The opt-in donation system asks people in the U.S. to record their choice as an organ, eye and tissue donor. In Arizona, the DonateLifeAZ Registry hit a milestone by totaling more than 4 million registered donors in 2020. With the current opt-in system, the U.S. has one of the highest organ donation rates across the globe, with data showing the U.S. in the top five in the world in donors per million population. But why not an opt-out system instead in which everyone would be a potential donor?

Our system differs from the opt-out system some countries use, most notably Spain. By opt-out we mean the legal authority to recover organs from a deceased donor unless the person registered a refusal. It otherwise assumes a person agrees to organ donation.

For the U.S., the opt-in system works best and often outpaces countries with an opt-out system. There are 58 organ procurement organizations (OPOs) that service the U.S. and its territories. The top 12 of those U.S. OPOs—roughly one-fifth of the system alone—have more donors per million than all of Spain. Also, Spain’s high donation rate itself was only realized 10 years after the adoption of the opt-out system because it based many of its hospital strategies on the U.S.’s already established system. So, why do they need those strategies if everyone is already supposed to be a donor?

Your Decision to Register versus Family Authorization

While countries with an opt-out system appear to have less obstacles by not requiring their people to register, they do not act on an individual’s donor status as authorization for donation. These nations still require a family’s consent in addition to opt-out authorization. Spain’s system is better understood as a “presumed intent” system but not authorization. Donation conversations with donor families are still required before proceeding, which don’t always lead to saving and healing lives.

For context, cases in which Donor Network of Arizona (DNA) require next-of-kin authorization for donation to occur with donors who did not previously register, families decline donation an average of 54% of the time. That means donation would potentially decrease in Arizona if it were to rely on family consent—albeit a determination we accept with respect—rather than a donor making their own legally binding decision to offer the gift of life.

In the U.S., the decision to register as a donor cannot be legally overridden by anyone other than the registered donor. It is considered an end-of-life decision, much like a will. Also, under the current system, DNA can contact a potential donor family for authorization if legal next-of-kin finds that being a generous donor matches their loved one’s values if that person were not already registered. In Spain, documentation of refusal means legal next-of-kin can never be contacted. Therefore, by law, zero potential for donation exists in such a case.

The opt-in system is based on the Uniform Anatomical Gift Act (UAGA), first adopted in 1968. This system is founded on our country’s values of individual rights, autonomy and choice. Organ, eye and tissue donation is an end-of-life decision we respect, even if sometimes the answer is no.