Intended for healthcare professionals


Presumed consent: a distraction in the quest for increasing rates of organ donation

BMJ 2010; 341 doi: (Published 18 October 2010) Cite this as: BMJ 2010;341:c4973
  1. John Fabre, professor1,
  2. Paul Murphy, consultant2,
  3. Rafael Matesanz, director3
  1. 1Department of Hepatology and Transplantation, James Black Centre, King’s College London School of Medicine, London SE5 9NU, UK
  2. 2Neuroanaesthesia and Critical Care, Leeds General Infirmary, Leeds, UK
  3. 3Organización Nacional de Trasplantes, Ministry of Health and Social Policy, Madrid, Spain
  1. Correspondence to: J Fabre john.fabre{at}
  • Accepted 5 September 2010

Spain has the highest rate of organ donation in the world and is often cited as a successful example of presumed consent legislation. However, the country does not have an opt-out register, nor is public awareness of the 1979 legislation promoted. John Fabre, Paul Murphy, and Rafael Matesanz argue that the presumed consent legislation is dormant, and that Spain in fact demonstrates it is possible to have the highest rates of organ donation without recourse to presumed consent

Spain has by far the world’s highest rate of organ donation from deceased donors (approximately 34-35 per million of population), which is more than twice that of the UK (approximately 15 per million of population).1 The vast majority of Spain’s deceased donors are heart beating donors diagnosed as brain stem dead in intensive care units (32 per million of population). Spain has a low rate for both live organ donation (five per million of population) and for non heart beating donation (also known as donation after cardiac death, or DCD) (2.3 per million of population, entirely from patients in whom cardiac arrest occurs unexpectedly outside hospital or in emergency departments).1 2 In contrast with Spain’s figures, donation after cardiac death has increased steadily in the UK, and in 2009 it comprised almost a third of deceased donors (4.7 per million of population, almost entirely from patients with anticipated cardiac arrest after withdrawal of cardiorespiratory support, usually in intensive care units).

Heart beating donation in the UK has continuously fallen over the past decade, from 744 donors in 2000 (12.7 per million of population) to 612 in 2009 (10.3 per million of population). In contrast, live organ donation has almost trebled over that time, to 961 in 2009 (15.8 per million of population)—more than the number of deceased donors. …

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