritten: machines that perfuse organs with warm, oxygenated blood now hold livers for up to a day, rescue livers every center in a country has refused, and have made hearts available from donors whose own hearts had stopped—donation after circulatory death, 2 percent of deceased donors in 2000, 49 percent in 2025. What the drama’s clock gets right is the shape of the thing: an organ is a perishable good moving against time through a system of human decisions. What it gets wrong is the number, and the desk files the numbers.

And the record’s fourth answer is about the size of the shortage underneath every argument. The national waiting list held 109,817 people in the Health Resources and Services Administration’s snapshot of July 30, 2026, about 87 percent of them waiting for a kidney. American surgeons performed a record 49,064 transplants in 2025, the fifth consecutive record year, from 16,550 deceased donors and 7,237 living ones—and the waiting list does not shrink, because 70,600 people were added to it in 2024 alone. The federal government’s current figure is that 12 people die each day waiting; the figure was 17 a day in the government’s own materials through 2025, and the desk prints both, dated, because the change is part of the record. The sections that follow file the law, the death determinations, the system’s keeper and its breakup, the consent question, the match itself, the queue-moving record in full, the clock, the viability questions of age and sex, the access ledger of race and insurance, the courts, the supply, the workforce, the forbidden market, the China file, and the inventions, closing with the cocked hat: the points where the record does not agree with itself, printed as disagreement.

1. The Law: What May Not Be Sold, and Who May Give

The foundation statute is the National Organ Transplant Act of 1984, and its central sentence is a prohibition. NOTA, Public Law 98-507, approved October 19, 1984, created the national network, the organ procurement organizations, and the scientific registry. Its Section 301, codified at 42 U.S.C. §274e, provides: “It shall be unlawful for any person to knowingly acquire, receive, or otherwise transfer any human organ for valuable consideration for use in human transplantation if the transfer affects interstate commerce.” The penalty is a fine of not more than $50,000, imprisonment of not more than five years, or both. “Human organ” is defined to include kidney, liver, heart, lung, pancreas, bone marrow, cornea, eye, bone, and skin, and any subpart. The prohibition has edges, and the statute prints them: “valuable consideration” does not include the reasonable payments of the transplant itself—removal, transportation, implantation, processing, preservation, quality control, storage—nor the donor’s travel, housing, and lost wages. Kidney paired donation, in which two incompatible donor-patient pairs exchange kidneys, was expressly carved out by the Charlie W. Norwood Living Organ Donation Act of 2007. Payment for plasma, sperm, and egg cells stands outside the organ definition entirely, which is why those markets are legal and the organ market is not.

The prohibition has been prosecuted rarely, and the first American conviction came twenty-seven years after the Act. Levy Izhak Rosenbaum, of New Jersey, pleaded guilty in 2011 in the first federal organ-brokering prosecution under NOTA: the record showed donors paid roughly $10,000 and recipients charged $120,000 to $150,000. No prosecution of an American recipient for buying an organ abroad appears in the sources the desk reviewed. The statute’s practical effect is structural rather than carceral: it sets the price of a legal organ at zero, which makes the queue—not money—the legal mechanism of allocation, and makes every question in this report a question about the queue.

Congress has been asked, in the current period, to pay donors without repealing the ban, and has so far paid expenses only. The End Kidney Deaths Act, H.R. 2687 in the 119th Congress, introduced April 7, 2025, would create a refundable tax credit of $10,000 a year for five years—$50,000 in total—for a non-directed living kidney donation, as a ten-year pilot, and would amend NOTA to state that the credit is not valuable consideration. It was referred to committee and, in the sources reviewed, has not passed. An advocacy estimate that the bill would save up to 100,000 lives is filed as unsubstantiated: no Congressional Budget Office score or peer-reviewed model was found behind it. What has been enacted is narrower. The Honor Our Living Donors Act, carried in the Consolidated Appropriations Act of 2026 and enacted February 3, 2026, forbids considering the recipient’s income when deciding a living donor’s eligibility for federal reimbursement of travel, lost wages, and dependent care, through a program capped at $6,000. The Living Donor Protection Act, which would bar life, disability, and long-term-care insurers from penalizing living donors and would write donation recovery into the Family and Medical Leave Act, was voted out of the Senate HELP Committee on February 26, 2026, the furthest it has advanced, and was not law as of October 2026. In the sources reviewed, no repeal of the sale prohibition and no government organ-market pilot was enacted in 2023–2026.

Deceased donation runs on gift law, not consent law, and the gift is made under the Uniform Anatomical Gift Act. The UAGA is a model state law first drafted in 1968 and revised in 1987 and 2006; some version is law in every state, and the 2006 revision has been enacted in 47 states by one count and 48 by another—a counting difference the desk prints rather than resolves. Its mechanism is first-person authorization: an adult’s documented gift, made most often at a motor-vehicle office or through a donor registry, is legally binding, and only the donor may amend or revoke it. Under the 2006 Act, when a registered donor becomes eligible, the next of kin are to be informed, not asked; the Uniform Law Commission’s commentary states that the Act “intentionally disempowers families from making or revoking anatomical gifts in contravention of a donor’s wishes.” The law and the practice are not identical: the same literature records that authorization is binding “although not always in practice,” and that procurement organizations historically sought family affirmation, proceeding over family objection more often since 2006. Where no authorization exists, a ranked hierarchy of surrogates—spouse, adult child, parent, adult sibling, and onward—may make the gift. There is no single federal registry; registration runs through the state registries and the National Donate Life Registry. Donate Life America counts more than 170 million registered donors in the United States and attributes about 60 percent of deceased donations to registration rather than family authorization. The federal government’s 2025 National Survey of Organ Donation Attitudes and Practices, 10,008 respondents, found 93 percent support for donation and 53 percent who said they were registered—a survey’s self-report beside a registry’s count, printed as the two different instruments they are.

2. The Determination of Death: Two Legal Roads, Both Under Dispute

Every deceased donation begins with a legal determination of death, and the governing text is the Uniform Determination of Death Act of 1981. The UDDA provides that an individual is dead who has sustained either irreversible cessation of circulatory and respiratory functions, or irreversible cessation of all functions of the entire brain, including the brain stem, with the determination made in accordance with accepted medical standards. The model act itself was enacted in 37 states and the District of Columbia by the 2018 count, while death by neurologic criteria is legally recognized in all fifty states through statutes modeled on it or through court decisions; the two figures count different things and are both printed in the literature. The states vary around the standard. New Jersey stands alone with a true religious exemption: since 1991, where a declaration on neurologic criteria would violate the patient’s personal religious beliefs, death may not be declared on those criteria at all. New York requires reasonable accommodation of religious or moral objection without exempting the patient from the legal fact of death; California and Illinois have shorter accommodations of the same kind. Only Florida, New Jersey, and Virginia require the declaring physician to hold neurology or critical-care expertise.

The effort to revise the Act failed, and the failure is itself a finding. The Uniform Law Commission empaneled a drafting committee in 2021; in September 2023 the committee paused its work indefinitely, citing, in its chair’s account, inertia, the political climate, the multitude of implications of changing the legal description of death, and the diverse perspectives of stakeholders. The draft would have replaced “irreversible” with “permanent” and would have defined the brain criterion as permanent coma, cessation of spontaneous breathing, and loss of brainstem reflexes—without requiring the testing of neuroendocrine function, the point on which the draft and the existing statute’s “all functions of the entire brain” diverge. The National Catholic Bioethics Center and the United States Conference of Catholic Bishops opposed the draft formally in July 2023 as a shift toward partial brain death; the Bioethics Center stated in April 2024 that there had been “a decisive breakdown in the public consensus on death and organ donation.” That sentence is filed as the Center’s stated position, not as a neutral finding. In the same season the clinicians unified their own standard: the American Academy of Neurology and three sister societies published a single pediatric and adult brain-death consensus guideline on October 11, 2023, 85 recommendations replacing the separate 2010 and 2011 guidelines. The guideline permits a declaration despite evidence of neuroendocrine function, which legal critics note sits in tension with the statute’s wording—a tension documented in the literature and contested as a legal matter, printed here at that grade.

The second road to death—circulatory—now carries nearly half the system, and it produced the decade’s gravest federal findings. Donation after circulatory death, DCD, in which death is declared after the heart stops and a stand-off period passes, grew from 943 donors, 12 percent of deceased donors, in 2010 to about 43 percent in 2024 and, by the Journal of the American Medical Association’s count of the national data, 8,129 donors, 49 percent, in 2025. The case that forced the federal inquiry is on the record. Anthony Thomas “TJ” Hoover, a Kentucky overdose patient, was taken toward organ recovery in 2021 after a death declaration; witnesses reported eye movement, thrashing, and crying; the recovering surgeon refused to proceed; a coordinator for the state procurement organization was alleged to have been told to find another doctor; the recovery was cancelled, and Mr. Hoover survived. The case is frequently mislabeled in secondary coverage as a brain-death case; it was a DCD-pathway case. The Health Resources and Services Administration’s investigation, announced July 21, 2025, examined 351 cases at the Kentucky organization in which donation was authorized but not completed between 2021 and 2024, and reported concerning features in 103 of them, 29.3 percent, including 73 patients showing neurological signs the agency called incompatible with donation and at least 28 patients who may not have been deceased when procurement was initiated. Those are the government’s published findings; the organization disputes them, and its decertification appeal, begun by the Department of Health and Human Services on August 5, 2026, was pending in the sources reviewed. On May 28, 2025, HRSA directed the national network to develop DCD policies on safeguarding patients entering the pathway and on communication with families.

The sharpest technical dispute in the field concerns a machine that restarts blood flow inside the donor’s body. In normothermic regional perfusion, NRP, after death is declared on circulatory criteria and the stand-off passes, a machine restores oxygenated blood flow to the organs in situ while the vessels to the brain are clamped; the technique improves organ quality and yield, including for hearts and lungs. The American College of Physicians—the ACP, a physicians’ body; no position by the similarly initialed ACLU was found in the sources searched, and any copy naming that organization on this subject should be held—called in April 2021 for a pause, describing the procedure as more accurately characterized as organ retrieval after cardiopulmonary arrest and the induction of brain death. Transplant-surgery societies answer that death turns on the permanent exclusion of circulation to the brain, which the clamping accomplishes, and that the practice should proceed under standardized protocols with specific disclosure. The OPTN Ethics Committee’s white paper, approved for publication in March 2024, is an ethical analysis and not policy; it found serious concerns about compliance with the dead donor rule, which holds that donors must be dead before procurement and procurement must not cause death, and required consistent, transparent protocols and adequate consent. As of early 2026 there was no formal federal policy governing NRP; a health-law survey of April 2026 reports a November 2025 federal safety communication flagging verified reports of unintended brain reperfusion during the procedure, a claim the desk grades single-sourced and unverified against a primary document. Senators put the subject to the Department in 2025. The dispute stands unresolved in the record, and the desk leaves it there.

