To ‘Opt in’ or ‘Opt out’? – Organ Donation in the UK

NHS 'Transplants save lives' website

NHS 'Transplants save lives' website

Organ donation is one of the miracles of modern medicine; the ability to transplant tissue from one person to another without rejection has brought dramatic improvements in the day to day lives of thousands of people, in many cases it is literally life-saving.

At present, however, the sad reality remains that demand outstrips supply. According to the Transplant Activity in the UK report for the financial year 2007/2008: 3235 transplant operations took place, but 7655 people were waiting for a transplant (up more than 6% from previous year), and 506 patients died while waiting for an organ transplant, (it is thought that this number could actually be as high as 1000 per year).

The debate that surrounds organ donation is fuelled by society’s moral obligation not to allow these people to die needlessly. When a person dies and they are not on the Organ Donation Register (ODR) and/or their family do not grant permission for their organs to be donated, then none can be used to help those suffering on the waiting lists.

The UK Government is desperate to improve the number of organs available for transplantation. In 2006 this led to the establishment of the Organ Transplant Taskforce, chaired by Elizabeth Buggins, in order to ‘identify barriers to organ donation and recommend actions needed to increase organ donation’.  Their most recent report The potential impact of an opt out system for organ donation in the UK, published 17th November 2008, has received widespread media coverage. With the aim to increase the number of people on the organ donation register, they examined potential benefits and the viability of a move from the current ‘opt in’ organ donation system, to a ‘opt out’ system where by every citizen in the UK is automatically registered to donate their organs when they die unless they actively decide not to.  

This post highlights relevant and useful online clips whilst briefly discussing the central ethical arguments presented by the report. It also complements this with suggested questions to use while discussing the topic.  

From an ethical perspective, the Taskforce concluded that society has a moral duty to boost donation rates and thereby improve the lives of patients by reducing their suffering. However, they were very specific when they stated that the “systems under which organs are removed for transplant are seen as morally acceptable… in other words the end cannot be seen to justify the means… the ethical goal in terms of organ donation is to acquire the maximum number of organs via a system that is seen to be morally acceptable and consistent with a society’s values“.  

In summary the report noted that an ‘opt out’ system move away from ‘informed consent’ towards ‘assumed consent’.  Public awareness of consent issues came to prominence with the organ retention scandals at Alder Hey Royal Children’s Hospital and the Bristol Royal Infirmary (Also see BBC News ‘Hospital to bury unclaimed organs’) . The subsequent Human Tissue Act 2004 has since made “consent a fundamental principle in the removal, storage and use of body parts, organs and tissues“. The report also noted that “It may not be appropriate to assume that all those that have failed to opt out have no objection to become donors“.

The Taskforce therefore concluded that a move towards an ‘opt out’ system “should not be introduced in the UK at the present time” and noted “that such a system has the potential to undermine the concept of donation as a gift, to erode trust in NHS professionals and Government, and negatively impact on organ donation numbers. It would distract attention away from essential improvements to systems and infrastructure and from the urgent need to improve public awareness and understanding of organ donation. Furthermore, it would be challenging and costly to impliement successfully. Most compelling of all, we found no convincing evidence that it would deliver significant increases in the number of donated organs.”


BBC Radio 4 Today Programme interview with Elizabeth Buggins Chair, Organ Donation Taskforce (17th November 2008 - 00:04:21)

In the above Radio Interview Elizabeth Buggins highlights the main reasons for why the Taskforce rejected the proposed move to an ‘opt out’ donor system.

  • There was little evidence that it would increase the number of donors, supported by evidence from Spain who has the best donor numbers in the world. No difference in the number of donations occurred in the 10 years following Spain’s introduction of an ‘opt out’ system in 1979. When, however, they increased the number of donor coordinators and organ retrieval teams, and ran a publicity campaign, the number of organ donors did increase. These actions are now being undertaken by the NHS in the UK.
  • Evidence from recipients and donors suggested that the concept that the organ is a ‘gift’ and is given through an altruistic act is very important and that presumed consent undermines these concepts.
  • Evidence suggested that an ‘opt out’ system would erode trust in doctors.
  • An ‘opt out’ system may divert attention away from what would make most difference – actions mentioned in first point.      

The Health Secretary Alan Johnson has announced a public education campaign aimed at adding 20 million people to the ODR by 2010 and increase this number to 25 million by 2013.

