How Is Organ and Tissue Donation Done in Other Countries?

Organ and tissue donation varies enormously from country to country, shaped by differences in law, culture, hospital infrastructure, and logistics. The most visible difference is whether a country uses an opt-in system, where you must actively register as a donor, or an opt-out system, where you are presumed willing to donate unless you say otherwise. But that legal framework is only one piece of the picture. Whether a donated organ actually reaches a recipient depends on hospital-level coordination, transport networks, how death is legally defined, whether families can override a donor’s wishes, and increasingly, technologies that keep organs viable outside the body for longer. Some countries share organs across borders through multinational allocation networks; one country has a regulated market for kidneys from living donors. Understanding how these pieces fit together helps explain why some nations transplant far more organs per person than others.

Opt-In Versus Opt-Out Consent

The most debated policy difference in organ donation is consent law. In opt-in countries like the United States, Germany, and Japan, a person must take an affirmative step to register as a donor. In opt-out countries like Spain, France, Austria, and Wales, everyone is presumed to consent to donation after death unless they have formally opted out. Intuitively, the opt-out approach seems like it should dramatically increase the supply of donor organs, and an older systematic review did find that presumed-consent laws were associated with roughly 25–30% higher donation rates in several studies, though the size of the effect varied considerably across them.¹

More recent research has complicated that picture. A 2024 analysis found that switching from opt-in to opt-out did not produce a measurable bump in donation rates when averaged across countries, and there was no gradual upward trend in donations after the switch either.² Another study argued that moving to opt-out in isolation, without other systemic reforms, confers no clear advantage and can even distract from more effective strategies.³ The takeaway is that consent law matters, but it is far from the whole story. Countries that perform the most transplants tend to pair their legal framework with robust hospital infrastructure, trained coordination staff, and public engagement campaigns.

The Family Veto Problem

Even in countries with presumed-consent laws, families frequently get the final say. Most opt-out jurisdictions have retained a family veto: if relatives object, the organ retrieval does not go ahead, even when the deceased had registered a decision to donate.⁴ This means the legal default of “everyone is a donor” is softened in practice. In some countries, family refusal rates run high enough to significantly blunt any benefit the opt-out law was supposed to deliver. The reasons families refuse are varied and often deeply personal: uncertainty about the deceased’s actual wishes, discomfort with the timing of the conversation, religious concerns, or simply shock and grief. Advocates for stronger opt-out systems argue that enforcing the presumed consent would respect individual autonomy, while opponents worry that overriding grieving families risks eroding public trust in the transplant system as a whole.

Spain’s Three-Tiered Coordination Model

Spain has for decades led the world in deceased organ donation per capita, and the reason is not simply its opt-out law. The country built a dedicated organizational infrastructure at three levels: a national transplant organization that sets strategy and provides round-the-clock logistical support, 17 regional offices aligned with Spain’s autonomous communities, and hospital-level donor transplant coordination units staffed by specially trained nurses and physicians, often with backgrounds in intensive care. These in-hospital coordinators identify potential donors, assess medical suitability, consult with families, and manage the clinical pathway from brain death to organ retrieval.⁵

This model has been widely influential. The United Kingdom, Portugal, and Italy have all adopted versions of the three-tiered structure.⁵ The lesson from Spain is that the bottleneck in organ donation often is not the law or public willingness. It is the ability to identify a potential donor in a hospital ward, have a skilled conversation with the family at the right moment, and move the donation forward through a complex clinical process on a tight timeline. Countries that invest in those hospital-level systems tend to do better, regardless of whether their consent framework is opt-in or opt-out.

Cross-Border Organ Sharing

Some countries do not allocate organs in isolation. The most established multinational system is Eurotransplant, a network founded in the late 1960s that now serves eight European countries, including Germany, the Netherlands, Belgium, Austria, and Hungary. It was originally created to optimize tissue matching for kidney transplants, and today about 65% of organs offered through Eurotransplant are utilized.⁶ The system pools waiting lists across borders so that a kidney recovered in Belgium, for instance, can go to the best-matched patient in Austria if no suitable local recipient exists.