3. The System and Its Keeper: One Contractor for Forty Years, Then a Breakup

For nearly forty years, a single private contractor ran the whole network, and its board was the network’s board. The United Network for Organ Sharing, UNOS, held the OPTN contract from the network’s first years and operated the matching system, the committees, the data, and the governance under one roof; the OPTN Board of Directors and the UNOS corporate board were the same body, a conflict of interest noted by overseers for years. The Health Resources and Services Administration launched the OPTN Modernization Initiative on March 22, 2023, aimed at governance, technology, and operations, with multiple contracts in place of one. Congress supplied the legal instrument the same year: the Securing the U.S. Organ Procurement and Transplantation Network Act, Public Law 118-14, signed September 22, 2023, amended the statute to let the Secretary award the network’s work to multiple entities, required the OPTN board to be separate from any contractor’s board, and removed the $7 million appropriations cap on the contract. Appropriations added $23 million for modernization in fiscal 2024.

The breakup proceeded in documented steps. In August 2024 the OPTN Board of Directors was separately incorporated, independent of the UNOS board for the first time in the network’s history, with board-support work awarded to the American Institutes for Research. On September 19, 2024, HRSA announced the first multi-vendor task orders to five firms—patient-safety and compliance systems, a matching-technology assessment, transparency and public engagement, patient-centered communication, and financial management—inside a multiple-award vehicle with fourteen vendors and a reported ceiling of $450 million over up to five years. A Transitional Nominating Committee reviewed more than 300 applications; regional elections ran May 2–6, 2025, and a national election May 27–June 2, 2025; a new 34-member independent board was announced June 5, 2025 and seated July 1—half transplant physicians and surgeons, nine recipients, donors, and family members, eight from the procurement, hospital, and public side—with no member permitted to sit on a vendor’s board. What UNOS kept, under a contract finalized in December 2025 and effective December 30, is the core it built: the national matching system and data services, extendable in quarterly options through December 29, 2026. What it lost is the rest: patient safety, transmission-event reporting, the professional-standards committee’s support, and committee support were removed from its scope for competitive award in early 2026, with the federal government running critical safety functions in the interim, including a new reporting line from December 29, 2025. UNOS stated publicly, on December 24, 2025 and January 9, 2026, that the agency declined its requests for transition language protecting the safety work and that the agency’s account of the transition contains false narratives. Both positions are on the record; neither has been adjudicated, and the desk prints them as positions.

The Government Accountability Office’s verdict on the modernization, delivered January 22, 2026, is that the plans lag the contracts. In report GAO-26-107434, the GAO found that HRSA entered contracts in 2024 to assess the network’s weaknesses, including inequitable allocation and insufficient investigation of serious events such as recovery begun before death, but “has not yet developed detailed plans for the next phase” of the modernization; that the agency began completing the required annual performance evaluations of UNOS retroactively only in March 2025, after years of none; and that it had not assessed the risks of the contractor’s supplementary services and fees charged to transplant programs outside the federal contract. The GAO made three recommendations; the Department concurred. In parallel, enforcement against the procurement organizations themselves reached a new pitch in the same period: on September 18, 2025, the Centers for Medicare and Medicaid Services moved to decertify the Life Alliance Organ Recovery Agency of Miami, citing years of unsafe practices and underperformance including a 2024 clerical error that caused a surgeon to decline a donated heart; the Department described it as the first mid-cycle decertification of a procurement organization in American history, and the agency did not appeal. On August 27, 2025, the administration had launched a public dashboard on allocation out of sequence, the practice examined in Section 6 below. Congressional oversight ran alongside throughout—Senate Finance since 2020, House hearings in September 2024 and July 2025, and a Ways and Means Oversight hearing on December 2, 2025 titled “Lives at Stake.”

4. Consent by Default: Opt-In Here, Opt-Out Abroad, and What the Evidence Shows

The United States is an opt-in country; much of Europe is, on paper, opt-out; and the best-known opt-out system’s own architects say the law is not what made it work. Under an opt-out or presumed-consent system, every adult is treated as a donor unless they registered an objection. Spain adopted the form in 1979, France operates it under its public health code, and the dated adoptions in the British Isles are Wales on December 1, 2015, England on May 20, 2020, Scotland in March 2021, and Northern Ireland in 2023; the Netherlands moved in July 2020. Most are soft opt-out: the family is consulted in practice and can stop the donation. Spain leads the world in deceased donation—53.9 donors per million population in 2024, 2,562 donors, ahead of the United States at 49.7 per million, with Portugal, the Czech Republic, and Belgium following; the ordering of the last two is disputed between reproductions of the same international data and is printed here without a forced resolution. But Spain’s rate sat at roughly 14 to 15 per million for a decade under its opt-out law, and began rising only after 1989, when the Organización Nacional de Trasplantes was created under Rafael Matesanz and built a network of hospital-based donor coordinators drawn from intensive-care physicians. In Spanish practice, presumed consent is not strictly applied: coordinators always interview the family, and if the family opposes, the procedure does not follow. Matesanz’s own verdict, in Kidney International, is that Spain’s law is a “theoretical presumed consent,” its effect on donation “considered insignificant,” and the Spanish approach “not substantially different from that in opt-in realities.” The popular claim that Spain leads because of opt-out is therefore graded disputed, contradicted by the system’s architects.

The comparative evidence as a whole does not settle, and the desk prints the disagreement as the finding. Cross-country regressions published in 2006 and 2014 found higher deceased-donation rates in presumed-consent countries, with the 2014 study also finding fewer living donors there and expressly not establishing causation. The best-adjusted comparison the desk found, a 2019 study of thirty-five OECD countries, found no significant difference in deceased-donor rates—20.3 per million in opt-out countries against 15.4 in opt-in, not significant—and significantly fewer living donors in opt-out systems. A 2026 study of twenty-six countries over twenty years found deceased rates about 6.9 per million higher under opt-out and living rates about 6.8 per million higher under opt-in, a substantial offset. A conceptual study put the default’s direct effect at roughly zero to five percent of recovery opportunities, since opt-in and opt-out produce identical outcomes except where neither the deceased nor the family expressed a preference. And in the five-year natural experiment of the 2020 switchers, England’s family consent rate fell from 69 percent to 57 percent between 2020 and 2025 with donor numbers below pre-pandemic levels, while the Netherlands’ active-registration variant fared better; the pandemic confounds both. The net grade on “opt-out raises donation rates” is disputed: associations run positive in some studies and null in the best-adjusted one, switch studies show no clear increase, and every major review treats the coordinator and infrastructure system as at least as important as the legal default.

5. The Match: How an Organ Is Actually Assigned

The assignment begins with one match run, and the order of the run is set by formula, organ by organ. When a procurement organization recovers a donor, it enters the donor’s data into the national system and the system generates the match run: every compatible waiting patient, ranked. The offers then move down the run, center by center; each center has one hour to accept or decline for its patient. The formulas differ by organ, and each is a public document. For livers, the ranking score is MELD 3.0, in force since July 13, 2023, computed from laboratory values on a scale of 6 to 40, with the sickest—Status 1A and 1B, acute liver failure and its pediatric counterpart—placed above all scores; children under twelve are scored by PELD-Cr. Since February 4, 2020, livers have been distributed through acuity circles, distance rings of 500 nautical miles drawn around the donor hospital for the highest-acuity patients, replacing the old map of local areas and regions. For lungs, the ranking since March 9, 2023 is the Composite Allocation Score, the first score built as a continuous distribution: twenty-five points of weight on survival while waiting, twenty-five on survival after transplant, fifteen on biology, twenty-five on patient access, ten on placement efficiency. For hearts, candidates stand in six statuses set in October 2018, driven largely by the machines keeping them alive—the sickest status belongs to patients on the most intensive temporary support—with a documented tightening of the balloon-pump route to Status 2 on September 17, 2025. For kidneys, the match weighs the kidney’s quality index, KDPI, against the candidate’s expected survival, EPTS, with the best fifth of kidneys offered first to the fifth of candidates expected to live longest, and waiting time counted not from listing but backdated to the start of dialysis; since March 15, 2021, kidneys are distributed through 250-nautical-mile circles. The direction of reform, under the name continuous distribution, is to replace every hard boundary with a single scored scale of the lung kind: lungs are converted, kidney and pancreas are in development without a date, liver is at an early stage, and heart at the concept stage.

Two features of the formulas matter for everything argued later in this report, and both are matters of design, not discretion. The first is that the kidney system formally practices longevity matching: it is written into the score that a young, durable kidney goes first to a candidate predicted to live long enough to use its years, which is a judgment about the best use of a scarce good adopted in the open, not a bedside preference. The second is that the scores measure medical urgency and expected benefit as the policy defines them; they contain no term for wealth, occupation, fame, or insurance. Whatever advantages money buys in this system—and Sections 6, 9, and 10 document real ones—it does not buy them inside the formula. It buys them before the formula, at evaluation and listing, and after the formula, at the offer.

6. The Computer in the Room, and Where Hands Move the Queue

The episode that occasions this report imagines a hospital’s algorithm reordering a list; the first documented fact is that there is no such algorithm, and the second is that the human machinery around the list moves more patients than any formula does. The ranking inside the match run is a fixed, published, policy-set computation. No machine-learning model ranks real candidates anywhere in the sources the desk found: that is a negative finding, printed as one. The one piece of software in the system that predicts is UNOS’s Predictive Analytics, displayed inside DonorNet to the center deciding whether to accept an offer: it estimates the time to the next offer for that patient and the likelihood of death without this organ. It advises the center’s accept-or-decline decision; it ranks no one. A federal privacy assessment of that tool, approved January 14, 2026, labels it “AI” in its own paperwork, while the network describes a statistical estimator; whether the system contains artificial intelligence is therefore, at the documented margin, a labeling dispute, and the desk files it at that size. The queue, in short, is moved by hands, and the record shows whose, and where.

