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It has been reported that the Hong Kong SAR Government has been considering opt-out legislation for organ donation. Dr Wing-man Ko, former Secretary for Food and Health, believes that a more active approach is needed.1 A background information paper was offered by the Food and Health Bureau on 14 June 2017.2 Although the organ donation rate in Hong Kong increased from 4.60 donors per million population (pmp) in 1996 to 6.30 donors pmp in 2016, the figure remains among the lowest in the world.3 According to international data in 2016, Spain has the highest donation rate in the world (43.4 donors pmp), while Hong Kong’s figure represents less than 20% of that rate.4 Hong Kong is now adopting the opt-in system, that is, only those who have given explicit consent will be donors. Other countries such as Spain and Singapore are adopting the opt-out system, that is, anyone who has not clearly refused is presumed a donor. By comparing the data of the opt-in and opt-out countries, some studies show that opt-out consent leads to a relative increase in the total number of organs transplanted,5 but the findings are inconclusive. As Shepherd et al5 remarked, “it may be too simplistic to state that the introduction of opt-out consent will increase deceased donation rates”. Based on a few important considerations, we do not think it will be helpful to improve Hong Kong’s donation rate by changing to an opt-out system. First, although it is recognised that an opt-out system is likely to bridge the gap between people’s intention and their behaviour by removing the need to undertake any action in order to become a donor,6 it is also recognised that donation rates are multi-causal and that an opt-out strategy may not actually help. For example, Spain’s opt-out consent legislation in 1979 did not have a positive influence on donation for 10 years. It has been through crucial organisational changes (such as certain incentives offered to its coordination networks and hospital coordinators) introduced since 1989 that have afforded Spain’s success.7 Second, in Hong Kong, a Centralised Organ Donation Register (CODR) that allows prospective donors to register their wish of donating organs after death through online registration or by email or fax was set up by the Department of Health in 2008. Hong Kong Med J 2017;23:658–60 DOI: 10.12809/hkmj177022

Opt-in or opt-out: that is not the question