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Is an opt-out system likely to increase organ donation?

BMJ 2019; 364 doi: (Published 06 March 2019) Cite this as: BMJ 2019;364:l967

Linked Patient Commentary

My three livers: how transplants gave me my life back

  1. Veronica English, head of medical ethics and human rights and policy lead on organ donation1,
  2. Emma Johnson, mother of patient Max Johnson2,
  3. Blair L Sadler, lawyer and senior fellow at the Institute for Healthcare Improvement3,
  4. Alfred M Sadler Jr, physician and senior adviser to California State University4
  1. 1BMA, London, UK
  2. 2Cheshire, UK
  3. 3Boston, Massachusetts, USA
  4. 4Monterey Bay, California, USA
  1. Correspondence to: V English venglish{at}, B Sadler bsadler{at}

As England’s presumed consent law for 2020 clears parliament, Veronica English and Emma Johnson say that evidence from Wales and other countries shows that it could increase transplantation rates. But Blair L Sadler and Alfred M Sadler Jr consider such legal changes a distraction lacking strong evidence: they say that public education and trained staff would have a proven impact

Yes—Veronica English, Emma Johnson

In an opt-out system for organ donation, dead donors’ consent is presumed (or “deemed”) unless there is evidence that they did not want to donate. Opt-in systems, as in England currently, require donors to give explicit consent while alive or require the family to consent. In both systems, families are still consulted.

Moving to an opt-out system can raise organ donation rates, helping to save and transform lives. A growing evidence base shows this to be the case when introduced with public support and as one part of a broader strategy including publicity, education, and infrastructure improvements.

People like Max Johnson might benefit: he had a lifesaving heart transplant at age 9. “Max and Keira’s Law,” the opt-out law due to come into force in England in 2020, is named after him and Keira Ball. She died aged 9, and her father gave permission for Max to receive her heart.1

International comparisons, using statistical methods to account for other factors affecting donation rates (such as health expenditure and mortality after road traffic incidents), show increasing evidence that an opt-out system is one of several factors associated with higher donation rates after death.

In 2008 a systematic review2 identified four methodologically sound comparative studies, all of which found that opt-out laws or practice were associated with increased donation rates. An update of this review by the Welsh government in 20123 and an evidence review by the Scottish government …

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