The largest hand is the decline. Transplant centers accept roughly one percent of the kidney offers the match run sends them, three percent of liver offers, five percent of heart offers; more than 99 percent of kidney offers are declined, the great majority by the center without notifying the patient in whose name the offer arrived. Survey evidence filed in the research records the two sides of that practice: 87 percent of patients say centers should have to tell them about offers declined for them, and 77 percent of program directors say candidates should not be notified. Since January 27, 2022, a further instrument has automated part of the refusal: Offer Filters, set by each center in advance, bypass offers automatically against center-chosen criteria, so that a share of declines are now issued by a rules engine executing the center’s standing instructions before any clinician sees the offer. None of this is concealed, and none of it is the formula’s doing: it is the lawful discretion the Final Rule itself preserves, quoted in Section 11, to decline an organ for a medically suitable candidate. It is also where clinical judgment, risk aversion under public outcome reporting, and a program’s appetite for marginal organs actually decide who is transplanted.

The second hand is the exception, and its two organ systems run on opposite clocks. For livers, exceptions are granted by a single National Liver Review Board, in place since May 2019: in the board’s early record it approved 87.8 percent of adult liver-cancer exception requests, 64.3 percent of other adult requests, and 71.5 percent of pediatric ones; cancer exceptions by rule receive a score three points below the median at transplant only after a mandatory six-month wait, a built-in brake, while non-standard exceptions in the literature added a mean of twelve points to a candidate’s score. For hearts, the exception runs the other way: approval rates exceed 95 percent, and the requested status takes effect immediately on submission and is reviewed retrospectively. In the 2018–2023 cohort examined in the literature, 25.2 percent of excepted heart candidates were transplanted before the review board had even received the application, and among them were 115 candidates whose exceptions were ultimately denied, who between them bypassed more than 7,000 potential recipients standing in the ordinary queue. The desk prints that pair of systems side by side because the record does: the same institutional invention, an exception, operating as a brake in one organ and as an accelerator in another.

The third hand is the departure from the run itself. Allocation out of sequence—an organ placed with a patient who is not next on the match run, under provisions meant for hard-to-place organs nearing their time limit—grew from 342 kidney transplants, 2.2 percent, in 2020 to 2,927, 15.7 percent, in 2023, on the figures published in JAMA Internal Medicine; for livers the share rose from 5 percent in 2019 to 18 percent in 2024; The New York Times put the phenomenon at nearly one transplant in five in February 2025. The federal response followed: a directive from the Health Resources and Services Administration on February 21, 2025, a public allocation-out-of-sequence dashboard that August, and a network memorandum of August 6, 2025 instructing programs to follow the match run. After the memorandum, the out-of-sequence share of kidneys fell from 24 percent to 15 percent—and daily kidney recovery and transplantation fell with it. Whether the crackdown traded transplants for equity or removed an abuse is genuinely disputed in the record; the desk files it as the system’s live cocked hat, and returns to it in Section 18. A claim that circulates in oversight testimony, that out-of-sequence placements occur in nearly twenty percent of all transplants, is graded disputed: it is a witness and advocacy figure, and the federal dashboard is the official instrument built to replace it.

The episode’s mechanism can now be tested exactly, and the desk reports the test in full. In the drama, a promised institutional donation moves a named patient past the patient the system ranked first. In the real system, that act would have to happen at a center, not at the list: the match run is generated centrally, its offers are logged, and a departure from the run is a recorded, auditable event—which is why the documented queue-moving cases in this report are found at the center-level discretion points, the declines, the exceptions, and the out-of-sequence placements, and not in edited rankings. Could a donation buy that discretion? The desk searched for the episode’s shape—a charitable gift or promised gift exchanged for an organ directed to a particular patient—in court records, federal investigations, and major-outlet reporting with named parties. The finding is plain: no case was found in which a donation was adjudicated, or officially found, to have purchased an organ or a place in line, and no documented case of a pre-transplant promise of a donation honored in exchange for an organ. The nearest shapes are these, each graded. In Chicago in 2021, Kayoko Hira, the wife of a Japanese hotel magnate, received a heart three days after listing, the hospital having obtained an exception that raised her priority, as a self-pay patient; the month after the transplant, a charity founded by her husband donated to a Chicago nonprofit whose principal officer was her surgeon’s wife, in the only gift that charity is recorded to have made to an American institution; the House Ways and Means Committee’s letter of January 27, 2026, quoted in Section 17, states that the case raises concerns about a possible pay-to-play arrangement; no adjudication or official finding of a quid pro quo exists, and the grade is alleged, under congressional inquiry. At UCLA between 2000 and 2004, two of four liver recipients with suspected organized-crime ties each donated $100,000 to the university within months after their surgeries; the surgeon stated in writing that no donation was offered as a quid pro quo, the hospital denied preferential treatment, and no finding of an exchange was made. A third shape never reached an operating room: a Japanese organized-crime figure was reported, by a retired FBI executive on the record, to have been willing to make a large donation to a hospital that would admit him; the embassy refused him a visa irrespective of the money, and he was transplanted in Australia. What the record does contain, documented, is money moving after transplants in gratitude—including the anonymous $40 million gift of 2015 to the Memphis institute that had transplanted Steve Jobs, identified in later reporting as his widow’s—and prominence moving through the lawful channels of the paragraph below. The drama’s mechanism is, on this record, an invention; the pressures it dramatizes are not.

Prominence, tested the same way, shows fast transplants with paper trails that end at the formula. Steve Jobs received his liver in Memphis in March 2009, weeks after clearing evaluation there in late February, having listed in both California and Tennessee; his hospital stated he was the patient with the highest MELD score of his blood type when the organ became available, Jobs himself said in 2010 that his California doctors advised the Memphis listing because the supply-and-demand ratio was more favorable, and no violation, audit finding, or official determination that money or fame altered his rank within the Tennessee list was found—the regional median wait where he was transplanted was 543 days against roughly three times that in his home region, which is the documented advantage, and it is the advantage of geography purchased by mobility. Mickey Mantle was listed in Dallas on June 6, 1995; an organ became available June 7; the surgery was June 8—the “one day” and “two days” of the retellings are the same timeline’s two endpoints. He was Status 2 in the pre-MELD system, no Status 1 or Status 2 patient stood in his area, his procurement organization put the average wait at his classification at 3.3 days, and the network stated after an audit that there had been no favoritism; the audit itself was never published, and the median waits printed against his case at the time range inconsistently from 67 to 183 days, filed here as inconsistency rather than as a number. Larry Hagman’s interval, by the documented dates—listed July 19, 1995, called August 22—is thirty-four days; Hagman said thirty-six days in his 1995 account and thirty-three in his memoir; the network insisted only the medical data in the system produced his match, and the “237-day median” that circulates against his name could not be verified in any source the desk found—the contemporaneous comparison printed by the Associated Press was an average wait of just over four months. The desk files the three cases together because the record files them alike: celebrity waits that were genuinely short, mechanisms that were lawful, explanations that were given and not disproven, and a residue of public suspicion that no document in the record either confirms or finally dispels.

The fourth hand belongs to the patient who can afford to hold more than one ticket. Multiple listing—registration at two or more transplant centers, in different areas—is legal and expressly permitted by the network, and each program decides for itself whether to accept the patient. The fullest data are from 2000–2013 and are printed with their dates: twelve percent of kidney candidates, six percent of liver candidates, two percent of heart candidates were multiply listed, and the multiply listed profile skewed white, college-educated, privately insured, and from higher-income ZIP codes, with transplant rates higher and waitlist death rates lower than the singly listed—for hearts, death at 8 percent against 12 percent. No comparably complete prevalence study for the 2020s was found, and the desk does not present the older rates as current ones. What the record establishes is the mechanism, which has not changed: a second listing requires a second full evaluation, travel, lodging near the center, and the ability to reach it on hours’ notice, none of it covered by insurance. The position money buys is real, lawful, documented, and purchased outside the match run entirely.

7. The Four-Hour Clock: What the Drama’s Number Gets Right and Wrong

The episode gives its liver four hours. The documented clocks are these, and the desk files them organ by organ. An organ’s cold ischemia time—the span it can spend cold, flushed, and still, between donor and recipient—runs, in the ranges commonly cited in the clinical literature: heart, four to six hours; lung, four to six hours; liver, eight to twelve hours; kidney, twenty-four to thirty-six hours; pancreas and intestine on their own shorter scales. Four hours is the floor of the heart’s window and the classic teaching figure for it. Applied to a liver, it understates the organ’s documented tolerance by half or more. The drama’s number is therefore wrong for the organ it chose, and right about the pressure: every deceased-donor transplant is a logistics operation run against a decay curve, and the liver’s curve, while longer than the heart’s, is measured in a working day, not in days.

Two further clocks govern the modern system, and both are newer than the drama’s premise suggests. The first is warm ischemia, the minutes an organ spends without blood flow at body temperature, which is the binding limit in donation after circulatory death: a DCD organ’s fate is largely decided in the interval between the withdrawal of support, the stand-off, and the cold flush, and it is why DCD kidneys and livers were once considered marginal goods. The second is the machine clock. Perfusion devices—pumps that circulate cold solution, or warm oxygenated blood, through the organ outside the body—stretch every window in the paragraph above and convert some of it from storage into assessment and repair time. Section 16 files the evidence in full; the summary for the clock’s purposes is that livers have been maintained on normothermic machines for up to twenty-four hours, lungs are reconditioned and tested on ventilated circuits before a center commits, and the practical consequence in 2026 is that the binding constraint on a transplant is increasingly not the organ’s hours but the system’s decisions. The four hours of the episode describe the transplantation of an earlier era more accurately than this one—which is the desk’s general finding about the episode’s premises, reached section by section.

