Impact of presumed consent for organ donation on donation rates: a systematic review
BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.a3162 (Published 15 January 2009) Cite this as: BMJ 2009;338:a3162
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For anyone who has endured the agony of waiting for a suitable organ,
be it for themselves or a near relative, it is clear that more must be
done to increase donor rates. However, as praiseworthy as the idea of
presumed consent may appear, it is not as popular as one might suppose.
The World Medical Association believes that a potential donor’s wishes are
of ‘paramount’ importance, whether by agreeing to donate or choosing to
refuse. ‘Consent’ and ‘autonomy’ are considered to be essential concepts
of medical law, but both may be overridden should legislation be passed in
favour of ‘presumed consent.’ Moreover, Britain is a multi-ethnic
society and not all faith groups support the concept of organ donation, in
fact some cultures are strongly opposed to it, for example, those whose
faiths are Shinto or Rastafarianism.
If ‘presumed consent’ were to be brought into the law then a very
expensive publicity campaign would be needed in the interests of
religious/cultural equality and harmony, to ensure that each and every
member of the community was properly addressed. This would be time
consuming and expensive.
However donor lists might dramatically increase in the UK today,
without the need for such consultation. Rather than legislate for
‘presumed consent’ outright, it is suggested that Parliament legislate in
favour of ‘enforced choice.’
‘Enforced choice’ would involve an individual having to indicate
either a yes or no answer to a compulsory organ donation question, as part
of the procedures surrounding important personal applications e.g. driving
licences and passports. Failure to answer the question would invalidate
the application process/document in question.
The benefit of this approach is that it firmly supports the notion of
autonomy, by allowing free choice. Those who profess a desire to donate
would have no excuse not to add their names onto the donor register,
likewise those who do not wish to donate have the right to record their
objections in the same manner.
Competing interests:
None declared
Competing interests: No competing interests
The results of the multi nation study adds power to my personal
beliefs that an opt out scheme provides the greatest hope for addressing
the dire organ demand and need in the UK. A Wales based campaign “Tell a
friend” headed by superstars and celebrities has helped to vastly increase
the number of registered donors, as well removing the stigma of discussing
organ donation and death. Unfortunately with Diabetes and other chronic
diseases on the increase, especially in areas such as the South Wales
valleys, coupled with increased life expectancy, demand is still
outstripping supply. I was therefore interested to read that the catholic
faith advocates organ donation as a “service of life” which made me ask
myself should the medical profession also view organ donation as a
“service of doctors”?
When we become doctors should organ donation become an obligatory
part of the “21st century Hippocratic oath”. Leading by example and “do as
I do not as I say” approaches may help encourage the public to actively
voice their wish to donate. With a vast discrepancy between the 90%+ who
would donate but the nearer 30% who hold a donor card any new incentive
must be worthy of trial. Such a step that all doctors will donate their
organs would send a powerful message to the British public. The same
principle may help the shortage for blood products.
During my time as Chairperson of the BMA Medical Students Committee I
led a successful threshers campaign to encourage new medical students to
sign up to the organ register. University visits by UK Transplant offered
students a donor card instead of the more traditional credit card and the
numbers of new donors was encouraging. Maybe now is the time for the same
to be done to “thresher doctors” and encourage a sign up at trust
inductions?
Competing interests:
None declared
Competing interests: No competing interests
Trust is important
The analysis is very teaching.
I would like to add another story - from Russia. After the fall of
the USSR transplantologists had a great chance to influence the new
legislation, and it was based on the presumed consent for donation. The
law is so straightforward, that even not describe how one may opt out.
The life brought new balance: later the new law was enacted - on
burial practice - and patients as well as relatives received back their
right of decision.
At last, series of scandals of malpractice with donor death
declaration and taking the organs (most not proved in court) brought
Russia transplantology almost to the nonexistence.
Of course, the poverty of the system is important, but absence of the
public control eroded the trust of citizens - despite the 'nice' law.
Competing interests:
None declared
Competing interests: No competing interests