Why your organ donation wishes deserve more than a checkbox at the DMV.

How Does Organ Donation Work?

Most people are introduced to organ donation as an act of generosity. In a way, people feel expected or even pressured to sign up for the program. You say yes at the DMV, check a box online, join a donor registry, and that choice is presented as a simple way to help save lives after death.

That is the version most people hear, and on the surface, it sounds uncomplicated. It might even make you feel like a good person who is willing to help others if something happened to you.

However, there is a lot more going on behind the scenes–stuff that you should know before signing up for the organ donation registry.

What most people think they are agreeing to when they ask themselves “Should you be an organ donor?”

What many people believe they are saying is, “If I die, and my organs can help someone, I would want that.”

They often think of it as a moral yes-or-no question, not as a decision with significant legal and medical consequences. That is partly because public-facing donor messaging is designed to make registration feel easy, fast, and positive.

However, it is a lot more complicated than a moral question. In fact, MIDEO has found that most people have no clue what they are agreeing to when they ask themselves “Should I be an organ donor.”

The truth is, once donor intent is documented, many systems treat that choice as First Person Authorization, meaning it is a legal and binding expression of the donor’s own decision.

The DMV checkbox makes everything feel simple…but it’s not

The DMV checkbox feels like no big deal because it happens in an ordinary moment. You are renewing your license and trying to move on with your day as quickly as possible. You don’t really want to be there, so you are answering questions as quickly as possible–often without thinking.

But that one decision may later carry far more weight than most people realize. Recent CMS guidance specifically points to driver’s license declarations and state donor registries as examples of first-person consent documentation that can govern the donation process. In other words, this is not just a feel-good symbol on a piece of plastic. In many cases, it is treated as a legally meaningful instruction.

That is the problem. A decision this serious is often made in seconds. All of this is done without a real discussion about donation after circulatory death, without any real explanation of how the process may unfold, and without making those wishes equally clear in an advance directive.

That is a major problem with plenty of ethical implications.

Why You Shouldn’t Put Organ Donor on Your License Without Understanding the Fine Print

For most people, saying yes to organ donation does not feel like making a complicated medical decision. It feels like doing something kind.

Here’s how things usually play out. You are standing at the DMV, trying to get through the line, and someone asks whether you want to be an organ donor. There is no long explanation. No one walks you through donation after circulatory death. No one explains how this choice may interact with your end-of-life care or your healthcare proxy.

Instead, it is presented as a simple good deed. What they don’t tell you is that checking the box can have massive consequences if you are involved in a medical emergency.

A quick DMV decision becomes a major medical decision–without you even knowing it

That is the part most people never fully hear. What feels like a helpful choice can later become a major instruction inside a hospital system. In cases where that documented wish exists, the patient’s decision to check the organ donation box can override any family objections at bedside.

This is exactly why the “organ donor” symbol on a license should not be treated as casual or symbolic. It will end up carrying more weight than a family conversation, more weight than what loved ones assume you wanted, and more weight than a rushed attempt to interpret your values during a crisis.

A decision this important should never be made in ignorance or left sitting on a piece of plastic without fuller context.

Why informed consent matters more than good intentions

Good intentions are not the same thing as informed consent. A person may want to help others and still have serious questions about how organ donation works, what happens in donation after circulatory death, whether they want to donate under all circumstances, and how their healthcare proxy should respond if the situation becomes complicated.

You shouldn’t be made to feel bad about having those thoughts and questions.

That is why MIDEO takes the position that your organ donation wishes should be completely thought through. If you want to donate, that’s great! But you need to do it in a way that you fully understand the impacts of your decision.

And if your answer depends on the circumstances, that deserves more than a checkbox at the DMV. It deserves a real advance directive, a prepared healthcare proxy, and language that leaves far less room for other people to decide what you “must have meant.”

Donation After Circulatory Death Has Changed the Organ Donation Conversation

For years, many people understood organ donation through the idea of neurological death. Essentially, a patient was declared dead by neurologic criteria, the donation process moved forward, and the public mostly saw it as a wonderful act of generosity.