Gordon Brown's reponse to the Organ Donation Taskforce report

Gordon Brown responds to the Organ Donation Taskforce report. BBC News 'Brown backs presumed consent' (17th November 2008 - 00:00:56).

In the above BBC online clip, Gordon Brown who supports a proposed move towards on ‘opt out’ system, states that he is “not ruling out a change in the law”, as he will review the situation in the future to assess how successful the proposed actions have been.

The following BBC online clip is an excellent resource as it includes interviews with Dr Vivian Nathanson, British Medical Association (FOR an ‘opt out’ system) and Professor John Fabre, Kings College London (AGAINST an ‘opt out’ system). This online clip is particularly useful as it contains responses from both of the interviewees to a specific set of questions (see below). For teaching purposes it would be useful to set students an exercise to answer these questions and identify possible ‘for’ and ‘against’ arguments prior to watching the clip. Their answers could then be compared with the responses of the interviewees.


  • Will presumed consent save lives?
  • Can’t the current opt-in system just be improved?
  • Is presumed-consent informed-consent?
  • Should the Government say who our organs belong to after we die?
  • If you opt out, how will it be ensured that your wishes are adhered to?
FOR (Dr Vivianne Nathonson) and AGAINST (Professor John Fabre) arguments for an 'opt out' donor system

FOR (Dr Vivianne Nathanson) and AGAINST (Professor John Fabre) arguments for an 'opt out' donor system (17th December 2008 - 00:03:14)

The next BBC online News clip provides a short summary of the this debate. A patient who suffers from Cystic Fibrosis and has been waiting for 16 months for a double lung transplant, describes why she is in favour of an ‘opt out’ donor system and the difficulties she has coping with her condition.  The news clip also explains why there is the current shortage of donors and hears the views expressed by Dr Kevin Gunning (Intensive Care Specialist) why an ‘opt out’ systems raises significant issues regards donor consent. (Also see BBC News ‘Q&A: Organ Donation Laws’)


BBC News 'Organ donation decision rejected' (17th November 2008 - 00:01:25)

Channel 4 News currently has two very useful online clips, which can be accessed below (Note – these may be only available for a limited time only). The first provides a good summary of the issues that surround an ‘opt out’ donor system and the second is a debate between Dr Evan Harris MP, Liberal Democrat Science Spokesman, and Professor John Fabre, Hepatology and Transplantation Kings College London. Professor Fabre makes a particularly strong point when asked by presenter Jon Snow: “Is there any moral objection to the idea that people should simple opt out of giving their organs?“, to which Professor Fabre replies: “For me, the moral objection is that the law is essentially one where you have an absence of an objection, which has never been an acceptable form of consent in clinical practice“.


Channel 4 News coverage (17th November 2008) 1st online clip (News summary) 00:02:23 and 2nd online clip (Debate - Dr Evan Harris and Professor John Fabre) 00:05:52

The following questions would be useful when discussing the issues that are presented in the online clips above (When answering these questions, consider the position and feelings of the following people: the donor; the donor’s family; the recipient; the recipient’s family; doctors; other healthcare professionals; and the Government):

  • What are the advantages and disadvantages of having an opt-in donor system?
  • What are the advantages and disadvantages of having an opt-out donor system?
  • What other ways might there be to make greater numbers of organs available?
  • Will society always have to rely on organ donations to carry out transplantations?
  • Why do doctors need consent to take a person’s organ?
  • Should the individual or the state decide what to do with people’s organs?

In one further online clip, coincidentally occurring in the same week as the presumed consent debate, an insight is offered into the future of organ donation and how scientists are developing medical techniques to improve treatment.

BBC News online clip ‘Windpipe transplant breakthrough’ (19th November 2008 – 00:01:28).

The ethical issues surrounding organ and tissue ‘transplantation’ can be found extensively in the UK curriculum: GCSE AQA Biology (4411),  Edexcel Unit B1 Science (2101), OCR Additional Science A (J631), OCR Additional Science B (J641)OCR Biology B (J643), WJEC Biology (1010);  and A level OCR Biology, WJEC Biology.


6 Responses to To ‘Opt in’ or ‘Opt out’? – Organ Donation in the UK

  1. EXPERTS advising the Government have rejected plans for a new system of

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