Organ donation policies vary widely across the world. Is it best to have a donation system in which people have opted in or out? To investigate, a team of UK researchers examined the organ donation protocols of 48 countries to determine which approach is most effective.
People have actively signed up for an opt-in system to donate their organs after death. Organ donation occurs automatically in opt-out systems unless a specific request is made before death for organs not to be taken.
Prof. Eamonn Ferguson acknowledges that because the two systems depend on individuals making active decisions, it can have the negative effects:
Individuals who wish to be supporters will not donate if an opt-in system is not implemented (a false negative). In an opt-out system, on the other hand, inaction will result in an individual who does not wish to become a donor (a false positive).
The United States currently uses an opt-in system. Organ donors allowed 28,000 transplants last year in the US. Every day, approximately 79 people undergo organ transplants. Unfortunately, approximately 18 people die every day due to a lack of donated organs.
What is the distinction between an opt-in or opt-out donor system?
People must actively sign up for an opt-in registry to donate their organs after death. The United States has an opt-in system. The primary way to register in most states is when applying for or renewing a driver’s license. An individual may also register online in the LifeSource service area. In Minnesota, there is also the option to register when applying for a hunting or fishing license. If a person fails to register, the decision will be made by the family at the time of death.
Organ donation occurs automatically in opt-out systems unless you make a specific request before death to not take organs.
Families will have the final say in this system. And they can override their loved one’s wishes to donate.
IS OPTING OUT A ‘BETTER’ FORM OF CONSENT?
A change in the law also raises legal and practical concerns. Opting-out laws range in severity but are usually classified as either ‘hard’ or ‘soft.’ A hard system will remove organs after death if the person has not opted out and the family has no role. This system raises a common objection that the state takes over the person’s body after death. This raises serious ethical concerns. Consent is an active process that we cannot ‘presume’ simply because there are no objections.
It is unclear if a system like this is acceptable to intensive care physicians, who play such an important role in the care of potential donors. There is a presumption in favour of donation under a soft system. But the family has the final say. This is much less troublesome from an ethical standpoint. However, it is not always apparent that the media and the general public understand the differences between a hard and a soft system. The universal objection to the former may have an adverse effect on the latter’s potential acceptability, which may have an adverse impact on donation.
Opt-in or opt-out donor system
To donate organs or tissues, an individual must first register. This is often referred to as an organ donation opt-in system.
Actually, 69 percent of People believe organ donation is important. But only one in every three people registers as an organ donor.
Several countries have turned to opt-out systems to increase similarly low donation rates. These countries include Wales, Iceland, and now England (by mid-2020).
In an opt-out system, we assume individuals have given their consent to be a donor before death unless they specifically request not to donate their organs. As a result, organs may be taken unless people express a desire not to be donors or their family members object. This is referred to as a “soft opt-out.”
In 2017, France introduced laws requiring doctors to only inform relatives about which organs they want to procure, rather than seeking their permission to procure. This is an example of a system with a hard opt-out.
We believe that if an individual has not registered their consent for their organ to be procured before death, then we should always seek the consent of family members.
Historically, Australian governments have been wary of adopting an organ donation opt-out system.
Several states are considering changing the current organ donation system. And a 2016 independent review found out ways to increase donation rates. But, an opt-out system was not considered preferable. We suspect this is because people have a negative reaction when someone takes away their choice.
Is an opt-in or opt-out donor system more effective?
The opt-in system has two main advantages that are unique:
The decision is legally binding. Registering to donate organs is a legally binding decision. Families are unable to change the decision. On the other hand, opt-out systems have only one path to “yes” and two paths to “no”—whether the person opted out or if the family objects to donation. Because of family objections, opt-out countries will not proceed with organ donation.
It is aligned with individual liberty. Requiring an affirmative donation decision by opt-in policies is consistent with the cultural emphasis on individual rights and autonomy principles, which the international opt-out experience does not achieve. Moreover, the Anatomical Gift Act controls the decision to donate in the United States. A legislative change to an opt-out system will weaken the current legal framework of donation, potentially exposing it to unforeseen legal consequences and negative public response.
Many proponents of an opt-out system point to Spain as an example. Spain is a leader in organ donation and has an opt-out law. However, Spain credits its success to a well-funded, nationally supported commitment to donation integrated into a nationalized healthcare system and practice rather than opt-out laws.
Donation rates in the United States’ opt-in system routinely outperform those in the best-performing opt-out international countries. In five years, the number of deceased organ donors in the United States increased by 30%, from 8,269 in 2013 to 10,722 in 2018.
Moving forward
According to one research, opt-out consent can increase deceased donation and decrease living donation rates.
We can use these results to inform policy decisions in the future. But we can improve them further by routinely collecting international organ donation information – such as consent type, procurement processes, and hospital bed availability – and making it publicly available.
The authors point out that countries that use opt-out consent already have a shortage of organ donors. As a result, completely changing the consent system is unlikely to solve such a problem. They suggest that implementing aspects of the “Spanish Model” or enacting consent legislation may be ways to increase donor rates.
Spain currently has the world’s highest rate of organ donation. The Spanish use opt-out consent. But experts credit their success to initiatives such as a transplant coordination network that operates both locally and nationally to increase the quality of public knowledge about organ donation.
The Bottom Line
Organ donation should continue just that: a donation. Based on the donor’s generosity and free will in the form of a donation, rather than on a default system of taking without consent.
