The Decision to Donate

Health & Wellbeing Editor Ella Lewis, LVI, on how organ donation is not a case of cut and shut.

Ella Lewis

Health & Wellbeing Editor, 2025

Artwork by Lorenza Rees

Deputy & History Editor, 2025

The organ shortage is - arguably - one of the greatest health care problems affecting the UK today. There are big questions over whether the current laws on organ donation are appropriate for fulfilling our collective needs. The organ crisis raises a question about freedom:

should the decision to donate fall to us as individuals, or to the NHS?

Currently, over 7,900 people await an organ transplant in the UK. The waiting list is the highest it’s been in ten years and, annually, hundreds die while waiting. With the demand for organs massively outweighing the supply, thousands of people are unable to receive the treatment they so desperately need.

One cause of the lack of organ donors is that you must die in a specific way for your organs to be suitable for transplantation. Usually, you must die in a hospital where life support machines are utilised to maintain oxygen supply to the organs until they are removed for transplantation. The two main types of death that permit the deceased to be a donor are brainstem death and circulatory death. The NHS states that brainstem death is ‘when a person on an artificial life support machine no longer has any brain functions’ meaning ‘they will not regain consciousness or be able to breathe without support’. Circulatory death is when the patient has been treated in the ICU for a while, but their death is inevitable, so medical interventions which prolong this are removed and the heart stops beating.

Only 1% of people die in conditions allowing them to donate, hence there being few people viable to be a post-mortem donor. The lack of medical equipment involved in preserving and transplanting organs also means that hospitals are not optimising the number of organs used for transplantation.

There are also large numbers of people who opt-out of organ donation. Misinformation around the process is one of the main causes of this; many have mistrust in the medical industry and fear that, if considered a willing donor, healthcare professionals may not do everything they can to save their life as using their organs for transplantation may be a priority. However, the NHS promises that their ‘duty of care’ means that ‘every effort will be made to save your life above all else’. Others are opposed to donation simply due to feeling uncomfortable with the idea of their organs being inside someone else. Some opt-out due to cultural and religious beliefs, mostly involving bodily integrity and how the body is handled after death.

With Wales being the first country in the UK to introduce and reap the benefits of an ‘opt-out’ system for organ donation in 2015, the rest of the UK has since followed suit. This system, known as ‘deemed consent’, means that unless you are part of an ‘excluded group’, or have opted out, you are automatically considered a willing donor. The groups exempt from this law slightly differ in each country. In England, Wales, and Northern Ireland, excluded groups include people under 18 years old, visitors, and people who have lived there for less than 12 months before dying.

Initially, this new system had a positive impact on transplant activity. For example, the year after the opt-out shift in England, there were 296 additional donors due to this law change. This was around a third of all donors! However, one may argue this opt-out system has proven to be insufficient for the needs of patients awaiting transplants as the organ crisis continues to affect the 7,900 people who await vital treatment.

If organ donation laws in the UK meant that post-mortem organ donation was mandatory, everyone living there for more than 12 months would be required, if they died in the correct circumstances, to be a donor. Clearly, there are several ethical arguments against this. However, once hearing of the impact this could have on this healthcare crisis, this option is near impossible to ignore.

Between 1st April 2023 and 21st March 2024, 6,794 people died in the conditions that made for a viable post-mortem donor. However, there were only 1,510 actual donors in total that year. While other technicalities may have prevented some donations, around 72% of potential donors could not be considered to donate. A big contributor was families refusing donation, with the family consent rate at 61%. Families of potential donors currently have the power to override the deceased’s decision, even if they had specifically opted in. This means that each year, many donations cannot be completed due to objection from families. If organ donation was mandatory, all possible donors would be treated as consenting and there would be a huge increase in donations, meaning more people could receive transplants faster and ultimately, fewer people on the transplant waiting list would die each year (418 deaths in 23/24). From a purely statistical view of transplant activity, this policy change seems highly beneficial and has the potential to contribute to saving hundreds of lives each year.

However, if organ donation was mandatory, this would seriously violate the role of autonomy in medical ethics. Upholding autonomy means that doctors must respect patient’s treatment decisions and with a mandatory system, this would not be the case. Even though there would be a benefit to society by increasing transplants, this would not outweigh the cost of people’s bodily integrity - a basic human right.

The NHS aims to provide free available healthcare for all and, while this is not the case due to the current transplant waiting list, making post-mortem organ donation mandatory may be regarded as exploiting UK citizens. Perhaps free healthcare would no longer be provided if we were forced to pay the price of losing our autonomy?

However, a mandatory system could help reduce some of the stress for the deceased’s’ families as the weight of the responsibility to ensure that what they would have wanted takes place can be emotionally heavy in addition to the mourning of a family member. Making important decisions while grieving is strongly advised against, as the process of grieving creates such a big emotional weight, making the decision making harder. Without the added pressure of making this important decision, family and friends could more easily find comfort in the positive outcome of lives being saved from the otherwise saddening situation of losing a loved one. They may even be able to feel a sense of purpose and pride in this time of loss without the stress of doing the right thing.

However, for families opposed to organ donation, this would have the reverse effect. Families may feel doomed and powerless as they cannot help their loved one receive the respect and treatment, they are supportive of, transforming an already overwhelming situation into a darker, more unbearable one. It would also discriminate against individuals and families who practice religions that do not permit organ donation and would also be discriminatory towards minority ethnic groups, which have some of the lowest donation consent rates due to cultural beliefs and social norms. Mandatory post-mortem organ donation could also de-humanise many deceased patients by suggesting they are seen by the NHS as purely a product for organs to transplant and not honoured with appropriate respect.

I don’t believe that post-mortem organ donation should be made mandatory in the UK as the ethical argument of loss of autonomy and personal integrity is stronger than any benefit mandatory donation would have to the healthcare system. Mandatory organ donation would not only lead to unhappy UK citizens but would be an act of discrimination against certain religious and ethnic groups in society; a personal attack on these individuals. Instead of a law change to a mandatory system, there is much else the NHS and UK government can do to help tackle the organ crisis, such as targeting misinformation and ensuring proper education on organ donation is provided to all UK citizens so individuals can make informed decisions that are not influenced by donation myths. A mandatory system may not be a viable solution to aid the 7,900+ people in the UK, who await a transplant, but alternative action needs to be taken to help solve the organ crisis.