Opt-out Organ Donation Saves LivesQuestions of consent diminish the effectiveness of many opt-out organ donation systems, dashing earlier hopes of increasing organ donation statistics
A single person can save eight lives through organ donation and can save or improve up to 100 lives by donating tissue, according to the Health Policy Partnership. But worldwide, […]
A single person can save eight lives through organ donation and can save or improve up to 100 lives by donating tissue, according to the Health Policy Partnership. But worldwide, organ donation faces persistent challenges.
The Global Observatory on Donation and Transplantation reported that in 2023 around 45,000 organs were donated from deceased donors, and 53,000 living transplants were performed, meeting less than 10% of global demand.
Organ donation rates vary considerably by country, and some experts wonder if the difference could be due to the type of organ donation system being used.
Opt-In versus Opt-Out
The U.S. currently employs an “opt-in” donation system for organ donation, meaning people need to make a conscious decision to check the box on their driver’s license application indicating that they are willing to be an organ donor.
But many other countries – like Spain, the U.K., Austria and France – have elected to use an “opt-out” donation system, in which individuals are assumed to be donors unless they register their decision to opt-out. Opt-in models often suffer from low participation.
“Not necessarily due to opposition,” the Health Policy Partnership explains, “but because of inertia or lack of awareness. People might have no objection to organ donation, but do not join registers due to ‘not getting around to it.’”
Statistically, opt-out policies lead to higher organ donation registration rates, which would theoretically lead to more organ donations and lives saved, according to a 2012 Cornell University study that helped launch campaigns pushing for the US to adopt such policies.
Unfortunately, this has not been shown to be true in practice. A 2025 study examined several countries in Europe who had converted from opt-in to opt-out policies, and found that the policy switch, on average, led to a “nonsignificant increase in annual deceased donor rates of +1.21 people per million population” and a “significant decrease in living donor rates of -4.59 people per million population.” Across four additional studies, the experts found that this was due to a “crowding out effect.” Essentially, the reduced willingness for living altruistic (vs. familial) donations was “attributable to a stronger belief that the organ supply is sufficiently met with deceased donations under opt-out (vs. opt-in).”
Organ Donation Policy and Consent
A different study, published in the BMJ Open in 2022, revealed a different reason: a lack of public awareness about opt-out policies, and the fine points involved in consent. Their analysis found that opt-in and opt-out policies have “strictly identical outcomes in eight out of nine situations.” They only differ, the authors wrote, “when neither the deceased nor the family have expressed a preference and defaults therefore apply.”
The issue, for the most part, is that if people haven’t explicitly communicated their wishes to families, the presumed consent of the opt-out system acts as a “weaker signal of preference” than the active consent of an opt-in system, according to researchers at the Max Planck Institute for Human Development in a 2024 paper published in Public Health. This has led to an increase in family refusal for organ donation.
For example, after the UK adopted their opt-out policy, the BBC reported that the nationwide organ donation consent rate fell from 69% in 2020 to 61% in 2024. In their article, they shared seven of the most common reasons for a patient’s family to refuse organ donation, according to data from The National Health Service (NHS), which included “family felt the donation process took too long,” “family did not want surgery to the body,” and “family felt patient had suffered enough.”
Potential Solutions
Although opt-out systems are generally designed to boost donation numbers, their effectiveness varies based on whether they are “hard” (strict, with no family veto) or “soft” (considering family input). While hard opt-out systems might lead to more organ donations, they raise major ethical concerns and popular objections regarding state control. And “soft” systems, as seen in the UK, often grant too much power of negation to family members. Effective systems, according to a recent study from the Steve Biko Centre for Bioethics, School of Clinical Medicine in South Africa, often combine the current legal framework with strong public awareness campaigns and improved healthcare infrastructure.
The authors of the study argue that rather than switching systems, the key to increasing organ donor numbers is carefully addressing barriers to donation as they occur in each country, “as well as ensuring that organ donation engenders public trust and is transparent and accountable to the patients and population it serves.”
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