The Moral Cost of Modern Transplant Medicine

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Commentary

In a time when trust in public health is already hanging by a thread, recent revelations from the U.S. Department of Health and Human Services (HHS) have delivered another blow—one that strikes at the very heart of medical ethics.

“Our findings show that hospitals allowed the organ procurement process to begin when patients showed signs of life, and this is horrifying,” Health Secretary Robert F. Kennedy Jr. said. “The organ procurement organizations that coordinate access to transplants will be held accountable. The entire system must be fixed to ensure that every potential donor’s life is treated with the sanctity it deserves.”

Hidden beneath the surface and quietly ignored by corporate media is a story that should horrify every physician, patient, and policymaker: the commodification of human life in the U.S. transplant system.

The Independent Medical Alliance (IMA), a coalition of physicians dedicated to restoring transparency and patient-centered care, has publicly denounced the findings of a recent HHS report. As president of IMA, I can tell you this: What we’ve uncovered is not a case of benign negligence. It is a deliberate erosion of the most sacred values in medicine—consent, dignity, and the inviolability of the human body.

A System That No Longer Sees the Patient

Organ transplantation is, in theory, one of the great achievements of modern medicine. When practiced ethically and transparently, it has saved countless lives. But like so many institutions corrupted by profit and policy, it has drifted far from its original mission.

In 2024 alone, more than 45,000 organ transplants were performed in the United States. That number should inspire hope—but instead, it invites scrutiny. A substantial portion of those organs were harvested under ethically ambiguous conditions, including donation after circulatory death (DCD) and questionable determinations of brain death. The line between patient and donor is blurring—and not in a way that honors either.

Organ Procurement Organizations (OPOs) are incentivized not by patient outcomes, but by volume. The more organs they harvest, the more funding they receive. Hospitals, too, receive significant reimbursement for transplant procedures, creating a perverse system in which terminal patients are seen less as individuals with complex medical stories and more as reservoirs of reusable parts. The New York Times has published an article that urges standards of death to be liberalized even further. “We need to figure out how to obtain more healthy organs from donors. ... We need to broaden the definition of death.”

Where Are These Organs Coming From?

The public assumes, understandably, that most organ donors are willing participants—cadaveric donors who’ve signed cards or checked boxes. But the data doesn’t support that rosy picture. A growing percentage of organ procurement comes from patients who are not dead in the traditional sense, but are declared brain dead or transitioned to DCD protocols under murky guidelines.

Let’s talk plainly: Who decides when a person is truly dead? And how confident are we, as physicians, that our criteria are airtight?

The Trouble With Brain Death

Brain death is defined as the irreversible cessation of all brain activity, including the brainstem. On paper, that sounds final. In practice, it’s anything but. There is no universal standard for determining brain death in the United States. Each state, and often each hospital, may have its own protocol.

Here’s how it’s supposed to be done:

1. Prerequisites:
   • Establish cause of coma (e.g., trauma, hemorrhage, anoxic injury)
   • Rule out confounding factors: intoxication, metabolic disturbances, hypothermia
   • Ensure normothermia, normal electrolytes, and absence of sedatives or paralytics
2. Neurological Exam:
   • No responsiveness to verbal or noxious stimuli
   • Absent brainstem reflexes:
     • Pupillary response to light
     • Corneal reflex
     • Oculocephalic reflex (“doll’s eyes”)
     • Oculovestibular reflex (cold calorics)
     • Gag and cough reflex
     • No spontaneous breathing on apnea testing (typically eight or more minutes off ventilator with rising partial pressure of carbon dioxide)

3. Confirmatory Testing (if clinical exam incomplete or legally required):
   • Cerebral blood flow studies
   • EEG (flatline)
   • Nuclear medicine perfusion scans

It’s a thorough process—when done correctly. But that’s precisely the issue: It’s not always done correctly. There are documented cases in which brain death was declared prematurely or without full testing. Hospitals under pressure to free up ICU beds or meet organ quotas may streamline protocols, sometimes performing incomplete assessments or skipping confirmatory imaging altogether.