That is no longer the whole story. Donation after circulatory death (DCD) has expanded dramatically and is now a major part of the organ donation system in the United States.

“To increase the donor pool, expanding organ donation from the conventional neurologic determination of death (NDD) to include circulatory determination of death (DCD) has been a well-established method of increasing donors in other countries.”

That is one reason the organ donation conversation has become more controversial and more important to understand.

What donation after circulatory death means

Donation after circulatory death involves organ recovery after the heart and circulation have stopped, rather than after a declaration of brain death.

This is a monumental shift. And it is something that raises its own clinical, ethical, and policy questions, especially around timing, consent, and how the process is managed in end-of-life situations.

Official ethics and policy materials recognize that DCD presents distinct considerations from traditional donation after brain death, which is exactly why it has drawn more scrutiny in recent years.

Part of the growth in DCD has come from changes in organ recovery and preservation practices. Advances like normothermic regional perfusion and other machine-perfusion approaches have increased DCD organ use because they can expand the number of organs recovered and improve organ viability.

That may be good news for transplantation, but it also means the system today is not the same system many donors thought they were opting into years ago.

Why this matters if you became a donor years ago

If you marked “organ donor” on your license a long time ago, there is a good chance you did so under a much simpler understanding of what organ donation meant. Many people never heard the term donation after circulatory death, never learned how much the practice has grown, and were never told that technological changes were reshaping how organs could be recovered.

Organ procurement teams are leaning on a growing reliance on DCD to maintain transplant access, and it is their duty to get as many usable organs as possible.

That is why this issue belongs in an advance directive, and it is our professional opinion at MIDEO that it should have nothing to do with your drivers license or checking a box at the DMV at all. It belongs in your MIDEO with an explanation of the consent you are providing.

If the organ donation system has changed, your wishes need to be revisited with the same seriousness. A decision you made quickly years ago should not be the legally binding directive. Unfortunately, it is–unless you do something about it.

The Organ Donation Controversy

Once in the ER, there may be a trauma or critical-care team focused on the patient in front of them, family members trying to understand what is happening, and an organ procurement process working under its own medical and logistical pressures.

A lot of people, including medical professionals, don’t like to admit it, but there is a lot of internal friction between the trauma teams and those heading up organ procurement. And that is one of the reasons MIDEO has been at the forefront of saying that there needs to be more education and informed decision making regarding organ donation.

And there are plenty of groups that agree with us. HRSA has pushed for national standards around donation after circulatory death, family education, and stronger patient protections, which tells you the system itself recognizes the need for tighter safeguards.

Why time pressure can change the feel of the situation

When organ donation becomes part of the conversation, time starts to matter in a different way. That does not mean every person involved has bad motives. However, it does mean organ viability, end-of-life care, family understanding, and hospital workflow can all start pressing on the same moment at once.

HRSA’s January 2026 DCD directive makes that tension clearly visible. In fact, it specifically calls for the ability to pause the donation process if there is concern for the patient, including concern about increased neurologic function or risk of pain.

A safeguard like that only appears when policymakers recognize that these situations can become ethically and clinically significant.

Families often feel rushed or confused

Families are losing trust in the organ donation process because the process is moving too fast. On top of that, organ teams lack the training needed to appropriately approach families, along with the timing and current methods.

Let’s look at HRSA’s modernization updates again. When watchdog agencies are explicitly requiring better education, better timing, and better communication, that is a sign that organ donation teams are failing families when they need them most.

The issue is not simply whether organ donation is good or bad. Instead, the issue is if the organ donation process is moving too quickly.

Could a Patient Experience Pain or Awareness During the Process?

This is something you want to know before agreeing to organ donation. Unfortunately, it is a question that a lot of websites and professionals promoting organ donation hesitate to answer.

If a person’s organs may be recovered after circulatory death rather than after brain death, then questions about awareness, pain, and neurologic function are significant concerns.

That silence is part of the problem we’re talking about in this article. At MIDEO, we aren’t afraid to speak up regarding this as you need to be fully informed.

