In opt-out organ donation systems, should the needs of those who choose to opt-out be deprioritised if they come to need a transplant organ themselves? Should such people be given additional negative points in the allocation algorithm? The principal argument in favour of this is one of fairness and avoiding ‘free-riding’. In addition, it has been argued that it would discourage opting-out and thus save lives by increasing the supply of transplant organs. On the other hand, a variety of different ethical and practical objections have been raised to the proposal and much of this paper is spent unpacking and evaluating these. Its ultimate conclusion is that there is a strong ethical case for deprioritisation. Whether this is the right public policy however very much depends on practical questions such as: To what extent would it improve supply? Would it be more or less effective than other policy changes? How effectively could it be communicated to the donating public? Would be seen as discriminatory? And would it improve or damage trust in the donation system?