Does healthcare policy have a responsibility to nudge society in the direction of the greater good?

Canadians are generally thought of as very friendly and helpful people willing to give you the shirts off of their backs. The majority of them, when asked, are willing to give you their organs after they’re gone…just don’t ask them to put it in writing! One of the challenges that every province in Canada faces is the low percentage of Canadians that register to be organ donors.

It is not a question of whether organ donation is in the best interest of the greater good as a single donor can benefit up to 75 people and save up to 8 lives1. The question is why aren’t more Canadians registered donors?

In Canada, although the vast majority of Canadians support organ donation, an individual must actively register as a donor. This is known as an “opt-in” system. The decision (or lack thereof) to NOT be a donor is the default option.

This is in contrast to presumed consent or an “opt-out” system. In this system an individual must actively opt-out of being a donor. Those who do not opt-out are presumed to have given consent to the hospital upon their death to use their organs to help others. In this case the default option is to be an organ donor.

Decision inertia

When posed with the question of being an organ donor or not, Johnson and Goldstein 3argue that Canadians choose not to donate because that is the default option when registering with the Ministry. Their argument presents three ways in which defaults influence someone’s decision on whether or not to donate.

First, people believe defaults are suggestive of recommendations of the policy makers. If this is the case then the defaults should reflect the recommendation of policy makers, which is for people to become donors.

Second, making a decision involves effort, which can be stressful and unpleasant. This is understandable since there are undeniably few topics more stressful than contemplating one’s own demise. Not making a choice and deferring to the default option is effortless and painless. If a person does not want to make a decision due to the discomfort it brings, then the decision that best supports the greater good and the will of the majority should be the deferred option.

Third, defaults are also suggestive of the status quo. Given that the vast majority of Canadians support and would donate their tissues, this argument strongly supports that we should change the default option to donate.

This would explain why there is such a discrepancy in donation rate in culturally similar and/or neighbouring nations. Germany, with an opt-in system has an organ donation consent rate of 12% compared to 98% or higher in Austria and Belgium.3 This difference in consent rate is also reflected in the number of patients transplanted per million of population (PMP). In 2012 Germany’s transplantation activity was 53.3 PMP while Austria and Belgium were 87 PMP and 93.9 PMP 4 respectively.


The impact of changing organ donation to presumed consent did not go unnoticed in Wales. Later this year, Wales will join the progressive list of countries that have adopted an organ donor “opt-out” strategy. Through the Human Transplantation (Wales) Act 2013, hospitals in Wales may presume that individuals over the age of 18 that have been living in Wales for more than a year want to donate their organs at death unless they specifically object. The Government of Wales has touted this Human Transplantation (Wales) Bill 5 as “arguably the most significant piece of legislation passed by the National Assembly for Wales since it acquired additional lawmaking powers in 2011”.

Canada lags behind

It is an unfortunate truth that Canadians lag behind many other industrialized nations when it comes to organ donation, including the United States. Canada transplanted 65.2 organs per million people versus 86.2 4 for our American counterparts. The healthcare system in Canada has been a source of pride when we compare ourselves to our neighbours to the south, but organ donation is one metric that we are blatantly losing.

The simple fact is: if we can significantly improve the donor rate in Canada we will save lives. The simple solution is to change the default option on organ donation to align with the values and beliefs of Canadians.




Theo Versteegh

Theo head shot

Theo is a physiotherapist in London Ontario. He graduated in 1998 and has worked across Canada, in the United Kingdom and the Middle East. He is currently completing his PhD in Physiotherapy at Western University. His research focus is on exploring the role of the neck muscles in preventing concussion.