Purpose of Review <p>Even as the number of organs donated and transplants performed increases, over 100,000 people remain on the waitlist, sparking discussions about organ underutilization. Primary community-based discussions have focused on improving opportunities for increased organ utilization, but little focus has been on the ethical obligation to honor the gift of donation from the donor and their family, and consideration of the broader financial implications has been limited.</p> Recent Findings <p>As organ recovery numbers increase, new concerns emerge, such as the staggering increase in non-use of recovered kidneys by 228% from 2018 and 2023. For nonrenal organs, there has been more than a tenfold variation in acceptance practices reported among transplant programs. Both of these point to the potential for organ underutilization.</p> Summary <p>Public participation in the organ donation process is rooted in the implicit promise that donated organs are gifts that will be used to save and heal as many lives as possible. Staggering increases in underutilization of donated organs raises significant ethical and economic concerns that must be considered as the community proposes changes to regulations and clinical practice.</p>