As of March 2025, three plaintiffs are suing the United Network for Organ Sharing (UNOS) across California, Washington, and Tennessee. Randall v. UNOS, Maddox v. UNOS, and Welch v. UNOS are the three ongoing lawsuits against the organization for its use of a race-based coefficient that altered specific health metrics of Black patients to disadvantage them in the process of getting kidney transplants. Specifically, at the California District Court, Anthony Randall is suing UNOS and Cedars-Sinai, the servicing hospital, because he believes that without the use of this coefficient, he would have gotten a kidney replacement by 2022 after five years of waiting on the transplant list, as opposed to receiving the kidney after filing the lawsuit. These plaintiffs are thus suing UNOS and their respective hospitals for injunctive relief on behalf of other disenfranchised Black patients for violating Title VI of the Civil Rights Act of 1964. 

While the state-level codes and standards for fiduciary duties vary among states, each case seeks injunctive relief and punitive damages regarding a civil rights violation, which places this case at an interesting intersection of medical malpractice resulting from a policy-level civil rights violation. Further, this case presents an opportunity to build on past precedents established through Simkins v. Cone and Davis v. Monroe County Board of Education, to establish a clear precedent on violations of Title VI as they relate to medical malpractice. This precedent would clarify and lower the standards of intentionality when it comes to discriminatory medical practices.

The National Organ Transplant Act of 1984 established the Organ Procurement and Transplantation Network (OPTN), which is administered by UNOS. Since 1984, UNOS has operated as an independent nonprofit under a federal contract, managing the OPTN to match organs to patients and maintaining a national transplant waiting list. One of the primary factors determining who gets an organ is the amount of time patients have spent on the waitlist; patients must meet a certain number of negative health markers to be added to that list. In other words, patient health markers must reveal a critical level of direness to render them eligible for a donor organ. One of these markers is the estimated glomerular filtration rate (eGFR) test, which must fall below 20 ml/min to qualify for a patient to be eligible for the waitlist. Since its establishment by the U.S. Congress in 1984, UNOS has utilized a “race-based coefficient” which artificially inflated the eGFR scores of Black Americans by 16-18%, preventing them from accruing wait time and preventing Black Americans from receiving kidney transplants even when they were eligible to receive them. This coefficient was introduced initially due to flawed studies that attributed differences in certain markers to race rather than non-racial factors that may have been at play. In 2022, UNOS admitted the inaccuracy of this coefficient (which had previously been questioned and invalidated in medical journals) and announced its intent to outlaw the use of the coefficient; however, it continued to utilize the inflationary coefficient for six months, and as of 2024, had only adjusted half of the wait times of Black Americans already on the waitlist. 

The legal framework for addressing civil rights violations in the medical field draws from various precedents established in cases pertaining to employment and harassment in federally funded schools. However, a foundational case that the Civil Rights Act and these three cases against UNOS rest on is Simkins v. Cone, which pertains to unequal treatment at hospitals on the basis of race. In Simkins, the U.S. District Court for the Fourth Circuit held that having received federal construction funds, private hospitals were obligated to act in a nondiscriminatory manner as outlined by the Fifth and Fourteenth Amendments. Simkins was the first application of the 14th Amendment, which prohibits racial discrimination by private entities, expanding the scope from government agencies to those that receive federal funds. 

This broadened definition of a public entity at the courts enabled Congress to pass the Civil Rights Act of 1964, which prohibits discrimination on the basis of race, color, and national origin in programs and activities receiving federal financial assistance. Randall’s claim that UNOS violated Title VI thus requires evidence and argument for two specific points: UNOS receiving federal funds is necessary to be considered a federally funded assistance program and its discrimination was intentional.  As it pertains to funding, UNOS receives approximately 10% of its budget from federal contracts and funding, likely leading to a clear argument regarding federal assistance. It is the intentionality, which has been defined and loosely expanded upon in various Title IX cases, that comes into question. If this case continues as a Title VI violation, it has the opportunity to—and should—codify language surrounding the intentionality, specifically deliberate indifference to racially discriminatory policies that led to disproportionate deaths of Black Americans. 

