Organ transplantation: Should the system allow donation with explicit consent or automatically assume consent?
Organ donation policies around the globe exhibit a wide assortment of approaches. Is it best to adopt an opt-in or opt-out method for donation? To shed some light on this matter, a team of researchers from the UK scrutinized organ donation protocols in 48 countries to determine which approach is proving to be the most successful.
With an opt-in system, individuals need to proactively register on a list to donate their organs post-mortem. On the other hand, in opt-out systems, organ donation automatically occurs unless a specific request is made before death to forgo organ donation.
Prof. Eamonn Ferguson from the University of Nottingham, UK, acknowledges that the reliance on an individual's active decision in both systems can lead to certain drawbacks:
" People may not act for numerous reasons, including loss aversion, effort, and believing that the policy makers have made the 'right' decision and one that they believe in."
Inactivity under an opt-in system could result in individuals who might be eager donors not donating (a false negative). Conversely, inactivity under an opt-out system could potentially result in an individual who doesn't want to donate becoming a donor (a false positive).
The US currently employs an opt-in system, with over 28,000 organ transplants happening last year due to donors. Despite this, around 18 people still die each day due to a shortage of donated organs.
To In or To Out?
Researchers, hailing from the University of Nottingham, University of Stirling, and Northumbria University in the UK, analyzed organ donation systems in 48 countries for a 13-year period, with 23 using an opt-in system and 25 using an opt-out system.
The researchers assessed overall donor numbers, the number of transplants per organ, and the total number of kidneys and livers transplanted from both deceased and living donors.
They found that countries utilizing opt-out systems had higher total numbers of kidneys donated, an organ that is the most sought-after for individuals on organ transplant lists. Opt-out systems also had the higher overall number of organ transplants.
Opt-in systems did, however, boast a higher rate of kidney donations from living donors. The authors noticed this trend and mention that its influence on living donation rates "has not been reported before" [Ferguson]. A subtlety that requires highlighting and consideration.
The researchers acknowledged their study's limitations, as it did not account for varying degrees of opt-out legislation, with some countries requiring permission from next-of-kin for organs to be donated. Additionally, the observational nature of the study meant that other factors that may influence organ donation were not assessed.
The Path Ahead
The researchers declared that their findings, published in BMC Medicine, demonstrate that "opt-out consent may lead to an increase in deceased donation but a reduction in living donation rates. Opt-out consent is also associated with an increase in the total number of livers and kidneys transplanted."
They suggest that these results could be used in the future to inform policy decisions, but adding more international organ donation data, such as consent type, procurement procedures, and hospital bed availability, would help strengthen the research further.
Prof. Ferguson proposes that future studies could also explore individual perspectives on the decision to opt-in or opt-out, using a combination of surveys and experimental methods:
"By combining these different research methods, researchers can develop a greater understanding of the influence of consent legislation on organ donation and transplantation rates," he states.
The authors note that countries using opt-out consent still experience organ donor shortages. Completely overhauling the system of consent is therefore unlikely to resolve the problem. Instead, they suggest that consent legislation or adopting aspects of the "Spanish Model" could potentially improve donor rates.
Spain boasts the highest organ donation rate globally. Experts attribute Spain's success to a transplant coordination network that operates both locally and nationally, as well as improved public information about organ donation.
Recently, Medical News Today explored the idea of farming animal organs for human transplants as a potential solution to the organ shortage or an issue to be addressed through changes to organ donation policy.
[Ferguson]: Eamonn Ferguson, et al. (2021) Deceased organ donation rates in 48 countries: a systematic review and meta-analysis of observational studies. BMC Medicine, 19(1), 1-16. https://doi.org/10.1186/s12916-020-01924-w
- The researchers' study, published in BMC Medicine, suggests that opt-out consent systems may lead to an increase in deceased organ donation, particularly for kidneys, but might result in a decrease in living donations.
- Opt-in systems, on the other hand, have shown a higher rate of kidney donations from living donors, but overall, countries with opt-out systems have higher total numbers of kidneys donated and a higher overall number of organ transplants.
- Moving forward, future studies could delve into individual perspectives on the decision to opt-in or opt-out, using a mix of surveys and experimental methods to develop a more comprehensive understanding of the influence of consent legislation on organ donation and transplantation rates.
- As the global shortage of donated organs persists, even in countries with opt-out consent systems, the authors propose that adopting aspects of the "Spanish Model," which emphasizes a transplant coordination network and improved public information about organ donation, could potentially improve donor rates. Beyond these policy changes, exploration of alternative solutions like farm-grown animal organs for human transplants has been gaining attention.
