Consent law is only one variable
Opt-in countries can reach 50 pmp (United States) or stay near 1 pmp (Japan). Soft-opt-out countries span from Spain's record 53.9 pmp to Bulgaria's 2.4 pmp under near-identical law. Iran, the only country to compensate living donors, eliminated its kidney waiting list by 1999. Israel and Singapore add a reciprocity layer to their respective opt-in and opt-out defaults.
The six categories below describe each consent model in plain language. The Finding panel that follows shows the within-model variation in donor rates. Three tiles at the bottom open the full dashboard, the research article, and the plain-language summary.
Opt-in (informed consent)
Default · Not a donor
You become a donor only if you actively said yes during your lifetime — by joining a donor registry, ticking a box on your driver’s license, or carrying a donor card. If you never said yes, your family will be asked to make a choice.
United States 49.7 pmp · 16,989 deceased donors (2024)
Germany 11.7 pmp · same law, very different outcome (2025)
Hard opt-out (presumed consent)
Default · Donor
You are treated as a donor unless you registered an objection during your lifetime. The law does not require asking your family — though in practice, most countries still do.
Czech Republic 34.3 pmp · top Eastern-European hard-opt-out performer
Bulgaria 2.4 pmp · same law, lowest in EU
Soft opt-out (presumed consent)
Default · Donor (family decisive)
You are treated as a donor unless you registered an objection — but if your family firmly refuses, that decision is respected. The law leans toward yes; the family keeps the final say.
Spain 53.9 pmp · world record, 85% family consent
ONT model · coordinator-driven, since 1989
Mandated and required choice
Default · None — must declare
Every adult must record a choice — yes, no, or “let my family decide” — when they apply for a driver’s license or government ID. No one is left undecided.
New Zealand 13.2 pmp · 51% adult registration
License-linked recorded choice (informational)
Reciprocity-based systems
Default · Opt-in or opt-out + waiting-list bonus
If you sign up as a donor, you get priority on the transplant waiting list if you ever need an organ yourself. The idea is simple: don’t give, don’t get. Israel layers this over an opt-in default (since 2010); Singapore layers it over an opt-out default (HOTA 1987).
Israel 10.4 pmp · opt-in with reciprocity; sustained registration rise (2024)
Singapore 4.8 pmp · opt-out with reciprocity; HOTA 2-year priority restoration (2024)
Regulated payment for living donors
Default · State-paid living donor
The state pays living donors to give a kidney to a stranger — a system used only in Iran. Most of the world rejects paying for organs as unethical, and has formally banned the practice since the 2008 Declaration of Istanbul.
Iran 13.0 pmp deceased + paid living (2023)
Eliminated kidney waiting list by 1999
Only national program of its kind worldwide
Consent law does not predict national donation rates.
22-fold gap in donor rate, identical legal default.
45-fold gap in donor rate, identical legal default.
pmp = deceased donors per million people (2023–2024 where available).
