As Wales prepares to become the first country of the United Kingdom to introduce an opt-out system for organ donation, a doctor writing in The BMJ this week, says support for such a system "is well intentioned but misguided."
Adnan Sharif, a consultant nephrologist at Queen Elizabeth Hospital in Birmingham, argues that even countries with opt-out systems have large waiting lists for transplants, and believes that more radical solutions are needed to increase organ donation.
From a British perspective, opt-out systems may not be a panacea for several reasons, he writes. For example, the Organ Donor Register is a register only of interest: being registered is not a commitment to donate, and not being registered is not a commitment not to. In fact, he points out that most deceased organ donors in the UK were never registered, and 59% of the 1,320 deceased donors last year were not originally registered.
"Therefore, having more names on the register with an opt-out system does not automatically translate into more organ donors."
He also argues that it is meaningless to change to an opt-out system without a change in attitude. "We still allow families to over-rule the wishes of their deceased loved ones despite them giving explicit consent in life," he writes.
Furthermore, black, Asian, and other minority ethnic people are under-represented as organ donors, "and switching to opt-out will not tackle this apathy," he adds.
Another concern is that countries with opt-out systems have fewer living kidney donors, which accounted for 34% of kidney transplants in the UK last year. This, warns Sharif, "would jeopardise the chance of transplantation for some of the most desperate patients."
He believes that we should not be restrained to a narrow view of just two options - opting in or out - and that we should consider more radical solutions, such as prioritising registered donors to receive organs.
"We celebrate the generous giving of organs, but we must also start rewarding the actual willingness to give, he says. "Apathy stems from a lack of interest, and we must stop kidding ourselves about a generalised lack of awareness."
He believes a more radical jolt to the consent process and registration system, rather than opt-out, is the best solution to achieve significant culture change. "Our message to unwilling donors must be clear: if you are happy to receive organs you must be willing to give. There are no legitimate excuses for hypocrisy," he concludes.