Opt-out systems of organ donation

By Simran Singh, Ashwin Sritharan and Simi Juriasingani

Most countries in the world operate with an opt-in system of organ donation where individuals must actively consent to organ donation. However, in recent years, some countries have switched to opt-out systems of organ donation. 

In the opt-out system, an individual’s consent to organ donation is presumed after his/her death, unless the individual has opted out from donating their organs prior to their death.

There are two approaches to implement an opt-out system: the hard approach and the soft approach. In the hard approach, an individual’s organs will be donated after their death if they have not opted out of organ donation and their family will have no say in this decision. In the soft approach, a deceased individual’s organs are presumed to be eligible for donation if they have not opted out; however, their family makes the final decision about donating their loved one’s organs.

Examples of opt-out systems

Spain

In 1979, Spain introduced the organ opt-out system using the soft approach. Currently, Spain leads the world in organ donation. In 2017, according to Chris Baraniuk from Independent, Spain had 2,183 deceased donors which allowed for 5,260 additional transplant surgeries, which contributed to more than 3,200 kidney transplants and 1,200 liver transplants. Additionally, 360 lung transplants and 300 heart transplants were also performed that year.

Spain has the highest number of organ donors per million people. According to CBC News, Spain has 50 donors per million compared to 22 donors per million in Canada. This is not just due to the opt-out system of organ donation, but also because of the cultural acceptance that has been cultivated through diligent efforts. Spain has made the conditions of their opt-out system  seem less restrictive to the general public via education and collaborating with mass media. The Spanish media broadcasts information about organ donation and the benefits of transplantation. It is a system that works in a transparent manner and they cover personal stories, which lets the population know that they are considered to be a part of the system.

Wales

On December 1^st, 2015, Wales was the first country in the United Kingdom to switch to the opt-out system using the soft approach with the aim to increase organ donation by 25% and it has seen some positive results. According to the Scottish Government, the consent rate of organ donation went up from 44% in 2014 to 65% in 2018. Additionally, according to The Guardian, family consent in Wales increased from 49% to 59% and the rate of living organ donation increased from 20% to 49%.

However, despite the positive results seen in Wales, many people oppose this law. For example, most Christian groups support organ donation but not the law because they believe that organ donation should be a gift and not something the government should get involved in. Additionally, some Muslim groups believe that the body should be buried whole. To overcome this barrier, the government is trying to educate the public via national campaigns. Some of their measures include advertising on television, advertising on billboards and having debates to inform the Welsh public about the shortage of organ donors and how the opt-out system works. 

Nova Scotia

Nova Scotia is going to be the first jurisdiction in North America to be switching their organ donation system from opt-in to opt-out on January 18^th, 2021. Nova Scotia made the decision to switch to an opt-out system with the aim of raising organ donation by 20% after seeing results in European countries like Spain. According to CBC News, approximately 90% of Canadians support organ donation, yet only 20% actually donate their organs. Therefore, Nova Scotia decided to make donating organs the default decision following death using the soft approach, where an individual’s family will still have a say.

What are pros and cons of opt-out systems?

Cons

One of the biggest disadvantages of the opt-out system is that the public believes that this system will affect the quality of medical care they receive. According to The Munich Eye, a survey by the Federal Centre for Health Education about opt-out systems shows that one third of the respondents believe that doctors are less likely to save a patient’s life and use their organs to save the lives of other people. This is based on the myth that doctors may find it more resourceful to harvest a patient’s organs than saving their life, which goes against the core of modern medicine and the Hippocratic Oath.

Another limitation of the opt-out system is that certain cultures and religions have major concerns about the organ donation process. For example, the Catholic Church supports organ donation but does not support presumed consent to donate organs since it appears to reduce the autonomy of an individual to make the decision to donate. Many are concerned that their right to choose is being taken away because the government is imposing their decision on people and invading their right to control their own body. Another major concern is the risk of facing a lawsuit from family members if an individual who opted out had their organs donated mistakenly due to a document being lost or overlooked. Some of these misconceptions can be reduced with education.

Pros

The 24 European countries using the organ opt-out system have reported significant success. According to The Munich Eye, Austria has a 99.98% consent rate for organ donation. In addition to increasing consent rates and organ donation, an opt-out system may also reduce corruption within some organ donation systems. Certain countries have serious shortages of donated organs and doctors in such areas are known to tamper with the waiting list to get their patients higher up in exchange for financial or other favours. This system may also reduce the exploitation of people who are poor. In some countries, people pay tens of thousands of dollars to a donor who is poor. These cases are especially dangerous because the donor, who is in need of the money, is vulnerable and unable to give free and informed consent to organ donation. 

Lastly, some people do not like to think about death and thus they do not make a decision about organ donation. With the opt-out system, they simply would not have to think about death since the choice to donate their organs will be automatic. A system where the default decision is to donate organs is simpler in this regard because it requires no effort, whereas making a decision to opt-in does requires effort. The caveat here is that it is still in everyone’s interest to ensure that they have thought about donation and made their views clear to their family to ensure that their wishes are adhered to within soft approach opt-out systems. Overall, opt-out systems make sense to many people since there are many patients on transplant waiting lists and opt-out systems have been shown to increase organ donation, which saves and improves lives. 

It is well known that a single organ donor can save up to eight lives and a single tissue donor can help save up to 75 people. Ultimately, it is up to every individual to think about organ donation, decide if that’s something they want to do and make their views clear to their loved ones. However, if opt-out systems can expedite the process of increasing organ donation, then why shouldn’t they be implemented across the board in an attempt to save and improve as many lives as possible?