To the Editor: An important factor in the well documented shortfall of organs and eyes for transplantation is the apparent reluctance of people to agree to donate.1 One nearly universal strategy in attempting to raise donation rates has been to encourage individuals to register their wishes about donation. Although evidence that this strategy increases donation rates is lacking, there is some evidence that more individuals make and communicate a decision with appropriate education.2

Most families consent to donation when the deceased had indicated this was their wish, and virtually none override a stated wish not to donate.3 When wishes are unknown, half of families consent and half refuse.3 Encouraging declaration of intention aims to increase the rate of consent for families who would otherwise not know the deceased individual’s wishes. For this to be successful, most individuals newly recording their wishes must indicate a desire to donate. This assumption has underpinned Australian education campaigns, including “Talk about it”, “Share your life, share your decision”, and most recently the national “Sign on to save a life” campaign.4

A simple review of New South Wales Roads and Traffic Authority organ donation data over the period of these campaigns suggests this assumption may not hold. From 1997 to 2004, a significant proportion of drivers licence holders newly indicated a preference about donation; the proportion indicating some decision rose from 59.4% to 78.6%. Over the same period, the proportion indicating yes to donation of all organs rose from 35.6% to 41.9% (a 17.7% increase); however, the proportion indicating no to any donation rose from 19.9% to 31.4% (a 57.8% increase).5

These results raise the possibility that encouraging individuals to make a decision about donation may increase the number of families who refuse donation. Individuals who had previously not made a decision about donation, when encouraged to do so, displayed an unwillingness to become organ donors at twice the rate of those who indicated willingness. Although it is imperative to recognise and respect the decision of individuals to refuse organ donation, this unwillingness may reflect either formalisation of a considered desire not to donate, or a decision made without personal discussion of fears and concerns about donation. Generalised education campaigns are limited in that they encourage action without addressing fears and concerns. Further policy should recognise a possible danger in simply exhorting the public to make a decision, and research should investigate why individuals are refusing to become organ and eye donors.