In 1984, with life-saving organ transplantation on the cusp of dramatic growth, Congress passed the National Organ Transplant Act (NOTA).  Its architects were determined to create an equitable system. The Task Force on Organ Transplantation urged the source of deceased donor organs should be altruistic, to protect the poor from being preyed upon by the well-off for their organs.

To cement the principle of altruism into law, NOTA established that all Organ Procurement Organizations (OPOs) must be non-profits. “The system must be led by non-profit interests, dedicated only to the needs of patients and with no concern for shareholders, market shares or profit,” wrote Task Force member Clive Callendar, MD.

The profit motive and saving lives rarely mix well. For example, according to recent studies, when private equity investors take over hospitals, they squeeze profits by borrowing against real estate assets while cutting costs and downgrading patient care. Harvard Chan School public health professor John McDonough called the marriage of private equity and healthcare “the sharp end of capitalism.” The private equity trend in healthcare continues despite poor results because there is too much money to be made.

How long can we keep profiteers' greedy hands off organ donation and transplantation?

For nearly a decade, ORGANize, an advocacy group co-founded by a former venture capitalist, Greg Segal, and funded by former Enron financier, John Arnold, have argued the non-profit model for organ donations isn’t working. Segal says he became an activist and critic of the transplant system after his billionaire healthcare investor father needed to wait five years for a heart transplant (he received a successful transplant and is alive today).

For ORGANize, OPOs became both symbols for their difficulties with the system, and a convenient target. They pressed the Center for Medicare and Medicaid Services (CMS) to develop a new methodology for OPO recertification that was structured to eliminate up to 70% of OPOs in 2026 and another 70% in 2030, likely cutting the current network of 55 OPOs nationwide down to as few as five.

The planned collapse of the OPO network creates a huge opening for a for-profit takeover. Segal claims his group has no interest in profiting from organ donations but ORGANize's actions raise doubts. For years, they used their high-level connections to spread unsubstantiated smears and disinformation about nonprofit OPOs to congressional committee staff and reporters at outlets like the Washington Post and NPR. The OPOs were never given a chance to respond, so ORGANize’s smears became accepted as fact by the Washington establishment.

The barrage of unsupported negative publicity has taken a toll, not just on OPOs, but the entire system, causing thousands of registered donors to remove themselves from registries. When private equity investors are about to make a move into a field, they prefer to be greeted as liberators. After transplant surgeons in dozens of organ donor service areas discover they no longer have OPOs to provide organs, that’s when the for-profit sector could be summoned to rescue communities from the “failed” non-profits.

Using a similar strategy of unanswered attacks on transplantation system governance, ORGANize urged Congress to support legislation, the U.S. Organ Procurement and Transplantation Network Act (2023), which includes provisions that will enable for-profit activity in organ donation and transplantation – sold as boosting competition and innovation –  while specifically eliminating the prior requirement that the OPTN contractor be a non-profit organization with expertise in organ donation and transplantation.

Since the law’s passage, the Health Resources and Services Administration (HRSA) shrank the role of its long-time nonprofit contractor, the United Network for Organ Sharing (UNOS), adding seven vendors, only one of which has organ donation and transplantation expertise. The other firms -- Beltway perennials with proficiency in areas like public engagement, public relations, financial management and IT -- lack the depth of experience needed to resist ORGANize’s dominant voice and political machinations.

When private equity first moved into the realms of hospitals and health care service providers, some were optimistic, arguing PE firms would bring capital, efficiency and fresh operational perspectives to a struggling system. The same claims will be made on behalf of for-profit takeover of organ donation and transplantation. “Running it like a business” will be offered as a panacea to fix the nation’s chronic organ shortage.

But organ donation and transplantation aren’t like a business. Donated human organs are not widgets or car parts. Today, the only country in the world that allows for-profit organ donation through payments to donors is Iran, where the poor are the sources of organs for the rich. Profit-seeking will fundamentally alter the ethics, structure, and outcomes of donation and transplant. Human organs will become commodities rather than gifts, discouraging voluntary donations while worsening the health care divide between rich and poor.

It would be a tragic misstep. It is also unnecessary. The US’ donation and transplant system continues to lead the world in transplants in total, per capita and is the world/’s fastest growing. The future of the life-saving gift of transplantation is bright, and patients are well-served by the altruistic model.

Martin Luther King Jr. wrote that the profit motive “encourages a cutthroat competition and selfish ambition that inspires men to be more concerned about making a living than making a life.” Nothing could be more out of sync with the altruistic ethic that prevails in the US donation and transplantation system and has made it the world’s best.