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.

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.

Chapter 3 tackles issues that are not necessarily directly related to the business cycle but will be important at various points in the historical section of the volume that covers every US business cycle since 1954. These include inflation, monetary policy, fiscal policy, tradeable securities, and secular stagnation. Because it is so poorly understood and since it will play a key role in the cycles of the 1970s and 1980s, more than half of this space is devoted solely to understanding inflation. The idea that it is a function of money supply growth is challenged, and a new set of definitions and classifications is offered.

Neoclassical economics – especially macro – is a mess. It has become irrelevant and divorced from the real world. Unfortunately, theory is important because it informs policy. This volume takes an alternate approach, one following the work of earlier Institutionalist and Post Keynesian pioneers.

The chapter opens with a quick review of the preceding theory and an outline of what one should expect to see in the real world if that theory is relevant. Several data points are selected as being the most significant, and the manner in which they fit on average over the entire period is demonstrated. These same data points are then repeated within each cycle as the chapter continues. Ten expansions and recessions are explained, including considerable detail as drawn from contemporary and later accounts. On occasion, there are side trips to related concepts such as shifting income distributions, the dramatic decline in the labor force participation ratio, secular stagnation, and the financialization of the economy.

The OPTN Board of Directors adopted strategies to build support and administrative capacity for implementing continuous distribution (CD). It also sequenced implementation of CD by organ to ensure adequate staff support for committees, learn from early implementations, and gain “small wins.” Implementation of CD began with lungs, because of the relative simplicity of the lung categorical allocation rules and the success of the lung committee in making substantial rule changes in the past. The lung proposal was completed, and its subsequent revisions indicated CD flexibility. CD implementation began for the more complex kidney and pancreas allocation prior to the finalization of lung CD. The kidney and pancreas CD proposals were near completion when the CD initiative was put on hold because of concern about the nonuse of donated organs. CD development was also under way for the more politically challenging liver allocation when CD was put on hold. The lung CD success serves as a proof of concept for CD. The kidney, pancreas, and liver efforts show the challenges encountered in making substantial planned organizational change.