Cut First, Ask Later — How U.S. Organ Procurement Organizations Turned Donation into a Business

The little circular mark on a U.S. driver's license is no small thing. Whether you are willing to donate your organs in a car accident is recorded in that very field. A Bilibili creator who goes by "Yuanli Xin Lai Le Ge Yang Zhuren" ("A New Director in the Ward") says he would genuinely like to recommend this system back home in China — most of the people he knows have signed up, and he has signed up himself. But he adds a caveat: it would only work in places without unscrupulous doctors. Otherwise, before the patient is fully dead, that little marker on the license becomes a pickup slip. So his advice to Chinese expatriates in the United States runs the other way: whenever you fill out any official form, check whether the donor box has been pre-checked for you, and if so, uncheck it.

This opening frames the main subject: America's human organ industry. The numbers look respectable on paper — 90 percent of Americans support organ donation, with roughly 170 million registered donors, about 60 percent of all adults. This is an opt-in system: if you don't register, you default to non-donor. The fact that registration has reached such a level owes about half of its success to the automobile: when you get your license at the DMV, the clerk casually asks whether you want to register, and that's enough. In some states a folk belief even circulates that agreeing to donation makes it easier to get a license — the truth of that is hard to pin down.

The Foundation — Opt-In and the UAGA

The institutional foundation is the UAGA — the Uniform Anatomical Gift Act. Its spirit is open: anyone can donate, including foreigners and undocumented immigrants. Good deeds do not require citizenship, only that the organs and tissues be intact. The standard workflow is not complicated either: first check the donor sticker on the license, then have a physician certify whether the organs are suitable, then hand the case over to a dedicated organ procurement organization — there are 55 such organizations across the country — which contacts the family. If the family cannot be reached, that is fine: the deceased's prior consent is enough.

The Loophole — "Reasonably Unavailable" and Good Faith

What actually leaves a crack open are the edge cases. If a patient is not a registered donor but their organs are in unusually good condition, the procurement organization will first try to reach the emergency contact. If it cannot, it documents that the contact is "reasonably unavailable." As long as the deceased never signed a written refusal of donation, the hospital has the authority to approve the removal on the dead patient's behalf. There is a respectable justification for this arrangement: don't let an unclaimed body go to waste. There is also a companion "good faith" provision — a hospital that performs a removal "in good faith" is shielded from legal liability.

Cut First, Ask Later — The Numbers Start to Look Wrong

Up to this point in the institutional design, one can still believe the system is well-intentioned. But over the past decade, the numbers have begun to look off. The volume of organ transplants in the United States has climbed from just under 30,000 in 2014 to nearly 50,000 in 2024, while the volume actually recovered from donors has surpassed 60,000 — and the surplus has simply been discarded. New Jersey has even made the news for throwing away 100 pancreases in a single day. Human organs are supposed to be removed only when they are needed; how did the practice turn into "cut first, ask later"?

The problem lies in the organ procurement organizations themselves. They are nominally nonprofits, but they do not rely on government appropriations. Their revenue comes from service fees billed to hospitals — family communication, body preservation, surgery fees, organ storage, cold-chain transport; every line item is chargeable, and any shortfall is fully reimbursable through Medicare. So these organizations are financially stable. Money has never been the issue.

The Lifeline Is the License — Three-Tier Rating and the KPI

The real lifeline is the operating license. Holding a license depends on two KPIs: donation rate and transplantation rate. Performance is graded into three tiers — the top 25 percent form Tier 1, the middle 50 percent Tier 2, and the rest Tier 3. A Tier 1 license renews automatically after four years; a Tier 3 rating risks decertification. Hold on to that license, and you keep your Medicare reimbursements and protect your service area — in other words, the territorial patch where you get to harvest organs. Lose it, and you are pushed out of the business.

Pressure cascades downward: the more surgeries performed, the higher the rating, the more stable the license. So organizations begin "pitching" the benefits of transplantation to patients and families — bluntly put, they apply pressure — and they negotiate with hospitals to authorize as many donations as possible. Once interests stack up high enough, corruption has somewhere to hide. Congressional hearings and media investigations have shown that the industry routinely harbors conflicts of interest, financial fraud, and staggering procedural violations.

Kentucky's 73 Cases — The Boundary of Live-Donor Removal

The Wall Street Journal reported a case in Kentucky: an organ procurement organization, in order to preserve its government contract, urged surgeons to remove organs from a living patient. A patient who had been declared brain-dead — and who had signed a consent form while still alive — opened his eyes on the way to the operating room; the surgeon dismissed it as a physiological reflex. Once on the table, the patient became fully awake and started to struggle, alarming the surgical team. The organization's response was to swap in a different surgeon and administer sedatives and muscle relaxants. Only when the surgeon forcefully resisted was the operation called off. The patient was eventually discharged and is still alive today.

A subsequent investigation found 73 similar procedures in Kentucky — cases in which the procurement process had already begun preparation while patients were showing signs of neurological activity or improving consciousness. New Jersey has also reported cases of organs being removed from patients who still showed vital signs. These cases share a common pattern: in order to grow supply and protect their certification status, procurement organizations intervened in physicians' determinations of death, pressuring hospitals to start the removal process while patients still had breathing or neurological activity.

Tens of Thousands Withdraw from the Registry

Last year, in the wake of these revelations, tens of thousands of Americans withdrew from the organ donation registry. The creator ends with a single sentence: if you carry an internationalist ideal and genuinely want to donate, that is still noble.