When Raven Kinser walked into a Virginia Department of Motor Vehicles office two summers ago, she completed a driver\u2019s license application that included the option to register as an organ donor. The form provides a checkbox to opt in, but not one to opt out. Kinser left the donor registration box unchecked, reflecting her decision to reverse an earlier donor registration. Six months later, after she was declared dead at Riverside Regional Medical Center in Newport News, Virginia, her parents say, they learned that her decision did not prevent organ procurement.<\/p>\n
Raven\u2019s case reveals a little-known gap in the U.S. donation system: There is no clear, nationally binding way to opt out \u2014 or to ensure a later \u201cno\u201d overrides an earlier \u201cyes\u201d in a different state.<\/p>\n
This gap, along with a range of other issues related to the organ procurement system, has become a point of bipartisan congressional concern. Late last year, the House Ways and Means subcommittee on oversight held a hearing<\/a> examining what members described as shortcomings, including alleged consent failures.<\/p>\n The panel\u2019s scrutiny of organ procurement organizations, or OPOs, and their consent practices is a first step toward a more meaningful accountability plan that could help maintain trust across the system, according to some committee staff members.<\/p>\n The trust in our organ procurement and transplant system \u201chas been eroded,\u201d said Rep. Terri Sewell of Alabama, the panel\u2019s senior Democrat, calling for stronger transparency and oversight to rebuild public confidence.<\/p>\n \u201cRespect for autonomy \u2014 our ability to make our own decisions (self-determination) \u2014 allows for both \u2018yes\u2019 and \u2018no\u2019 decisions and for changing one\u2019s mind,\u201d Margaret McLean, a bioethicist at Santa Clara University, said in an email.<\/p>\n \u201cMedical decision-making is not well served in a context of ambiguity,\u201d she said.<\/p>\n And if a donor revokes consent, she added, \u201crevocation by that person should carry the same ethical and procedural weight as the initial authorization, perhaps more.\u201d<\/p>\n Raven Kinser Changed Her Mind<\/strong><\/p>\n Raven was 25 when she died. Her parents, Jeff and Jaime Kinser, were at home in Michigan when they received the phone call that shattered their world. They drove through the night to the Newport News hospital, where they learned Raven\u2019s disposition had been referred to LifeNet Health, the region\u2019s federally designated OPO. LifeNet is rated<\/a> a failing OPO by the Centers for Medicare & Medicaid Services, meaning it doesn\u2019t meet the government\u2019s standards for how well it finds donors and recovers usable organs for transplant compared with other organizations.<\/p>\n Under federal law, hospitals are required to refer deaths and imminent deaths to OPOs, which take responsibility for donation-related decisions and discussions.<\/p>\n OPOs occupy a hybrid position in the health care system, as private nonprofit entities that hold exclusive, federally authorized contracts to recover organs within defined regions. They are regulated by CMS and overseen by the Health Resources and Services Administration, but that oversight occurs primarily through certification standards, performance metrics, and periodic audits rather than routine public disclosure requirements. With donor registries largely managed at the state level and no unified federal reporting requirement for removals, comprehensive national data on revocations is elusive.<\/p>\n OPOs are meant to separate bedside care from organ procurement decisions \u2014 to help prevent conflicts of interest and preserve the trust that decisions about life-sustaining treatment are made solely in the dying patient\u2019s interest. But the policy can be fraught<\/a>, leaving families unsure who is in control if and when conflicts arise.<\/p>\n The Kinsers, for instance, felt their daughter would not have wanted to go through the donation process, but, at the time, had no evidence. Jaime remembers telling her husband that Raven would have been mad at them for letting it happen. In an effort to stop it, Jaime inquired about whether she would be asked to sign a consent form. But a LifeNet staff member told her that wasn\u2019t an option because donation was Raven\u2019s \u201cliving will,\u201d Jaime said. Meanwhile, Raven\u2019s parents said, her personal effects, including her Virginia driver\u2019s license, which bore no donor designation, had not yet been turned over to the family, leaving them no meaningful way to challenge LifeNet\u2019s determination in real time.<\/p>\n Jaime struggled with this outcome, even mentioning in Raven\u2019s obituary that she was an organ donor. \u201cHow would you try to make peace with something that you felt was so wrong but had no proof?\u201d Jamie said.<\/p>\n Two months passed before the Kinsers gained possession of the license, which, as they had expected, showed that Raven had not opted to be an organ donor.<\/p>\n According to the Kinsers, LifeNet staff told them that Raven\u2019s status as a registered donor was established by her designation on her older Michigan license.