Procedural Justice in Allocation Out of Sequence Organ Transplantation (AOOS): An Ethical Analysis Open Access

Abstract

In 2025, the New York Times published an article uncovering potential misconduct within the organ donation system: a new practice, called “out of sequence organ transplantation” (AOOS), designed to address the persistent shortage of transplantable organs through the mitigation of nonuse. Since then, new policy regulations and clarifications have led to a near prohibition of the practice in the United States of America-despite its generally consistent use in several European countries (Masotti et al., 2026). Thus, AOOS has quickly become a contentious topic among both those in and outside of the organ transplantation sphere. This thesis will use a focus of procedural justice to provide a thorough evaluation of viable considerations for and against the practice of AOOS, examining its implications on both utility and equity across stakeholders. Additionally, it explores procedural requirements necessary for the practice to be reimplemented ethically in the US.

The findings of this evaluation suggest that the potential benefits of AOOS are substantial, including reducing organ nonuse, increasing total transplantations, improving the utilization of medically complex organs, and reducing waitlist mortality. Further, this analysis suggests that the potential consequences of its implementation be largely mitigated through the creation and consistent application of a fair and dynamic procedure. Thus, rather than eliminating AOOS entirely, new policies should be developed, prioritizing both oversight and transparency, and developed in conversation with stakeholders.

Table of Contents

PART 1: Introduction and Background............................................................................................1

Introduction..........................................................................................................................1

AOOS Emergence................................................................................................................4

Non-use and Non-Recovery: ..............................................................................................6

Verbiage of “Organ Transplant Waiting Lists” ...................................................................9

AOOS: A Direct Response to Nonuse and Non-recovery of Donor Organs.................... 10

Justifications for a focus on Procedural Justice ............................................................... 13

Procedural Justice............................................................................................................. 14

Public trust....................................................................................................................... 15

Stakeholders .................................................................................................................... 17

AOOS Topical Considerations......................................................................................... 20

PART 2: Arguments in Support of AOOS Usage......................................................................... 21

Status-Quo Bias: .............................................................................................................. 22

“Skipping the Line” ........................................................................................................ 25

Nonuse justifies AOOS ................................................................................................... 27

Lowering Non-recovery.................................................................................................... 31

The Impossibility of Procedural Justice ........................................................................... 34

Lowering waitlist death or delisting death:....................................................................... 37

Not all AOOS usage is unethical: .................................................................................... 39

Evaluation........................................................................................................................ 40

PART 3: Arguments Against AOOS Usage ................................................................................. 42

Introduction...................................................................................................................... 42

Violation of Accepted Procedure ..................................................................................... 43

Nonuse justifies AOOS .................................................................................................... 46

Transplant Center Bias ..................................................................................................... 48

Procedural justice requires transparency: ........................................................................ 52

Guiding how the decisions are made:............................................................................... 55

Evaluation:........................................................................................................................ 56

Part 4: Final Evaluation and Application...................................................................................... 58

Introduction..................................................................................................................... 59

Reframing procedural justice .......................................................................................... 59

Utility and Equity are not opposing values...................................................................... 63

Public Trust...................................................................................................................... 65

Proposed ethical conditions for AOOS usage .................................................................. 67

Conclusion & Final Ethical Conclusion .......................................................................... 70

Glossary:....................................................................................................................................... 71

Bibliography: ............................................................................................................................... 74

About this Master's Thesis

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School	Laney Graduate School
Department	Bioethics
Degree	M.A.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Medical Ethics Ethics
Keyword	Bioethics English Out-of-sequence organ allocation organ transplantation
Committee Chair / Thesis Advisor	Gerard Vong, Emory University
Committee Members	Jonathan Crane, Emory University Megan Urbanski , Emory University

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