In one documented case from a major metropolitan hospital, a patient declared brain dead still had spontaneous movements and reactive pupils—until a more experienced intensivist reversed the call and the patient recovered. That is not “rare.” That is underreported.

Even the apnea test, long considered a gold standard, is increasingly controversial. It requires removing the patient from mechanical ventilation long enough to provoke a rise in CO₂. But this test, by definition, stresses the brain and may worsen injury. In borderline cases, it can tip a patient from injured to truly nonviable. And it assumes that the absence of any spontaneous respiration equals death, a standard that conflates clinical irreversibility with absolute neurologic death.

The Rise of DCD and the Ethical Quagmire

Donation after circulatory death is another increasingly common method of procurement. In DCD, life support is withdrawn, and after the heart stops—typically for just two to five minutes—organ harvesting begins. The ethical argument here is that the patient has died a “natural” death. But how natural is it when withdrawal of care is timed and orchestrated to maximize organ viability?

Imagine this scenario: A family is told that their loved one is not brain dead but has “no chance” of recovery. They agree to withdraw support. Moments after the heart stops, a surgical team—already scrubbed and waiting—enters the room. The skin is still warm. The body is still perfused. And the scalpel goes in.

That’s not hypothetical. That’s protocol in many transplant centers today.

And it’s not only adults. Pediatric DCD cases are growing, too, with parental consent forms often filled out under stress, confusion, or duress.

This is not medicine. It’s logistics.

Incentives, Pressure, and Profit

The transplantation field has become a multibillion-dollar industry. The average kidney transplant is reimbursed at more than $300,000. Liver and heart transplants exceed $1 million. OPOs operate as pseudo-nonprofit organizations, but are rewarded financially based on volume.

HHS oversight of these organizations is minimal. Even after several critical reports by the Office of Inspector General, no sweeping reforms have followed. In 2022, a Senate committee hearing revealed that one-third of OPOs had failed basic performance metrics—but not one was shut down.

Meanwhile, transplant candidates who refuse certain medical mandates—such as COVID-19 vaccination—have been removed from waitlists, despite being otherwise viable recipients. So we will reject a healthy, unvaccinated patient but harvest a heart from someone whose family didn’t understand what “circulatory death” really meant?

That’s not health care. That’s institutionalized hypocrisy.

What Must Be Done

This is not a call to end transplantation. It is a call to reclaim the ethical foundation of organ donation before it’s too late. We can—and must—do better.

Policy Recommendations:

• Standardized, federally mandated brain death protocols across all 50 states
• Mandatory confirmatory testing (4-vessel cerebral angiogram or cerebral perfusion nuclear scan) for all brain death declarations
• Real-time video documentation of brain death exams and DCD processes
• Mandatory waiting period before DCD procurement to ensure true irreversibility
• Full, informed consent recorded on video, with independent patient advocates present
• Transparent audit logs from every OPO, published annually
• A publicly searchable transplant registry, including donor status and procurement pathway

These are not radical ideas. These are the bare minimum requirements for a system that claims to respect life.

Final Thoughts: Medicine Must Be Moral or It Is Nothing

There is no dignity in a system that cuts corners to save organs. There is no science in a system that calls someone dead based on arbitrary timelines and vague reflex testing. There is no trust in a system that silences physicians who speak up.

The medical profession is not a manufacturing line. Our job is not to optimize supply chains—it is to protect life, and when necessary, honor death. We must stop pretending that efficiency is equivalent to morality.

For years, I have trained residents and students to perform brain death exams. I’ve overseen transplants. I’ve supported grieving families and celebrated recipients. But I’ve also seen the shift—the slow erosion of principle under pressure. It’s time to draw a line.

Let us be the generation that doesn’t look away.

From the Brownstone Institute