How Spain Became the World Leader in Organ Donation
February 15, 2023 · News & Updates
When someone asks me why I believe opt-out organ donation works, I tell them to look at Spain. For more than 30 consecutive years, Spain has held the title of world leader in organ donation. In 2022, they recorded 46.3 deceased donors per million population — more than double the rate of the United States at roughly 17 per million. But here's what I really want people to understand: what makes Spain's model so successful isn't just its opt-out legislation — it's the entire system built around it. This isn't just a law change — it's a systems change.
The Spanish Model
Spain adopted opt-out organ donation legislation in 1979, but donation rates didn't dramatically improve until the creation of the Organización Nacional de Trasplantes (ONT) in 1989. The ONT introduced a network of transplant coordinators in every hospital, standardized protocols for identifying potential donors, and built a culture of donation that permeates the entire healthcare system. I keep coming back to this point: the system, not individuals, is what determines outcomes.
"It's not just the law. It's the system — the coordinators, the training, the culture. You need all of it." — Dr. Rafael Matesanz, founder of the ONT
What Makes It Work
Key elements of Spain's success include:
Hospital coordinators: Every hospital with an ICU has a dedicated transplant coordinator — usually a physician — who identifies potential donors and approaches families. There are over 180 such coordinators across Spain.
No financial barriers: All transplant-related costs are covered by Spain's universal healthcare system. There is no financial disincentive for hospitals to participate.
Expanded criteria: Spain pioneered the use of expanded criteria donors, including older donors and those who died from cardiac arrest (not just brain death). This significantly expanded the donor pool.
Public trust: Decades of transparent, ethical practice have built extraordinary public trust. Family refusal rates in Spain are among the lowest in the world — under 15%.
"In Spain, organ donation is not seen as an extraordinary act. It is the normal thing to do." — ONT annual report
Why YCOD Looks to Spain
Spain proves what I've been saying since I started YCOD: opt-out legislation alone isn't enough — but it's the critical foundation you build everything else on. Combined with proper infrastructure, training, and cultural investment, opt-out laws can transform organ donation rates. When we at YCOD advocate for New York's Bill A07954, we emphasize that the legislation should be paired with real investment in donation infrastructure, just as Spain did with the ONT. The goal isn't just to change the law — it's to build a system that saves the maximum number of lives. After a family member needed a kidney transplant, I couldn't stay on the sidelines. Spain shows us exactly what's possible when a society decides that saving lives through donation is the default, not the exception.