The Fragility of Optimization: Performance Metrics in Organ Donation

• In Event: Medical Sociology Section Roundtables
  In Refereed Roundtable (90 minute): Table 4. The Institution of Medicine

Abstract

More than 100,000 Americans await an organ transplant. Organ procurement organizations (OPOs) sit at the center of this system, seeking donation consent from families and allocating organs to recipients. In 2019, federal reforms introduced new performance metrics and the threat that low-performing OPOs would lose their contracts in 2026. Although transplant numbers have risen, stakeholders describe mounting strain, declining trust among hospital providers, and growing public skepticism. Why have accountability reforms coincided with intensified conflict in a trust-dependent system? Existing research on metric reactivity and institutional recoupling shows how performance regimes distort behavior, encourage gaming, and generate internal turmoil. I extend this literature by identifying a downstream mechanism: performance pressures recalibrate the relative weight of competing institutional logics, privileging optimization over relational legitimacy. Drawing on 90 in-depth interviews with OPO professionals and critical care providers nationwide, as well as observations of one OPO’s internal meetings, I show how efforts to maximize measurable output have eroded practices of restraint and discretion that historically sustained trust. First, OPOs increasingly “enforce the registry,” pursuing organ recovery even when families object, despite the relational costs to hospital collaboration. Second, OPOs have expanded donor eligibility criteria, pursuing more medically uncertain cases to increase procurement, generating frustration among hospital staff over resource use and perceived waste. Third, OPOs have more frequently relied on expedited, out-of-sequence allocation pathways, prioritizing efficiency over procedural fairness to avoid organ discard. Across these domains, performance pressures shift the balance between efficiency and fairness, authority and discretion, and output and legitimacy. These findings suggest that accountability regimes in morally and relationally fragile systems can intensify not only productivity but fragility itself. By reweighting logics toward optimization, performance reforms risk undermining the trust and cooperation on which long-term performance depends.

Author

• Will Schupmann, University of California-Los Angeles