What we actually know about awareness at the end of life

In DCD, the patient is not brain dead. They are, in the words of the American Society of Anesthesiologists, “still completing the dying process but [have] not yet been declared dead.” Life support is withdrawn, the heart stops, a mandatory waiting period passes (typically five minutes in the U.S.), and only then is death declared and organ recovery allowed to begin.

However, many DCD donors have devastating brain injuries but retain some degree of neurologic function up until life support is withdrawn. Whether — and to what extent — these patients can experience discomfort, awareness, or pain during the dying process is a question the medical literature itself describes as unresolved.

A 2022 systematic review of end-of-life care in DCD donors found “wide and persistent variation” in how hospitals handle the period just before death, driven in part by “concerns regarding ethical ambiguity.”

The review noted that some patients — including those with conditions like ALS or high spinal cord injuries — are known to retain awareness, and that standard tools for assessing distress at the end of life are imperfect.

The defenders of DCD will tell you that proper protocols include sedation and analgesia, that comfort care is the priority, and that the focus is dignity. That’s true in principle. The question is whether it’s true in every case, every hospital, every time.

In practice, Dr. Mirarchi’s most common medical ethics consultation was related to the DCD process and when a patient’s family had conflict with the process. The conflict is real and the turmoil should not need to occur. This is an issue of informed decision making. No different than the risk and benefit discussion that occurs to give informed consent to a surgical procedure as common as taking out your appendix. The family wants to be assured that the donation process will not cause their loved one pain.

Why this concern should be taken seriously

In donation after circulatory death, the timing and process are different from the version of organ donation most people think they understand. That is because this new technique uses something called normothermic regional perfusion technology.

Before moving forward, it’s a good idea to get an idea of what normothermic regional perfusion is. In short, “NRP involves using a machine to pass blood through organs in a person’s body after the heart has irreversibly stopped beating. Vessels are clamped during this procedure to prevent blood flow to the brain.”

HRSA’s 2026 ethical analysis of normothermic regional perfusion says that post-declaration recirculation in circulatory-death cases raises concerns about compliance with the Dead Donor Rule and with nonmaleficence, the duty to do no harm.

Read that previous statement again. That means the concern here is real pain happening during the DCD organ procurement process.

If regulators are discussing pause mechanisms, pain risk, and neurologic-function concerns, then no one should pretend this is some sort of conspiracy theory. It is a complex end-of-life decision that can unfold in a medically intense setting, and the patient deserves to understand that before their donor status is ever treated as authorization.

Of 351 cases HRSA reviewed, 29% showed “concerning features.” Those features included problems with patient-family interactions, medical assessments and team interactions, recognition of high neurologic function, and recognition and documentation of drugs in records.

That phrase — recognition of high neurologic function — deserves to be sat with. It refers to cases where patients being prepared for organ donation showed signs of neurologic activity that should have prompted a pause in the procurement process.

In at least one widely reported case, a man who had been moved toward organ recovery began moving and moaning while being transported to the operating room. The procedure was stopped. He survived. He now lives in Kentucky and is undergoing physical therapy.

Why no one should consent without understanding this debate

This is why informed consent matters so much. A person may still decide they want to be an organ donor after learning all of this. But that decision should come after understanding the controversy.

That is exactly why MIDEO takes the position it does. No one should enter the organ donation system based only on a rushed DMV interaction. If you want to donate, that choice should be made with your eyes open. If you do not, that should be unmistakably clear, even if you’ve already checked the “Organ Donor” box at the DMV.

And if your answer depends on the circumstances, those details belong in an advance directive where your healthcare proxy can understand them and defend them.

If, after understanding all of this, you want to opt out — that’s your right too, and the same documentation applies in reverse. A driver’s license designation is not the only way your wishes can be communicated, and in most cases, it’s the worst way.

Instead, MIDEO can help you put your wishes in video form that trauma responders can quickly view at bedside. We can also help remove you from the organ donation registration if that is your choice. But I am happy to say that we are able to keep our patients donation friendly and supportive by placing language in the MIDEO that addresses the organ donations concerns.

What Percentage of People Are Organ Donors?

