Close Calls and Skipped Lines: The Fraught State of Organ Donation

Podcast: The Daily
Host: Michael Barbaro
Guest: Brian Rosenthal, Investigative Reporter
Release Date: July 30, 2025

Introduction to the Investigation

In this episode of The Daily, host Michael Barbaro engages in a deep-dive conversation with investigative reporter Brian Rosenthal about his extensive investigation into the organ transplant system in the United States. Rosenthal uncovers significant issues within the system that jeopardize donor safety and challenge the fairness of organ allocation.

The Genesis of the Investigation

Rosenthal’s inquiry began with a "vague suggestion" to examine the organ transplant system, which was not previously on his radar.

Brian Rosenthal [01:27]: “It began when I got a vague suggestion from a source that I should look into the organ transplant system.”

Attending the American Transplant Congress in Philadelphia provided Rosenthal with the initial insights that propelled his investigation. A particularly alarming panel discussion revealed critical flaws within the system.

Rosenthal [02:11]: “One panelist was talking about how we violated trust in the system. We violated transparency. She said we have a system in chaos.”

Government Pressure to Increase Organ Transplants

A pivotal element of Rosenthal’s findings is the substantial pressure exerted by the federal government to escalate the number of organ transplants. This push originated from President Trump's administration, particularly under Health Secretary Alex Azar, whose personal connection to the issue influenced policy reforms.

Rosenthal [04:00]: “The government, under President Trump's first administration, really tried to tackle that problem by pushing the system to recover more organs and coordinate more transplants.”

Azar and Trump implemented stringent measures, including threatening organ procurement organizations (OPOs) with the loss of their contracts if they failed to meet increased transplant quotas. This coercive approach aimed to address the longstanding issue of over 100,000 Americans awaiting transplants.

Understanding the Organ Procurement Process

OPOs are nonprofit entities responsible for identifying potential organ donors, typically patients nearing death due to reasons like overdoses or accidents. There are two primary pathways for organ donation:

1. Donation after Brain Death (DBD): The most common and straightforward method, where donors are declared brain dead, and organs are preserved on machines until transplantation.

2. Donation after Circulatory Death (DCD): A more complex process where life support is withdrawn, and organs are harvested after the heart stops beating.

Rosenthal [05:35]: “There are these organ procurement organizations that I mentioned. They are nonprofit groups that exist in every state, and they have employees in hospitals basically looking for people who are dying and might be candidates to donate their organs.”

Donation after Circulatory Death vs. Donation after Brain Death

The Trump administration's reforms significantly increased the use of DCD, tripling its prevalence. While this approach has enabled around 40,000 additional transplants, it introduces greater ambiguity and risk.

Rosenthal [07:58]: “There has been a huge increase in donation after circulatory death since these regulations came into effect. Usage has tripled.”

DCD requires careful determination that a patient will not recover, a judgment that can be subjective and prone to error. Rosenthal highlights cases where patients showed signs of recovery during the DCD process, nearly leading to the withdrawal of life support prematurely.

Rosenthal [08:55]: “Donation of circulatory death is just much less black and white than donation after brain death.”

Risks to Donors: Near-Misses and Misjudgments

Rosenthal discusses alarming instances where patients, presumed to be dying, display signs of life moments before organ retrieval, risking premature withdrawal of life support.

Rosenthal [09:01]: “...one of the doctors said that they were not comfortable moving forward, and she put her foot down, and the patient was returned to his hospital room, where, unexpectedly, he recovered.”

An investigation in Kentucky revealed 73 out of 350 cases where plans to retrieve organs were halted too late, as recovery signs were initially overlooked.

Rosenthal [11:25]: “...73 of those cases, they stopped at the last minute. But they should have stopped much sooner because the patient was showing signs of regaining consciousness sooner, and those signs were initially ignored.”

This pattern suggests systemic issues where healthcare professionals may prioritize organ retrieval over patient well-being due to regulatory pressures.

