Organ Transplantation: Should the System be Opt-in or Opt-out Approach?
In a global examination, organ donation policies sport a massive variation. Is it better to have a system where people actively opt-in or one where they automatically opt-out? A team of researchers from the UK has delved into the organ donation protocols of 48 countries to shed light on this question.
With an opt-in system, people have to actively sign up to a registry to donate their organs posthumously. In contrast, in opt-out systems, organ donation automatically occurs unless a specific request is made before death for organs not to be taken.
Prof. Eamonn Ferguson, the lead author from the University of Nottingham, UK, admits that the two systems' reliance on active decisions from individuals can lead to drawbacks:
"Folks might 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."
Inaction in an opt-in system can lead to individuals who would want to be donors not donating (a false negative). On the other hand, inaction in an opt-out system can potentially lead to an individual that does not want to donate becoming a donor (a false positive).
The United States currently utilizes an opt-in system. According to the US Department of Health & Human Services, 28,000 transplants were made possible last year due to organ donors. Regrettably, around 18 people die every day due to a shortage of donated organs, unable to undergo surgery.
In or Out?
Researchers from the University of Nottingham, University of Stirling, and Northumbria University in the UK scrutinized the organ donation systems of 48 countries for a period of 13 years—23 using an opt-in system, and 25 using an opt-out system.
The study authors measured overall donor numbers, the number of transplants per organ, and the total number of kidneys and livers transplanted from both deceased and living donors.
Interestingly, they found that countries using opt-out systems of organ donation had higher total numbers of kidneys donated—the organ that the majority of people on organ transplant lists are waiting for. Opt-out systems also had a greater overall number of organ transplants.
Opt-in systems, however, had a higher rate of kidney donations from living donors. The apparent influence that policy had on living donation rates "has not been reported before," says Prof. Ferguson, "and is a subtlety that needs to be highlighted and considered."
The authors acknowledge that their study was limited by not distinguishing between different degrees of opt-out legislation, with some countries requiring permission from next-of-kin for organs to be donated. The observational nature of the study meant that other factors influencing organ donation remained unassessed.
Moving Forward
The researchers state that their results, published in BMC Medicine, show 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 findings could be utilized in the future to inform policy decisions, but they could be strengthened further through the collection of international organ donation information, such as consent type, procurement procedures, and hospital bed availability, and making this information publicly available.
Prof. Ferguson suggests that future studies should also analyze the opinions of those who have to make the decision to opt-in or opt-out:
"Further research outside of this country-level epidemiological approach would be to examine issues from the perspective of the individual, in terms of beliefs, wishes, and attitudes, using a mixture of survey and experimental methods."
"By combining these different research methods," he says, "researchers can develop a greater understanding of the influence of consent legislation on organ donation and transplantation rates."
The authors note that countries using opt-out consent still experience organ donor shortages. Completely changing the system of consent is, therefore, unlikely to solve such a problem. They suggest that consent legislation or adopting aspects of the "Spanish Model" could be ways to improve donor rates.
Spain currently has the highest organ donation rate in the world. The Spanish utilize opt-out consent, but their success is attributed to more than just the consent system. A transplant coordination network operating both locally and nationally, and improving the quality of public information available about organ donation, have been credited with Spain's high donation rates.
Recently, Medical News Today ran a spotlight feature on the potential use of animal organs for human transplants as a solution to the organ shortage. Could this be a viable solution, or should changes be made to organ donation policy instead?
Written by James McIntosh
- The study, published in BMC Medicine, reveals that countries with opt-out organ donation systems have higher total numbers of kidneys donated, a greater overall number of organ transplants, and more total livers and kidneys transplanted from both deceased and living donors.
- Opt-in systems, on the other hand, have a higher rate of kidney donations from living donors, according to the research conducted by a team from the University of Nottingham, University of Stirling, and Northumbria University.
- To address organ donor shortages, Prof. Ferguson suggests that future research should focus on the opinions of individuals, studying beliefs, wishes, and attitudes towards organ donation, using a mix of survey and experimental methods.
- Implementing changes in organ donation policy or adopting aspects of the "Spanish Model," which combines opt-out consent with a transplant coordination network and improved public information, could potentially improve donor rates, the authors note, but completely changing the system is unlikely to solve the organ shortage problem.