Different allocation algorithms reflect different national priorities. A review of deceased-donor kidney allocation systems in the United States, Canada, and Eurotransplant found that governance structures, whether centralized or provincial, significantly shape how allocation rules get designed and reformed.⁷ Some systems weigh tissue matching heavily; others prioritize time on the waiting list, geographic proximity, or pediatric recipients. There is no single “best” algorithm, and every system involves tradeoffs between fairness, efficiency, and logistics.

Cross-border kidney paired exchange programs add another layer. These are arrangements where a living donor who is incompatible with their intended recipient in one country is matched with a compatible pair in another country, and the kidneys are swapped. At least four established transnational programs exist, including partnerships between Australia and New Zealand, between the Czech Republic, Austria, and Israel, between Spain, Italy, and Portugal, and among the Scandinavian countries.⁸ There have also been cross-border exchanges between the United States and Canada, including a 10-way domino chain carried out between 2009 and 2010.⁹

Iran’s Regulated Kidney Market

Iran stands alone as the only country in the world with a legal, government-regulated system for compensating living unrelated kidney donors. The program started in 1988, and by 1999 it had completely eliminated the kidney transplant waiting list. By the end of 2005, more than 19,600 kidney transplants had been performed in Iran, the vast majority from living unrelated donors, with a much smaller share from living related donors and deceased donors.¹⁰ Proponents argue that the regulated structure prevented many of the ethical abuses associated with black-market organ sales. Critics worry that the system still disproportionately draws donors from lower-income populations. No other country has adopted Iran’s approach, and international transplant organizations have generally discouraged paid donation.

Organ Trafficking and the Declaration of Istanbul

The global shortage of organs has fueled an underground trade. Transplant tourism, where patients travel to another country to buy an organ, exploits vulnerable people in poorer nations and exposes recipients to unregulated surgical conditions. The Declaration of Istanbul, first issued in 2008, was a landmark statement by transplant professionals worldwide calling for the prohibition and criminalization of organ trafficking and transplant tourism.¹¹ A 2018 updated edition reinforced the call for governments to develop laws criminalizing trafficking in human organs and trafficking in persons for the purpose of organ removal.¹² Many countries have since strengthened their legal frameworks, though enforcement remains uneven, particularly in regions where transplant infrastructure is weak and demand far outstrips supply.

Donation After Circulatory Death

How death is declared directly affects organ donation, and countries differ on this. In donation after brain death, organs are retrieved from someone whose brain has irreversibly stopped functioning but whose heart is still beating on a ventilator. In donation after circulatory death, the donor’s heart has stopped, and a waiting period passes before organs can be retrieved. This second pathway raises more complex ethical and logistical questions, because the time between heart stoppage and organ recovery creates a window of warm ischemia that can damage the organs.

Practices vary widely. Programs in Europe, Australia, the United States, Canada, Israel, China, and parts of South America and the Middle East all handle donation after circulatory death differently, from surgical techniques to how they manage the resulting tissue damage.¹³ Guidelines for uncontrolled donation after circulatory death, where the cardiac arrest is unexpected, show particularly large differences from country to country, with major gaps in the evidence base underlying each protocol.¹⁴ These differences mean that an organ considered transplantable under one country’s criteria might be declined under another’s.

Cultural and Religious Barriers

Laws and infrastructure only go so far when cultural beliefs create resistance to donation. A systematic review of barriers among Chinese and Korean individuals in the United States found several recurring themes: limited knowledge about organ donation, distrust of the healthcare and organ allocation systems, cultural avoidance of death-related conversations, and a desire for the body to remain intact, rooted in the Confucian concept of filial piety.¹⁵ Strong family values combined with reluctance to discuss death openly made organ donation a particularly difficult topic, even among younger and more acculturated individuals.

