Our Organ Transplant System Isn’t the Failure It’s Made Out to Be

Thanks to a robust network of hospitals, nonprofit organizations, and government support, the U.S. remains a leader in organ transplantation. This community, which is managed by United Network for Organ Sharing (UNOS), saves tens of thousands of lives every year. Despite this success, opponents of UNOS are advocating to dismantle the transplant system as we know it.

As a private, nonprofit organization under contract with the federal government to manage the national organ transplant system, UNOS spearheads the complex, multidisciplinary organ procurement, matching, and delivery processes. With its contract up for renewal this spring, UNOS has come under heavy scrutiny, including in a recent guest column published in the New York Times, in which UNOS and other system organizations’ performances were blamed for the death of a kidney transplant candidate. This is just one example in a series of accusations made across news media, social media, and even in Congress.

Painting with such a broad and biased stroke creates an unfair representation of our highly nuanced organ transplant system and the people who run it. As transplant surgeons with a long history of involvement with the system — including one of us (Roberts) serving as a past Board President of UNOS/Organ Procurement and Transplantation Network (OPTN) — we have intimate knowledge of both its successes and its shortcomings. While UNOS has room to improve operationally — and is working to do so — we clearly see the organization’s life-changing results in our operating rooms and offices. More work lies ahead, however, such as addressing the fact that a rising number of organs are recovered but not transplanted.

Neither UNOS nor organ procurement organizations (OPOs), which facilitate recovery and organ offers to hospitals, have control over whether medical centers ultimately accept and transplant organs into patients. Though the former two have taken all the blame to date, this remains an issue that concerns the entire system. Leaving our nation’s transplant centers out of this critical discussion is a serious oversight. For our entire system to save more lives, transplant centers need to have clear organ acceptance criteria, the appropriate resources to process available organs, and the tools and flexibility to utilize organs from more medically complex donors.

Regarding the success of the system, the numbers speak for themselves: In 2022, the U.S. broke world records by performing over 42,800 organ transplants in just one year, which also included our country’s 1 millionth transplant. Ever since the system was formally established in the ’80s, UNOS has been a crucial facilitator for those life-saving surgeries. The recommendations for division of labor as suggested this week by Carole Johnson, administrator of the Health Resources and Services Administration (HRSA), may be well intentioned but present a significant risk of further fragmentation and negative consequences due to a lack of coordination between government agencies and contractors. This coordination is essential for a functional and successful system. UNOS specifically has been handicapped by a meager budget for years, and despite this has a well-developed system. We believe that given the recent 10-fold budget increase by the Biden administration, the current contractor has the potential to rectify the shortcomings that have been highlighted in the press.

Those of us who have had the privilege of working with the system understand the dedication of this largely volunteer network convened by UNOS. They continue to advance the system and its structure by forming diverse board committees made up of organ recipients, living donors, families of deceased donors, physicians, surgeons, nurses, social workers, OPOs, and other healthcare professionals. Each committee and its members are devoted to furthering the impact of the system in a fair and equitable manner. We see UNOS as a key force in connecting donors and recipients — restoring hope for not only those whose lives are saved, but also for their families, friends, and communities.

While no organization is perfect and UNOS is no exception, we have personally witnessed constant progress toward the goal of saving as many lives as possible. Opponents of UNOS cite problems such as poor utilization of donors or racial inequality in the organ donation system. Colleagues have also criticized the pace at which policy changes are made. However, this is in large part due to the peer review process behind it, which necessitates a public comment period. Any decisions that will affect the lives of every transplant patient in the country must be made carefully, and we can attest to the fact that UNOS leverages this process to address issues and continuously improve the system. The most recent effort to rectify racial inequities by the OPTN Board of Directors was a unanimous decision to require transplant hospitals to use race-neutral calculations when estimating a patient’s level of kidney function. This action helps ensure that all transplant candidates have equitable opportunities to receive a new kidney, a major step for restorative justice in healthcare.

To ensure continued progress toward a more equitable organ donation and transplantation system, Congress requested a report on the state of our transplant system from the prestigious National Academy of Sciences, Engineering, and Medicine (NASEM). This request was made as part of the Further Consolidated Appropriations Act 2020. The NASEM report, released in February 2022, offers improvement recommendations for every part of the transplant system, from UNOS accelerating organ allocation frameworks to addressing transplant centers’ challenges in facilitating weekend surgeries. These legitimate hurdles are surmountable, and the organ transplant community is making strides to alleviate them. Even so, opponents of UNOS rarely mention this report.

Demonizing a system that has demonstrated its worth is needlessly destructive. By weakening public trust and misleading decision-makers, these attacks can put people on the transplant list in great jeopardy. Eroding public trust also has the potential to have a negative effect on organ donation, which is based on altruism and trust. If UNOS is replaced with new organizations that lack its decades of experience, it would likely have consequences for not only the 100,000-plus people currently in need of a new organ, but also future transplant candidates.

The organ donation and transplant system must continue to be run by experts, informed by patient needs, and backed by hard data. Attacking our complex and nuanced organ transplant system without realistic solutions only diverts time and resources from this lifesaving work.

Peter G. Stock, MD, PhD, Nancy L. Ascher, MD, PhD, and John P. Roberts, MD, are professors of surgery at the University of California San Francisco Medical Center.