England's Opt-Out Organ Donation Law: Why Presumed Consent Hasn't Boosted Transplants

The Conversation examines England's 2020 opt-out organ donation law, its soft opt-out framework, and why opt-out has not delivered the expected boost in transplants. With thousands still waiting and a year of donation decline, the article analyzes the roles of families, living donors, and public policy in shaping outcomes.

• Consent is not simply a switch from opt-in to opt-out; family decisions remain crucial in many cases.
• England's system shows only partial movement toward opt-out, with 39% opt-in, 4.3% opt-out, and 56.7% deemed consent.
• Living donation has fallen in some contexts, potentially offsetting gains from opt-out, and could be affected by perceptions about the system.
• Policy lessons for other countries emphasize clear registration of wishes, family communication, and monitoring unintended effects.

Author: The Conversation

Overview of England's opt-out reform

England changed its organ donation law in 2020, adopting a soft opt-out model where adults are presumed willing to donate after death unless they opt out. The aim was to increase the organ supply, but recent figures show persistent gaps: 8,746 people in the UK remain on transplant waiting lists, and only about 1,650 transplants have occurred since April 2026. The urgency of the NHS Blood and Transplant appeal after donation fell by 9% highlights the ongoing challenge of turning presumed consent into more donations. The article delves into why opt-out has not delivered the anticipated gains and what this means for policy makers.

How consent operates in England

England’s system treats every eligible adult as a donor unless they record a decision not to be. If no action is taken, this is termed deemed consent, although individuals can opt in by registering a wish to donate. In practice this is a “soft” opt-out, meaning families retain the final say. The practical implications are clear: clear communication of an individual’s wishes matters for the family, as it can influence the final decision regardless of the register. The consent landscape in England shows 39% opt-in, 4.3% opt-out, and 56.7% deemed consent, according to the latest activity report.

What the data show about practice and outcomes

Across all cases, family consent has fallen from 69% in 2020–21 to 59% in 2024–25. When someone had opted in, families agreed to donation 87% of the time; under deemed consent that drops to 46%, and it is 0% when the person had opted out. This pattern underscores how the family’s knowledge of the person’s wishes can override the register, even in a system designed to increase donations. Studies cited in the article indicate that organ recovery rates are identical under opt-in and opt-out, and opt-out is only advantageous when the deceased has not expressed an opinion and relatives don’t hold strong views on donation.

Why families say no and what the research suggests

A key question is why families say no when consent is assumed. A recent study finds uncertainty is higher under deemed consent, but this alone does not explain lower consent rates. The primary explanatory factor is anticipated regret—how badly relatives expect to feel if they make the wrong decision. The deceased’s own views also influence whether families consent, with more negative personal views about donation reducing willingness. These findings align with a BMJ Open study showing that the opt-out framework changes family decision dynamics and that the actual recovery rates do not depend on opt-in versus opt-out policies.

Living donors and potential unintended consequences

Living donors remain a vital source of organs. In 2025–26 there were 826 living donors, primarily kidney donors, with 7,203 people waiting for a kidney (including 138 children). The article notes that opt-out may contribute to a 29% fall in living donation, particularly for kidneys, as people may assume the opt-out system has already addressed shortages, reducing incentives to donate while alive. This suggests opt-out could inadvertently depress living donation while failing to deliver the expected gains from deceased donation.

Implications for policy and future directions

Countries considering opt-out, such as Germany, can learn from England’s experience. The priority is to ensure individuals understand they can still register their wishes and to encourage conversations with families about those wishes. Health services also need to address reasons people oppose donation and monitor whether rising opt-out rates prompt more people to opt out. Equally important is ensuring living donation is not overlooked as a pathway to address shortages. The article argues that without these measures, changing the law may have limited impact and could generate unintended effects.

Conclusion

The English opt-out reform has not produced the expected boost in organ donation. Family influence, the dynamics of deemed consent, and a rapidly rising opt-out register must be understood in context. Policymakers should promote family discussions, maintain support for living donation, and track both opt-out rates and their broader social effects to avoid unintended consequences while exploring potential improvements for future reforms.