By 15, Marcus Edsall-Parr had been waiting most of his life for a new kidney, and he knew the drill. Three days a week in exhausting dialysis sessions. No playing sports. No eating his favorite foods. And in nearly a decade on the transplant list, no luck getting an organ.

Then, last spring, his doctor called. There was a perfect match.

Marcus was at the top of the waiting list — the first in line. But the kidney didn’t go to him. Or to the next person on the list, or the next. It went to a middle-aged man 3,557 spots further down.

That’s because in more and more cases, the list is a lie.

For decades, fairness has been the guiding principle of the American organ transplant system. Its bedrock, a national registry, operates under strict federal rules meant to ensure that donated organs are offered to the patients who need them most, in careful order of priority.

But today, officials regularly ignore the rankings, leapfrogging over hundreds or even thousands of people when they give out kidneys, livers, lungs and hearts. These organs often go to recipients who are not as sick, have not been waiting nearly as long and, in some cases, are not on the list at all, a New York Times investigation found.

Last year, officials skipped patients on the waiting lists for nearly 20% of transplants from deceased donors, six times as often as a few years earlier. It is a profound shift in the transplant system, whose promise of equality has become increasingly warped by expediency and favoritism.

Under government pressure to place more organs, the nonprofit organizations that manage donations are routinely prioritizing ease over fairness. They use shortcuts to steer organs to selected hospitals, which jockey to get better access than their competitors.

These hospitals have extraordinary freedom to decide which of their patients receive transplants, regardless of where they rank on the waiting lists. Some have quietly created separate “hot lists” of preferred candidates.

“They are making a mockery of the allocation system,” said Dr. Sumit Mohan, a kidney specialist and researcher at Columbia University. “It’s shocking. And it’s going to destroy trust in the system.”

Patients can wait months or years for an organ as their health declines, rarely told where they sit on a transplant list and not knowing whether they have ever been skipped. They just don’t get the call that can mean the difference between life and death.

Over the past five years, more than 1,200 people died after they got close to the top of a waiting list but were skipped, the Times found. It is possible that their doctors would have decided the organ wasn’t a good fit for them, but they were denied a chance to find out.

One of those people was Corey Field, a Minnesota grocer who was 10th on a list for a liver when he was skipped in 2023. It was his last chance: He died two months later. His wife, Laura Field, was shaken after learning from the Times what had happened. It’s not that her husband was entitled to an organ, she said, but he had deserved a fair shot.

“Corey was not just a number in a database,” Laura Field said. “He was a good husband, father, grandfather, son, brother and a friend. His life mattered.”

More than 100,000 people are waiting for an organ in the United States, and their fates rest largely on nonprofits called organ procurement organizations. Every state has at least one, and they have government contracts to identify donors, recover organs and distribute them to patients.

When an organ becomes available, an algorithm identifies the eligible patients who have compatible blood types and other matching traits, like height and weight. Those patients are then ranked on a list, with priority given to people who are sicker, have been waiting longer and are nearby, among other factors.

The procurement organization is supposed to offer the organ to the doctor for the first patient on the list. But the algorithms can’t necessarily identify exact matches, only possible ones. So doctors often say no, citing reasons like the donor’s age or the size of the organ.

If that happens, the organization is supposed to keep ticking down the list until the organ is accepted. This process repeats about 200 times a day across the country, with a new list created for every donated organ.

Until recently, organizations nearly always followed the list. On the rare occasion when they went out of order and gave the organ to someone else, the decision was examined by the United Network for Organ Sharing — the federal contractor that oversees the transplant system — and a peer review committee. Ignoring the list was allowed only as a last resort to avoid wasting an organ.

Now, however, skipping patients is so common that UNOS and the committee are too overwhelmed to examine each case closely.

The leaders of procurement organizations acknowledged to the Times that they sometimes deviated from waiting lists, but said they did it to save lives.

They said there is an inherent tension in the transplant system. Procurement organizations are being squeezed by the government to place more organs, while hospitals, which are judged on patient outcomes, routinely reject them. So organs deteriorate while doctor after doctor declines them.

