An Ethical Analysis of Allocating Organs Out of Sequence

Recently, in response to the problem of underutilization of organs available for transplant, there has been an increase in organs allocated out of sequence (AOOS). AOOS occurs when Organ Procurement Organizations and/or transplant programs deviate from the calculated rank-order list of potential recipients on the national organ waiting list. While AOOS attempts to decrease organ nonuse and improve organ placement efficiency, this practice raises questions about fairness and public trust. To address these concerns, the Organ Procurement and Transplant Network Ethics Committee undertook an ethical analysis of AOOS, a condensed version of which we present here. While AOOS represents a tempting solution to nonuse, we argue it is not fully justified by utility, as the data remain unclear whether AOOS has a significant positive impact on organ nonuse. There are further concerns regarding the ethical principles of respect for persons, transparency, and equity. We conclude that AOOS should not come to be regarded as the prevailing solution to mounting pressure placed on the transplant community precipitated by nonuse, and that the transplant community should strive to develop system-wide solutions to organ waste though the development of a more transparent and comprehensive policy framework.

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Publication Details

Journal
Current Transplantation Reports
Published
2025-08-05
DOI
https://doi.org/10.1007/s40472-025-00486-4
Primary Topic
Organ Donation and Transplantation
Type
article
Field-Weighted Citation Impact
0.00

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article

An Ethical Analysis of Allocating Organs Out of Sequence

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Current Transplantation Reports
Organ Donation and Transplantation
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An Ethical Analysis of Allocating Organs Out of Sequence

Lois E. Shepherd, Matthew B. Wilkinson, Laura Madigan-McCown, Megan Urbanski, Gloria Chen, Robert D. Truog, Oluwafisayo Adebiyi, Sanjay Kulkarni, Andrew Flescher, Erica Stohs, Joel T. Wu, Grace Lee, L. Paolillo, Joshua R. Dillon, S. Bullock, Sena Wilson-Sheehan, Felicia Wells-Williams, Laura Jokimaki
article en

Abstract

Recently, in response to the problem of underutilization of organs available for transplant, there has been an increase in organs allocated out of sequence (AOOS). AOOS occurs when Organ Procurement Organizations and/or transplant programs deviate from the calculated rank-order list of potential recipients on the national organ waiting list. While AOOS attempts to decrease organ nonuse and improve organ placement efficiency, this practice raises questions about fairness and public trust. To address these concerns, the Organ Procurement and Transplant Network Ethics Committee undertook an ethical analysis of AOOS, a condensed version of which we present here. While AOOS represents a tempting solution to nonuse, we argue it is not fully justified by utility, as the data remain unclear whether AOOS has a significant positive impact on organ nonuse. There are further concerns regarding the ethical principles of respect for persons, transparency, and equity. We conclude that AOOS should not come to be regarded as the prevailing solution to mounting pressure placed on the transplant community precipitated by nonuse, and that the transplant community should strive to develop system-wide solutions to organ waste though the development of a more transparent and comprehensive policy framework.

Current Transplantation ReportsVol. 12(1)
Rutgers, The State University of New Jersey (US), Creighton University (US), Tufts University (US), Indiana University Health (US), University of Minnesota (US), Harvard University (US), Emory University (US), Virginia Commonwealth University (US), University of Virginia Health System (US), House of Representatives (NL), WinnMed (US), Henry Ford Hospital (US), Yale University (US), Stony Brook Medicine (US), Maine Medical Center (US), New England Organ Bank (US), Committee on Publication Ethics (GB), Office of Legacy Management (US), Mayo Clinic in Florida (US), Association of Organ Procurement Organizations (US), Rutgers New Jersey Medical School (US), University of Virginia (US), Indiana University – Purdue University Indianapolis (US), Stony Brook University (US), University of Missouri–Kansas City (US), The University of Texas at Austin (US)
U.S. Department of Health and Human Services, Health Resources and Services Administration
Openalex Percentile: Top 73%
Organ Donation and Transplantation
DOIOpen Access PDFOpenAlex
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