Kidneys and hearts and livers, oh my!

Kidneys and hearts and livers, oh my!

I’m sure it comes as no surprise that in most countries, there is a significant disparity between the demand and supply of organs for transplantation.[1] This pressure is becoming increasingly urgent as we stare into the face of an ageing population and the escalation of non-communicable diseases.[2] The scarcity of appropriate organs matches is not just a biological problem but also a practical one. In Australia, there is a requirement that deceased donors need to have died in hospital and only 2% of these deaths occur in circumstances that are suitable for transplantation.[1]

The Australian scene

It’s not all bad news. Australia has made commendable effort towards increasing donation rates. Between 2017 and 2018, Australia saw the national consent rate rise from 59% to 64% which has saved the lives of 1,544 Australians.[3] With the inclusion of living organ donors, 1,782 lives have benefited from transplantation.[3]

However, even for those with transplants, time still ticks. Transplanted organs have limited lifespans and only serve to extend the life of those living with organ failure. Just as there are many lives saved through donation, there are equally as many who remain on a wait list. Despite technology being able to assist a patient as they wait, sadly, some die waiting for a transplant.[3]

Donation outcomes against organ availability
Source: Australia New Zealand Organ Donation Registry 2015.[4]

Are we in or out?

Australia’s current system for registering as a donor operates on an opt-in basis whereby individuals can join the Australian Organ Donor Register with their Medicare Card number.[5] The limitations of the opt-in basis have raised a debate regarding transitioning to an opt-out system. In England, from 2020 onwards the law surrounding donation will be one of presumed consent where all adults will have by default agreed to be a donor unless they choose not to.[6] The opt-out system utilises the behavioural economic concept of bounded rationality where defaults or a status quo bias can nudge an individual towards making a particular choice. The idea is that a decision-maker is more likely to stick with the default state that involves less cognitive conflict, even if changing would make them better off.

Applying this concept to Australia’s current opt-in system, the default of not donating is the easier option which suggests a sub-optimal number of potential donors. Often, this is due to a lack of information about the donation process or the implication that a decision-maker will incur physical, cognitive and emotional costs in the course of changing their donation status.[7]

Globally, Spain is the recognised leader in terms of donation outcomes and employs an opt-out system.[8] But is this system really as effective as it seems? Even for Spain, the donation figures did not increase for the decade after the system was first implemented. In fact, it was the investment in new transplant coordination facilities and increased training of medical professionals that facilitated the rise of organ donations.8 Similarly, in Wales, the initial lack of increase in donors following the implementation of an opt-out system highlights the importance of public awareness and support.[9]

The conversation

Despite an individual’s stance on donating, in Australia and in the majority of presumed-consent countries, it is still the deceased individual’s family that has the final say.[3] Although the infrastructure for the donation decision may have an impact on consent rates, it is far more important that Australians are educated and aware of the donation process but also that if a choice is made, appropriate discussions have been held with family. Similarly, it may be more helpful to consider normalising the consideration of organ donation with patients undergoing end-of-life care. Policies targeting publicity and education to patients, their families, medical professionals and the general public may be able to effectively buffer the shortage in demand for organs.

[1] Organ and Tissue Authority (2018).  Progressing Australian organ and tissue donation and transplantation to 2022. Retrieved from

[2] Australian Institute of Health and Welfare (2016). Australian Burden of Disease Study: Impact and causes of illness and death in Australia 2011. Retrieved from

[3] Organ and Tissue Authority (2019). Progressing Australian organ and tissue donation and transplantation to 2023. Retrieved from

[4] Organ and Tissue Authority (2019). Progressing Australian organ and tissue donation and transplantation to 2020. Retrieved from

[5] The Department of Health (2018). The Australia Organ Donor Register. Retrieved from

[6] BBC News (2018, August 5). Opt-out organ donation ‘in place by 2020’ for England. Retrieved from

[7] Johnson, E.J. and Goldstein, S. (2003). Do Defaults Save Lives? Retrieved from

[8] Willis, B.H. and Quigley, M. (2014). Opt-out organ donation: on evidence and public policy. Retrieved from

[9] BBC News (2017, December 4) Wales’ organ donation opt-out law has no increased donors. Retrieved from