Dynamic Pooling and Regional Participation in Deceased-Donor Organ Allocation

Moving from geographically fragmented to pooled waiting lists in deceased-donor organ transplantation can improve efficiency, but it raises concerns about regional fairness and participation incentives. This paper studies Pareto gains from such transitions in a multi-class queueing model with impatient agents, perishable items, and a tractable homogeneous compatibility friction. In contrast to standard approaches that emphasize static match quality or overlook regional incentives in dynamic contexts, this analysis identifies dynamic risk pooling as the primary source of Pareto improvements for regions. Pooling reduces organ waste resulting from stochastic supply-demand fluctuations, temporal mismatches, and random compatibility outcomes. Although this dynamic surplus theoretically enables Pareto improvements, a purely utilitarian policy that treats all patients equally across regions often fails to achieve these improvements when regions are asymmetric. In these situations, utilitarian redistribution removes an excessive number of organs from high-supply regions and violates their participation constraints. To address this conflict, it is demonstrated that the set of achievable utilities can be represented by mixtures of static priority index policies. Building on this structure, the Constrained Pareto Frontier Search (CPFS) is proposed as a polynomial-time procedure that computes an approximately optimal allocation policy with arbitrarily small participation-constraint violations. The results indicate that, by adjusting priority indices to ensure redistribution remains within the gains from pooled supply, demand, and compatibility risk, policymakers can achieve global efficiency while maintaining local participation incentives.