Organ and tissue donation: how the systems work

Organ and tissue donation saves and improves lives, demand exceeds supply almost everywhere, and the systems governing it differ in ways worth understanding.

Opt-in and opt-out

Opt-in systems require you to register a wish to donate.

Opt-out systems, sometimes called presumed or deemed consent, treat adults as willing unless they have registered an objection.

Several countries have moved from opt-in to opt-out in recent years. Evidence on whether this increases donation rates is mixed — the systems that perform best generally combine legislation with substantial investment in transplant infrastructure and in specialist staff who conduct family conversations.

The crucial point in nearly all systems: families are consulted, and in practice donation rarely proceeds if the family objects, whatever the legal position.

Which means registering is necessary and not sufficient. Telling your family is what actually determines the outcome.

What can be donated

Organs — kidneys, liver, heart, lungs, pancreas, and in some circumstances intestine. These require very specific circumstances of death, generally in intensive care with the body's circulation maintained.

Only a small proportion of deaths occur in circumstances permitting organ donation, which is why registered donors frequently do not become donors.

Tissue — corneas, skin, bone, heart valves, tendons. Tissue donation is possible after a far wider range of deaths and within a longer window, and it is considerably less well known.

Corneal donation in particular is possible for most people and transforms sight for recipients.

Who can donate

Most people, and there are fewer exclusions than people assume.

Age is rarely an absolute bar — organs have been donated by people well into old age, and suitability is assessed at the time.

Many medical conditions do not exclude donation. Some infections and some cancers do, and this is assessed case by case.

Restrictions relating to sexual behaviour, travel history and other factors have been substantially revised in many countries in recent years toward individualised risk assessment.

The practical advice from donation organisations is generally: register anyway, and let the professionals assess suitability at the time.

The concerns people raise

Will they try less hard to save me? The teams treating you and the teams involved in donation are separate. Donation is only considered after death has been confirmed, by criteria established independently of donation.

This concern is common and it is not supported by how the systems work.

Can I still have an open coffin? Generally yes. Donation is a surgical procedure conducted with care and the body is reconstructed.

Will it delay the funeral? Usually by a short period. Donation teams are aware of the family's needs.

Religious objections. Most major religious traditions permit and many actively encourage donation, though positions vary within traditions. If it matters to you, seek guidance from someone within your own tradition rather than assuming.

Cost. Donation does not generally cost the family anything.

What to do

Find out what system operates where you live. Whether opt-in or opt-out, and how to register a decision either way.

Register. This takes a few minutes online in most countries.

Tell your family. This is the step that matters most and the one most often skipped.

Families asked about donation are in shock, being asked a question they were not expecting, about someone they have just lost. If they know what you wanted, the decision is straightforward. If they do not, they frequently decline, because declining feels safer.

One sentence, said once at a kitchen table, is what determines this.

Record it in your advance directive as well, and tell your healthcare proxy.

If you do not want to donate, register that and tell them too. Objection is equally valid and equally worth recording, particularly in opt-out systems.

For families being asked

You will be approached by a specialist nurse or equivalent whose role is this conversation.

You are entitled to time, to ask questions, and to know exactly what is proposed.

You can ask which organs and tissues, whether you can donate some and not others, what happens to the body afterwards, whether you will be told about the recipients, and how long it will take.

Most systems provide anonymous information to donor families about outcomes, and many facilitate anonymous correspondence with recipients.

Families who consented frequently describe it later as the one meaningful thing to come from the death. Families who declined sometimes regret it, and sometimes do not.

There is no obligation, and there should be no pressure.

Body donation is different

Donation to medical education or research is a separate arrangement, made directly with an institution, generally requiring registration in advance.

It is not compatible with organ donation in most cases, and institutions frequently decline donations for a range of reasons, so a fallback plan is necessary.

Discussed in more detail in our article on disposition options.

Donation systems, registration processes and legal frameworks differ by country. Check the arrangements where you live, and tell your family your decision.