8. Viability: Age, Sex, and the Question of Which Organs Count as Good

“Viability” in the record is three questions wearing one word: which donors are used, which organs are accepted, and whose body the formula measures fairly. The donor pool has aged past anything the system of 1998 imagined. More than 40 percent of American deceased donors are now fifty or older, and nine percent are sixty-five or older; no upper age limit for donation exists in national practice. The kidney system formalized the older organ a generation ago in the category once called the expanded-criteria donor—sixty or older, or fifty with hypertension, death by stroke, or elevated creatinine—whose kidneys were directed, with consent, to candidates who traded quality for a shorter wait. The modern form of the same practice is the KDPI scale itself, which prices every kidney’s expected durability into the match rather than sorting donors into good and refused. The direction of the record is unambiguous: the system transplants organs it once discarded, from donors it once declined to approach, and Section 12 files the uncomfortable counterweight—that even so, 29.3 percent of the kidneys it recovered in 2024 were never transplanted.

The sex question has a formula, a fix, and a dispute, in that order. The old liver score ran on creatinine, a blood marker of kidney function that also tracks muscle mass; at equal liver and kidney severity, women’s lower creatinine produced lower scores, and women waited sicker. The literature quantified it: before MELD 3.0, women’s transplant opportunity ran at a sub-hazard ratio of 0.88 against men and their waitlist mortality at 1.39. MELD 3.0, in force July 13, 2023, added albumin to the computation, lowered the creatinine ceiling, and added an explicit term for female sex, +1.33 points. In the first study of the new era, the disparities in transplant opportunity and waitlist mortality became statistically non-significant; a multicentre study found the ninety-day transplant-probability gap narrowed from 51.7 against 46.0 percent to 53.8 against 50.6. Then the record divides. A Hepatology study of 63,021 candidates found women’s early advantage under the new score attenuated over time and the gap widened again by the study’s end, with height mediating the effect and taller women receiving no significant benefit. A Frontiers in Transplantation analysis of the registry concluded the new score failed to improve women’s waitlist survival at all, their 180-day mortality hazard rising across eras. The claim “MELD 3.0 closed the sex gap” is therefore graded disputed: narrowed on transplant probability, contested on survival, and unresolved on size. In kidney, the registry record shows women fourteen percent less likely than men to be waitlisted in 2017–2020 and twenty-one percent less likely to receive a living-donor kidney—while supplying the majority of living donors, sixty percent of the National Kidney Registry’s Good Samaritan donors among them. In lung, women were thirty-two percent less likely than men to be transplanted before the Composite Allocation Score and remain sixteen percent less likely after it, a gap the authors attribute to body size and to sensitization from pregnancy and transfusion: the smaller chest and the more experienced immune system are both, in the record, documented mechanisms rather than imputations.

9. The Access Ledger: Race, and the Repairs on the Record

The largest single repair in the system’s history was made to a laboratory formula, and it is documented to the person. The kidney-function estimate used for a generation, eGFR, multiplied the result for Black patients by 1.159—about sixteen percent higher at the same blood value. Because transplant waiting time accrues from the threshold of kidney failure, the multiplier delayed recognition, referral, and listing for Black patients as a matter of arithmetic. The National Kidney Foundation and the American Society of Nephrology’s task force recommended the race-free equation in 2021; the network required race-neutral calculation from July 27, 2022, and in January 2023 required every kidney program to review its Black candidates and restore waiting time the multiplier had taken, with a program deadline of January 4, 2024. The completed-study count, published in JAMA Internal Medicine in 2026, is 21,119 adults who received modifications, a median of 1.7 years restored, 51,061 person-years in total, across 230 centers; an interim count from early 2024 recorded 14,701 candidates credited and 2,470 of them transplanted. After the modifications, deceased-donor transplant rates for Black candidates rose by 5.3 transplants per thousand listings. The implementation leaked, as implementations do: at one large center, of 274 eligible candidates only 109, or 39.8 percent, actually received their modification, most of the rest for want of historical laboratory documentation. The desk files the repair as the record presents it: a discrimination located in an equation, corrected by an equation, with the correction itself unevenly delivered.

The disparities that remain are documented at each gate of the process, and the desk files them gate by gate rather than as one atmosphere. At listing: Black patients remain less likely to be waitlisted relative to their share of kidney failure, and in preemptively listed cohorts followed through 2024, Black and Hispanic patients reached preemptive deceased-donor transplants at rates comparable to white patients in the most recent era while remaining far less likely to receive preemptive living-donor transplants—adjusted sub-hazard ratios of 0.31 and 0.61 against white patients—and more likely to start dialysis instead. Hispanic patients were 24.18 percent of kidney waitlist candidates and received 18.9 percent of kidney transplants in 2024, and carried a twenty-three percent higher adjusted risk of removal from the liver list by death or deterioration. At the offer: in registry data on 160,871 candidates who received offers between 2010 and 2020, a candidate’s being Black lowered the odds that the center accepted an organ on their behalf for liver, at an odds ratio of 0.93, and lung, at 0.80, while a donor of the candidate’s own race raised acceptance odds across heart, liver, and lung—a finding its authors present as observational, filed here at that grade. The registry’s own 2024 report attributes the year’s largest gains in deceased-donor kidney transplant rates to Black patients, following the waiting-time policy, and states in the same volume that living-donor access disparities persist, particularly for non-white and publicly insured patients. Both sentences are the system’s, and both stand.

10. The Insurance Companies: The Gate in Front of the List

Before the formula, before the match run, before the list itself, there is a financial clearance, and it is a documented step in the process, not an imputation about it. The federal patient guidance states plainly that a person is not listed by beginning dialysis or contacting a program; a program must evaluate and accept them, under its own standards, and it advises that long-term success requires insurance or other resources, because anti-rejection drugs and follow-up continue for the life of the transplant. Center literature prints the step in the open: one major system describes referral papers going first to a financial coordinator who verifies with the insurer that evaluation and surgery are covered—clearance taking three to five days—before the center schedules the patient’s first appointments; a university patient guide lists “adequate insurance and prescription coverage” among its standard selection criteria for the waitlist, between cardiac clearance and support at home. Insurers administer their own layer above the centers: prior-authorization policies that approve an evaluation for six months and a listing for twelve before requiring renewal, and documentation schedules specifying the forms, clearances, and letters of medical necessity without which the file does not move.

The insurers’ second instrument is the network: the transplant is covered where the plan says it is covered. The large carriers run designated transplant networks under their own names—Optum’s managed transplant program, reporting 199 center-of-excellence facilities and 1,146 programs and more than 9,080 transplants managed in 2024; Cigna’s LifeSOURCE network, more than 400 programs at over 120 centers; Aetna’s Institutes of Excellence; the Blue Cross Blue Shield system’s Blue Distinction Centers—each evaluating facilities on outcome rates and steering patients to them. The steering has prices attached. One state employee plan schedule pays a transplant at a designated facility at ten percent coinsurance and at a non-designated facility at thirty; one university’s 2026 schedule lists transplant services as covered only through the excellence network, with out-of-network care not covered at all; the federal employees’ Blue Cross brochure reimburses travel and lodging to its designated centers up to $5,000 per transplant, $10,000 for a recipient of twenty-one or younger, for members living fifty miles or more away. The networks publish outcome criteria and volume behind them, and the record does not show them to be a pretext; it shows them to be a second allocation system, run on contracts, standing in front of the public one. A patient’s organ is assigned by the national formula. A patient’s hospital is, in large part, assigned by their plan.

What coverage decides at the margin is also on the record, in policies and in one judgment. Medicare has covered kidney, heart, lung, liver, pancreas, intestinal, and combined transplants in Medicare-approved programs under national coverage determinations, with organ-acquisition costs paid on a reasonable-cost basis; but for the group whose Medicare rested solely on kidney failure, coverage historically ended thirty-six months after a successful transplant, taking the immunosuppressive drugs with it—a cliff associated in the literature with reduced adherence and increased rejection. Congress closed the drug half of the cliff for that group with the Part B immunosuppressive-drug benefit, enacted December 27, 2020 and effective January 1, 2023: drugs only, no other services, expressly not a substitute for full coverage. Coverage determinations still exclude whole categories: vascularized composite allotransplantation—hands, faces, and their kin—is classed experimental, investigational, or unproven in current Cigna, Blue Cross Blue Shield of Michigan, and Independence Blue Cross policies, and therefore unpaid, whatever the surgical record in Section 16 shows. And in the one appellate judgment the desk found on a retransplant exclusion, the Tenth Circuit in 2007 affirmed a plan’s refusal to pay for a second liver transplant seventeen days after the first, under an exclusion for more than one organ of the same type that the court found unambiguous; the plan had approved and paid for the first. The payer research runs the same direction at population scale: a 2025 systematic review of fourteen American studies found Medicare and Medicaid patients, particularly minority patients, referred less and rejected from waitlists more than the privately insured, with higher post-transplant mortality and graft failure; liver candidates on Medicare or Medicaid carried a twenty percent higher adjusted hazard of delisting by death or deterioration than the privately insured in the national data of 2002–2018. The insurance system is not an allegation against the transplant system. On the record filed here, it is the transplant system’s front door.

11. Injunctions and Judges: The Record of Courts Asked to Move the List

The episode’s premise is an emergency in a courtroom’s reach; the documented record contains exactly one instance of a judge touching an individual’s place in the allocation system, and the judge’s own memorandum states what he did not do. Sarah Murnaghan was ten years old in the spring of 2013, listed for lungs since December 2011 with cystic fibrosis and, in her physicians’ account, weeks to live. Under the lung policy of the day, the Under 12 Rule, children under twelve had first claim only on lungs from donors under twelve and stood last for adult lungs, unranked by the severity score used for everyone older. The Secretary of Health and Human Services declined to intervene on June 4, 2013. On June 5, Judge Michael M. Baylson of the Eastern District of Pennsylvania issued a temporary restraining order directing the Secretary to direct the network to “immediately cease application of the Under 12 Rule as to Sarah Murnaghan so that she can be considered for receipt of donated lungs from adults based on the medical severity of her condition as compared to the medical severity of persons over 12.” A materially identical order followed for Javier Acosta, eleven, the next day. In his supplemental memorandum of June 7, Judge Baylson wrote: “Finally, this Court did not in any way, shape, or form dictate when or whether Sarah should receive a lung transplant. The only legal effect of the ruling is that, for the limited duration of the TRO, Sarah will be treated the same as adults and will receive a ranking based on the details of her case relative to others.” The order suspended an eligibility rule for two named children; it awarded no organ, ordered no operation, and stopped no other patient’s surgery. Murnaghan received adult lungs on June 12, 2013; the graft failed within hours; she received a second pair on June 15. The network’s board, meeting June 10, created a case-by-case exception route for children under twelve rather than suspending the rule wholesale, and made the exception mechanism permanent in June 2014; in the five years after, of twenty-four children granted exceptions, one besides Sarah received an adult organ. The criticism and the defense are both in the journal of record: a leading ethicist called the intervention “a troubling precedent” and a circumvention of due process, noting the court sought no evidence on the discrimination claim; the children’s counsel answered that they had asked only for access ranked by medical urgency, which a binding regulation already required.

