Who gets the kidneys and livers and hearts donated by people who die? For decades, the U.S. government has enforced strict rules — devised by doctors and ethicists — to ensure they go to the patients who need them the most. The system is supposed to be fair.

Increasingly, it is not. Doctors in the United States transplant more than 40,000 organs from deceased donors per year — the most in the world. And in more and more cases, officials skip patients at the top of waiting lists and send organs to people who are not as sick and have not been waiting as long. Those recipients are disproportionately white and better educated.

Last year, this happened nearly 20 percent of the time — six times as often as in 2020. Some people never got a transplant and ended up dying. I’ve been working with a team of Times journalists to uncover the problem, and our story was just published.

In today’s newsletter, I’ll explain why people at the front of the line don’t always receive the transplants they need.

‘Making a mockery’

More than 100,000 people in the United States are waiting for a transplant. But they don’t all appear on one list. Instead, a new list is created for each organ that becomes available — about 200 a day.