More than 99,358 men, women and children are on organ transplant lists in the United States. Pressure on family members to donate organs can therefore be intense. The medical excuse was created to address this potential coercion. It is a fabricated anatomical or physiological reason given to a donor (with or without the donor’s request) that provides an immediate shield against coercive pressure by family and friends on the potential donor. While the long-term risks and benefits of the medical excuse have not been studied, they could arguably include: 1) Reinforced perception that donation is expected; hence, declining donation is aberrant, and requires legitimization by external authority; 2) Eroded family trust of transplant physicians; 3) Eroded family trust in the individual reporting a “true” medical excuse; 4) Falsification of potential donor’s medical record; 5) Development of “toxic secrets” in the family unit; 6) Paternalism; and 7) General erosion of trust in both health care providers and the healthcare system. This author proposes a system of transparent and balanced communication where both the potential donor and the transplant team are clearly cognizant of the voluntary nature of the purported donation and where provisions for “opting-out” occur at any point along the pre-transplantation continuum.