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.

Today we take for granted that when a candidate for President wins the election he will run for reelection in four years. If they win reelection, a new president will be sworn in at the end of the current President’s second term. However, for most of American history, until the ratification of the Twenty Second Amendment in 1951, this cycle of presidents serving for at most two terms was governed by tradition and norms, rather than law. In this section we explore the historical debate on presidential term limits, the long-standing tradition of two-term presidents, the passage of the Twenty Second Amendment, and ongoing attempts to repeal or modify the Amendment.

There are different types of investigations of the President: congressional investigations, federal criminal investigations, state criminal investigations, civil suits in state courts, and if the United States were to submit to jurisdiction, potentially even proceedings before international tribunals. The discussion in the preceding chapters focused on impeachment and criminal prosecution. But first must come an investigation. Some investigations have neither impeachment nor prosecution in mind, at least at the outset. Yet investigations of all types can be an effective check on presidential power.

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.

Throughout this book we note frequent references to the “Executive Branch.” However, from the text of Article II of the Constitution, which outlines the powers of the Executive Branch, it is unclear who composes the branch. Within Article II, there are two clearly enumerated members of the Executive Branch: the President and the Vice President. Article II, Section 2 references the existence of principal officers who lead executive departments, but it does not define what executive departments should exist.

The OPTN draws on a variety of expertise in designing organ allocation rules. Expertise arises from both explicit and tacit knowledge. Explicit knowledge includes generally accepted theories and empirical regularities that are accessible without first-hand experience of practice in some domain of knowledge. Tacit knowledge arises from experience, such as professional practice. In addition to this contributory tacit knowledge, it may also arise through interaction among participants in some domain of knowledge. Through its committee system, the OPTN taps the contributory knowledge of practitioners and patients and creates interactional tacit knowledge, especially among committee staff. Explicit knowledge arises from analysis of near universal longitudinal data on transplant candidates and other data collected within the transplantation system. These data support predictions of policy outcomes through simulation models and optimization tools utilizing machine learning.

The Constitution establishes the President as the head of the Executive Branch where virtually all the administrative capacity of the federal government lies.

Article II, Section 2 of the Constitution states that “[t]he President shall be Commander in Chief of the Army and Navy of the United States, and of the Militia of the several States, when called into the actual Service of the United States.” Unlike the vesting clause discussed earlier, which had significant debate during the Constitutional Convention, the Commander in Chief clause was an occasion for little debate at the Convention. Because the Founding generation recently and personally had fought a war to gain their independence from Great Britain, the Founders were acutely aware of the need to vest military command in a single civilian individual.

On the eve of the first impeachment of Donald Trump in late 2018, constitutional law scholars Laurence Tribe and Joshua Matz published an insightful book emphasizing the critically important role of impeachment in establishing checks on abuse of power in the presidency. The authors’ vision, much like that of the Framers, was that the threat of impeachment can stop the worst abuses by a president. For reasons we explore here, it has not always worked out that way. Nonetheless, the proper role of impeachment in the US constitutional framework, including what the House and Senate should do to carry out their responsibilities in an impeachment proceeding, is important to discuss here.

Since the nation’s founding in the late eighteenth century, it has experienced trying times, including a civil war, two world wars, a Cold War with the Soviet Union, acts of domestic and international terrorism, a decade-long economic collapse in the 1930s precipitated by a stock market crash and a global trade war, another economic collapse after the 2008 financial crisis, a violent attempt to overturn a presidential election, civil unrest precipitated by racial tension, anti-war protests, and protests against immigration policy. All of these events, as well as countless others, have required the nation to act quickly and decisively to respond to unprecedented circumstances.