Donate Life America says more than half of adult Americans have registered their decision to be organ, eye, and tissue donors. That means that this controversy touches almost 170 million people, many of whom likely have no clue that the primary way organs are donated has changed.

That is what makes this conversation so important.

A common decision with uncommon consequences

More than half of adults may be registered, but that does not mean more than half could explain what donation after circulatory death is, what first-person authorization means, or how a donor registry can affect what happens later in a hospital.

In fact, the way donor registration is usually promoted shows the opposite. The question is not just what percentage of people are organ donors. The better question is how many of those people truly understood the full implications of what they agreed to.

MIDEO’s position is that no one should be left guessing about that after the fact. If your organ donation wishes matter, they belong in your advance directive too, where your healthcare proxy and medical team can see your true wishes.

Why popularity is not the same as informed consent

Informed consent, in every other area of medicine, has three requirements:

• The patient understands the procedure
• The patient understands the alternatives
• The patient understands the material risks

We see this process play out in medical settings all of the time. For example, a surgeon cannot remove an appendix without walking through all three. A clinical trial cannot enroll a participant without documenting all three. A dentist cannot pull a tooth without all three.

For some reason, organ donation is allowed to skip the conversation entirely.

This is not how informed consent works anywhere else in healthcare. And it’s worth asking why we accept it here.

We’re not arguing the 170 million Americans who registered are wrong to support donation. Many of them, given full information, would still say yes — and that’s their right! The argument is that registration as it currently works isn’t really consent in the medical sense of the word. It’s willingness. Those are not the same thing.

A patient who has thought through the difference between donation after brain death and donation after circulatory death, who knows about the ongoing federal investigation into procurement practices, who has decided which protocols they would and would not consent to, and who has documented those wishes in a place clinicians can actually find them in an emergency — that patient is genuinely consenting. A patient who checked a box at the DMV in 2009 is not. The consequences are total. There is no take-back. There is no “let me think about that again.”

“It is very common for me to get a medical ethics consultation to come and address the family conflict with the organ procurement team. The conflict is often that the team wants to move forward and that family is not ready,” says Dr. Mirarchi.

At that moment as it is today, if the patient is an organ donor, then the procurement team has every legal right to move forward despite the family conflict. This is why this is so important to address the informed consent issue at the beginning of the designation process. This is also why we suggest that the issue of organ donation be addressed in a MIDEO. It is very powerful and even consoling to families to see their loved one giving permission to the procurement process and removes any family concern or guilt.

Should You Be an Organ Donor?

This is about your autonomy, not someone else’s agenda.

That matters because a lot of pressure can build around this topic. There is public pressure to “do the right thing.” There is institutional pressure to increase donor participation. There may be emotional pressure from family members who want to honor what they think you would have wanted.

But none of those pressures should outrank your actual wishes.

So should you be an organ donor? Maybe yes. Maybe not. Maybe you’re not sure. But it can be done with controls.

For some people, the answer will be yes. Many, after reading everything in this article, will still want to be donors under any circumstance the law allows. They’ve weighed the protocol variation, the DCD debate, the federal findings, the pace of change in transplant medicine and they’ve decided that the chance to save lives outweighs everything else.

For others, it will be no. Some people, after reading the same information, will decide that they don’t want to participate in this system as it currently exists or that they simply don’t want their body used after death, for whatever reason they hold. That is also a real, considered, valid choice. And we’d note that opting out is harder than opting in, in part because the system isn’t built to make “no” easy. We’ll come back to that.

For others still, the answer may be yes under certain conditions and no under others. For example, they’d consent to donation after brain death but not after circulatory death. They’d consent to donating kidneys but not their heart. They’d consent only if certain protocols (like normothermic regional perfusion) are not used. They’d consent only if their family agrees in the moment. They’d consent only after a specified waiting period, or only at certain hospitals, or only with their faith community’s input. These conditions are not exotic.

These are exactly the types of conversations about organ donation that we should be having. This is not a loyalty test or a virtue signal. It is a personal medical decision that should reflect your values, your understanding of the current system, and your comfort with how organ donation works today.

