Intended for healthcare professionals


A nudge in the right direction for organ donation—but is it enough?

BMJ 2011; 343 doi: (Published 14 September 2011) Cite this as: BMJ 2011;343:d5726
  1. Hugo Wellesley, consultant anaesthetist
  1. 1Great Ormond Street Hospital, London WC1N 3JH, UK
  1. hugowellesley{at}
  • Accepted 2 September 2011

Applicants for a UK driving licence are now asked to decide whether to join the NHS Organ Donor Register. Hugo Wellesley argues that although this should boost the number of people on the register, the number of people who ultimately donate organs will not rise unless we act to increase people’s underlying willingness to donate

As part of attempts to increase the number of registered organ donors, the UK government has introduced “prompted choice” about donation for driving licence applications online, and the Welsh Assembly is considering adopting presumed consent.1 2 In this article, I examine the likely effect of these strategies on actual rates of donation and what we can do to increase people’s willingness to donate.

Prompted choice

Since August everyone who applies for a UK driving licence online has to complete a question asking whether they wish to join the NHS Organ Donor Register.1 There are three options: “Yes, I would like to register”; “I am already registered”; or “I do not want to answer this question now.” The last response was chosen to prevent a potential legal challenge resulting from mandating a response during an unrelated transaction.3 Mandated choice (where people are obliged to answer the question) would require new legislation.

People cannot declare a preference not to donate because this would require the creation of a “No” registry. It is not clear, however, why people shouldn’t be given the option to say, “No, I do not want to register,” (rather than, “I do not want to donate”), which would allow them to opt out of registration without requiring a separate registry. To have, “I do not want to answer this question now” as the only way to say “no” represents an artificial constraint of free choice and risks making people feel manipulated. This could …

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