Why It Matters

The gap is not about willingness

When Indians are surveyed about organ donation, a large majority say they would be willing to donate. When families are actually asked, in a hospital, hours after a death, most decline.

That contradiction is the entire problem. It is not caused by opposition to donation. It is caused by the fact that the family has never discussed it, does not know what their relative would have wanted, and is being asked to decide on behalf of someone else at the worst moment of their lives. Faced with that, saying no is the safer answer.

This is a solvable problem. Countries that have raised their donation rates did not change their populations' beliefs. They made the conversation ordinary, and made sure trained people were available to have it well.

What can be donated

Donation falls into two categories, and they work very differently.

Organs — only after brain-stem death

Kidneys, liver, heart, lungs, pancreas and small intestine can only be retrieved when someone is declared brain-stem dead while still on ventilator support. This is rare: it accounts for a very small share of all deaths, which is why every such opportunity matters so much.

Tissue — possible after most deaths

Corneas, skin, bone, heart valves and blood vessels can be donated after a natural cardiac death, at home or in hospital, usually within a few hours. Corneal donation alone could end most corneal blindness in India, and it is the donation most families are never told is possible.

What brain-stem death actually means

This is the single most misunderstood part of organ donation, and the misunderstanding costs lives.

Brain-stem death means the brain stem has permanently and irreversibly stopped functioning. The person cannot breathe on their own, will never regain consciousness, and cannot recover. It is legally and medically death — not a coma, and not a vegetative state. A person in a coma can recover; a person who is brain-stem dead cannot, ever.

The heart may keep beating because a ventilator is pushing oxygen into the lungs. That is what makes organ donation possible, and it is also why families find it so hard to accept: their relative looks asleep, and warm.

Under Indian law, brain-stem death must be certified by a board of four doctors, including a medical administrator and a neurologist or neurosurgeon, none of whom may be part of any transplant team. Two separate sets of tests are conducted six hours apart. The process is deliberately slow and deliberately independent.

How the process works

If donation is agreed, the sequence is fixed and is the same in every hospital:

1. Death is declared and certified by the four-doctor board, entirely separately from any question of donation.
2. A transplant coordinator speaks to the family. Consent is theirs to give or refuse.
3. Medical suitability is assessed — blood tests, infection screening, organ function.
4. NOTTO and the state SOTTO allocate the organs against the national waiting list. Neither the family nor we have any say in who receives them.
5. Retrieval is performed surgically, and the body is returned to the family for the funeral.

The recipient is never told who the donor was, and the donor family is never told who received the organs. Some families later exchange anonymous letters through the hospital, but only if both sides want to.

The law

Organ donation in India is governed by the Transplantation of Human Organs and Tissues Act, 1994, amended in 2011. Two things are worth knowing:

• Buying or selling organs is a criminal offence. Both the seller and the buyer can be imprisoned. No money changes hands in a legitimate donation, ever.
• Allocation is centralised and rule-based. Waiting lists are maintained by NOTTO and the state networks, prioritising medical urgency, compatibility and waiting time. No hospital, NGO or family can jump the queue.