When a choice can carry this much legal and clinical weight, the patient should be the one defining it.

We understand the urgency. We don’t dispute the math. But urgency is not the same as consent, and another person’s emergency does not relieve you of the right to make your own informed decision about your own body.

That is why the better question is not just, “Should I be an organ donor?” It is, “What do I actually want, and have I stated it in a way that protects me?” That’s only something that you can answer for yourself.

You are allowed to ask harder questions than the form lets you ask. You are allowed to want specifics. You are allowed to say yes, but only under these circumstances or no, and I want that documented somewhere it cannot be missed. That is not selfish, and it is certainly not anti-donation. It is what informed consent is supposed to look like in any other medical context, and it is what it should look like here.

“I’ve been in countless situations where the organ donation process has gone well and I’ve been in countless situations where the process has trampled on patient autonomy (the patients rights to decide),” says Dr. Mirarchi.

“When it tramples on the patient’s and families rights, often staff get reactive and begin to pressure, even badger, the family when it should be the opposite they should become supportive and help resolve conflict.”

“Saving one life should not pressure one’s death. I’ve seen this result in a complete loss of potential organs because of how the process went. I have often also encountered families being completely devastated because they had no idea that their loved one had this designation on the drivers license. And the reason the surviving family was devastated is because the process steam rolls them over and they can’t stop it. I’ve had to become involved with family members where they couldn’t stop it and I’ve also been in situations where we were able to stop it because it was the right thing to do for the patient.”

That is what’s supposed to matter most, what is right for the individual patient whose life is about to end.

So, start having those conversations with the people you care about and the people you trust. Schedule an appointment with MIDEO and have those conversations with us.

Why Your Organ Donation Wishes Belong in Your Advance Directive

Organ donation should be addressed directly inside advance care planning.

If your wishes are not clear, your healthcare proxy may be left trying to interpret them in a chaotic and emotional moment. That is a dangerous place for anyone to be. A proxy should not have to guess whether you wanted to donate, whether you had concerns about donation after circulatory death, or whether your answer depended on the circumstances. They should already know. They should be able to speak with confidence because you already spelled it out.

State it clearly with MIDEO

Here is what happens when an advance directive is silent on organ donation: Your DMV registration becomes the default answer. Also, in certain states, the decal designation on your license will trump the advance directive.

When the DMV registration becomes the default answer, families will be told, gently but firmly, that your decision was already made. The conversation ends there.

MIDEO gives people a way to do what a DMV checkbox never can: explain their wishes clearly, in their own words, as part of an advance directive. If you want to be an organ donor, MIDEO helps you make that unmistakable. If you do not, MIDEO helps you make that unmistakable too. And if your answer is more nuanced than either extreme, MIDEO gives you a place to spell that out so your care team and your proxy are not left guessing.

A MIDEO recording lets you say: “I want to be a donor under brain death criteria, but not under DCD.” Or: “I’m comfortable donating kidneys but not my heart.” Or: “I want to be a donor only if the following conditions are met.” Or: “I do not want to be a donor, and I want my family supported in honoring that.”

Whatever your specific wishes are, you say them on camera, and they exist in a form no one can credibly misinterpret.

The video is paired with a legally compliant written advance directive, so you have both the legal document and the unambiguous voice recording. And the entire package is retrievable at the bedside through a QR code in a split second — meaning when an emergency happens, the clinician treating you can have your actual wishes in front of them in seconds.

Update your donor status if your wishes have changed

And if your wishes have changed, that matters too. In many states, removal requires going back to the source registry and explicitly opting out. If you live in Pennsylvania, use the Donate Life PA registry to update your status. Learn more about creating a Pennsylvania advance directive with MIDEO.

MIDEO can help you remove yourself from the donor registry, update personal information, or specify more detailed donation preferences.

Do not let a DMV checkbox decide this for you. If you have never clearly addressed organ donation in your advance directive, now is the time. Create or update your MIDEO so your voice is not reduced to a symbol on a driver’s license.

Document Your Organ Donation Wishes With MIDEO