Skipping patients is a necessary, if imperfect, solution, they said.

“Expedited placement is problematic because it means that we’re not following the list that the patients and the public believe that we are, but it speaks to the desperation of making sure that organ gets transplanted into somebody,” said Dorrie Dils, president of the association representing most of the country’s 55 procurement organizations.

She and others said they break from the lists only to place lower-quality organs that have been repeatedly rejected. But, data show, that is often not the case.

The Times analyzed more than 500,000 transplants performed since 2004 and found that procurement organizations regularly ignore waiting lists even when distributing higher-quality organs. Last year, 37% of the kidneys allocated outside the normal process were scored as above-average. Other organs are not scored in the same way, but donor age is often used as a proxy for quality, and data show there is little difference in the age of organs allocated normally compared with those that are not.

And while many people in the transplant community believe ignoring lists is reducing organ wastage, there is no evidence that is true, according to an unreleased report by a group of doctors and researchers asked by the transplant system last year to study the practice.

Last month, after receiving a summary of the Times’ findings, the federal Health Resources and Services Administration, which oversees the UNOS contract, said that procurement organizations should not be allowed to ignore waiting lists and ordered increased oversight.

The Times analysis also found that skipping patients is exacerbating disparities in health care. When lists are ignored, transplants disproportionately go to white and Asian patients and college graduates.

“We have violated our own principles. We have violated transparency, trust in the system,” Dr. Nicole Turgeon of the University of Texas at Austin told a crowd at the most recent American Transplant Congress, a large annual gathering.

“Everyone’s really trying to do the right thing, I honestly believe that. But we have a system in chaos.”

Routine shortcut

In 2020, procurement organizations felt under attack. Congress was criticizing them for letting too many organs go to waste. Regulators moved to give each organization a grade and, starting in 2026, fire the lowest performers.

They scrambled to respond. They assigned more staff to hospitals to identify donors, grew more aggressive with families and recovered more organs from older or sicker donors.

Those steps increased donations and transplants, dozens of employees said. Both hit record highs last year, when there were 41,115 transplants.

At the same time, the organizations increasingly used a shortcut known as an open offer. Open offers are remarkably efficient — officials choose a hospital and allow it to put the organ into any patient. The Times analysis found thousands of examples in the last five years.

In Los Angeles in 2023, for instance, the procurement organization OneLegacy resorted to an open offer for a heart after trying only the first two patients on the waiting list. It chose Keck Medical Center of USC, which gave the heart to the 115th patient on the list, a woman in her late 50s who was “stable” and healthier than dozens of people higher up, records show.

The eighth person on the list was Damon Gault. He was 55, ran a brewery in Northern California and, after decades of cardiac problems, had been hospitalized for months, hoping for a new heart.

Gault died six weeks later.

His fiancée, Jennifer Sakai, was stunned when the Times told her he had been skipped. “That’s not fair,” she said. “There’s a system in place to ensure that people have that opportunity, and they’re obviously failing.”

In a statement, OneLegacy said it had allocated the donor’s other organs and had less than 12 hours to find a recipient for the heart before the planned removal. It chose Keck because the hospital was already sending a surgeon to take the lungs. Keck said the patients at its hospital who were higher on the list were not good matches for the heart.

Historically, procurement organizations used open offers in only about 2% of cases, the Times found. Virtually all organizations now skip patients at least 10% of the time, almost always through open offers. A few do it more than 30%.

Watchdogs failing

Federal regulators have known since 2022 that more people were being skipped, according to meeting notes obtained by the Times. But until last week, they had done little to address it.

The U.S. Centers for Medicare & Medicaid Services monitors hospitals and procurement organizations. The Health Resources and Services Administration tracks the system overall. But for years, they deferred to UNOS.

Records show that when the system’s oversight committee reviews instances of bypassed patients, it closes more than 99.5% of cases without action, usually concluding that the organ was at risk of going to waste. In the last five years, the committee has never gone further than sending “notices of noncompliance,” the mildest action it can take.

