How does organ donation and transplantation work legally in India?

Living donation in India is governed by the Transplantation of Human Organs and Tissues Act (THOTA), 1994 and its 2011 amendment. The Act splits donors into two tracks: near-relative and other-person.

Near relatives — spouse, son, daughter, father, mother, brother, sister, grandfather, grandmother, grandson, granddaughter — go through the Hospital Authorisation Committee, which verifies identity, relationship, voluntary consent, medical fitness and absence of coercion. 'Other persons' (non-relatives with a close emotional bond) go to the State Authorisation Committee with documentary proof of relationship (photos, communications, joint events), affidavits from donor and recipient, and often an investigation — the rejection rate is higher, deliberately, to prevent commercial exchange.

The 2011 amendment recognises swap / paired exchange donation — two donor-recipient pairs where each intended donor is incompatible with the intended recipient donate across, subject to State Authorisation Committee approval. Living donation criteria: adult (18+), medically fit, voluntary, informed consent, and free of prior coercion or financial inducement. Foreign nationals can donate to Indian relatives with embassy verification, State Authorisation Committee approval and visa handling. Minors are generally not allowed (with bone marrow and blood exceptions), mentally incapable persons cannot donate, and prisoners need special permission.

Donateable organs and tissues from living donors: kidney (one of two), partial liver lobe, partial pancreas, partial intestine, partial lung lobe, bone marrow, blood, skin and bone. The procedure runs: approach the transplant hospital, medical and psychological evaluation of donor and recipient, Hospital Authorisation Committee meeting, application with documents, verification, approval (4-12 weeks), surgery and post-op care. All donor expenses are borne by the recipient; total transplant and lifetime immunosuppressants typically cost ₹3-25 lakh.

Deceased donation runs on the certification of brain death under Section 3 THOTA. Four doctors — the treating doctor, an authorised specialist, a neurologist or neurosurgeon, and a doctor nominated by government — perform two examinations separated by six hours, including specific clinical tests and an apnoea test, with all criteria met.

Once brain death is certified, a Transplant Coordinator approaches the family with sensitivity, shares any prior donation pledge, and obtains family consent — in practice family consent is obtained even where a pledge exists. Organ retrieval covers heart, lungs, liver, kidneys, pancreas and intestine, along with tissues like corneas, skin, bone and heart valves. Retrieval is time-critical because of cold ischaemia limits.

Matching and allocation run through the NOTTO national waiting list, using blood-type compatibility, tissue typing (HLA matching), urgency, geographic priority (intra-state first, then national), and child prioritisation, decided algorithmically. Transport uses green corridors with police escort by ambulance or flight — significant infrastructure is mobilised for each donation. The recipient hospital is notified, the surgical team is ready, and the donor's body is restored to a dignified appearance before return to the family for funeral.

Documentation covers the death certificate, donation records and chain of custody. Bereavement counselling supports the family. India's donation rate remains low — roughly 0.5 per million against Spain's ~46 per million — with Tamil Nadu, Telangana and Kerala running the strongest state programmes. Awareness campaigns are ongoing.

Authorisation runs on two tracks depending on donor type. The Hospital Authorisation Committee handles near-relative donations, constituted by the hospital and drawn from the medical superintendent, surgeon and physician. It verifies donor identity, relationship proof, voluntary consent, medical fitness, and absence of coercion or inducement, and records its decision in writing. Timeline: 2-6 weeks.

The State Authorisation Committee, constituted by the State Government, handles non-near-relative donations. Its members — an experienced surgeon, physician, social worker and government representative — apply stricter scrutiny including affidavits, photographs, evidence of the bond, a joint interview of donor and recipient, and often an investigation. Timeline: 4-12 weeks.

Application documents: donor and recipient identity proof, relationship proof, medical reports, affidavits, photographs together, family tree (for relatives), source of funds (recipient affordability), and the hospital's recommendation. Verification proceeds through inquiry, background check, interview and document examination.

Common rejection grounds: insufficient evidence of relationship or bond, suspected commercial transaction, donor economic vulnerability suggesting inducement, multiple donors or recipients suggesting brokers, medical contraindications, or procedural issues. Appeal lies to the Appellate Authority within 30 days, and thereafter by writ to the High Court.

