The Spanish Model and the ONT

The Spanish Model (Spanish: modelo español) is an organizational approach to deceased organ donation, built around the Organización Nacional de Trasplantes (ONT), Spain's national transplant organization, created in 1989, that has made Spain the country with the highest deceased-donation rate in the world for more than three decades.[1][2] Spain reached roughly 40 deceased donors per million population (pmp) by 2015 and exceeded 49 pmp by 2023, well above most other high-income countries.[2][3] The Spanish experience is widely cited as evidence that high donation rates are achieved primarily through organizational infrastructure and coordination, not through changes in consent law.[1][2][4]

Origins

Spain enacted presumed-consent (opt-out) legislation in 1979, but its deceased-donation rate did not rise for another decade and was about 14 donors pmp in 1989.[1][2][4] The transformation began only when the ONT was established in 1989 and implemented a coordinated organizational system; the rate rose to roughly 22.6 pmp by 1993 (then the world's highest) and continued climbing thereafter.[2][4] This sequence, a flat decade under the opt-out law, followed by rapid improvement once the organizational system was built, is the central historical argument that the organizational model, rather than the legislation, drove Spain's results.[1][2][4]

Elements of the Spanish Model

The model rests on several interlocking features:[1][2]

• In-hospital transplant coordinators. Each procurement hospital has a designated transplant coordinator, typically a physician (often an intensive-care doctor) working part-time in the role, responsible for proactively identifying potential donors, conducting systematic death audits, and approaching families.[1][2] Embedding the coordinator inside the hospital, close to the intensive care unit where most potential donors are, is regarded as the model's defining innovation.[1][2]
• A three-tier coordination network. Coordination operates at the national (ONT), regional (autonomous-community), and hospital levels, providing a continuous structure linking individual donor hospitals to national logistics.[1][2]
• Systematic donor detection and death audits. Hospitals continuously review deaths (including in the emergency department and ICU) to identify every potential donor and to measure where the donation process succeeds or fails.[1][2]
• Training, professionalization, and reimbursement. Coordinators receive specific training in the donation process and in communicating with families, and hospitals receive funding that supports donation activity.[1][2]
• Quality and audit programs and public confidence. A national quality-assurance program, transparency, and a generally supportive public climate underpin the system.[1][2]

Role of the ONT

The ONT is a technical agency of the Spanish Ministry of Health that coordinates and oversees donation and transplantation nationally: it operates the round-the-clock organ-sharing logistics, maintains national registries, supports the coordinator network, sets and audits standards, and publishes activity data.[1][2] It does not itself perform transplants; it organizes the system in which hospitals and transplant centers operate.[1][2]

The consent-law question

A recurrent point in the literature is that Spain's success is frequently and incorrectly attributed to its 1979 presumed-consent law.[1][2][4] In practice, Spanish coordinators approach families and seek their support before donation proceeds, so the system functions in a manner closer to a "soft" opt-out, and the opt-out provision is not the operative driver.[1][4] Reviews comparing countries conclude that the transferable lesson of the Spanish Model is the organizational and human infrastructure, not the default rule of consent.[1][2][4] See comparative donation systems and PMP metrics and consent models: opt-in vs opt-out.

International influence

Elements of the Spanish Model have been adopted or adapted by other countries and regions seeking to raise donation rates, and the model informs international guidance and capacity-building efforts in donation and transplantation.[1][2] Studies of attempts to transplant the model elsewhere emphasize that results depend on faithfully implementing the in-hospital coordination and detection infrastructure, not merely importing legislation.[1][4]

See also

• Comparative donation systems and PMP metrics
• Consent models: opt-in vs opt-out
• NHS Blood and Transplant and UK deemed consent
• Organ procurement organization (OPO) · Donation after brain death (DBD)

References

• Matesanz R, Domínguez-Gil B, Coll E, et al. How Spain reached 40 deceased organ donors per million population. Am J Transplant. 2017;17(6):1447-1454. doi:10.1111/ajt.14104. https://www.sciencedirect.com/science/article/pii/S1600613522250060
• Matesanz R, Domínguez-Gil B, Coll E, Mahíllo B, Marazuela R. How Spain reached 40 donors pmp / Spanish model overview (ONT founded 1989; in-hospital coordinators). See also ONT, Organización Nacional de Trasplantes. https://www.ont.es/
• Global Observatory on Donation and Transplantation (GODT) / IRODaT 2023 deceased-donor rates (Spain ~49 pmp; United States ~48 pmp). https://www.transplant-observatory.org/ ; Government of Spain, transplant figures (La Moncloa, 2025). https://www.lamoncloa.gob.es/lang/en/gobierno/news/paginas/2025/20250116-transplant-figures.aspx
• Fabre J. Presumed consent for organ donation: a clinically unnecessary and corrupting influence in medicine and politics. Clin Med (Lond). 2014; and related analyses of the Spanish system. PMC4954124. https://pmc.ncbi.nlm.nih.gov/articles/PMC4954124/