Organ donation, the opt-in or opt-out debate
The shortage of transplant organs is a pressing issue around the world. In an effort to increase the number of donated organs, various initiatives have been implemented in a number of countries to prompt people to donate their organs in the event of death.
Some of these interventions are referred to as nudges. Nudges are psychological and refer to behavioural change interventions that alter people’s behaviour by modifying the context of their choice in such a way as to make the “better” option the most salient or easiest choice without substantially changing the underlying incentive structure.
Several countries, such as Germany, Denmark, Lithuania and the Netherlands have a default opt-in registry whereby citizens have to actively choose to register as an organ donor. However, some countries, such as Austria, Spain, France, Italy, Belgium, Sweden and Greece have an opt-out system whereby citizens are automatically registered as organ donors and have to actively choose to opt-out if they prefer not to be an organ donor.
However, whether opt-in or opt-out, most organ donation legislative systems include a clause that allows the final decision to donate to be made by family members of the deceased.
In the United kingdom the NHS Blood and Transplant reported in 2016 that more than 500 families vetoed organ donations between 2010 and 2015 despite being informed that their relative was on the opt-in NHS Organ Donation Register. This translated into an estimated 1,200 people missing out on potential life-saving transplants.
This was one of the reasons why England recently announced plans to change their opt-in registry to an opt-out one in 2020.
However, a recent study from Queen Mary University of London argues this move is unlikely to result in any significant increase in donated organs. Although the authors of the study note that several studies have shown that default opt-out systems have substantially increased registered donations and give examples from Belgium where kidney donations increased from 10.9 to 41.3 per million people during a 3-year period, and from Singapore where kidney donations increased from 4.7 to 31.3 per year over a 3-year period.
Nonetheless, in the study, published in May this year, the authors argue that under an opt-out system the family would perceive the donor’s preference as weaker because it involves a passive choice to donate compared to a default opt-in system where an active choice to donate is made.
The study concludes that the opt-out system is unlikely to increase actual rates of organ donation or reduce veto rates, all it will do is increase the number of people on the organ donation register.