There is currently a major shortage of organs available for transplant in the UK. Over 6,500 people are on the waiting list for organ transplant, and whilst there are half a million deaths in the UK per year, fewer than 6,000 people die in circumstances where they can donate their organs. This is creating a widening gap between the number of people on the waiting list and the number on the donor register.

An ongoing debate surrounding the topic of organ donation is whether an opt-in system or an opt-out system allows the clinical need to be better met.

Under an opt-in system, the public can register their interest in becoming a donor. This can be implemented as a 'soft' system , where relatives can oppose donation even when the deceased has opted in. Alternatively, it can be employed as a 'hard' system in which any wishes of the relatives are superseded by those of the deceased.

An opt-out system is based on presumed consent; everyone is an organ donor unless they explicitly refuse. This can also be divided into 'soft' or 'hard' systems, depending on whether involvement of family consultation is sought.

There is a growing debate over which system is better due to technological advancements, which make it more possible than ever for people to receive and survive a transplant operation. Additionally, the kinds of illness resulting in organ failure are on the rise¹.

Yet while both systems have their benefits, it is important for us to recognise the possible ethical implications of each.

At face value the opt-in system, currently practised in the majority of the UK, seems to give the public more explicit consent as to whether they want to donate their organs after death, therefore providing them with a greater sense of control. This protects people who do not want to donate from donating based on presumption.

However, considering 59% of the 1,320 deceased donors in 2014 were not originally registered for organ donation², there is dispute as to whether this applies in practice. How much weight does the organ register actually have in patient consent?

Even when assuming an opt-in system does give more consent, research suggests that the opt-out system significantly improves the rates of organ donation. There has been an increase in donation rates of up to 25% in countries such as Austria and Singapore³, which surely enables doctors to be more able to provide best care for patients in need of organ transplant.

So which is better? 

Many leading organisations such as the BMA advocate a change in the UK from voluntary donation to a system of 'soft' presumed consent, where consent of the family is sought alongside presumed consent of the deceased. Could this be an optimal solution to achieve the best of both systems? Wales introduced this system in December 2015, and people over the age of 18 are now deemed to have consented to organ donation unless they have opted out.  

Regarding the new system, Maria Battle, Chair of Cardiff and Vale University Health Board, has stated that 'there is so much more awareness of organ donation in our communities and it has encouraged families to have those vital conversations with their families and loved ones about their wishes at the end of their life'.

This suggests that not only has the opt-out system had an almost immediate positive impact on rates of organ donors, but also (regardless of which system is used) that there are benefits that come with encouraging families to speak about wishes surrounding donation before the death or loss of capacity of a loved one.

Are we actively encouraging the public to be more willing to speak about organ donation amongst families? In 2013, the UK was recorded to have one of the highest family refusal rates for organ donation. Based on this evidence, should we not be focusing our efforts on advancing a change in public attitude towards speaking about what happens to organs after death, rather than simple legislation?

Conversations surrounding organ donation with patients and their families are the 'powerhouse' behind increasing available organs. As doctors, we are in the privileged position to encourage these discussions. Let us not forget that approximately three people die each day in need of an organ transplant – and every conversation we have with patients about organ donation could potentially save a life.

The opinions expressed in this article are those of the author and do not necessarily reflect the views and policy of the MDU.