Indigenous communities face their own distinct concerns. A qualitative study of Aboriginal and Torres Strait Islander attitudes in Central Australia found that organ donation was perceived as a new and culturally unfamiliar concept. Participants described the body as belonging to the land, and giving away a part of it challenged spiritual beliefs about what happens after death.¹⁶ These findings underline that consent frameworks designed by and for majority populations do not automatically translate to every community within a country. Meaningful engagement with specific cultural concerns is a separate challenge from setting the right policy default.

How Countries Register Donors

In opt-in countries, the mechanics of how and where people sign up matter enormously. The United States offers one of the most interesting case studies. About 98% of registered donors sign up through the Department of Motor Vehicles when getting or renewing a driver’s license, and additional registration is available through Apple’s Health app, Donate Life websites, hunting licenses, and tax returns. As of 2021, the US had roughly 169 million registered organ donors.¹⁷ Experiments where organ procurement organizations directly staffed DMV offices saw immediate jumps in registration rates, particularly at locations that previously had the lowest enrollment.¹⁸ The lesson is that making registration easy and embedding it in a process people are already doing matters more than awareness campaigns or public appeals.

Tissue Banking and Cornea Donation

Organ donation gets most of the attention, but tissue donation is a parallel system with its own infrastructure. Tissues like corneas, bone, skin, heart valves, and tendons can be recovered from donors who may not be suitable organ donors, and many are stored in tissue banks for later use. In the United Kingdom, NHS Blood and Transplant brought tissue banking and organ transplantation under one organizational umbrella in 2005, meaning that roughly 95% of all deceased donors are now facilitated by a single organization. The UK’s tissue bank in Liverpool handles consent, retrieval, processing, storage, and dispatch of donated tissue. Annually, there are about 450 multi-tissue donors and 2,500 eye donors in the UK, resulting in thousands of transplants.¹⁹ Not every country has this level of consolidation. In many nations, tissue banking operates through a patchwork of regional or hospital-based programs, and screening standards for infectious disease risk remain inconsistent across borders.²⁰

Getting Organs There in Time

An organ is only useful if it reaches the recipient before the cells start to die. Cold ischemia time, the window during which a removed organ can survive on ice, varies by organ: a kidney can tolerate many hours, while a heart has a much shorter window. In a country like Italy, where donations and transplant centers are dispersed across the peninsula, studies have measured the distances and speeds of organ transport and found that some deliveries consumed 90% or more of the available cold ischemia time.²¹ That is dangerously close to the edge.

Ex vivo organ perfusion, which keeps organs metabolically active outside the body by pumping them with oxygenated fluid instead of just packing them on ice, is changing this calculus. For hearts in particular, this technology can extend the viable transport window and enable the use of donor hearts from more remote locations or those with characteristics that would previously have led to discard.²² Drones are also emerging as a transport tool, particularly for short-range transfers. Case studies from North America, Europe, and Asia have shown that unmanned aerial vehicles can safely deliver donor organs while maintaining temperature and structural stability, with successful transplantations reported.²³

Xenotransplantation and Its Regulatory Patchwork

If the supply of human organs cannot meet demand, what about animal organs? Xenotransplantation, the transplantation of organs from one species to another, is edging closer to clinical reality, primarily using genetically modified pigs. Several research groups in China have produced transgenic pigs with genetic edits designed to reduce immune rejection.²⁴ But regulatory treatment of pig organs differs sharply from human organ donation. In the United States and Europe, a pig organ intended for human transplant is classified not as a donated organ but as a medicinal product, placing it under the oversight of the FDA or the European Medicines Agency. That means the entire process, from generating the pig to performing the transplant and monitoring the patient for life, must comply with pharmaceutical-grade manufacturing and quality standards.²⁵ The risks that regulators worry about most include latent pig viruses that could cross into human populations and the still-unresolved problem of delayed graft rejection, which can destroy a transplanted animal organ weeks or months after surgery.²⁶ The few xenotransplant procedures performed to date have been carried out under compassionate-use or experimental protocols, and no country has yet approved routine clinical use.