Assessing Global Organ Donation Policies: Opt-In vs Opt-Out

Abstract

This paper argues that there is little difference between opt-in and opt-out organ donation systems for increasing donor numbers when used in isolation. Independently diverting to an opt-out system confers no obvious advantage and can harm efforts to bolster donations. Rather, it is essential to address barriers to organ donation on several levels along with a switch in system. Moreover, for many countries, it may be more beneficial to adequately capacitate the donation system already in place, rather than entertain a significant change with its attendant resource requirements. For decades, the international transplant community has been involved in vigorous debate as to the merits of moving from default opt-in systems to opt-out policies to grow organ donor numbers and better meet the everincreasing demand for lifesaving transplants. Opt-out is certainly en vogue, with Wales, England and Nova Scotia recently switching over, Scotland due to become opt-out in March 2021 and Northern Ireland and Canada seriously considering a similar move. Thanks to several countries making the switch from opt-in to opt-out over the last 20-30 years, there are sets of robust longitudinal data that aid in analysing the efficacy of donation systems. However, these data are often contradictory and largely inconclusive, suggesting other factors may be in play. This paper reviews some emerging trends in opt-in versus opt-out organ donation policies and considers recent data that elucidates some of the main contentions across each. Ethical frameworks underpinning donation systems, such as informed consent, trust and transparency, are discussed in detail. Substantial time is also devoted to opt-in vs opt-out systems in developing countries, which tend to be excluded from many analyses, and where the challenges faced are magnified by socio-economic constraints. This constitutes a major gap in recently published literature, as developing countries often lag far behind their developed counterparts in donor and transplant numbers.

Liver Transplantation in Developing Countries

“…Developing countries often have poor collection of organ transplantation activity and limited resources to make the LT data publicly available. This is particularly evident in most countries in Africa, and in some countries in Asia (36). This non-transparent activity and the public lack of awareness prevent organ donation from reaching its maximum potential in these regions.…”

“…In some developing countries with two-tier healthcare systems, such as South Africa and India, wealthy patients often have easier access to transplant than those with limited resources (36). This modality also augments the public mistrust in organ transplantation in those countries.…”

“…Opt-in (explicit consent) and opt-out (presumed consent) are two systems that exist for organ donation after death. In opt-in system, potential donors need to actively give the consent for their organs to be used after death, whereas in opt-out system no active consent is needed, and an individual is presumed to give the consent unless they specifically indicate the opposite (36,44). Opt-out systems many increase donation rates and may overcome challenges in deceased organ donation including culture and religious beliefs and transplant awareness (34,36).…”

“…In addition, hard consent, soft consent and mandated consent exist and are used in many countries (36). Hard consent leaves no involvement of family in donation process, an individual whereas soft consent involves family.…”

An Ethical Defense of a Mandated Choice Consent Procedure for Deceased Organ Donation

“…Ethical challenges also arise in systems where families are asked to make a decision about organ donation when a deceased loved one has not indicated their donation preferences (Etheredge 2021 ; Tennakore et al 2021 ). Such a procedure is in place in most countries, opt-in system or otherwise (Young 2012 ).…”