Organ donation: decide for yourself, either way

At the end of 2025, 8,199 people in Germany were waiting for a donor organ. Whether someone donates organs after death is usually settled not at a desk but in intensive care, often by relatives who are losing someone. This article explains how donation works in Germany, who can donate and what the Bundestag is debating. A clearly marked section gives my personal opinion. Disclosure: I am a transplant surgeon and chair the Eurotransplant Council of Medicine and Science. I write here in a private capacity.

The situation in Germany

According to the German Organ Transplantation Foundation (DSO), 3,020 organs were donated after death in 2025. Even so, Germany ranks low internationally. In the Council of Europe’s figures for 2023, deceased donors per million population were 49.4 in Spain, 32.7 in Belgium, 27.6 in France, 22.7 in Switzerland, 20.9 in Austria and 17.3 in the Netherlands, against 11.6 in Germany. Within Eurotransplant, the network through which eight countries share organs, Germany is a net importer.

How deceased donation works in Germany

In Germany, organs may be removed from a deceased person only after the “final, irreversible loss of the entire function of the cerebrum, cerebellum and brainstem” has been established (Section 3 of the Transplantation Act, TPG). The medical term is irreversible loss of brain function; the everyday term is brain death. It accounts for only a few per cent of deaths and can be diagnosed only in intensive care.

A guideline of the German Medical Association (Bundesärztekammer), currently its fifth revision from 2022, sets out how the diagnosis is made. Two experienced specialists, at least one of them a neurologist or neurosurgeon, must establish it independently of each other. Neither may take part in organ retrieval or transplantation.

The DSO is the legally mandated coordinating body: it organises donation together with around 1,250 donor hospitals. Under current law, the so-called decision model (Entscheidungslösung), the person’s own declaration comes first. If there is none, the next of kin are asked whether they know of one. If they do not, retrieval is allowed only with their consent, and they must be guided by what the deceased would presumably have wanted.

“Too old or too ill”: a common misconception

Many people assume they are unsuitable and therefore never decide. But there is no upper age limit. Whether an organ is suitable is assessed individually at the time of death, by the organ’s condition rather than the year of birth. In 2025 the median age of donors in Germany was 59. The oldest donor that year was 91; the liver was donated. The oldest donor recorded in Germany so far was a 98-year-old woman. In Spain, almost a third of donors in 2025 were over 70.

Since 1999 there has even been a dedicated scheme, the Eurotransplant Senior Program (ESP): kidneys from donors aged 65 or over go preferentially, and regionally, to recipients aged 65 or over. Evaluations showed shorter waiting times without worse patient or graft survival.

Pre-existing illness rarely rules people out. According to the German Federal Institute for Public Health (BIÖG, formerly BZgA), most people can donate even with chronic diseases. There are only a few exclusions, such as active cancer, unexplained or highly contagious infections, or severe sepsis (blood poisoning). Cancer that was successfully treated in the past does not usually prevent donation. So the question of donation arises regardless of age or health.

Donation after circulatory death: what other countries do differently

Many European countries also use a second route: donation after circulatory death (DCD). Here death is determined by the permanent cessation of circulation rather than by loss of brain function. The Maastricht classification distinguishes uncontrolled DCD, for example after failed resuscitation, from controlled DCD (category III), which is the focus here.

How controlled DCD works

1. A patient in intensive care has catastrophic damage with no prospect of recovery, often to the brain, but does not meet all the criteria for brain death.
2. The treating team decides to withdraw life-sustaining treatment because it can no longer help the patient. This decision is made independently of any possible donation; only afterwards is it established whether donation would reflect the patient’s wishes.
3. Treatment is withdrawn. After circulation stops, a mandatory waiting period follows in which nobody touches the body (the “no-touch” period). It is five minutes in the UK, the Netherlands, Spain, Belgium and France, and by law at least 20 minutes in Italy.
4. Death is then declared and the organs are retrieved. Often a heart-lung machine first restores blood flow to the abdominal organs (normothermic regional perfusion), while a balloon in the aorta prevents blood from reaching the brain again.

A study of 631 dying patients in three countries tested whether five minutes is enough: in 14%, heart activity briefly resumed after it had stopped, at the latest after 4 minutes 20 seconds. All died; the authors considered the five-minute rule supported.

In 2023, DCD accounted for 63% of all deceased donors in the Netherlands, 55% in Belgium, 50% in the UK, 48% in Switzerland, 45% in Spain and 13% in Austria. Spain reported 56% for 2025.

