Recent news coverage about problems with the U.S. organ transplant system failed to mention the coroner’s role in organ donation. That’s surprising because most donated organs come from deceased donors.
There were almost 17,000 such donors in 2024.
Almost 70% of those donors died of non-natural causes such as motor vehicle accidents, drug overdoses, or head injuries. Such deaths always fall under the jurisdiction of a coroner or medical examiner (C/ME). That’s why hospital personnel must inform the C/ME of any planned deceased organ donation.
Let’s start with a quick overview of our complex organ and tissue donation system.
What laws and agencies govern organ donation?
The United States has fifty-five organ procurement organizations (OPOs), each covering a specific region of the country. The OPOs use a proprietary computer system run by UNOS, a not-for-profit organization that contracts with the federal government to match and place donated organs.
Why is the Department of Health and Human Services (HHS) looking into the reform of OPOs? Because OPOs are certified by Centers for Medicare & Medicaid Services (CMS), an agency within HHS. Another HHS agency, HRSA, oversees UNOS.
Bottom line, the entire organ donation and transplantation system is under the purview of the Secretary of HHS. That’s obvious in this alarmist and politically-tinged July 21, 2025 HHS press release.
State laws may vary slightly, but most fall in line with the 2006 revised Uniform Anatomical Gift Act (UAGA). As a result, the general process of organ donation is similar across the country.
The two categories of deceased organ donors
Donation after brain death
More than 80% of deceased organ and tissue donations take place after brain death. The medical criteria for brain death, also known as death by neurological criteria, are well-defined.
Donation after circulatory death (DCD)
In 2024, about 16% of deceased organ donors fell into this category. Briefly, DCD is when the patient’s doctor(s) makes the determination “that continued life-sustaining support of circulatory and lung function for this patient is futile, is not in the patient’s best interest, and should be withdrawn.”
Donation after circulatory death cases are the ones that have been in the news. Donation after circulatory death is time-sensitive, emotionally-fraught, and complex.
In DCD cases, the OPO may ask the C/ME or a forensic pathologist to make urgent decisions about whether or not organ procurement may proceed. The C/ME may have minimal information because the patient IS NOT YET DEAD and therefore not yet a coroner’s case.
What’s the coroner’s role in approving organ donation?
The C/ME is notified of all planned organ donations by the hospital. The first thing the C/ME must do in all cases is to determine whether or not the death falls under his or her jurisdiction. If it does, the C/ME then determines what they need to determine the cause and manner of death.
Useful Guides
The American Association of Tissue Banks and the Eye Bank Association of America publish a fantastic training and education guide to C/ME deceased donor cases. It offers “examples of beneficial practices and case studies that illustrate how such practices have been successfully utilized in tissue and eye donation cases under death investigator jurisdiction.”
The National Association of Medical Examiners issued a 2007 position paper on deceased organ procurement. It states “that the procurement of organs and/or tissues for transplantation can be accomplished in virtually all cases, without detriment to evidence collection, postmortem examination, determination of cause and manner of death, or the conducting of criminal or civil legal proceedings.”
Thanks to Kelly Keyes, Chair of the Board of Directors at the International Association of Coroners and Medical Examiners (IACME), for informing me of a recently published standard about C/ME collaboration with OPOs. Although the linked document is marked DRAFT, Kelly noted it’s now final. Its detailed content should help guide C/MEs who are developing agreements or memoranda of understanding with OPOs, regardless of location within the United States.
Can organ donation proceed in homicide or suspicious death cases?
C/MEs have almost universal authority to deny an organ or tissue recovery for medicolegal reasons. However, that is becoming an increasingly rare occurrence. OPOs can provide blood samples, CT scans, organ pathology reports, and other information to the C/ME.
Coroners can also approve or deny retrieval of specific tissues or organs. The coroner can also specify that OPOs can remove organs only “for transplantation.” In those cases, healthy organs will go for transplant, while the coroner will have access to the diseased or damaged organs at autopsy.
The Case of Pennsylvania
I’m highlighting Pennsylvania because that’s where I live and where I was a coroner. PLEASE feel free to share your experience in the COMMENTS!
Pennsylvania amended its organ donation law in 2018 to become the 48th state to adopt the Uniform Anatomical Gift Act. Afterwards, I collaborated with my regional OPO to develop this Standard Operating Procedure (SOP) for my Coroner’s Office. It’s free to download and customize as needed for other jurisdictions.
Tissue donation (especially corneas, bone, and skin) is much more common than organ donation. In 2023, for example, the Chester County Coroner’s Office approved organ donation by seven donors and tissue donation by eighty-eight donors.
Experience with organ donation after circulatory death varies. In rural Lycoming County, PA, population 113,000, long-time Coroner Chuck Kiessling has never had a DCD case. In suburban Chester County, population c. 525,000, I had two such cases in four years.
Conclusions
Politicians and the Secretary of HHS have sensationalized recent news about “near-fatal” errors at one OPO in Kentucky. UNOS and OPOs have already implemented changes that further minimize previously low risks. There is no reason to opt-out of being an organ donor.
Coroners and medical examiners play a crucial role in organ donation. While the process of deceased organ donation is similar across the country, variations of practice do exist between jurisdictions.
Overall, the trend is for collaboration between C/MEs and OPOs. The goal of this collaboration is to maximize life-saving organ donation while ensuring complete and accurate death investigations.
Updated August 9, 2025, to include reference suggested by K. Keyes.