“The oversight is almost nonexistent, and that’s been true basically forever,” said Dr. Seth Karp, a Vanderbilt University surgeon who served on the committee, which he noted is largely made up of transplant doctors and procurement officials policing themselves.

Dr. Richard Formica, a Yale University surgeon who is president of the transplant system, said the committee members were volunteers who did their best. He said it was difficult for them to determine the motivations behind out-of-sequence allocations.

Some procurement organizations complicate oversight by obscuring their open offers, according to current or former employees at 14 organizations.

Many said they phoned doctors directly, so the details of open offers were not documented in the centralized computer system. Several said they logged an offer in the system only if the organ was successfully placed, making the practice look more effective. Others said they always entered “time constraints” as the reason for skipping patients, even if that was false.

Because of this, it is impossible to gauge whether line-skipping prevents wasted organs. But data suggest it does not. As use of the practice has soared, the rate of organs being discarded is also increasing.

“If we were doing this and the discard rate was going down, then we could say: ‘Well, there are some trade-offs. It may introduce racial and socioeconomic inequities, but we should look at it,’” said Dr. Stephen Pastan, a transplant medical director at Emory University Hospital. “But that’s not what is happening.”

Marcus’ lost match

The kidney that could have helped Marcus Edsall-Parr was donated by a man in his 20s who died in Texas last April. It was in exceptional condition, records show.

Marcus’ doctors at University of Michigan Health, Michael Englesbe and Meredith Barrett, became excited. They had gotten to know Marcus and his parents, Kath Edsall, a veterinarian, and Alice Parr, a veterinary technician. Marcus, who was adopted at age 5, had had kidney problems and developmental delays since infancy.

Marcus was rarely a match for transplants because testing suggested that his antibodies would reject almost any new organ. His doctors had declined other kidneys, determining they weren’t good fits. This was the most promising one yet.

The University of Illinois Hospital Transplantation Program had first dibs on the kidney for a multi-organ transplant. But those special-priority operations often fall through, which made it likely that allocation would shift to the regular list — topped by Marcus.

Englesbe told Marcus to hurry to the hospital. He called the Texas procurement organization, LifeGift, and the Illinois hospital to say he wanted the kidney. He offered to pick it up himself.

Soon after the kidney arrived in Illinois, the multi-organ operation was canceled. Under the transplant system’s rules, LifeGift was supposed to offer the kidney to Marcus. It had time: The organ had been outside the donor’s body for just 10 hours. But instead, it gave an open offer to the Illinois hospital.

This was not unusual. Last year, records show, LifeGift skipped patients for 29% of kidney transplants.

Englesbe found out hours later, when surgeons were already transplanting the kidney into a man in his 40s who had been waiting less than six months.

The doctor told Marcus and Edsall, who began sobbing. They drove home.

Edsall learned the full story months later from the Times. She was glad the kidney had been used. But she could not help feeling angry.

“What made them decide Marcus wasn’t good enough for that kidney?” she said. “What was the deciding factor so that somebody said, ‘This man deserves it more than he does’?”

In an interview, Kevin Myer, the chief executive of LifeGift, said the organization had acted in good faith to place the kidney. “It’s really tragic that Marcus did not get this kidney because of the system. Not because of our inattention or intention to bypass Marcus or anything like that,” he said. “Do I feel terrible that he didn’t get his opportunity? Yes, frankly.”

The University of Illinois said allocation was LifeGift’s responsibility.

Marcus eventually got a transplant, from a donor who died in Arizona last June. But the kidney was less compatible and in worse condition than the one he had missed out on.

He still has to spend two days a week at dialysis, where a machine filters toxins from his blood.

If his kidney functioning does not improve, Marcus may go back on the transplant list. His parents know he cannot survive on dialysis forever.

His doctors are still furious. “We’ve built this system to try to be fair to people, and this just seems so unfair,” Barrett said, adding: “We followed the rules, and the rules didn’t seem to apply for him.”

The doctors filed a complaint about the incident. They got no response.