Consent law is only one variable
Within the same legal model, donor rates vary by an order of magnitude or more — 22× across soft-opt-out, 45× across opt-in. The six models below set the legal default; the within-model variation is what national systems and coordinators build on top of it.
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, 80% family consent (2024)
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. The practice has been formally prohibited under the 2008 Declaration of Istanbul; Iran's program remains the only national exception.
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).
