Is an Opt-Out Setup the Way to Increase Organ Donations?

What are the problems in using an opt-out scheme in organ donation?

Posted Oct 12, 2018

The idea of an opt-out system is that it automatically registers everyone and presumes consent to donate—so if you do not want to, you must take yourself off the register, whereas an opt-in system requires explicit consent to donate and indicates willingness.

However most organ donation legislative systems, whether opt-in or out, include a clause that allows the final decision to donate to be made by family members.   

The national health service in the UK Blood and Transplant reported in 2016 that more than 500 families vetoed organ donations since April 2010 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. Plans to introduce an opt-out system in England by 2020 are currently being discussed in parliament, but our findings suggest that this creates ambiguity and won’t reduce family veto rates.

In three experiments in our study, American and European participants from countries that have either a default opt-in or default opt-out system were presented with a fictional scenario and asked to take on the role of a third party to judge the likelihood that an individual’s ‘true wish’ was to actually donate their organs, given that they were registered to donate.

Overall, regardless of which country the participants came from, they perceived the donor’s underlying preference to donate as stronger under the default opt-in and mandated choice systems as compared to the default opt-out and mandatory donor systems.

What we show is that it is harder to judge the underlying wishes of the deceased if they were on an opt-out and mandatory donation register. Why? Because making a free choice indicates what your preference is, and if you don't get to actively choose, and you are listed as a donor on the register, then it isn't clear if you really wanted to donate your organs. This matters because if in the event of death and your relatives have to decide what to do, they may veto the organ donation if they can't tell for sure what your underlying wishes were.

In 2017/18 there were 6,044 people in the UK waiting for a transplant while 411 patients died while waiting on this list. Similarly, this year in the US there are over 114,000 people on the waiting list to receive an organ and it is estimated that 20 people die each day while waiting on the list.

To address problems like these, behavioral interventions, such as nudges, have been used to provide practical solutions that are based on psychological and behavioral economic research.

An example of a nudge is an automatic default, such as the ones often used in organ donation legislative system. The rationale behind an automatic default is that it can bridge the gap between a good intention and the effort needed to implement that intention into practice.

Our findings are important because they challenge the efforts of many nudge enthusiasts to promote the use of opt-out defaults in organ donation. We show that only for the active choice donation registers do they reflect what the underlying wishes of the donor were.

To help increase actual rates of organ donation, we need more transplant coordinators working with families to help them understand the issues before being faced with a monumental and distressing decision. We also need to offer people a way to indicate explicitly what they wish to do. This should involve an expressed statement of intention if their wish is to donate, or an expressed statement of intention if there is an objection to donate. This reduces the ambiguity in trying to infer what one wanted to do when it comes to donating their organs.


Lin, Y., Osman, M., Harris, A. J., & Read, D. (2018). Underlying wishes and nudged choices. Journal of Experimental Psychology: Applied.