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  • Writer's pictureDuke Medical Ethics

Life Saving Choice: Organ Donation Systems

As life expectancy has increased worldwide, the number of individuals who suffer from chronic conditions in old age has drastically increased. One common chronic condition is organ failure—more individuals are living longer and eventually need a new organ to maintain healthy function. The biggest issue facing this area of medical treatment is a lack of viable organs. Countries around the world have created systems to address this disparity in available organs, largely separated into systems that assume everyone is a donor or that assume one must explicitly authorize donation. In this paper, the organ donation systems of two countries—the U.S. and Spain—are compared with respect to in respect to their successes, challenges, and failures in closing the gap.

The two major categories for organ donation are “opt-in” systems and “opt-out” systems. In an opt-in system, individuals register themselves as organ donors if they desire to donate organs after death (Kazemayni, 2004). In an opt-out, or “presumed consent,” system, individuals must register to be removed from the donor list (Kazemayni, 2004). When controlling for other determinants, presumed consent does show a sizeable positive affect overall on donation rates (Abadie & Gay, 2004). Mandated choice, or systems in which every individual is required to indicate their desire or refusal to serve as a donor in the instance of their death, has also been shown to increase donation rates (van Dalen & Henkens, 2014). Additionally, in countries that switched from opt out to presumed consent or mandated choice, the rate of agreement to donate remained constant among already registered donors but increased among non-donors (van Dalen & Henkens, 2014).

United States

The United States operates under a system of explicit consent. Individuals can register as organ donors when obtaining a driver’s license, via an online national registry, or by joining their state registry of organ donors (UNOS, 2018). Outside of some cases in which families express strong objections, the deceased’s wishes are followed when the deceased is eligible to donate. (UNOS, 2018). In cases in which the individual had not “opted in” to be an organ donor prior to their death, families are asked for authorization for organ procurement (UNOS, 2018). In 1984, Congress passed the National Organ Transplant Act to establish the Organ Procurement and Transplantation Network (OPTN), a private, non-profit entity that retains experts on organ donation and maintain the list of individuals in need of organs (US Dept. of Health and Human Services, 2018). The OPTN is contracted by the federal government and overseen by the Public Health Service and a national policy board which establishes membership criteria and medical criteria for organ allocation. This contract is and always has been held by the United Network for Organ Sharing, or UNOS (USDHHS, 2018). Under UNOS, 57 organ procurement organizations (OPOs) are overseen by multiple government agencies and health care associations and are the only organizations recognized to legally recover organs from a donor in the United States (AOPO, 2018). If two physicians determine a patient meets the criteria for brain death or circulatory death, and a trained organ requestor obtains authorization from the patient’s previously stated wishes or from the family, the primary physician contacts UNOS (UNOS, 2018). A computer algorithm based on UNOS policy determines to whom each organ donated will be offered (UNOS, 2018). Due to the careful system in place to maintain a potential donor’s individual rights, lack of trust of the U.S. healthcare system, and an opt in system, the U.S. lacks the number of donors it needs—currently approximately 100,000 individuals are waiting on an organ transplant (Steinbrook, 2007).


In contrast, Spain utilizes an “opt-out,” or presumed consent system (Miranda et al., 1999). Like in the United States, Spain defines brain death as the total loss of all brain functions, though in Spain it must be declared by three physicians uninvolved with the procuring or transplant of the organs (Miranda et al., 1999). Individuals in Spain must ask to be removed from the donor list, or they are presumed to have authorized donation. Nevertheless, families are asked for authorization to donate anyway; thus, despite an official presumed consent system, Spain in practice requires familial authorization (Matesanz, R., 2003). Much of the success of the Spanish system—noted for having the highest donation rate of any country and for having an continuous increase in donors over a ten year period—is attributed to the three-level system of organ donation (Matesanz, 2003). The Spanish National Transplant Organization (ONT) is coordinated at three levels: national, regional, and in the hospital (Matesanz, 2003). The national and regional levels are nominated and paid for by Spanish government officials and are responsible for all policy decisions (Matesanz, 2003). The third level, in the hospital, requires a hospital transplant coordinator in every hospital approved to do transplants; this role is filled by a physician who works with a team of nurses and reports to the hospital director (Matesanz, 2003). Many of the coordinators also work as anesthesiologists or other positions directly involved in donation and transplants (Matesanz, 2003). In addition to conducting ongoing brain death audits, coordinators and related personnel receive continued medical training.(Matesanz, 2003). Perhaps most significantly, Spain launched sustained efforts to improve education about organ donation to the general public, including a twenty-four hour hotline, periodic meetings of journalists, hospital trainings on effective communication, and management plans for negative publicity (Matesanz, 2003). Spain’s system to increase organ donation is made successful not only by its presumed consent model, but also by the implementation of extensive educational campaigns as well as double-duty physicians acting as transplant coordinators.

Closing the Gap

The U.S. currently fares better in donation rates than some nations worldwide, but it still falls behind nations like Spain where an opt-out system in combination with training and public awareness campaigns have raised donor rates. If the U.S. were to adopt such a system, questions such as the necessity of familial consent and the logistics of opting out would arise. Kennedy et al. raises the question of the moral justifiability of blocking a policy that could narrow the gap between needed life-saving organs and availability of those organs (1998). In the U.S. alone, 100,000 individuals are waiting on an organ transplant (Steinbrook, 2007). However, the innate American culture of individualism stands out as a blockade to any such legislation. Langone and Helderman point out that “selling” an opt-out policy regarding donating something as individualistic as one’s own organs, even post-mortem, would face fierce opposition in US society (2003). Additionally, if it was not legally required to consult families of individuals who did not opt-out, there may be legal conflicts if a family decides they do not want the deceased individual’s organs donated. Instead, it may be best to implement a mandated choice policy. While it does require individuals to make a choice regarding their donor status, it is more difficult to argue that it violates individualistic rights. Mandated choice is designed to honor, as wells as necessitate, individual choice, potentially satisfying the competing moral dichotomy of individual freedom versus beneficence toward others. Despite the downside that mandated choice precludes the possibility of familial authorization post-mortem, the option appears to be the lesser of two evils.

Both countries discussed, and every country worldwide, face disparities between available and needed organs. As life expectancy, and thus the population of individuals who may suffer from organ malfunction and failure, continue to increase, the gap will continue to widen. This gap is hard to close because of the limited donor pool and short “shelf life” of donated organs. However, if efforts are made to maximize the turnover from potential donor to donor, countries can begin to narrow this gap. To do so, each country must match their organ donation system with cultural and religious considerations. Perhaps more importantly, the benefits of organ donation must become common knowledge.

This article was written by Heather Cozzie of Wake Forest University. References and Acknowledgements can be found in the first issue of our journal under "Current Issue"

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