England made organ donation the default, so why are fewer families saying yes?

Source: The Conversation – UK

England changed its organ donation law in 2020. All eligible adults are now presumed willing to donate their organs after death unless they opt out. The change was intended to increase the supply of donated organs, but 8,746 people in the UK are still waiting for a transplant, and just 1,650 transplants have taken place since April 2026.

This year, NHS Blood and Transplant, which manages organ donation in England, issued an urgent appeal after donation fell by 9%. So why has opt-out not delivered?

Opt-out is often held up as one of nudge theory’s big successes. A widely cited 2003 paper found that countries using it had higher donation rates. But recent studies have not supported that advantage.

To understand why the change has not had the expected effect, it helps to look at how the law works. Under England’s system, every eligible adult is treated as a donor unless they record a decision not to be. If you do nothing, you are classed as having “deemed consent”. (Confusingly, you can still opt-in by registering a wish to donate.)

It is also a “soft” opt-out, which means your family has the final say. That makes conversations with relatives just as important as anything on the register, because a clear message from you, whether through the register or over dinner, tells them what you wanted.

The figures show what happens in practice. In England, 39% of eligible people have opted in and 4.3% have opted out. The remaining 56.7% fall under deemed consent.

That last group is important because families often rely on what they know about the person’s wishes. When someone had opted in, families agreed to donation 87% of the time. Under deemed consent that falls to 46%, and it is 0% when the person had opted out.

Across all cases, family consent has fallen from 69% in 2020–21 to 59% in 2024–25.

Why do families say no?

Why are families more likely to say no when consent has only been assumed? One possibility is that relatives are less certain about what the person wanted.

A recent study found uncertainty was higher under deemed consent, but that did not explain the lower consent. Instead, the factor that did explain the difference was “anticipated regret” – how bad relatives expected to feel if they made the wrong decision by not consenting.

The same study found that the person’s own views also affected whether they agreed to donation. If that person feels negatively about donation, they are less likely to agree.

Consistent with this, a recent study showed that organ recovery rates are identical under opt-in and opt-out, and that opt-out is only advantageous when the deceased has not expressed an opinion (deemed consent) and family members don’t have a strong view on organ donation.

Meanwhile, more people are leaving the register. Opt-outs rose from 0.6 million in 2019 to 1.5 million in 2020, when the law changed, and reached 2.9 million in 2026. Opt-ins have grown too, from 23.6 million in 2017 to 28.7 million in 2026, but opt-outs have grown much faster in proportion.

Researchers have suggested another explanation: the “lone-wolf effect”. Seeing others leave a register, or hearing negative views, pushes people to opt-out more strongly than seeing others opt in draws them in. This is known as the good-shepherd effect.

The rise in opt-outs is consistent with this explanation, although it does not prove that the effect is responsible.

Opt-out may also change how people think about organ donation. To some people a gift starts to look like state-sanctioned theft, while to others it becomes something mundane and everyday. Either change could make people less likely to opt in and more likely to opt out.

Living donors

Deceased donors are not the only source of organs. Living people can give a kidney or part of their liver – and in some countries, part of a lung – to a relative, in response to a public appeal, or to a stranger with no appeal at all. Kidneys are the most needed organ, so living donors matter a great deal.

In 2025–26 there were 826 living donors, mostly kidney donors. In the same year, 7,203 people were waiting for a kidney, 138 of them children.

Opt-out may also be contributing to the problem. One study linked it to a 29% fall in living donation, especially of kidneys. One explanation is that people may assume the opt-out system has already dealt with the shortage, reducing the incentive to become a living donor.

Countries that have adopted opt-out, or are considering it, such as Germany, can learn from England’s experience. One priority is to make clear that people can still register their wishes to donate, and to encourage them to do so.

People also need to be encouraged to tell their families what they want, since relatives are involved in the final decision. Health services also need to understand why some people oppose donation and address those concerns.

They should also monitor whether rising opt-out rates lead more people to opt out, and make sure living donation is not overlooked. Without those measures, changing the law may do little to increase organ donation and could have unintended effects.

Eamonn Ferguson receives funding from NHS Blood and Transplant (NHSBT) and the National Institute for Health and Care Research (NIHR). He is also an Honorary Professor of Health Psychology at NHSBT and has provided behavioural insights and evidence to the NHSBT “For the Individual Assessment of Risk” (FAIR) project.

Original source: https://analysis1.mil-osi.com/2026/10/09/england-made-organ-donation-the-default-so-why-are-fewer-families-saying-yes/