Beyond that case, the courts’ transplant docket is policy litigation, and its pattern is suits that move the agency rather than orders that move the organ. In November 2017 Miriam Holman, twenty-one, on an artificial lung in a New York intensive-care unit, sued over the use of the local donation area as lung allocation’s first unit. The district court denied her restraining order on November 20; within four days, on the Secretary’s direction after an emergency review the court’s pressure produced, the network replaced the local area with a 250-nautical-mile circle, the case was dismissed as moot, and lung geography had changed in about a week. Six liver patients sued in July 2018 in the case called Cruz; the agency directed a new policy, and the acuity circles of Section 5 are its descendant. The circles were then sued in their turn: in Callahan, four candidates and fourteen transplant centers sought to enjoin the liver policy’s nationwide start. The district court denied the injunction, briefly stayed implementation pending appeal—the policy lived for one day in May 2019 before the court ordered the work of implementing it paused, a pause of a policy, not of a patient—and on January 16, 2020 denied the renewed motion, writing the doctrine in its own words: “The Court’s role in this case is not to determine which policy is best, but whether the policymakers in question acted at very least within legal requirements.” The circles took effect February 4, 2020. The kidney circles met the same challenge in Adventist Health and the same result: injunction denied in the district court in March 2021, the denial affirmed by the Eighth Circuit that November, the policy likely lawful. The governing text under all of it is the Final Rule, 42 C.F.R. §121.8, which requires allocation policies based on sound medical judgment, ranked by objective and measurable medical criteria from most to least urgent, not based on a candidate’s place of residence or listing except as the Rule permits—and which preserves, in the same breath, a program’s ability to decline an organ for a medically suitable candidate. Courts review that framework for arbitrariness under the Administrative Procedure Act, with deference; the framework’s individual decisions—the exception, the status, the declined offer—run through the network’s own review boards, which is the administrative path the Rule builds instead of a courtroom.

The plain statement the desk was asked to test can now be made. On the record searched—court opinions and dockets, the network’s and the agency’s documents, the peer-reviewed journals, and the major newspapers—no instance was found of an American judge ordering an organ to a specific patient, ordering a transplant to proceed for a specific patient, or enjoining a specific other patient’s scheduled transplant in order to reorder a list. The claim that such injunctions are a routine judicial tool is graded unsubstantiated. What judges have done is narrower and, in the Murnaghan case, considerable: suspended a rule’s application to a named child for a matter of days so that she could be ranked, and, in the policy cases, set the timetable on which the agency rewrote the map. The candidacy cases run on a different track entirely and end without judgments: Sandra Jensen, denied a heart-lung transplant in 1995 on account of her Down syndrome, was accepted after advocacy and press, transplanted January 23, 1996, and her case produced California’s 1996 statute, the first of what are now forty state laws against disability discrimination in transplantation; Amelia Rivera, three, refused a kidney at the same Philadelphia hospital in 2012 with “mental retardation” noted in her file, received her mother’s kidney in July 2013 after a public campaign and the hospital’s apology, and New Jersey’s statute followed. The federal bill named for Charlotte Woodward, a heart recipient with Down syndrome, passed the House unanimously in September 2024, was reintroduced in 2025, and advanced in a Senate committee in June 2026; in every source it is a bill, not a law. The courtroom, on this record, is where the rules of the list are argued. It is not where organs are handed out.

One staging detail of the episode deserves its sentence against the record. The drama conducts its emergency hearing remotely, the parties and the judge alike arguing from gridlocked cars. The real record’s emergencies were slower in their furniture and fast in their effect: the Murnaghan application was filed, heard, and ordered within days in a courtroom in Philadelphia in June 2013, the Holman emergency hearing sat the day after filing in November 2017, and in both matters the consequential act was not the judge’s order but the agency’s response to the pressure of the filing. Remote hearings are now ordinary judicial furniture and nothing in the record makes the drama’s version implausible as procedure; what the record does not contain is a hearing, remote or otherwise, at which an organ changed hands.

12. The Supply: 109,817 People, a Record Year, and the Organs Not Used

The arithmetic of the shortage, stated with each figure’s date attached, is this. The waiting list held 109,817 people in the federal snapshot of July 30, 2026; a second live snapshot counted 108,790 candidates, of whom 61,109 were active—the two figures are different days, not a disagreement. Of the list, 95,492 were waiting for a kidney, about eighty-seven percent. In 2024, 70,600 people were added to a waiting list, and 167,230 were on one at some point in the year. The current federal framing is that twelve people die each day waiting; the same government’s materials through 2025 said seventeen, some 2025–26 charity materials say thirteen, and the hard counts beneath the framings are by organ: 3,743 adult kidney candidates removed from the list by death in 2024, and 4,901 removed as too sick to transplant—for kidney alone, more people left the list by deterioration than by death. Against that, the system’s production sets a record every year and loses ground anyway: 46,632 transplants in 2023, 48,149 in 2024, 49,064 in 2025 on the network’s count—a figure the Medicare agency’s October 2026 rule prints as 49,065, a one-count difference of late reporting, filed as such. Deceased donors supplied the growth: 16,989 in 2024, the most of any country in absolute terms, then 16,550 in 2025, the first decline in more than a decade. Living donors contributed 7,030 transplants in 2024—the second-best year ever, behind only 2019—and 7,237 in 2025, about ninety-one percent of them kidneys, the rest mostly liver segments, including a record 709 living-donor liver transplants in 2025.

The living-donor system’s machinery deserves its own paragraph, because it is the one part of the supply that runs on exchange. A non-directed donor—a person who gives a kidney to a stranger—typically starts a chain of transplants through the paired-exchange networks, each recipient’s own incompatible donor passing a kidney to the next stranger in line. The National Kidney Registry, the largest of these networks, facilitated 1,744 living-donor kidney transplants in 2024, roughly twenty-nine to thirty percent of the national total, and passed its ten-thousandth facilitated transplant in January 2025. Its voucher program separates the exchange in time: a donor gives now, and a named holder—a grandparent for a child, a parent for a future need—redeems the voucher for a living-donor kidney later; voucher-based donations rose from 2 in 2015 to 314 in 2024, seventy-two percent of the registry’s Good Samaritan donations that year. Good Samaritan kidney donations of all kinds rose from seventeen in 2000 to 439 in 2024; a second tabulation counts 455 non-directed kidney transplants for the same year, a difference of definition, not of fact, printed as both. Registration, the deceased side’s raw material, stands at more than 170 million names—against the governing constraint the field repeats in every explainer: only about three deaths in a thousand occur in circumstances that permit organ donation at all.

The supply’s paradox is printed in two registry ratios, and they point in opposite directions. Organs recovered per donor rose to 3.35 in 2024. Organs transplanted per donor fell to 2.66, from 3.08 in 2013, with kidneys at 1.32 transplanted per donor, the lowest of the period; 29.3 percent of the kidneys recovered in 2024 were never transplanted. The registry’s own commentary ties the fall to the rise in marginal donors—older, sicker, more often DCD—whose organs centers decline. The system is thus, on its own numbers, simultaneously producing its largest supply and discarding its largest share, and the two facts are the same fact seen from opposite ends of the offer process of Section 6: a wider net catches more fish the buyers refuse. Any account of the shortage that begins with public willingness to donate has the record backwards at the margin; the marginal organ in 2026 is lost at the acceptance desk, not at the registry.

13. The Workforce: Enough Surgeons Is a Question the Record Splits

The physical system is 250 transplant hospitals among 452 network members, fifty-five donation service areas, and a map with holes in it. The count of procurement organizations itself splits in the sources—fifty-five in the network’s and the Congress’s December 2024 accounting and in the GAO’s November 2025 figure, fifty-six in the Medicare agency’s current oversight writing—a certification-versus-membership difference the desk prints without resolving. About fifteen percent of Americans live more than two hours from a transplant center, and the record associates distance with lower listing and higher waitlist death; across the 130 heart and lung centers, fifty-seven percent of the rural population lives more than an hour away against twenty-eight percent of the urban, and the two-hour-plus population is disproportionately Southern, Midwestern, Western, and uninsured. Into this map the Medicare agency’s revised certification process inserts a new cost of entry: an editorial in the field’s journal, filed as analysis rather than as the agency’s finding, calculates that a new program may have to operate eighteen to twenty-four months and perform forty to fifty transplants without Medicare reimbursement to earn approval, in a system where more than half of liver and kidney recipients are publicly insured.

On the question the desk was asked—whether America has enough transplant surgeons—the literature carries two narratives, and both are sourced, and they are about different things. The improvement narrative is a match table: in abdominal transplant fellowship, unfilled positions fell from thirty-five percent in 2007 to six percent in 2023, and the filled share rose from a median of seventy-four percent before the specialty society’s 2018 pipeline effort to ninety-two percent in 2019–2023. The crisis narrative is an application count and a burnout survey: a 2025 editorial in the field cites society data for a thirty-five to forty percent decline in fellowship applications since 2014 and burnout rates of fifty-six to sixty percent among transplant surgeons; a 2024 paper’s claim that about a quarter of fellowship positions go unfilled annually matches the pre-2019 era of the match table, not its present. Where the shortage is not contested is one floor down, in transplant medicine: in 2024, 43.3 percent of advanced heart failure and transplant cardiology positions and 34.2 percent of nephrology positions went unfilled in the national match, sixty-two percent of transplant hepatology positions went unfilled in the 2023 match, and a workforce projection in the literature foresees a thirty-five percent shortage of adult hepatology providers by 2033. No definitive national projection of surgeon supply against demand was found. The headline claim that America lacks transplant surgeons is graded disputed—established for the adjacent medical fellowships, contradicted on fill rates for the surgical one, and resting, in its strongest form, on applications and burnout rather than on practicing headcount. The procurement map, meanwhile, is about to be redrawn by the ratings of Section 3: under the December 2020 rule’s first full cycle, measured on 2024 data, the Medicare agency’s October 30, 2026 final rule counts fourteen service areas in the lowest tier and twenty-one in the middle—thirty-five of fifty-five areas opened to competition once appeals resolve—with independent analyses noting that the lowest-tier areas serve disproportionately non-white populations. The decertifications already begun are filed in Section 3; multiple organizations sued over the framework in 2025, and the litigation was live in the sources reviewed.

