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Voices & Opinion

POV: Organ Donation System Is Thriving, Not Broken—but There Is Room for Improvement

Two officials with New England Donor Services rebut criticism of organ donor operation

In the fall of 2024, BU Today published a POV by Katherine O’Malley, a policy analyst at BU’s School of Public Health, arguing that the nation’s organ donation system is broken and suggesting solutions. After it was published, Lisa Paolillo (LAW’94), the chief legal officer of New England Donor Services, and Alexandra Glazier (LAW’96, SPH’97), the president and CEO of the organization, submitted this rebuttal POV.

One would be hard-pressed to find another area of the US health system that improves, grows, and innovates at the same pace as community-based nonprofit Organ Procurement Organizations (OPOs). This year will be the 14th year in a row where OPOs will coordinate record numbers of deceased organ donors, resulting in over 40,000 lifesaving organ transplants, by far leading the world in deceased donation.

Despite this continued growth and progress, pieces such as the recent POV that appeared on BU Today that point fingers at OPOs—which, in reality, are just one part of a larger organ transplant system—have a detrimental effect on public trust and have negatively impacted the rates of donor registration, costing lives in the process. The reality is that opportunities for organ donation to happen are rare: fewer than 1 percent of deaths occur in a manner where donation is medically possible. A potential donor must have suffered a devastating brain injury, and subsequently be hospitalized, intubated, and placed on mechanical ventilation before being declared dead.

OPO staff respond on-site at over 4,000 hospitals nationwide whenever they are notified of a patient who might be a potential organ donor, conducting a medical screen to determine if the patient may meet medical criteria for donation. If there is an opportunity for donation, OPOs approach families—treating all families equally—to request authorization (if the patient had not registered as a donor) and support them through the donation process, explaining how their generous decision to make a lifesaving gift will be honored. Donation only occurs after a patient has been declared dead by an independent hospital physician, either using neurological criteria (brain death) or circulatory criteria following a family’s decision to remove ventilator support.

New England serves as a national model for organ donation

As leaders of the OPO serving the six states of the region, New England Donor Services (NEDS), we know firsthand the dedication required to establish an effective community-based organization that works to increase donation. NEDS was the first OPO in the United States, established in 1968 by Nobel laureate Joseph Murray, who had performed the world’s first successful organ transplant in Boston in 1954. Murray recognized the importance of an independent nonprofit to coordinate donation as a collaboration between the donating public, hospitals, and transplant programs. In fact, the current national system of OPOs established in the 1980s was modeled after NEDS.

These historical roots continue to propel NEDS forward as a leader in donation. This year, NEDS will drive donations to another record high with a projected increase of 84 percent in organ donors in just the past five years. This places NEDS as one of the top three largest and clinically busiest OPOs in the nation.

Regulations must align to address organ nonuse

One of the most important areas for further improvement in the system of transplant is around the nonuse of available organs. In 2023, the US did not use over 8,000 kidneys that were donated by the public, surgically recovered, and offered out for transplant by OPOs, but not accepted for transplant by a transplant program. At the same time these kidneys went un-transplanted, over 3,800 wait-listed kidney patients died while on the transplant wait-list.

This nonuse of recovered kidneys is the result of significantly misaligned regulatory incentives. While OPOs are incentivized under federal performance regulations to coordinate organ donation from older and more medically complex donors, transplant centers are incentivized to remain conservative about which organs they use—evaluated on surgical outcomes of patients they transplant, but not on the outcome of patients who never receive a transplant.

OPOs are advocating in Washington, D.C., to modernize the existing regulatory structure. Current regulations for OPO performance metrics are based on data from archaic death certificates rather than from a more modern source of data available in electronic medical records. Further, the OPO metrics are not even risk-adjusted for such basic factors as cause of death, age, and medical comorbidities, and OPOs are held accountable for the medical decisions of transplant programs on whether or not available organs are transplanted. These performance measures should be reformed and modernized to more accurately evaluate OPO performance and drive performance improvement.

OPOs embracing innovation to address challenges and increase donation

OPOs are nonetheless improving performance powered by innovation in collaboration with transplant partners. For example, the placement of surgically recovered organs into an external device that continuously pumps blood increases the viability of organs while they are transported to recipients. OPOs are also employing techniques such as abdominal normothermic regional perfusion (A-NRP), which uses a machine to pump blood through the organs while still in the decedent’s body after the donor has been declared dead. This can increase the viability of the organs and allow for functional assessment prior to surgical removal and transplant.

There is much OPOs can and must do to continue to serve the donating public and those in need of transplant. However, we should acknowledge that the heart and soul of transplantation starts with a core group of public health nonprofits that are delivering on their collective mission in a big way.

Alexandra Glazier (LAW’96, SPH’97), is the president and CEO of New England Donor Services and an assistant professor at Brown University’s School of Public Health. She can be reached at aglazier@neds.org.

Lisa Paolillo (LAW’94) is the chief legal officer of New England Donor Services. She can be reached at lpaolillo@neds.org.

“POV” is an opinion page that provides timely commentaries from students, faculty, and staff on a variety of issues: on-campus, local, state, national, or international. Anyone interested in submitting a piece, which should be about 700 words long, should contact today@bu.edu. BU Today reserves the right to reject or edit submissions. The views expressed are solely those of the author and are not intended to represent the views of Boston University.