ROBERT SIEGEL, HOST:

From NPR News, this is ALL THINGS CONSIDERED. I'm Robert Siegel.

AUDIE CORNISH, HOST:

And I'm Audie Cornish. We've been looking this week at the billion-dollar business of human tissue donation. It starts when someone - maybe you - agrees to be an organ donor. There might be something on your driver's license - maybe a red heart, a pink dot, or the word "donor" - to prove it. And that means you've also likely agreed, even if you don't realize it, to donate more than your organs. NPR correspondent Joseph Shapiro explains.

JOSEPH SHAPIRO, BYLINE: 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, until Laura Siminoff explained it, that I'd also signed up to donate my tissue.

LAURA SIMINOFF: Mm-hmm.

SHAPIRO: So I pulled out my driver's license.

SIMINOFF: OK.

SHAPIRO: This is my Washington, D.C., driver's license.

SIMINOFF: Mm-hmm.

SHAPIRO: Siminoff studies why people choose, or don't choose, to become organ and tissue donors. She's a professor at Virginia Commonwealth University, at the medical school. She takes my driver's license, and sees the red heart in the upper left-hand corner.

So am I a tissue donor?

SIMINOFF: Yeah, you should be - because you have a heart - unless there's some stipulations.

SHAPIRO: So this heart, this says - this is my...

SIMINOFF: It just means you're - it means you're a donor. It means you're a tissue and an organ donor.

SHAPIRO: When I signed up, I knew about organ donation. That'd be living organs - things like my heart, lungs, kidneys. Tissue is not nearly as well-known - certainly, it wasn't 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 ACL.

An official at the Department of Motor Vehicles where I live explained that - and this is the way it works in almost every state - when you get your driver's license or renew it, you're given a choice. There's a box to donate, or not donate; and the "yes" box says, I want to donate my organs and tissue.

Every state now has laws that make that decision to donate, a legally binding one. To understand why, I got a history lesson from Alta Charo. She's a professor of law and bioethics at the University of Wisconsin.

ALTA CHARO: In colonial times in the United States, the body was not seen as being the property of anybody. It was the subject of civil authority. For example, issues around burial were entirely up to civil authorities.

SHAPIRO: 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.

CHARO: It wouldn't matter which way we thought of it - until we got to a point where pieces of this body could be useful to other folks.

SHAPIRO: And that starts to happen 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 do the first cornea transplants.

CHARO: And 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?

SHAPIRO: 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 the fact that donated tissue can better someone else's life - that bypass operation, or the ACL repair. But sometimes, donated tissue - that'd be skin - goes for someone else's elective plastic surgery, like penis enlargement surgery. I asked Alta Charo about helping someone else's cosmetic surgery.

So are you OK if your tissue goes to plump up some Hollywood starlet's lips?

CHARO: Well, I think it's a waste of perfectly good tissue, 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.

SHAPIRO: But some people do have a problem with that. So all but 11 states let donors make more choices than just, I'll donate or not donate.

SIMINOFF: OK. Let's...

SHAPIRO: Laura Siminoff, the professor who studies why people donate or not, explains that after you sign up at the DMV, you can then make more specific choices - or restrictions - by going to a state registry online.

SIMINOFF: OK. Your whole eyes...

SHAPIRO: All right.

SIMINOFF: Your heart valves and vessels...

SHAPIRO: Yes.

SIMINOFF: OK.

SHAPIRO: Each state is different. But as a resident of Washington, D.C., I can make choices for nearly 20 organs and tissues.

SIMINOFF: So now we see what some of the problems with the website - is your pericardium. How many people know what the pericardium is, right? That's the tissue around your heart.

SHAPIRO: Mm-hmm.

SIMINOFF: Do you want to donate that?

SHAPIRO: Then there's one state that, when it comes to choice, seems way ahead.

So this is California?

SIMINOFF: This is California. See, it's different.

SHAPIRO: On California's website, you can limit what tissue you donate, and how it gets used.

SIMINOFF: And then there's - here's the other limitation: "My gift of skin may be used for life-saving and reconstructive purposes only."

SHAPIRO: Which means?

SIMINOFF: Which means no cosmetic purposes - no plumped lips.

SHAPIRO: And that's in California, the land of...

SIMINOFF: Right.

SHAPIRO: ...the land of the plumped-up lips.

SIMINOFF: Yes, absolutely.

SHAPIRO: Siminoff says the only way to truly protect your choice, is to make sure your family knows your wishes because if the tissue bank calls to ask for a body and a family member hesitates, the tissue bank will probably back off. There are now more than 101 million Americans who have signed up to be organ and tissue donors.

Joseph Shapiro, NPR News.

CORNISH: This project was reported with help from the International Consortium of Investigative Journalists. To see what choices your state offers for organ and tissue donation, go to NPR.org.

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