Justifying Organ Allocation Out of Sequence

The rise of Allocation Out of Sequence (AOOS) in organ transplantation in the United States has raised significant ethical concerns. By the end of 2024, 20% of kidneys were transplanted out of the standard match sequence, drawing regulatory scrutiny. Critics argue that AOOS fails to prevent organ nonuse, does not address underlying inefficiencies in organ allocation, lacks transparency, and worsens transplant-related disparities. In this paper, I outline the factors contributing to the expansion of AOOS and evaluate the normative arguments for and against its use. I suggest that the strongest critique of AOOS involves procedural justice. Drawing on a constructivist framework, I argue that AOOS violates the expectation that allocation policies be grounded in collective agreement. I identify considerations that should inform the revision of the AOOS pathway, emphasizing the need for shared norms to ensure procedural legitimacy.