No donation procedure can ever be undertaken without the consent of the donor's Next of Kin (NOK).  The organ, eye and tissue banks need the permission of the donor's closest living relative before beginning the surgery.

The actual hierarchy of the NOK differs state by state.  Generally speaking, though, it is similar to the following order:  Spouse, child, parent and then sibling.

This is where most problems with donation arise.  Either the NOK cannot be located or family members have different opinions on whether or not the decedent wished to donate.

One of the touchiest areas of NOK consent is the driver's license.  By law the donation options indicated on a person's driver's license are a legally bininding document.  However, those asking the NOK about donation do not ask to see the license - they depend on the NOK for consent.

Organ, eye and tissue banks could legally begin the donation process for a donor that consents for donation on his or her license despite the fact that the NOK does not want the donation to take place.  No procurement organization, though, would ever take such action.  This is why it's vitally important to ensure your entire family is aware of your wishes to donate.

The second touchy area is homosexual unions or 'Gay Marriage'.  While a lesbian couple may be recognized as 'Spouses' and thereby NOKs in California, were the couple in an accident in Wisconsin or any other state not recognizing such unions the surviving partner would have no NOK rights.

This is why it's vitally important to have some sort of federal civil union program in place for same-sex couples..