Swap donation requires evaluation of all four parties and examination of the relationship within each pair, with State Authorisation approval. Foreign donors and recipients face embassy verification, visa handling, State Authorisation approval and additional scrutiny. The approval process itself is free at committee level; hospital-related charges are separate.

Commercial dealings in organs are strictly prohibited under Section 19 THOTA — paying or receiving payment for an organ, arranging sale, soliciting or advertising, or acting as middleman all fall within the offence. Penalty: 5-10 years imprisonment plus a fine of ₹20 lakh to ₹1 crore. Hospitals and doctors are equally liable, facing hospital licence cancellation, medical practitioner registration cancellation and civil damages. Several illegal kidney rackets have been exposed in India, with international trafficking networks exploiting vulnerable poor donors — enforcement has been aggressive post-2008.

Committees look for indicators of commercial transaction: an economically vulnerable donor, recent contact between donor and recipient, unrealistic relationship claims, multiple donors or recipients with a common broker, payment trails, foreign recipient exploiting Indian poor, and documentation inconsistencies. Illegal activity can be reported through the NOTTO grievance mechanism, local police, the medical council, hospital authority, or NGOs like MOHAN Foundation and ORBO.

The anti-trafficking framework layers Section 143 BNS (trafficking), the Immoral Traffic (Prevention) Act, and cross-border investigations onto THOTA. Donor protection requires voluntary consent, pre-donation counselling, the right to withdraw consent any time before surgery, and post-operative care obligations on the recipient and hospital. Recipient screening tests capacity to pay legitimate medical expenses, and questions source of funds when suspicious. The State Authorisation Committee is the critical gatekeeper for non-relative donations.

Recent enforcement has produced multiple FIRs against hospitals, doctors and brokers, high-profile arrests, and cancellation of hospital transplant licences. India is a signatory to the Declaration of Istanbul (against transplant tourism) and the WHO guiding principles. Foreign patients can seek legitimate medical tourism with proper authorisation, but trafficking masked as medical tourism is strictly prohibited and receives State Authorisation Committee scrutiny. Whistleblower tipoffs receive identity protection.

Pledging donation is straightforward. Register online at notto.abdm.gov.in using Aadhaar, mobile and email, specify the organs and tissues you wish to donate, inform your family (essential — see below), download the donor card, and link it to your ABHA (Ayushman Bharat Health Account). Registration is free, voluntary and withdrawable any time. In practice the family makes the final decision at the time of death — your pledge guides them but family consent is required, so communicate your wishes clearly while alive. The NOTTO database, donor card and ABHA integration all allow the treating hospital to verify a pledge.

Body donation for medical education is separate — register with medical colleges (AIIMS, JIPMER, state medical colleges). Tissue donation (corneas, skin, bone, heart valves) has separate consent procedures.

Religious perspectives are largely supportive. Hinduism treats donation as sacred duty (Dana), backed by religious authorities and Bhagavad Gita references. Islam permits donation under necessity (Darura), supported by the Islamic Fiqh Academy of India, with Saudi Arabia and Iran allowing it. Christianity generally supports donation as an act of love; Sikhism encourages it as sewa; Buddhism and Jainism support it as compassion or selflessness. Zoroastrianism / Parsi practice is complex due to specific funeral customs.

Common myths — donation affects funeral, doctors won't try to save you, older donors aren't useful, the family will be charged, the body will be disfigured — are all false: the body is restored to dignified appearance, retrieval and transplant teams are separate, any age can donate something, there is no cost to the donor family, and there is no visible disfigurement. Awareness campaigns run around National Organ Donation Day (27 November) and Indian / World Organ Donation Day (13 August), with NGOs like MOHAN Foundation, ORBO and Gift of Life Foundation active. Roughly 5 lakh Indians wait for organs each year against only ~3,000 transplants — the demand-supply gap is huge and awareness matters.

State initiatives worth noting: Tamil Nadu's Cadaver Transplant Programme, Telangana's Jeevandan, Kerala's KNOS and Karnataka's Jeevasarthakathe. Specific situations: suicide or homicide victims may face autopsy delays and magisterial permission requirements; accident victims are common deceased donors; COVID-recovered cases are assessed medically case-by-case; brain death post natural causes is the most common scenario. Resources: NOTTO 1800-11-4770 and MOHAN Foundation 044-26203570.