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We all know that organ donation saves lives, but only a third of us sign up to be donors. That鈥檚 why plans to move to an opt-out system of consent for organ donation across the whole of the UK are garnering broad support. Yet despite the idea鈥檚 popularity, it is unlikely to cut the numbers of people who die while on the organ waiting list. For that, we will need to look at other approaches.

Most of the UK currently works on an opt-in basis, meaning a person鈥檚 organs are only used if they have recorded their wish to donate on a register or told their relatives. This doesn鈥檛 meet our needs, though: nearly 500 people a year die while on the organ waiting list.

There is a seemingly obvious solution. If many people would be happy to donate, but just don鈥檛 get round to telling anyone, why not assume everyone has given consent unless they actively opt out? 聽This is an example of 鈥�nudge theory鈥�: making changes in default choices to remove our bias towards inaction. Spain uses an opt-out system and has one of the highest donation rates in the world.

British MPs debated the idea last week, with broad support for the change, and the government is already consulting on proposals for England to have what is known as 鈥渟oft opt-out鈥�, meaning that relatives can still say no. But in fact, the evidence doesn鈥檛 support the idea that any kind of opt-out system will boost donation rates.

Surprising fall

In December 2015, the same soft opt-out system was introduced in Wales, a place with a similar culture, health service and demographics to England. Against expectations, there were slightly fewer cases of organ donation the following year, dropping from 64 to 61.

These numbers are so small that it鈥檚 probably too soon to blame the new law 鈥� it may just be random fluctuation 鈥� but it still suggests we won鈥檛 see a significant rise if England adopts this system.

The question is: why isn鈥檛 it working? It鈥檚 not because relatives still have a veto. What is often not appreciated is that only a tiny fraction of deaths occur in circumstances that permit organ donation. Most of the time, the major organs are unusable because they have gone for too long without oxygen. The exception is those people who end up brain-dead and in an intensive care unit, supported on a ventilator that keeps their blood oxygenated and heart beating.

This happens in less than 1 per cent of all deaths. It usually arises due to a major head injury, such as from a car or motorbike crash, often involving a young person.

Life-and-death decisions

Hospital staff may just not have time to broach the subject of organ donation with the family or they may be too uncomfortable to do so. It is also understandable that some relatives will say no as they are likely to be in shock.

In Spain, which introduced its opt-out scheme in 1979, donation rates didn鈥檛 rise until 10 years later, when its national transplant service was overhauled and hospitals installed dedicated staff with .

Spanish hospitals are also . This might prove too controversial for the UK, where some newspapers seem to delight in assuming the worst of doctors when it comes to end-of-life decisions.

At the moment, the proposed changes in the UK appear to have enough support to go ahead. As long as they don鈥檛 reduce donation rates, this is probably no bad thing. But let鈥檚 not kid ourselves that they will abolish deaths on the waiting list. To achieve that, we are also going to have to make some more difficult decisions.