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A human kidney, if properly refrigerated, will keep for up to 48 hours (PDF). After it is harvested from a donor, the kidney is chilled in an ice bath, flushed with a preservative solution like Viaspanä or Custodiolä, and placed in a carefully labeled picnic cooler. It is then walked, flown or driven to its final destination: the abdominal cavity of a transplant recipient. Since demand for organs is so high, procurement organizations rarely have trouble finding patients. Of the 102,427 Americans awaiting organs in July 2009, 80,211 needed new kidneys.

In spite of overwhelming need, kidney offers are almost always turned down. Rigorous screening might indicate a good match, but patients can choose to wait for something better. According to a recent study by Juanjuan Zhang of MIT’s Sloan School of Management, just 2.9% of the kidney offers made are accepted. It is about twice as likely that a mobile home will be equipped with a fax machine (1 in 17.25).

The culprit for this high rate of rejection, Zhang suggests, is herd behavior. Just as a house too long on the market has trouble selling, so a kidney too often declined has trouble finding a recipient. Many patients, seeing that others have said no to a kidney, simply assume that something is wrong with it. They repeat the same decision rather than making their own, and the organ cascades down the list. In Zhang’s sample, the average kidney was not accepted until it reached the 34th patient, who had already declined 15 other kidneys and spent 209 days on the waiting list.

Every minute an organ spends in storage causes incremental cell damage. Repeated rejection by patients means that each year, scores of kidneys available for transplant reach and then surpass their two-day expiration date. They must be cast aside. According to the Department of Health and Human Services, 8.2% of recovered kidneys were discarded because no recipient was located, the list was exhausted, or storage time lasted too long.

The refusal of viable kidneys creates a dilemma. On the one hand, patients are encouraged to be picky, to act in their own self-interest. The positive effect of this is clear: 5 years after transplant surgery, 84.2% of recipients are still alive. But at the same time, the loss of usable organs means that some patients never get what they need. The odds someone on the kidney waiting list will die in a year are 1 in 14.29.