The United Network for Organ Sharing (UNOS) began as the network administrative organization (NAO) overseeing the voluntary sharing of organs among transplant centers. It subsequently became the administrator of the Organ Procurement and Transplantation Network (OPTN), which Congress created to allocate deceased-donor organs when it nationalized them in 1984. The OPTN continuously makes incremental changes to organ allocation rules, raising concerns that the path dependence of allocation rules would hinder more radical change. Under pressure from the federal government, the OPTN gradually reduced the role of geographic boundaries in its allocation rules. However, it also introduced other categories so that allocation rules became increasingly complex. It initially considered continuous distribution (CD), a radical change, as an alternative for eliminating historical geographic boundaries. The OPTN subsequently committed to implementing CD for all solid organs because it offered improvements in efficiency, equity, and transparency, and because its relative simplicity would allow more expeditious incremental changes to allocation rules.

Organ transplantation offers patients greater longevity and quality of life. The allocation of scarce deceased-donor organs involves high stakes for patients, transplant centers, and Medicare. The US Congress delegated authority for the development of allocation rules to the Organ Procurement and Transplantation Network (OPTN), which engages stakeholders in the process. In 2018, the OPTN committed to replacing categorical allocation rules with continuous distribution, a new framework that sought to eliminate inefficiencies and inequities at categorical boundaries. The transparency of the OPTN provides an opportunity to observe this attempt to implement a consequential planned organizational change. The process reveals the extent to which the stakeholder rulemaking of the OPTN, an example of constructed collaboration, can implement radical as well as incremental change. More generally, it offers insight into the roles of expertise and values in high-stakes and complex organizational decision-making.