Ethical Implications of Current Organ Donation Systems
by Xiwen Liang
Clinical organ transplantation saves millions of lives but also poses profound ethical challenges at nearly every stage, from identifying candidates for transplants to allocating scarce organs for equitable treatment and distribution. While both organ donors and waitlist candidates have increased in the past few years, the persistence gap between supply and demand makes rationing inevitable [1], treating moral tensions around fairness, autonomy and societal obligations. Here, we’ll examine the ethical dilemmas inherent in the transplant process, particularly in one of the two most critical stages, donor consent, by examining how different systems of consent have been used around the world and their ethical applications.
There are two commonly used organ donation systems: opt-in vs. opt-out. The opt-in system, where organs are donated only after one has given clear consent for donation. This system is used in the United States, and several other countries such as Canada, Denmark, and the Republic of Ireland. However due to the visible gap between the number of organs available and the number of patients in need, some countries, such as Spain, France, Chile, and Singapore, utilize an opt-out system, where individuals are presumed to donate after death unless explicitly stated otherwise.
While at first glance, the opt-out system may seem to be the most obvious solution to close the gap between the resources and the needs, there are actually several ethical factors that come into play when looking at whether or not the system is ethical. Many religious and socio-cultural beliefs oppose organ donation, viewing it as a violation of bodily integrity or as disrespectful to the dead. Additionally, in the case of religious belief that was not known about the deceased, family members should have the right to dispose of the remains that suit their belief. With the opt-out system, this right of family members will be easily negated, hence unethical. The opt-out system, if it is not a publicly educated policy, may appear to be untransparent and strip away chances of one to decline the donation. Ultimately, the opt-out system, which in large part revolves around the idea of presumed consent, is unethical. The question of whether or not presumed consent can be seen as consent raises ethical debates. In many countries, the law of organ donation is not publicly educated, meaning that many people may not even realize that they must actively opt out if they wish to retain control over their bodies after death, implying that in this case, the consent is not informed nor volunteered. This leads to the violation of autonomy, as presuming consent may have the power to override personal, religious, or cultural beliefs, even if the individual would not have agreed.
One may argue that if the situation is made clear to the individual and family members at the bedside, the barriers could be avoided. However these barriers are not unavoidable without the premise of time. With a topic with a premise of assumed death in front of the individual and their family, it will be hard to obtain one’s true will regarding organ donation, and in some senses, it may even lower the chances of willingness to donate.
On the other hand, an opt-in system overcomes these ethical problems. This system alleviates people’s distrust of the healthcare system regarding organ donation consent, as a clear statement of consent must be obtained before the procedure. Further, by requiring individuals to register as donors ensures that organ donation reflects a deliberate choice rather than an assumption. This safeguards autonomy, reduces the risk of violating personal rights to their body, and families and communities are also more likely to feel that decisions were made with the donor’s knowledge and approval, preventing potential mistrust in transplant programs.
In addition to the protection of autonomy, opt-in systems align with the principle of non-maleficence by minimizing the possibility of psychological or cultural harm to individuals and families who might otherwise feel violated by presumed consent. As said before, an opt-out system can easily violate an individual's integrity, and they may feel pressured to not opt-out as the societal norm may be to stay in the system; nonetheless, both of these scenarios violate one’s autonomy as a consent given under pressure is not real consent.
However, while ethically stronger, proponents may argue that an opt-in system results in a lower donor registration rates compared to opt-out systems, raising the tension with the principle of beneficence, since fewer organs means fewer lives saved. Arshad et al., after comparing 35 Organisation for Economic Cooperation and Development countries’ kidney donation (17 opt-out and 18 opt-in) and transplant rates, concludes that there are no significant differences in the total number of deceased organ donors across countries with 20.3 donors per million population(PMP) in opt-out and 15.4 PMP in opt-in countries. However there exists a significant difference in the numbers from living donors, with 4.8 PMP in opt-out and 15.7 in opt-in. In the end, Arshad et al. concludes that there are no overall differences between the total number of transplantation rates, suggesting that even though there may be a difference in the source of organs between the two systems, the overall transplantation rate does not differ [2]. Concluding that with all ethical implications and data support, opt-in systems should be the choice for organ donation systems.
Citation:
U.S. Department of Health and Human Services, Health Resources and Services Administration. Organ Donation and Transplantation. Health Systems Bureau, last updated 18 Aug. 2025, data.hrsa.gov/topics/health-systems/organ-donation.
Arshad, Adam, Benjamin Anderson, and Adnan Sharif. “Comparison of Organ Donation and Transplantation Rates between Opt-Out and Opt-In Systems.” https://www.kidney-international.org/article/S0085-2538(19)30185-1/fulltext