Intended for healthcare professionals


Impact of presumed consent for organ donation on donation rates: a systematic review

BMJ 2009; 338 doi: (Published 15 January 2009) Cite this as: BMJ 2009;338:a3162
  1. Amber Rithalia, research fellow1,
  2. Catriona McDaid, research fellow1,
  3. Sara Suekarran, research fellow1,
  4. Lindsey Myers, information specialist1,
  5. Amanda Sowden, deputy director1
  1. 1Centre for Reviews and Dissemination (CRD), University of York, York YO10 5DD
  1. Correspondence to: C McDaid cm36{at}
  • Accepted 22 December 2008


Objectives To examine the impact of a system of presumed consent for organ donation on donation rates and to review data on attitudes towards presumed consent.

Design Systematic review.

Data sources Studies retrieved by online searches to January 2008 of Medline, Medline In-Process, Embase, CINAHL, PsycINFO, HMIC, PAIS International, and OpenSIGLE.

Studies reviewed Five studies comparing donation rates before and after the introduction of legislation for presumed consent (before and after studies); eight studies comparing donation rates in countries with and without presumed consent systems (between country comparisons); 13 surveys of public and professional attitudes to presumed consent.

Results The five before and after studies represented three countries: all reported an increase in donation rates after the introduction of presumed consent, but there was little investigation of any other changes taking place concurrently with the change in legislation. In the four best quality between country comparisons, presumed consent law or practice was associated with increased organ donation—increases of 25-30%, 21-26%, 2.7 more donors per million population, and 6.14 more donors per million population in the four studies. Other factors found to be important in at least one study were mortality from road traffic accidents and cerebrovascular causes, transplant capacity, gross domestic product per capita, health expenditure per capita, religion (Catholicism), education, public access to information, and a common law legal system. Eight surveys of attitudes to presumed consent were of the UK public. These surveys varied in the level of support for presumed consent, with surveys conducted before 2000 reporting the lowest levels of support (28-57%). The most recent survey, in 2007, reported that 64% of respondents supported a change to presumed consent.

Conclusion Presumed consent alone is unlikely to explain the variation in organ donation rates between countries. Legislation, availability of donors, organisation and infrastructure of the transplantation service, wealth and investment in health care, and public attitudes to and awareness of organ donation may all play a part, but their relative importance is unclear. Recent UK surveys show support for presumed consent, though with variation in results that may reflect differences in survey methods.


  • We thank the peer reviewers who commented on this article and the peer reviewers who commented on a draft of the full report which was included as an appendix to the report from the UK Organ Donation Taskforce (

  • Contributors: AR contributed to the protocol, study selection, data extraction, quality assessment, data synthesis and manuscript writing. CM contributed to data extraction, quality assessment, data synthesis and manuscript writing. SS was involved in data extraction, quality assessment and manuscript writing. LM devised the search strategy, carried out the literature searches, managed the references and wrote the search methodology sections of the report. AS contributed to the protocol, checking of data extraction and quality assessment, manuscript writing and had overall responsibility for the project and is guarantor.

  • Funding: This project was funded by the NIHR Health Technology Assessment Programme (project number 08/33/01) and will be published in full in Health Technology Assessment (see HTA Programme website for further information). The views and opinions expressed are those of the authors and do not necessarily reflect those of the Department of Health.

  • Competing interests: None declared.

  • Ethical approval: Not required

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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