This paper ethnographically explores competing interests and goals, particularly related to adjudicating patient eligibility, in transplant medicine in the United States by focusing on a leading transplant center in the Midwest. Based on interviews with transplant team members and observations of multidisciplinary meetings (MDM) at a nationally ranked academic medical center in the Midwest, referred to as Pacific Hospital, this ethnography examines Pacific’s transition to work more high-risk patients into eligibility from 2019. This transition has been partly influenced by the implicit and explicit values promoted by national organ donation and data registry organizations, such as the ‘growth’ narrative of UNOS (United Network for Organ Sharing) and the ‘outcome’ criteria such as survival rates monitored and emphasized by SRTR (The Scientific Registry of Transplant Recipients). This study elucidates how Pacific’s transplant team maintains the precarious balance between the institutional goal of increasing patient volume and achieving favorable outcomes. Engaging multiple perspectives from different transplant team members, this ethnography reveals inherent uncertainties and ambivalence in the adjudication process. It focuses on internal factors such as institutional hierarchy, individual roles, and differing attitudes toward risks and outcomes set by national regulatory bodies, which collectively influence the adjudication dynamics during MDMs.