In Alexander v. Sandoval, Justice Scalia established the notion of intentionality, writing “Title VI itself directly reaches only instances of intentional discrimination.” However, this intentionality has been expanded to incorporate less overt instances of intentionality that are difficult to gauge; Davis v. Monroe County Board of Education established that “deliberate indifference” to known acts of harassment that led to severe damages constituted an intentional violation of Title IX. Furthermore, it outlined that the harassment that occurred under this “deliberate indifference” must be “serious and systematic” enough to prevent students from enjoying basic educational opportunities. Murrell v. School District further developed a four-part standard necessary to sustain a Title IX deliberate indifference claim: the federally funded organization at hand must have had 1) direct knowledge of harassment, 2) was deliberately indifferent, and 3) the harassment was so severe, pervasive, and objectively offensive, 4) that it deprived the victim of access to educational benefits or opportunities provided by the school. 

The conditions for intentionality, particularly “deliberately indifferent” intentionality established in cases involving Title IX violations, are relevant to Title VI violations due to their legislative foundationality. Bryant v. Independent School District established that because Congress based Title IX on Title VI, the court’s analysis of what constitutes intentionality behind sexual discrimination under Title IX can inform the analysis of what constitutes intentional racism under Title VI. Thus, the standards are transferable. Williams v. Port Huron Area School District similarly argued that the standard for Title VII racial harassment claims may be adopted  and applied in conjunction with  the standards used in Title IX cases. Justice Scalia created an incredibly high barrier in Alexander v. Sandoval when he wrote that intentionality—murky and counterintuitive to the protective purpose of equal protection laws—was necessary to determine an organization’s discriminatory behavior as violating Title IV. However, the application of Title IX standards of “deliberate indifference” opens the scope of punishable discriminatory behaviors to a more reasonable extent. Particularly in the context of systemic practices that have a wide-reaching discriminatory effect, such as UNOS’s policy that inflated the eGFR scores of Black Americans, punishing the “deliberate indifference,” at the very least, is critical to achieving justice for the Black patients who are still alive despite having been forced to suffer physical and economic damages by these harmful policies. 

The notion that Black Americans would have higher eGFR scores that would make them less susceptible to health decline from kidney failure had been disproven as a scientific fact in journals prior to 2022 when UNOS announced the termination of this policy due to its discriminatory and severe effects. This already points to deliberate indifference—arguably, the primary organization that matches organs to patients in the U.S. would have had access to and been aware of the discriminatory nature of this existing policy. However, this speculation of awareness aside, the fact that UNOS announced its termination of this discriminatory policy and then subsequently continued to use it for six more months reveals this very “deliberate indifference” that resulted not only in severe and offensive harassment but also in loss of life and economic damages for a significant portion of the Black population. As of January 2024, UNOS had only adjusted the eGFR score of 14,849 out of 27,500 Black Americans.  

In hearings to dismiss these cases, both Randall and Welch were denied the ability to pursue claims seeking injunctive relief, as both had had their eGFR scores adjusted. They no longer had a personal stake in the outcome of the lawsuit. However, these two parties and Maddox all acted within their statute of limitations for their claims under Title VI; thus, as they move forward in their lawsuits regarding rather clear civil rights violations, judges in their respective states also have an opportunity to codify standards surrounding the intentionality of Title VI violations. In a Congressional Research Service (CRS) report to Congress, researchers determine that standards for Title VI claims of private racial harassment are judicially constructed and derive from standards created by the Supreme Court to evaluate Title IX claims. One consideration and recommendation to Congress is passing legislation that adds additional protected classes to Title VI, directly addressing the threshold of racial discrimination in federally funded institutions, such as schools. These three cases against UNOS have an opportunity to clarify those standards as they pertain to Title VI violations while reaffirming that it does not set an unnaturally high standard for the severity of damage. Furthermore, given that these cases intersect with medical responsibilities, perhaps the notion of “deliberate indifference” can warrant consequences equivalent to the loss of life and instability due to this discriminatory practice by UNOS.