14. The Market the Law Forbids: Transplant Tourism and the Black Market

The world’s standard number for the illegal market is nineteen years old, and it has never been replaced. The World Health Organization’s estimate that five to ten percent of kidney transplants worldwide are commercial dates to a consultation in 2007. It is the figure still cited—often as “ten percent of all transplants”—and any presentation of it as a current measurement is unsubstantiated on the record the desk reviewed: the organization has published no revision, and the denominator it described was kidneys. The governing definitions are those of the Declaration of Istanbul, first issued in 2008 and revised in 2018, which separates organ trafficking, transplant commercialism, and transplant tourism into distinct terms. The market’s geography, as documented in studies and prosecutions, runs from sellers in South Asia, the Middle East, Eastern Europe, and parts of Africa and Latin America to recipients arriving from wealthy countries—the United States, the Gulf states, Israel in an earlier period, Japan, and Western Europe among them—with clinics in a rotating set of destination countries. Prices on the record vary by study and decade and are printed as ranges, not as a price list: recipients paying from $10,000 to $200,000 for a kidney package, and sellers receiving, most often, $1,000 to $2,500 of it.

One country runs the exception openly, and its own follow-up data are the strongest argument filed against it. Iran operates the world’s only legal, regulated system of paid living kidney donation, through government-supervised charities; its proponents credit it with eliminating the kidney waiting list. The follow-up of the vendors themselves, in the study by Zargooshi published in 2001, found seventy-five percent reporting their goals from the sale unmet and seventy-six percent saying the sale of kidneys should be banned. Both claims are in the record—the list eliminated, the sellers’ verdict on selling—and the desk does not reconcile them. Enforcement elsewhere is a prosecution record, and the desk files its landmarks: Rosenbaum in the United States in 2011, Section 2 above; the Netcare hospital group’s guilty plea in South Africa in 2010; the Medicus clinic convictions in Kosovo in 2013, with sentences on retrial in 2018; and the Ekweremadu case at the Old Bailey in 2023, the first organ-trafficking conviction under the United Kingdom’s Modern Slavery Act, nine years and eight months for a serving Nigerian senator found to have brought a young man to London to sell a kidney to his daughter. One policy experiment is documented end to end: Israel’s 2008 law ended reimbursement for transplants performed illegally abroad, and Israelis transplanted abroad fell from 155 in 2006 to thirty-five in 2011—the record’s cleanest demonstration that the demand side of this market answers to law, in the one case where a wealthy country legislated against its own patients.

15. China: The Prisoner-Organ File, Attributed and Graded

No section of this report required more care in the filing, and the desk states its method at the top: every claim below carries its maker’s name and its grade, and the desk asserts none of them in its own voice. What is admitted by the Chinese state itself is the foundation. In 2005, China’s then vice-minister of health, Huang Jiefu, acknowledged that organs from executed prisoners were the main source of China’s transplants. Beijing’s position since is that a voluntary citizen donation system became the sole source on January 1, 2015. The official volumes, through the Global Observatory on Donation and Transplantation, are 13,238 transplants in 2016, 20,333 patients in 2022, and 23,905 in 2023. Against those stand the investigative claims: the 2016 Kilgour, Gutmann, and Matas report’s estimate of 60,000 to 100,000 transplants a year, implying a supply the official donor numbers cannot explain—disputed, with the Washington Post’s 2017 immunosuppressant-demand analysis filed as counter-evidence and the authors’ rebuttal filed beside it. Two peer-reviewed findings carry the matter past estimation: Robertson, Hinde, and Lavee showed in BMC Medical Ethics in 2019 that China’s official donation data for the reform years fit a quadratic formula almost precisely, a pattern the authors conclude indicates systematic falsification; and Robertson and Lavee’s 2022 analysis in the American Journal of Transplantation examined seventy-one published transplant papers in which brain death could not properly have been declared before procurement began. The China Tribunal of 2019, chaired by Sir Geoffrey Nice, found forced organ harvesting from Falun Gong practitioners proven beyond reasonable doubt; the tribunal was a non-governmental people’s tribunal, not a court, and it expressly found the evidence insufficient to reach the same conclusion for Uyghurs—a distinction the desk preserves because the tribunal itself drew it. United Nations human-rights experts stated on June 14, 2021 that they were “extremely alarmed” by reports of organ harvesting from detained minorities, citing information they called credible. The Chinese government’s position, stated in 2022, is that the allegations are “purely fabricated” and have “no factual basis.” In the United States, the Stop Forced Organ Harvesting Act and the Falun Gong Protection Act have passed the House of Representatives repeatedly; neither is law, and a reported Senate passage of a related bill in September 2026 rests, in the sources the desk found, on movement-affiliated reporting only and is filed unverified against the congressional record. The desk’s summary of the file is the file: an admitted historical practice, a claimed and dated reform, official statistics independently found to bear the signature of manufacture, a tribunal’s finding at its own stated limits, an alarmed United Nations statement, a flat official denial, and no adjudicated resolution. Readers weighing the parts should weigh the instruments that produced them, which is why the instruments are named.

16. What Changed Since 1998: The New Organs and the New Machines

A reader who last considered this subject in 1998 knew a system of brain-dead donors, organs on ice, and a waiting list for hearts, livers, and kidneys; nearly every element of that picture has been amended, and the desk files the amendments in the order they changed the supply. The first is the donor. Donation after circulatory death, negligible in 1998, supplied forty-nine percent of deceased donors by 2025, and its second act was the heart: the first American adult DCD heart transplant, at Duke in December 2019, was followed by a 2023 New England Journal of Medicine trial finding DCD hearts non-inferior to brain-death hearts at six months, ninety-four percent survival against ninety. DCD hearts went from zero percent of American heart transplants in 2013 to 17.1 percent in 2024. The ethics dispute over the perfusion technique that recovers many of them is filed in Section 2 and stands unresolved.

The second amendment is the machine between the donor and the recipient. Kidney pumping, vindicated in the 2009 New England Journal trial of Moers and colleagues—delayed graft function of 20.8 percent against 26.5 for static cold storage, one-year graft survival of ninety-four against ninety—is now routine: 86.8 percent of DCD kidneys were pumped in 2023–25. Normothermic liver perfusion, in the COPE consortium’s 2018 Nature trial, halved graft injury, halved the discard rate, and lengthened preservation by more than half; livers are maintained for up to twenty-four hours, and in the VITTAL trial twenty-two of thirty-one livers rejected by all seven British centers were rescued and transplanted after assessment on the machine. Lungs are ventilated and tested outside the body, with the Toronto program’s thousand-case series accepting about sixty-five percent of the lungs it perfused. The machine changed the verb of the enterprise: an organ is no longer merely stored; it is examined, and increasingly, treated, on the way.

The third amendment is the donor the old system refused. The HOPE Act’s first HIV-positive-to-HIV-positive transplants were performed at Johns Hopkins in March 2016; by November 2024 about five hundred such kidney and liver transplants had been done, a New England Journal trial that year found HIV-positive kidney donation non-inferior, and a federal final rule of November 27, 2024 made kidney and liver HOPE transplants standard practice outside research protocols, with the other organs still research-only. Hepatitis C followed the same arc faster: the DONATE HCV trial of 2019 transplanted hearts and lungs from hepatitis-C-positive donors into forty-four uninfected recipients and cured every one of those followed with antiviral drugs; a Toronto protocol prevented infection outright in 116 consecutive cases; by 2024 about ten percent of American heart transplants came from hepatitis-C-positive donors. Organs once destroyed on diagnosis are now inventory, and the waiting list is shorter by exactly their number.

The fourth amendment is the animal, and its record is a chronology of firsts with their endings attached, as the desk files all of them. A gene-edited pig heart was transplanted into David Bennett on January 7, 2022; he died at about day sixty, without typical rejection, a latent pig virus later found in the graft with its role disputed. A second pig heart, Lawrence Faucette’s, followed in September 2023 and lasted about forty days. Pig kidneys entered living patients in March 2024: Richard Slayman’s functioned until his death at day fifty-two, which the autopsy recorded as sudden cardiac death with no rejection of the graft; Lisa Pisano’s was removed at day forty-seven and she died that July; Towana Looney’s, placed November 25, 2024, was removed at day one hundred thirty after rejection that followed a reduction of her immune suppression for an unrelated infection. The record case is Tim Andrews: his pig kidney, placed January 25, 2025, functioned 271 days, a record, before removal on October 23, 2025—and in January 2026 he received a human kidney, becoming, in the Lancet’s September 2026 account, the first person bridged from a pig organ to a human one. Five patients had received pig kidneys under expanded access by September 2026, one of them past nine months. The regulatory gate opened in 2025: the Food and Drug Administration cleared the first company-sponsored pig-kidney trial, United Therapeutics’ UKidney study, on February 3, 2025, with its first transplant performed November 3, 2025 at NYU, and cleared eGenesis’s trial application on September 8, 2025, its study expected to begin in early 2027. No pig organ is approved for general use anywhere in the world. China’s parallel record includes a pig liver placed as an auxiliary graft in a living man in May 2024, removed at day thirty-eight, the patient dying at day one hundred seventy-one, and the first pig lung placed in a brain-dead human, which functioned nine days, reported in Nature Medicine in August 2025.

