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Opt-In vs. Opt-Out donor registration systems: which is best?

Around the world, approaches to organ donation vary widely. The concept of an opt-out system sounds strong on the surface, but research shows that an opt-in system is likely to produce the most donors.

What’s the difference between an opt-in and opt-out system?

With an opt-in system, people must actively sign up to a register to donate their organs after death. The U.S. has an opt-in system. In most states, the primary way to register is when applying for or renewing a driver’s license. In the LifeSource service area (Minnesota, North Dakota and South Dakota) a person can also register online and in Minnesota, there’s also an option to register when applying for a hunting or fishing license. If a person doesn’t register, the family will make the decision at the time of death.

In opt-out systems, organ donation will occur automatically unless a specific request is made before death for organs not to be taken. In this system, families would have the final say and can overrule their loved one’s wishes to be a donor.

Is an opt-in or opt-out system more effective?

There are two primary benefits of the opt-in system, particular to the U.S.:

1) The decision is legally binding: Registering as a donor is legally binding. Families cannot override the decision. Conversely, opt-out systems have only one pathway to “yes” with two pathways to “no”—if the individual opted out or if the family objects to donation. Opt-out countries will not proceed with organ donation over family objection.

2) It aligns with American values of individual rights: Requiring an affirmative donation decision through opt-in policies is aligns with the U.S. cultural emphasis on individual rights and autonomy principles that is not achieved in the opt-out international experience. In addition, the decision to donate in the U.S. is within the Anatomical Gift Act. A legislative change to an opt-out system would undermine the existing legal framework of donation, opening it to possible unforeseen legal consequences and negative public response. 

Arguments for an opt-out system often look to Spain, as a leader in organ donation with an opt-out law. However, Spain attributes its success not to opt-out laws but rather to a well-funded, nationally promoted, commitment to donation integrated into a nationalized hospital system and practice.

The U.S. opt-in system donation rates routinely exceed those of the best performing opt-out international countries. In five years, the United States experienced a 30 percent increase in deceased organ donors, from 8,269 in 2013 to 10,722 in 2018.