With Renewed Calls for Presumed Consent, Let's Look at the Donation and Transplant Rates of Opt-In vs Opt-Out Countries

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Abstract

Organ donation rates vary dramatically around the world, even among countries with mature donation programs. Healthcare policy makers, regularly point to the apparent effectiveness of countries with Opt-Out donation laws (also known as Presumed Consent) in contrast to Opt-In donation laws.

Unfortunately, the results of moving to Opt-Out have not been shown to substantively increase donation in lower donation rate countries [6] and Opt-In has been demonstrated to perform as well or better than Opt-Out[1]. Further, Wales, the most recent adopter of Opt-Out, showed an intial increase in Donors per Million (DPM) from 19.6 to 20.9 in its first year, but are projected to see a decrease in its second year to 17DPM.

While it is intuitive that Opt-Out should result in significant increases in donation, the implementation of the law belies this presumption. Ultimately, even Opt-Out countries prove reluctant to conclude that organs of the deceased are property of the state and family wishes to not donate are routniely followed, despite the law [7]. This is known as "Soft Opt-Out", and is the international standard of practice. Thus, this legal backdrop calls for an analysis of donation rates across countries with mature donation programs and "normalizing" (nDPM) the international standard of Donors per Million population to incorporate widely varying regional death rates between regions.[9].

An analysis of Opt-In vs Opt-Out donation and transplantation rates normalized for death rates illustrates that Spain, continues to lead the world with a nDPM of 41.6. However, when the countries are compared based on transplant rates, the US is the world's leader' (assisted by a high Living Donation rate).

The variation identified in this international analysis can also be seen even more dramatically in an analysis of donation and transplantation across the US States.

Six US states that are large enough to qualify for the international rankings exceed the best international donation and/or transplant rates including: Pennsylvania, Texas, Arizona, Utah, California, and Minnesota.

The data and cited analyses illustrate that the legal framework underlying donation is not a definitive determinant of donation success. That is more likely influenced by national investment in the donation system[10] and cultural factors, such as religion (6 of the leading Opt-Out countries range from 66-94% Catholic), a topic which deserves greater study.

References:

1. IRODATNewsletter 2016 Report; http://www.irodat.org/img/database/pdf/NEWSLETTER2016_SecondEdition.pdf.

2. European Commission Journalist Workshop on Organ Donation and Transplantation; http://ec.europa.eu/health//sites/health/files/blood_tissues_organs/docs/ev_20141126_factsfigures_en.pdf.

3. US Organ Procurement and Transplant Website; https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/.

4. US Organ Procurement and Transplant website; https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/.

5. US CDC National Vital Statistics Report for 2014;https://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_04.pdf.

6. Rithalia, A. et al (2009) Impact of Presumed Consent on Donation Rates: a systematic review: British Medical Journal;338;a3162.

7. Organ Donation and Transplant Activity: Wales; https://nhsbtdbe.blob.core.windows.net/umbraco-assets/1518/wales.pdf.

8. Boyarsky, B. et al (2011) Potential Limitations of Presumed Consent Legislation: Transplantation; Volume XX, Number X.

9. Sheehy, et al, Investigating Geographic Variation in Mortality in the Context of Organ Donation, The American Journal of Transplantation; 2012;doi: 10.1111/j.1600-6143.2011.03981.

10. Presumed consent: a distraction in the quest for increasing rates of organ donation BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c4973 (Published 18 October 2010) Cite this as: BMJ 2010;341:c4973.

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