On June 1, 2007, a Dutch reality TV show called De Grote Donorshow (The Great Donor Show) premiered on the channel BNN with a controversial premise: a terminally ill 37-year-old woman would donate one of her kidneys to one of three people who desperately needed a transplant, and viewers of the show would be able to send advice on who to pick via text message. Understandably, prior to its airing, the show generated much outrage among the Dutch population, with many public figures criticizing the unethical nature of the show’s competition. Some politicians even attempted to prevent the airing of the show (Chee, 2007).

 

     Before discussing what actually happens on the show and its impact, it is important to understand the nature of organ donation systems. Organ donation systems are broadly classified as opt-in or opt-out systems. Under an opt-in organ donation system, people must actively sign up to register their organs after death (McIntosh, 2014), while in an opt-out system, people are automatically registered to donate unless they specifically request before death for their organs not to be taken. Each system has its benefits and drawbacks; as Professor Eamonn Ferguson of the University of Nottingham notes, opt-in systems may result in inaction, where people who want to donate never make the decision, while in opt-out systems, patients who do not want to donate their organs may become donors (McIntosh, 2014).

 

     Back to the show: who does the donor choose? Once the audience sends their messages, the donor is allowed to make her final decision, but before she reveals her choice, the host interjects and reveals that the show is fabricated. While the three recipients are real patients who require kidney transplants, the terminally ill woman is an actor, and no donation was about to take place. Rather, the purpose of the show is to reveal the Dutch organ donation system’s pitfalls and focus attention on the chronic shortage of organs in the country. The host adds that it would’ve been too cruel to compel the patient to “play God” and pick between three potential recipients, especially in a reality TV setting.

 

     Despite the mixed reviews in response to the reveal, the impact of the show was crystal clear: the day after the show aired, 30000 people requested donor forms (“De Grote Donorshow”, n.d.). The show sparked nationwide discussion surrounding the country’s organ donation systems and how improvements could be made, and after years of deliberating and planning, the Netherlands officially switched to an opt-out system in 2020 under the Donor Act; under the new system, if an individual over the age of 18 wishes not to donate their organs, they must explicitly indicate their objection to becoming a donor after death (Statistics Netherlands, 2023). Data indicates that since the policy change, over 10.7 million people have recorded their donation choice with the Donor Registry, with a nearly even split between the “consent” and “no consent” choices; some also chose to delegate the decision to their next of kin (Statistics Netherlands, 2023).

 

     While the data offers valuable insight into the impact of the Donor Act, the question still remains: which system of organ donation is better? Proponents of the opt-out model may argue that it directly addresses the issues relating to organ scarcity by increasing supply and that as long as the general population is aware of the default option, the model is ethically viable. Experts like Dr. Dorry Segev, a surgeon at New York University’s Grossman School of Medicine, disagree with this reasoning, highlighting the opt-out model’s violation of bodily autonomy, a core pillar of medical ethics, by automatically assuming consent. Dr. Segev argues that the opt-out system “is not a magic bullet {...} the perception becomes, ‘We will take your organs unless you take the time to fill out a form.’ That’s a dangerous perception to have” (Brazier, 2016). To understand which system works better, Professor Ferguson and other researchers across three British universities examined the organ donation systems of 48 countries (23 opt-in and 25 opt-out systems) over the course of 13 years and analyzed variables like “overall donor numbers, numbers of transplant per organ and the total number of kidneys and livers transplanted from both deceased and living donors” (McIntosh, 2014).

 

     The team of researchers reported that the opt-out systems had the greatest overall number of organ transplants, and the opt-in systems had the greatest number of kidney donations from living donors (McIntosh, 2014). Prof. Ferguson states that opt-out systems may lead to an overall increase in organ donations, particularly livers and kidneys, from deceased donors, a decrease in donations from living donors, and that future studies on the topic must consider the varied mechanisms by which opt-out systems operate and the “beliefs, attitudes, and wishes” impacting people who choose either opinion (McIntosh, 2014).

 

     A third position argues that the opt-in/opt-out condition may not even be the most important factor in determining the number of available organs. According to Dr. Scott Halpern, a physician and bioethicist at the University of Pennsylvania, there are several other factors, like an efficient donor coordination network, which may play a larger role in ensuring organ donation requests are met (Graff, 2017). Dr. Halpern points to Spain’s organ donation framework, widely regarded as one of the world’s most successful, as an example; he argues that while Spain has an opt-out system, a number of other factors, like expanded criteria for organ suitability and strategic placement of donor coordinators in hospitals to interact with the families of potential donors, make a much larger contribution to the framework’s success (Graff, 2017).

 

     Constructing an organ donation system is complex and multifaceted. In addition to whether a country adopts an opt-in or opt-out system, factors like the number of healthy organs donated and coordination between hospitals across the country play a major role. Factors outside the organ donation framework such as doctor-to-patient ratio, prevailing cultural values and beliefs surrounding death and bodily autonomy, the robustness of healthcare infrastructure, and emphasis on preventative care will also determine the organ donation system’s ability to adequately address transplant needs. When considering new policies, experts must balance the ethical implications of organ donation with the need to address the critical shortage of organs.