Opt-out donor registration: objective success or subjective failure?
By Marcel Brons and Dwight van Schoorl
A political war has been raging on Dutch political battlefield for the past few years: the donor problem. At 15 donors per million people, Dutch donor rates are relatively low by European standards. In countries such as France, Spain or Belgium, that figure is two or three times as high. The Dutch shortage of donor organs claims 130 lives every year. However, a new law from MP Pia Dijkstra should reduce that number. The bill is set to change the existing donor registration into an opt-out system, whereby people are automatically registered, and must unregister themselves if they don’t want to donate. Approved in 2018, the new law will take effect in 2020, but has faced a lot of criticism. Using the Policy Success Assessment Map, we will evaluate whether this new law can be seen as a policy success. The Assessment Map defines four different dimensions of success, but because the bill has yet to take effect, we will only focus on the programmatic and political dimensions.
First, we will look at the programmatic successes. Does this policy achieve its goals, and make a positive contribution to society? The Dutch law has yet to take effect, but neighbouring Belgium already has an opt-out system, so that could provide an indication. Belgium has 30 donors per million people, among the highest in Europe and more than twice as much as The Netherlands. Other countries with opt-out systems, such as Spain, Belgium, Croatia, France and Italy have similar figures.1 A lot of Dutch patients get their organs from Belgium – so many, that it puts the Belgian system under pressure.
There is definitely evidence from foreign cases to suggest that the new donor law will be a programmatic success. However, there are also practical concerns. People with disabilities, as well as some elderly people, may lack the ability to give consent. In an opt-out system, their consent will be assumed, even though they may not be able to make an informed decision on revoking that consent. Additionally, some 4500 registered donors cancelled their registration within a week of the bill’s approval, indicating that the law’s political complications may hamper its programmatic success. Nevertheless, based on evidence from other cases, we predict the bill to become a programmatic success.
Politically, the new donor registration law was highly controversial. The Second Chamber vote of September 2016 was closely followed by media and general public alike. In the end, the law was approved by the smallest of majorities: 75 votes in favour, trumping 74 votes against. One vocally opposed MP infamously missed the vote due to public transport delays, tipping the scale in the bill’s favour. In February 2018, the law was finally approved by the Senate - again, by a small margin. Although the new opt-out donor registration is now law, it comes with a wafer-thin political mandate.
Public opinion is equally divided. A poll conducted in 2018 shows a minimal majority of 51% in favour of the new donor bill. Some public criticism centres around the violation of one’s bodily integrity, protected by Article 11 of the Dutch Constitution. Liberal politicians tend to fear government intrusion, while Christian politicians emphasise the importance of self-determination and personal choice. The Netherlands is a predominantly Protestant country, which could provide an explanation for the controversy surrounding the new donor bill. Other Protestant countries, such as Germany, are similarly hesitant, while many Catholic countries such as Belgium, Spain and Croatia have had opt-out systems for much longer.
The new donor registration bill is a clear example of a policy that lacks political success, despite likely being a clear programmatic success. There is a lot of evidence to suggest that the bill will increase donor rates as intended, yet it only got a thin political mandate and still faces a lot of resistance in The Netherlands. In fact, some of the political controversies spilled over into programmatic success, after 4500 donors unregistered out of protest. Furthermore, some of the opposition to the bill was rooted in The Netherlands’ Protestant heritage, demonstrating how cultural context can hamper or even override programmatic success.
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