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Today, the Welsh government has published proposals to change the way organ donation is organised from an opt-in to an opt-out system. The soft opt-out system they propose would allow people to register their preference not to donate, and would include some flexibility so that families can still refuse that their loved one’s organs be donated after they have died. The Welsh government said that a bill will be introduced in 2012, legislation in place by 2013 and the system up and running by 2015.

8,000 people per year need a transplant, only 3,000 operations are carried out, and more than 1,000 people die each year while waiting for a transplant.

In the UK, around 8,000 people per year need a transplant, only 3,000 operations are carried out, and more than 1,000 people die each year while waiting for a transplant. Despite the fact that repeated surveys have shown that a significant majority (about 90%) are in favour of organ donation, less than a third of citizens are on the donation register. If people believe in the practice in principle, why do they not add their names to the register?

The mismatch between the survey data which tells us people are supportive of organ donation and the low number who register, strongly suggests that the reason is not unwillingness to donate. It may be as simple as people not getting round to it, but many people don't get round to making much-needed wills either. It seems likely that many of us aren't keen to contemplate our own deaths. There may even be fleeting flickers of superstition that the possibility that preparing for death might bring it about.

If this is the case, shifting to a system of presumed consent is surely a good idea. This is a perfect example of Nudge in action – change the choice architecture to one of presumed consent, reflecting what we know about people’s support for organ donation, and the inertia of the public is bypassed to ensure that as many people as possible donate their organs after death.

After a taskforce report in 2008, the UK government decided not to go with an opt-out system. Since then, a number of other measures have been implemented or proposed to increase the number of registered donors.

Earlier this year, a soft Nudge was introduced with the addition of a compulsory question about organ donation to the driving licence application form. This idea behind doing this is to get more people to sign up to the register by making it something embedded in what they are already doing. Although it might help a bit, this sort of measure is pretty pale in comparison to the Welsh proposal.

Last month the Nuffield bioethics committee recommended that the NHS should pay the funeral expenses of those who donate their organs, raising ethical questions and bringing the suggestion that this could be the beginning of a slippery slope towards payment for donation. Such a move certainly brings the possibility of destabilising the altruism currently intrinsic to the donation of organs.

Arguably, the opt-out system undermines altruism, given that it bypasses the making of an active decision to do something selflessly. But if the opt-out system enables people to act on something they agree with, and at the point of their own death to give life to someone else, this is surely a good thing to do, regardless of whether it meets a tight definition of altruism.

Join the organ donation register here.


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