<\/p>\n An emailed statement attributed to Douglas Wilson, LifeNet executive vice president, said the OPO follows federal law on organ donation, the Uniform Anatomical Gift Act<\/a>, and queries applicable state donor registries, relying on time stamps and governing law to determine the most recent<\/a>, legally valid expression of intent. Under that framework, a prior donor authorization remains enforceable unless a valid revocation is recorded in the regional OPO\u2019s donor registry.<\/p>\n Because of privacy laws, Wilson said, LifeNet could not comment on the specifics of any individual case.<\/p>\n Raven Kinser\u2019s choice not to be a donor when she applied for a Virginia license in July 2024 was not reflected in the registry LifeNet consulted, according to her parents, who said that is what the organization told them. According to Lara Malbon, executive director of Donate Life Virginia, which manages the state\u2019s organ donor registry, if someone changes their donor status while completing a Virginia driver\u2019s license or ID transaction, \u201cthat information is sent to our registry, and the registry is updated daily to reflect those changes.\u201d Malbon also said Virginia\u2019s registry includes only people who have \u201caffirmatively said \u2018yes\u2019 to becoming an organ, eye, and tissue donor, and it retains records solely for those who have made that decision.\u201d<\/p>\n The Kinsers said they were never told why Raven\u2019s Virginia DMV record was insufficient, or how an older yes from Michigan could outweigh a newer no in Virginia.<\/p>\n In December, the Kinsers filed a complaint with the Health Resources and Services Administration, urging federal regulators to investigate LifeNet\u2019s actions and require OPOs to provide families with documented proof of the donor\u2019s current status at the time of referral. They also called for OPOs, which operate as federally designated regional monopolies but are structured as private nonprofits, to be made subject to public records laws.<\/p>\n When Opting Out Doesn\u2019t Stick<\/strong><\/p>\n Such confusion is not unique to the Kinser family. It is a consequence of the organ donation consent process in the United States.<\/p>\n \u201cI have also wondered that: why there\u2019s not just one\u201d registry for organ donation, Jaime said. \u201cIf you go to get a firearm, you have one federal place.\u201d<\/p>\n Here\u2019s how the system works: Americans typically register their organ donation intentions when they apply for driver\u2019s licenses through state DMVs, and that decision remains governed largely by state law. That has led to 50 different sets of rules and very little federal regulation of what has become an over $5 billion industry<\/a> in the U.S.<\/p>\n In some states, a donor checkbox is a binding legal document. In other states, the same choice may have different rules about when it takes effect, what it covers, and how it can be revoked.<\/p>\n Those differences can be big. State rules determine whether a person\u2019s \u201cgift\u201d is limited to transplantation or also includes research and education. They determine whether the donation authorization includes tissue. And they can determine what counts as a valid revocation and when it is legally recognized.<\/p>\n Because of the system\u2019s fragmentation, though, signals can cross when someone changes their mind, like Raven; it\u2019s not always reflected from one state system to another.<\/p>\n Under state versions of the Uniform Anatomical Gift Act, a donor\u2019s most recent legally valid expression of intent is meant to control.<\/p>\n \u201cPersonal autonomy is paramount to everything,\u201d said Adam Schiavi, a neurointensivist who studies end-of-life decision-making. \u201cIf I say I want to be a donor, or if I say I don\u2019t want to be a donor, that has to take precedence over everything else.\u201d<\/p>\n But states differ in how revocation must be recorded and which registry is considered authoritative if someone has lived in more than one state. Those inconsistencies can create uncertainty when records conflict across jurisdictions.<\/p>\n \u201cIt has to be the most recent expression, not the most recent yes,\u201d Schiavi said.<\/p>\n In Michigan, a change to someone\u2019s donor status is reflected immediately in the secretary of state\u2019s system, but only affirmative \u201cyes\u201d registrations appear in the registry. Removal information remains in internal motor vehicle records. In Virginia, the state registry includes only those who have affirmatively said \u201cyes,\u201d retaining records solely of donors, creating potential gaps if someone believes a DMV change alone is sufficient.<\/p>\n Elsewhere, processes and volumes differ sharply. New Mexico updates driver records in real time but does not transmit status changes to its donor registry. Instead, donor services receive restricted search access. The state logged nearly 15,000 removals in late 2021 and almost 30,000 in 2022. Florida, which maintains formal removal records through weekly DMV data files, reported 356,161 removals in 2020, more than 1.5 million in 2023, and over 1.2 million in 2025. Kentucky processed 847,371 donor registrations from 2020 to 2025, but only 16,043 icon removals, with registry withdrawal handled separately. In 2025, more than 570,000 Texans opted into the registry, while over 31,000 individuals requested removal.