The laws of different countries allow potential donors to permit or refuse donation, or give this choice to relatives. The frequency of donations varies among countries.

Opt-in vs. opt-out

There are two main systems for voluntary systems: "opt in" (anyone who has not given consent is not a donor) and "opt out" (anyone who has not refused is a donor). In some systems like in Australia (14.9 donors per million, 337 donors in 2011), family members are required to give consent or refusal, or may veto a potential recovery even if the donor has consented. Opt-out legislative systems dramatically increase effective rates of consent for donation.^[2] However, because of cultural and infrastructural factors, public policies and other factors, this does not translate directly into increased rates of donation.

Some countries with an opt-out system like Spain (34 donors per million inhabitants) or Austria (21 donors/million) have high donor rates and some countries with opt-in systems like Germany (16 donors/million) or Greece (six donors/million) have lower rates. However Sweden, which has an opt-out system, has a low rate as well (15 donors/million). Health authorities in Sweden have suggested that the government pay 30,000 - 40,000 Kronor for funeral costs if a person donates their organs.^[3] The president of the Spanish National Transplant Organisation, has acknowledged Spain's legislative approach is likely not the primary reason for the country's success in increasing the donor rates, starting in the 1990s.^[4]

United States

Under the law of the United States, the regulation of organ donation is left to states within the limitations of the Uniform Determination of Death Act, the National Organ Transplant Act of 1984, and the United Network for Organ Sharing (UNOS). Each state's Uniform Anatomical Gift Act seeks to streamline the process and standardize the rules among the various states. Many states have sought to encourage the donations to be made by allowing the consent to be noted on the driver's license. Donor registries allow for a central information center for an individual's wish to be a donor. It is a pure consent system rather than an extended consent system or a dissent opt-out system. The issue of consent is pressing, as the number of patients on the waiting list in the country has increased from approximately 20,000 in 1990 to over 100,000 in 2010. Alongside absolute organ donation increases from the late 1980s up until the mid-2000s, donation rates did not increase or decrease significantly from 2004-2010.^[5]

Landstuhl Regional Medical Center (LRMC) has become one of the most active organ donor hospitals in all of Germany, which otherwise has one of the lowest organ donation participation rates in the Eurotransplant organ network. LRMC, the largest U.S. military hospital outside the United States, is one of the top hospitals for organ donation in the Rhineland-Palatinate state of Germany, even though it has relatively few beds compared to many German hospitals. According to the German organ transplantation organization, Deutsche Stiftung Organtransplantation (DSO), 34 American military service members who died at LRMC (roughly half of the total number who died there) donated a total of 142 organs between 2005 and 2010. In 2010 alone, 10 of the 12 American service members who died at LRMC were donors, donating a total of 45 organs. Of the 205 hospitals in the DSO’s central region—which includes the large cities of Frankfurt and Mainz—only six had more organ donors than LRMC in 2010.^[9]

Japan

The rate of organ donation in Japan is significantly lower than in Western countries.^[10] This is attributed to cultural reasons, some distrust of western medicine, and a controversial organ transplantation in 1968 that provoked a ban on cadaveric organ donation that would last thirty years.^[10] Organ donation in Japan is regulated by a 1997 organ transplant law, which defines "brain death" and legalized organ procurement from brain dead donors.

India

Organ selling is legally banned in India. Numerous studies have documented that organ vendors have a poor quality of life (QOL) following kidney donation. Live related renal donors have a significant improvement in the QOL following renal donation using the WHO QOL BREF in a study done at the All India Institute of Medical Sciences from 2006 to 2008. The quality of life of the donor was poor when the graft was lost or the recipient died.^[11]