DCD is not permitted in Germany, because the TPG requires irreversible loss of brain function to be established before any retrieval. In 2015 the German Ethics Council recommended keeping brain death as the prerequisite. More voices are now calling for controlled DCD, among them the German Transplantation Society (2024), the German association of transplant recipients (BDO, January 2026) and a working group of the German intensive care society DIVI (September 2026). Nothing has been decided so far.

The political debate

In January 2020 the Bundestag rejected an opt-out system and instead passed the Act to Strengthen Decision-Making on Organ Donation. It came into force in March 2022 and brought more information, counselling in GP practices and an online register.

On 24 September 2026 the Bundestag held a first reading of three proposals and referred all of them to its health committee:

• Cross-party group bill (printed paper 21/7570), backed by 254 MPs from CDU/CSU, SPD, Greens and Left. Anyone who consented or did not expressly object would be a potential donor; an objection must be reliably retrievable at any time. Relatives would be asked whether they know of a declaration but would have no right of decision of their own (except for minors). People who had lacked capacity for at least a year before death and left no declaration would be excluded.
• Bill from the Bundesrat, the chamber of the federal states (21/2738): also an opt-out system. Everyone should engage with the question at least once in life, without having to justify their decision.
• Motion by 58 MPs (21/8050). It would keep the decision model. Everyone would be asked shortly after their 18th birthday for their position (yes, no or undecided), with no disadvantage for giving no answer, and registration would be made easier.

Arguments made for opt-out

Supporters point to surveys: 85% of people in Germany view organ donation positively, but only 45% have documented a decision. Without a declaration, relatives must decide on the person’s behalf, which the DSO says weighs heavily on them. An opt-out rule combined with nationwide information could prompt people to engage with the question. Countries with opt-out also tend to have higher donor rates on average, although not every analysis finds the difference statistically robust.

Arguments made against

Critics counter that silence must not be treated as consent, as motion 21/8050 puts it. Bodily self-determination is at stake, they argue, and that includes the freedom not to engage with one’s own death. Some also fear that such a rule could damage trust in transplant medicine and weaken the role of relatives, who often know the person best.

There is also an empirical objection: opt-out alone explains little of the difference between countries.

• Spain introduced an opt-out law as early as 1979, yet its donation rate remained unremarkable for a decade. The rise began only with the national organisation (ONT) built from 1989: transplant coordinators in every donor hospital, systematic training, more intensive care beds. In practice, the family is always asked.
• Wales switched to a “soft” opt-out system in 2015. An evaluation found higher consent rates afterwards, but these rose in the rest of the UK as well. Donor numbers did not increase (101 versus 104 before).
• A comparison of 35 OECD countries (2012–2016) found no statistically significant difference in deceased donors (20.3 versus 15.4 per million), but fewer living donors in opt-out countries.
• An analysis of five countries that switched (Argentina, Chile, Sweden, Uruguay, Wales) found no rise in donation rates.
• A 2009 systematic review found an association with higher donation rates but rated the studies as methodologically limited; infrastructure, causes of death and health spending also mattered.

The data suggest that without well-functioning hospital processes, from identifying potential donors to intensive care capacity, donation barely rises even under opt-out; whether opt-out adds anything beyond that remains open.

My position

This section reflects my personal opinion.

I support the opt-out model (Widerspruchsregelung). Not only because it may increase the number of donors, but above all because I believe people should make a self-determined decision for or against donation during their lifetime, rather than leaving it to their relatives, who must then make it in an extremely difficult situation.

It is objected that people must also have the right not to decide. Yes – but then it is as in inheritance law: if you leave no will, the state provides statutory rules of succession.

I find the German name “Widerspruchslösung” (“objection solution”) unfortunate. In reality, it brings about a decision.

What you can do in practice

• Organ donation register: Since 18 March 2024 you can record your decision online at organspende-register.de. Registration is open from age 16, using the German ID card’s online function or a health insurer’s app. Options are consent (also excluding or limited to certain organs), objection, or handing the decision to a named person. Entries are voluntary, free and can be changed.
• Donor card: The paper card remains valid. On it, too, you can record yes, no or restrictions. In Germany you can object from age 14 and consent from 16.
• Avoid contradictions: Multiple documents should agree; the most recent declaration applies. A will is unsuitable, because it is opened too late.
• Advance directive and donation: An advance directive (Patientenverfügung) that refuses life-prolonging treatment conflicts with a wish to donate, because donation requires intensive care to continue for a limited time. The BIÖG suggests stating explicitly that, should donation be possible, you consent to intensive care as an exception, optionally time-limited (“for no longer than ___ hours”). A refusal can be recorded the same way.
• Talk to your family: Tell your relatives what you have decided and where it is documented. In an emergency, they will be asked first.

This article is general information and not individual medical advice. Decisions about tests and treatment belong in a conversation with your own physician.