Part 3 in a four-part series
Maybe you've agreed to be an organ donor. There might be something on your driver's license — a red heart, a pink dot or the word "Donor" — to show it. That also means you've very likely agreed — even if you don't realize it — to donate more than just your organs.
I know that I'm an organ donor. I signed up years ago, when I renewed my driver's license. But I had no idea that I'd also signed up to donate my tissue. That is, until Laura Siminoff, a professor at Virginia Commonwealth University's medical school, explained it to me.
Siminoff studies why people choose — or don't choose — to become organ and tissue donors. Looking at my driver's license, she notes the red heart in the upper left-hand corner. "It means you're a donor," she says. "And it means you're a tissue and an organ donor."
When I signed up, I knew about organ donation. Living organs are things like my heart, lungs and kidneys. Tissue is not nearly as well-known — certainly not to me.
Tissue includes tendons, ligaments, skin, bones, heart valves, corneas. They're taken from a cadaver, and unlike organs, they don't go straight from the donor to a recipient. Tissue is recovered, sterilized and turned into scores of medical products.
Veins are used in heart bypass operations. Bone is used in spinal fusion surgery or builds up the jaw around a dental implant. A tendon from a cadaver can repair someone else's torn knee ligament.
Lucinda Babers, the director of the D.C. Department of Motor Vehicles, explains that in Washington — and this is the way it works in almost every state — when you obtain a driver's license, or renew it, you're given a choice to donate or not donate. The box to check says: "I want to donate my organs and tissue."
Every state now has laws that make that decision to donate a legally binding one.
"All 50 states have passed legislation authorizing recovery agencies to honor a registered donor's decision to make an anatomical gift," says Aisha Michel of Donate Life America, the group that helps states develop their donor registries.
To help me understand why every state has such laws, Alta Charo, a professor of law and bioethics at the University of Wisconsin, gave me a history lesson.
"In Colonial times, in the United States, the body was not seen as being the property of anybody," she explains. "It was the subject of civil authority. For example, issues around burial were entirely up to civil authorities."
A dead body was a problem — something that local authorities needed to dispose of safely and cleanly.
It wasn't something with monetary or even personal value. "It wouldn't matter which way we thought of it," Charo says, "until we got to a point that pieces of this body could be useful to other folks."
That started happening in the late 1800s. American medical schools began needing human bodies for teaching. That gave grave robbers incentive to steal corpses.
Then, in 1905, surgeons completed the first cornea transplants.
Notes Charo: "Now the question was: Who has the authority to decide whether those pieces of the body, whether it's whole organs or individual tissues, can be given away, can be taken without permission?"
Courts have struggled with that ever since.
I like the idea of donating my organs. They might save someone else's life. And I like that donated tissue can better someone else's life, possibly with a bypass operation or an ACL repair.
But sometimes donated tissue is used for someone's elective plastic surgery, like a penis enlargement procedure.
I ask Charo if she would be OK with her tissue being used to plump up some Hollywood starlet's lips.
"Well, I think it's a waste of perfectly good tissue," she says, "but I've got plenty of it. And, you know, bless her, she'll have great-looking lips. Or, actually, in some cases, from the pictures I've seen, really silly-looking lips."
But some people do have a problem with that, so all but 11 states allow donors to choose more than just "I'll donate" or "I won't donate."
Siminoff explains that after you sign up at the DMV, you can then make more specific choices — or restrictions — by going to a state registry's website.
Each state is different. But as a resident of Washington, D.C., I can make choices for nearly 20 organs and tissues.
Then there's California, which, when it comes to making choices, offers more than most other states. There, residents can limit what tissue they donate — and how it is used.
"Then here's the other limitation," says Siminoff, reading from the Donate Life California website. "'My gift of skin may be used for lifesaving and reconstructive purposes only," she reads, "which means no cosmetic purposes — no plumped lips," she says of the state that's often known for Hollywood and its use of cosmetic surgery.
Siminoff says the only way to truly protect your choice is to make sure your family knows your wishes. If a tissue bank calls to ask for a body, and a family member hesitates, the tissue bank will most likely back off, even if someone has checked the box at the DMV to give formal, legal permission.
There are now more than 101 million Americans who have signed up to be organ and tissue donors.
NPR's Sandra Bartlett and Barbara Van Woerkom contributed to this story. This series was co-reported with the International Consortium of Investigative Journalists, a project of the Center for Public Integrity.