On 13 September 2016, the Dutch House of Representatives held a roll-call vote on a change to the organ donation law. One by one, members answered “voor” (for) or “tegen” (against). The bill passed 75 to 74.
The donor form kept its four choices: yes, no, my family decides, or a named person decides. What changed was the meaning of silence. Until then, an adult who never sent the form back simply wasn’t on the register. Under the new law, after two letters and no reply, they would be registered as having “no objection”.
The bill had been waiting since December 2012. Nearly four years and a one-vote majority, for the box that gets ticked when nobody ticks a box. The Dutch had tried the polite way first. In 1998 they opened a national donor register with an education campaign and, in the words of Eric Johnson and Daniel Goldstein in Science, “a mass mailing (of more than 12 million letters in a country of 15.8 million)”. The consent rate did not move.
Their paper, published in 2003, shows what was at stake in one chart. Germany asked people to opt in, and 12 percent were counted as consenting to donate. Next door, Austria counted everyone who hadn’t opted out, and reached 99.98 percent. Every opt-in country on the chart sat below 28 percent and every opt-out country above 85.
Most people never answer the letter, so whoever decides what silence means has decided for most people.
In a company, that decision tends to fall to whoever set up the system. The supplier contract renews unless someone objects in writing. The new AI assistant opens shared files to the whole company because that was the setting on launch day. Meanwhile the leadership team spends a quarter on the policy, launches it at a town hall and posts it on the intranet. The default went live in March, chosen by an implementation consultant who has since moved on to another client. Brussels has caught on, at least for personal data. Since 2018, Article 25 of the GDPR has required that “by default” only the data needed for each purpose are processed.
In 2020 the Dutch wrote again: nearly 7 million letters to adults with no choice on the register, each saying what would happen if they ignored it. The minister started the mailing in a library in Katwijk, and almost 800 libraries helped people fill in the form. On 1 January 2020, 49 percent of adults had a choice on the register. Three years later it was 73 percent. The ministry told the Senate it could not say how much of that came from the law and how much from the media campaign. It did record that before the letters even went out, “no” had risen to 36 percent of registered choices, which it called a logical result: the people who had to act were the ones who did not want to donate.
Defaults move the register further than the operating theatre. Johnson and Goldstein estimated that opt-out raised actual donations by about 16 percent, and a 2019 study of 35 OECD countries found no significant difference in deceased donors. In the Netherlands a doctor still sits down with the family, and if they are sure the person did not want it, there is no donation.
On 1 November this year, 3,560,134 people were on the Dutch register under “no objection”. None of them filled in the form. A vote of 75 to 74 filled it in for them.
If someone in your organisation is about to roll out a new system, send them this one. And if it was forwarded to you, you can subscribe at vanguards.media.
David
Sources: Eric J. Johnson and Daniel Goldstein, “Do Defaults Save Lives?”, Science, 2003. Eerste Kamer, bill 33506 (Actief Donorregistratiesysteem), 2012-2018. Minister for Medical Care, letter to the Senate on bill 33506, 2021. Donorregister, news of 1 July and 1 September 2020, and register figures of 1 November 2026. Statistics Netherlands (CBS), 2023. Adam Arshad, Benjamin Anderson and Adnan Sharif, Kidney International, 2019. Regulation (EU) 2016/679 (GDPR), Article 25.