The fifth amendment is the part of the body that was not, until this century, transplanted at all. Vascularized composite allotransplantation—hands, faces, and their kin—began just inside the reader’s 1998 horizon: the first modern hand transplant on September 23, 1998, its graft later lost when the recipient stopped his immune suppression, and the first face transplant on November 27, 2005, Isabelle Dinoire’s. The National Academies’ 2025 count is about 151 hand and 53 face transplants worldwide as of December 2024, thirty-eight and twenty of them American. The frontier cases are dated and single: the first whole-eye transplant, with a partial face, on May 27, 2023—the eye surviving, sight not restored; the uterus, a graft by design temporary, first delivered of a live birth in Sweden in September 2014 and standing at forty-eight American transplants and thirty-three births by May 2024; and the first human bladder transplant, at UCLA on May 4, 2025, with a second in February 2026. Against these stand the honest negatives the desk was instructed to file with the firsts: no 3D-bioprinted solid organ has ever been implanted in a human being; whole organs grown from emptied scaffolds remain preclinical; tolerance protocols that free recipients from lifelong immune suppression work in trials—twenty-four of twenty-nine patients weaned in the Stanford series, twenty-five of thirty-two off drugs in Northwestern’s—with infections, a death, and graft-versus-host risk on the same record; and the only fully approved total artificial heart remains the SynCardia device, the newer BiVACOR having first been implanted in July 2024 as a bridge. The state of the art in 2026 is a system that takes organs from donors dead two ways, repairs them on machines, accepts them infected and cures the infection, borrows them from pigs for months at a time, and transplants the bladder, the uterus, the hand, and the face—and still ends every year with a waiting list longer than the one it started with, because the demand it serves grows as fast as the art. That is the whole of the state of the art, and it is why the queue of Sections 5 and 6, and not the laboratory, remains the system’s contested ground.

17. The Controversies Ledger: The Charges Against the System, Item by Item

The desk was asked for the full list of controversies attacking transplantation, and files it as a ledger: each charge stated, each weighed on the instrument that produced it, each graded in the open—documented, adjudicated, inquiry-concluded, committee-stated, alleged, or not found. Several entries are treated at length elsewhere in this report and are entered here in summary with their section named; the rest stand on the documents cited in the clippings below. The ledger’s discipline is the report’s: a congressional letter is evidence that Congress alleged, a dismissed lawsuit is evidence that a claim was made and not sustained to judgment, and neither is promoted into a finding.

Corrupt oversight and the monopoly. Documented as to structure and breakup: for nearly forty years one contractor ran the network with its own board as the network’s board, the Senate Finance Committee investigated the system across multiple Congresses, and the monopoly was ended in law by the Securing the U.S. Organ Procurement and Transplantation Network Act of September 22, 2023 and in fact by the multi-vendor contracts and independent board of 2024–2025, filed in full in Section 3. At the House Energy and Commerce hearing of September 11, 2024, transplant surgeons testified to forty years of effectively no oversight of the procurement organizations; the witness Greg Segal relayed whistleblower allegations he described as credible—Medicare fraud, executives joyriding on taxpayer-funded jets, records falsified, organs harvested from patients whistleblowers believed would have survived, kickback schemes, settlements and nondisclosure agreements burying information—stating in the same testimony that he is not an oversight body and could not investigate the claims himself. UNOS answered the same day that the allegations were serious and unfounded; an industry rebuttal memo of September 15, 2024 called the testimony hearsay and stated it knew of zero procurement-organization fraud prosecutions in ten years. The allegations stand at testimony grade; the oversight failure they describe is corroborated in its general form by the GAO’s findings in Section 3.

The money at the procurement organizations. Committee-stated, with the audited amounts printed beside the charges because both are the record. The Ways and Means Oversight hearing “Lives at Stake” of December 2, 2025 heard that eighteen of the twenty-one most profitable procurement organizations sit in the lowest performance tiers, and the committee states that its investigation found overbilling of Medicare for costs including executive compensation, lobbying, meals, and entertainment. The Inspector General’s own audit of August 2023, on a base of $101.6 million in education-overhead costs across fifty organizations, estimated $664,295 in unallowable costs and recommended recovery of $72,208—real findings, and smaller than the rhetoric by two orders of magnitude. The committee’s jets inquiry is documented as an inquiry: its April 2025 request for information asks whether procurement organizations used organ-transport jets for personal use, and its July 23, 2025 letters demanded flight logs from three organizations, inquiring whether an Indiana subsidiary’s jets flew non-mission charter flights for executives, staff, and some financial donors billed to Medicare; personal use stands alleged, not adjudicated. Kickbacks have exactly one adjudicated procurement case in the record found: two Alabama Organ Center directors pleaded guilty in 2011 to conspiracy and fraud for kickbacks from a funeral home—$498,551 in restitution, prison terms of about a year, in 2012; no current kickback conviction was found, and no specific multimillion-dollar executive salary figure was verified in the primary hearing documents reviewed, the committee’s summary naming executive compensation as a category without a number. The structure that makes the questions perennial is documented: the organizations—fifty-five by the 2025 counts of the Congressional Research Service, the committee, and the GAO, fifty-six in the Medicare agency’s blog—hold exclusive regional service areas and are reimbursed by Medicare at cost for allowable expenses. Two further billing charges stand at allegation grade: the Chase complaint’s claim, quoted in the Dallas entry below, that organizations procure kidneys they know are not viable in order to bill for the procurement—against which the governing rule, as a federal court summarized it in dismissing that very suit, reimburses only kidneys procured and intended for transplant, not kidneys known to be unviable—and testimony at the December 2025 hearing that more than 7,000 pancreases have been harvested since 2020 under a rule crediting organs recovered for research that did not occur.

Waiting-list skipping. Documented and disputed in its size, filed in full in Section 6: allocation out of sequence grew to 15.7 percent of kidney transplants in 2023 on the journal figures, The New York Times put the bypassing of top-listed patients at nearly twenty percent in 2024, the federal dashboard built to measure the practice opened in August 2025, and the share fell after the network’s follow-the-match-run memorandum while total transplants fell with it. The charge that the queue is routinely jumped is sustained by the system’s own data; the charge’s exact rate depends on the instrument, and the desk prints the instruments.

Premature recovery. The government’s findings, filed in full in Section 2: of 351 Kentucky cases examined, 103 showed concerning features, seventy-three patients showed neurological signs the agency called incompatible with donation, and at least twenty-eight may not have been deceased when procurement preparation began; the Kentucky organization disputes the findings and has appealed its decertification. A scale figure circulating as “over one hundred cases where recovery was initiated on patients showing signs of life” resolves, against the primary release, into the 103 concerning-features cases—of which the possibly-not-deceased subset is twenty-eight—and is printed here in its exact federal framing rather than its circulating one. A transplant surgeon testified to the September 2024 hearing of a donor found still alive as surgeons prepared, an administrator’s suggestion that the movement was a brainstem reflex, and his refusal to proceed; that account stands at testimony grade.

The Dallas whistleblower case. Alleged in litigation, and dismissed. Patrek Chase, a former kidney-transplant program director at Parkland Health, filed a False Claims Act suit in March 2023 alleging that the transplant teams shared between Parkland—the public hospital, whose patients are largely Medicaid and charity care—and UT Southwestern’s university hospital—whose patients are largely privately insured—judged kidneys unusable for Parkland patients at least thirty-six times in one year and transplanted the same kidneys into UT Southwestern patients, the same physicians running both programs; the shared-team structure itself is documented in the court’s orders, Parkland having contracted all its transplant services to UT Southwestern. The Washington Post reported the allegations on September 17, 2025; neither institution commented to the paper, citing the litigation. The United States declined to intervene in June 2025, and in January 2026 the district court dismissed every defendant—UT Southwestern on immunity grounds, the procurement organizations and Parkland for failure to plead specific false claims with the particularity the Act requires—entering final judgment with prejudice on January 26, 2026. The dismissals were on pleading and immunity grounds, not a merits finding on the medical facts; the allegation therefore stands exactly where the docket leaves it: made under oath in a complaint, reported by a national newspaper, tested by no trial. Chase’s complaint also alleged that Loyola University Medical Center kept three sets of books—an internal system, a quality manager’s spreadsheet he was told not to share externally, and an outside-facing record showing fake or thinner data—to hide liver graft failures, including operating-room deaths recorded internally as graft failures but not as transplant deaths outside; that allegation was dismissed with the same action and stands at the same grade. The further charge in circulation, of research records falsified specifically to protect program accreditation, was searched for and not found as phrased; the nearest documented relative is the Ways and Means letter of November 19, 2025 relaying nearly a dozen whistleblowers’ claims against the New Jersey Sharing Network—a fraudulent research program at taxpayer expense, documents manipulated for federal investigators, and one hundred pancreases discarded in a single day, which the organization told the committee did not occur—committee-stated, unresolved.

Foreign nationals and the price of a place. Committee-stated, on the committee’s own paper, with one correction to the circulating account entered in the open: the letters went to two hospitals, not one. On January 27, 2026, Chairman Jason Smith and Oversight Chairman David Schweikert of Ways and Means wrote to the University of Chicago Medical Center and to Montefiore Medical Center, citing the New York Times investigation of December 16, 2025, demanding documents by February 10 under threat of subpoena and asserting jurisdiction through the hospitals’ tax exemption, which the chairman’s release said should be terminated if the hospitals prioritized foreign nationals over American lives. The Montefiore letter states that overseas patients make up twenty percent of Montefiore’s lung transplant recipients, generating tens of millions of dollars—twenty percent, of lung recipients, at Montefiore, as the committee states it citing the newspaper, not the looser “up to twenty percent at one facility” of secondary circulation. The Chicago letter states that overseas patients make up eleven percent of that center’s heart and lung recipients and that its sixty-one international transplants of 2020–2024 were the nation’s most. The Montefiore letter quotes a former transplant financial coordinator at the hospital: “We had patients who we’d been working with, who had been waiting their turn, and then someone from Kuwait would come and jump the line,” and alleges colleagues altered or omitted health information to move international patients quickly. The Hira case in the Chicago letter is filed in Section 6. Nothing in the matter has been adjudicated; the hospitals’ answers were demanded, not yet public in the sources reviewed.