Fairness in Organ Allocation

Beyond safety concerns, Rosenthal uncovers that governmental pressure has compromised the fairness of organ distribution. The traditional, algorithm-driven process aims to allocate organs based on factors like waiting time and severity of illness, ensuring equitable distribution.

Rosenthal [17:07]: “It's an algorithm, and the biggest factors are how long you've been waiting and how sick you are.”

However, the introduction of "out of sequence allocation" allows OPOs to bypass the established list, favoring relationships with certain hospitals. This shift undermines the fairness and transparency of the system.

Rosenthal [18:33]: “They have come up with a new plan called out of sequence allocation, which is when they simply call up a hospital that they have a relationship with and say, hey, we have an organ. You can put it into any one of your patients.”

Since 2020, nearly 20% of organs have been allocated out of sequence, a stark increase from 3%.

Case Study: Marcus's Story

A poignant example Rosenthal shares is that of Marcus, a Michigan teenager with chronic kidney issues. Despite being high on the transplant list, an available kidney was diverted to a less needy patient due to OPO's out-of-sequence practices.

Rosenthal [19:44]: “They ended up putting the kidney into a patient who had only been waiting for a few months. They were number 3,558 on the list.”

This decision was justified by the OPO based on the kidney's location and viability window, yet logistics made the transfer to Marcus feasible.

Rosenthal [21:18]: “Illinois is not that far away from Michigan. The kidney had only been outside the body for about nine or 10 hours at that point, and kidneys remain viable for up to 48 hours.”

Marcus eventually received a transplant, but with a less compatible kidney, highlighting the tangible human cost of these systemic issues.

Rosenthal [23:00]: “He did get a kidney, but it was not as good of a kidney... it's not really functioning at all. And he is gonna have to get back on the transplant list and wait for a new one.”

Federal Response and Legislative Actions

In response to Rosenthal’s findings, the Trump administration has begun addressing these critical issues. Measures include:

• Cracking Down on Out-of-Sequence Allocation: Immediate acknowledgment of line-skipping as a significant problem, prompting policies aimed at reinstating fairness in organ distribution.

• Revising DCD Guidelines: New nationwide guidelines to regulate the increasingly aggressive procurement practices associated with DCD.

Furthermore, Congress has shown bipartisan support for these reforms, with recent hearings referencing Rosenthal's investigative report to push for comprehensive system overhauls.

Rosenthal [26:13]: “...they have cracked down on the procurement organization in Kentucky, and they have ordered the transplant system to write new guidelines around donation after circulatory death nationwide.”

Conclusion: The Future of Organ Donation Systems

While Rosenthal acknowledges the noble intent behind organ donation and the lifesaving nature of the system, he emphasizes the urgent need for reforms to ensure donor safety and equitable organ allocation.

Rosenthal [28:28]: “This is a system that saves thousands of lives every year. But... the system is also under strain.”

He remains optimistic that bipartisan support and ongoing legislative efforts can rectify the identified flaws, honoring the invaluable gift of organ donation while safeguarding human lives.

Rosenthal [28:35]: “This is what everybody wants is to honor that tremendous gift of organ donation.”

Implications for Organ Donors and Recipients

The revelations from Rosenthal’s investigation prompt critical reflection on trust in the organ donation system. While the process remains fundamentally life-saving, the uncovered issues necessitate vigilance and advocacy for systemic improvements to preserve both fairness and the integrity of organ transplantation.

Michael Barbaro [28:21]: “We have entrusted ourselves, our organs... to this system that you have been investigating. So should what you have found here change how we think about that decision? Being an organ donor?”

Rosenthal [28:28]: “...it seems like this is a rare issue where there is bipartisan support toward the idea that something needs to be done.”

This comprehensive investigation by Brian Rosenthal sheds light on the complex and often troubled landscape of organ donation in the United States, urging stakeholders and the public alike to advocate for necessary reforms to uphold the sanctity and fairness of this critical system.