<\/p>\n According to a federal official who asked not to be identified for fear of professional repercussions, OPOs have been highly effective at lobbying states to broaden the definition of consent and authorization \u2014 shaping how those terms are applied, whether those statuses must be renewed, and how easy or difficult it is for someone to opt out.<\/p>\n In subsequent correspondence with federal officials, the Kinsers have urged reforms to prevent OPOs from relying on older registry entries when a more recent state DMV record exists, and they have called for criminal penalties in cases in which consent is knowingly misrepresented. Federal regulators have not indicated whether such proposals are under consideration.<\/p>\n Congress Takes a Closer Look<\/strong><\/p>\n Ethicists have long cautioned that consent must be more than a checkbox and must remain grounded in respect for the donor-patient. In an October position paper<\/a> on organ transplantation, the American College of Physicians emphasized that clinicians\u2019 primary duty is to the patient in their care, and that maintaining trust requires transparency and safeguards to prevent conflicts of interest from blurring that \u201cbright line.\u201d<\/p>\n Advocates say those steps leave unresolved the core problem raised by the Kinser family: the lack of a clear, legally binding way for people to say \u201cno\u201d and for that decision to follow them across state lines.<\/p>\n The Association of Organ Procurement Organizations<\/a> said it \u201csupports strengthening donor registries and enhancing registry interoperability to ensure that an individual\u2019s documented donation decision is honored.\u201d But OPOs have also argued that current policies protect donation as a legally enforceable gift and prevent families from overriding a loved one\u2019s \u201cyes\u201d in the midst of grief. They argue that stronger, more durable consent helps reduce missed donations and saves lives.<\/p>\n Congress and federal regulators are considering changes to the nation\u2019s organ donation system, including how consent is recorded and what should happen when a donor changes their mind.<\/p>\n Sen. Ron Wyden (D-Ore.) proposed legislation<\/a> last year to create new federal standards for patient safety, transparency, and oversight of organ transplants, including a formal authorization for hospital or OPO staff to pause harvesting if there is any \u201cclinical sign of life.\u201d<\/p>\n HHS press secretary Emily Hilliard said the agency is \u201ccommitted to holding organ procurement organizations accountable\u201d and to \u201crestoring integrity and transparency\u201d to organ donation policy, calling reforms essential to informed consent and protecting donor rights. CMS issued related new guidance<\/a> March 11, but it does not address the problems highlighted by the Kinsers\u2019 case.<\/p>\n Critics of the organ transplant system say it is difficult for families to obtain documentation or independently verify how consent determinations were made in disputed cases.<\/p>\n HRSA has launched a sweeping modernization of the Organ Procurement and Transplantation Network, the national system that oversees organ allocation and transplant policy. Federal officials have described the overhaul as the most significant restructuring of the transplant system in decades, aimed at breaking up a long-standing contractor monopoly, strengthening patient safety oversight, and replacing aging technology infrastructure.<\/p>\n Central to that effort is modernizing the OPTN\u2019s data systems: improving interoperability, audit trails, and transparency in how decisions are documented and reviewed. A more modern federal data architecture could make it easier to trace which registry was queried, what time stamp controlled, and how a consent determination was reached in disputed donations that span multiple states. But the modernization effort would not change the underlying state-by-state legal framework for donor authorization and what counts as a valid \u201cno.\u201d<\/p>\n Meanwhile, Donate Life America, a national nonprofit that supports state donor registries, also runs the National Donate Life Registry<\/a>, a central database that allows people to sign up as organ donors directly. Unlike many DMV systems, the national registry lets people log in at any time to view, update, or remove their registration and print proof of their decision. The group is also starting a project to let participating states send registrations directly into the national system, creating one place to track donor sign-ups and removals across state lines.<\/p>\n Each of the proposals comes with trade-offs, and both advocates and OPOs have raised concerns about how they would work in practice.<\/p>\n \u201cJust doing a dump truck dump of information is not going to do much unless you really apply it through checking and auditing,\u201d said Arthur Caplan, a professor of bioethics at New York University\u2019s Grossman School of Medicine. \u201cIt could be like the IRS. They don\u2019t have to audit everybody. Just do a spot audit once in a while.\u201d<\/p>\n The Kinsers aren\u2019t opposed to organ donation itself. They celebrated Raven\u2019s donation in her obituary, and in their complaint to federal regulators, they wrote, \u201cWe are NOT anti-organ donation, and we will never take away the gift of life our oldest daughter gave to others. However, that was not LifeNet\u2019s choice to make.\u201d<\/p>\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/p>\nUSE OUR CONTENT<\/h3>\n