Paper play: the adjudicated American cases. Three clusters meet the standard of a fine, a settlement, a sanction, or a finding. In Los Angeles, on September 7, 2003, St. Vincent Medical Center accepted a liver offered for its patient who ranked second on the match list, who was abroad, and transplanted it into another of its patients, a Saudi national who ranked fifty-second, behind nine other St. Vincent patients; the Saudi embassy paid the hospital $339,000 for the transplant, twenty-five to thirty percent above the usual rate; staff then falsely reported to the network that the intended patient had received the liver, submitted a falsified pathology report, and sustained the falsification until a 2005 audit exposed it. The network designated St. Vincent a Member Not in Good Standing in March 2006—the first public sanction in its twenty-year history—the federal government revoked the program’s designated status, and the liver program was never reinstated; the program director, indicted in 2010 on eight counts including falsification of records, was acquitted by a federal jury in 2011, the institution’s falsification and the director’s personal culpability having been adjudicated separately and oppositely, and the desk keeps them separate. In Chicago, federal and state False Claims suits unsealed in 2003 alleged that three hospitals falsely reported liver patients as critically ill to house them in intensive care and move them to the top of the list in 1996–1998; the University of Chicago paid $115,000, Northwestern Memorial $23,587, and the University of Illinois $2,003,290.78 in settlements, the hospitals denying legal wrongdoing, the suit having been brought by a whistleblowing liver surgeon. In Albany, a network audit found documentation unsupported for the urgent Status 1A listings of a heart program; the program was suspended in October 2003, and New York State fined the medical center $18,000 in May 2004, finding that a physician had exaggerated patients’ severity—in five cases falsely claiming they would die within a week—to move them up the list. Beyond these, and St. Vincent, no other American fine, suspension, or closure specifically for exaggerating sickness to inflate priority was verified in this research; the absence is reported as a research result, not as proof none exists.

Paper play: the German scandal. Inquiry-concluded, with its principal trial ending in acquittal. The German Medical Association’s inquiries found manipulation of allocation data at no fewer than four university hospitals—Göttingen, Regensburg, Munich, and Leipzig—with at least 107 clear manipulation cases across the inquiries. The methods were the mirror image of the American clusters: the three laboratory variables of the MELD score falsified upward at Göttingen; at Munich, patients’ blood samples adulterated with urine to make them appear sicker, in two cases samples taken from a person who had never been a patient; at Leipzig, thirty-eight people falsely registered as dialysis patients across 2010–2012 to raise their liver priority, the clinic stating it could not rule out that money had changed hands; at Regensburg, a surgeon gave a Jordanian patient a false local address to present him as a resident, with an organ destined for a European recipient sent to the Middle East. The Göttingen surgeon was tried from 2013 on attempted-manslaughter counts and acquitted on all of them, the Federal Court of Justice rejecting the appeal in 2017 and the judge holding the breach of medical ethics not punishable under the law as it stood; he was later awarded some €1.2 million in damages for his eleven months in custody. The prosecution found no evidence of bribery; a per-transplant bonus in the Göttingen surgeon’s contract was reported as rumor and never proven, and the motives the literature settles on are institutional—volume, prestige, funding, competition between hospitals. A secondary claim that the scandal produced multiple convictions, which appears even in a federal white paper, is contradicted by the acquittal record and is not used. The consequence most often quoted is that German donation fell by up to forty percent; the foundation’s own statement of January 2013 put the decline at between twenty and forty percent, and the counted donors fell from 1,296 in 2010 to 1,046 in 2012 and 876 in 2013, a fall of about a third across the scandal years—with the foundation’s later peer-reviewed analysis disputing the simple trust story, the decline having begun before the scandal and the authors attributing it chiefly to hospitals’ failure to recognize and report potential donors. The forty percent figure is the top of the foundation’s contemporary range and, approximately, the cumulative fall to 2017; printed bare, without its baseline, it misleads, and the desk does not print it bare.

Bought organs, brokers, and coercion abroad. The market’s general file stands in Section 14; the ledger adds its two newest documented entries and its captivity record. In Kenya, a joint investigation by DW, Der Spiegel, and ZDF published in April 2025 traced a network running through Mediheal Hospital in Eldoret and an agency recruiting recipients from Germany: one named German recipient told the investigators she paid between $100,000 and $200,000 for her transplant, the investigation reporting payments up to $200,000; young Kenyan donors described being promised $6,000 and paid $4,000, some receiving $2,000, and being handed consent documents in English they could not read; a former employee, anonymous, described donors signing papers naming them relatives of recipients they had never met. Kenya’s Health Ministry had already found five red flags at the hospital in a December 2023 review—unproven donor-recipient relationships, untranslated documents, samples exported to India without approval, high-risk cases, absent oversight—concluding suspicious activity without sufficient evidence of trafficking; on April 17, 2025 the ministry suspended all kidney transplant services at Mediheal pending audit, and the hospital denies sourcing donors or knowledge of illegal transactions. No Kenyan conviction was verified in this research; the grade is documented investigation and official action, the underlying trafficking alleged. The captivity record is older and adjudicated in part: in Rawalpindi in October 2016, Punjab police freed twenty-four people—twenty men and four women—held in a building on false promises of jobs, one man hours from a scheduled removal, the police register charging kidnapping and illegal detention under Pakistan’s transplant act, the victims’ accounts of their confinement ranging from weeks to months across the reporting; in Lahore in April 2017, federal agents raided a makeshift hospital mid-transplant, donors and Omani recipients unconscious on the tables; in Gurgaon, India, the 2008 raid on the Amit Kumar network—laborers enticed with job offers, some testifying to removal at gunpoint or under anesthesia without consent—ended in convictions in 2013. The mechanism beneath the raids is documented in the literature rather than the dockets: a peer-reviewed synthesis of the kidney-selling research and field studies from Bangladesh find sellers routinely paid less than promised and receiving no post-operative care, families driven by debt traps and dowry obligations, brokers forging kinship papers; and PBS NewsHour’s January 2023 account from Nepal’s “Kidney Valley” records a nineteen-year-old lured across the Indian border by a job promise, his kidney removed in Kolkata under a blood-test pretext, $4,500 in his hand and his health gone. The desk files these as the market’s documented floor: whatever the unmeasured share of Section 14, the trade’s labor practices are not in dispute in any source reviewed.

Prominence and the queue. Filed in full in Section 6 with the episode’s mechanism test: Steve Jobs’s documented two listings and highest-score explanation, with no official finding that fame moved him within a list; Mickey Mantle’s one day to an available organ and two days to surgery, Status 2 with no higher-status patient in his area, and the network’s unaudited-in-public statement of no favoritism; Larry Hagman’s thirty-four days by the dates, thirty-six by his account, thirty-three by his memoir, and a circulating 237-day median the desk could not verify and does not print. The VIP charge, tested against documents, resolves into lawful mobility, genuine medical urgency, and explanations that stand unrebutted and unproven in roughly equal measure.

China. Filed in full in Section 15, attributed and graded: the admitted executed-prisoner era, the claimed 2015 reform, the formula-fitting official data, the tribunal’s finding at its stated limits, the United Nations experts’ alarm, the official denial, and no adjudicated resolution. The ledger enters it here so the list is complete: it is the largest open file in this report.

18. The Cocked Hat: Where the Record Does Not Agree With Itself

Three bearings give a triangle, not a point, and this report’s triangle is printed here as the paper prints its own position: honestly inside it. The desk files, in one place, the disagreements the sections carried. Twelve people die each day waiting, on the federal government’s current page; seventeen was the same government’s figure through 2025, and the hard counts by organ sit beneath both. The waiting list is 109,817 on one dated snapshot and 108,790 on another, and the transplant total for 2025 is 49,064 in the network’s release and 49,065 in the Medicare agency’s rule. Whether MELD 3.0 repaired the sex gap is disputed between studies that measured transplant probability and studies that measured survival. Whether America lacks transplant surgeons is disputed between a match table showing filled positions recovered and a literature of falling applications and burnout, while the shortage in transplant medicine stands uncontradicted. Whether presumed consent raises donation is disputed between the cross-country associations and the best-adjusted null result, with Spain’s own architects testifying against the popular version. Whether the crackdown on out-of-sequence allocation removed an abuse or cost transplants is disputed in the system’s own before-and-after numbers. Whether the federal safety findings against the Kentucky procurement organization are sustained is disputed by the organization, with its appeal pending. What fraction of the world’s kidney transplants are bought is unknown on any current measurement; the only number is from 2007. What China’s transplant volume truly is, is contested between official statistics, an independently published finding that the reform-era data fit a formula too precisely to be counts, and estimates the official record cannot house. And whether the predictive software at the edge of the match is artificial intelligence is, on the documents, a dispute about a label. The controversies ledger carries corrections of its own kind: Germany’s post-scandal fall in donation is a range with a baseline—about a third across 2010–2013 on the counted donors—not the bare forty percent of circulation, and the 237-day median attached to Larry Hagman’s thirty-four days could not be verified in any source and is printed nowhere in this report as a fact.

The desk’s summary, then, in the plain terms the record supports. Organ donation in America in 2026 is a national, public, formula-ranked system wrapped in private gates: a financial clearance before the list, a center’s discretion at the offer, a review board’s exception inside the score, a second listing for those who can pay for one, and an insurer’s network deciding at which hospital the formula’s answer is carried out. The law forbids the sale of organs absolutely and polices the queue instead; the courts guard the rules of that queue and have never handed out an organ; the judges’ single intervention for a named patient suspended a rule for two children for a few days and is remembered, thirteen years later, precisely because it stands alone. The shortage is real and arithmetical—109,817 waiting, 49,064 transplanted in the best year in history, twelve dead a day on the current count—and a documented share of it is manufactured at the acceptance desk, where 29.3 percent of recovered kidneys are refused into discard. Abroad, the forbidden market persists on a scale nobody has measured since 2007, the one legal paid system’s own vendors say it should end, and the China file stands graded and unresolved. Over it all, the art itself has been transformed in a generation: two roads to death, machines that repair organs in transit, donors once refused now routine, a pig kidney that kept a man alive long enough to receive a human one. A television drama asked, on Sunday night, whether a computer or a rich man can move a name up the list. The record’s answer, filed in full above, is that the computer does not exist, the rich man’s lawful instruments are the duplicate evaluation and the second listing, the hands that move the list belong to centers and boards and are documented to the percentage point—and that the list itself, its length, its arithmetic, and its dead, is the story the drama was standing in front of.

The Companion Essay

The argument this file does not make is published by this paper’s publisher on his own program, The Chris Abraham Show, in his own voice, as “The Farce of the Farce of Justice.” The essay argues that the episode’s just outcome arrived by accident—a human hand, and not the allocation system, moved the queue—and that the proceeding which ratified the accident afterward is theater calling itself vindication. It is the publisher’s argument, in the publisher’s voice, on the publisher’s own site. This paper prints no part of it and adopts none of it; the link stands so the reader can follow the argument the desk declined to carry, from the record above to the case the record supports in another man’s telling.