Would you opt out of saving a life?

Hey everyone! On the phone a couple days ago my father (a family practice doc) and I got onto the topic of organ donation, and I thought I’d expand on our conversation a little bit here for you all. As you all know, in the United States to be an organ donor we have to opt in, meaning we have to sign up to have our organs be used for those who are in need of a transplant in the case of our deaths. There are, of course, some reasons people can’t be donors. For instance, medical reasons include having HIV, a metastatic cancer, and Creutzfeldt-Jacob disease (a neurodegerative disease and a more common type of prion disease). Some people are opposed to being an organ donor based on religious or other beliefs, such as some conservative Jews or Jehovah Witnesses. However, according to organdonor.gov, a website maintained by the U.S. Department of Health and Human Services, an estimated 95% of adults support organ donation, but only 54% are signed up as donors. In the U.S., the need for organs vastly outnumbers the supply. There are over 144,000 people on the national transplant list, but only about 35,000 transplant surgeries have been performed in the U.S. The website also says that an average of 20 people die each day that are waiting for a transplant. That’s CRAZY high, especially when considering that organs from 1 donor can save up to 8 lives!!

As with most things, there is of course more than one way to arrange the system. There is a number of countries who use an ‘opt out’ system, where consent to be an organ is presumed unless the donor or the donor’s family has explicitly expressed a wish to not have the deceased’s organs used (before or after death). These countries include Spain, France, Wales, Austria, Belgium, Chile, Singapore…the list goes on. Differences between the countries in the actual policy exist, of course, but overall this system has been incredibly successful, with organ donor numbers skyrocketing compared to before the policies were implemented. An interesting report I found on the presumed consent policy among European countries saw an increase to 99% of their populations registered as donors compared to about 30% with a previous opt-in approach. So the question is, if such a high percentage of Americans really do support organ donation, isn’t adopting an opt-in policy the most efficient way to handle this situation?

This consideration begs the question- does presumed consent for organ donation violate informed consent? After all, they and their family do have the opportunity to opt out during their life or after death in case the donor had at some point to their knowledge expressed a wish to not be an organ donor. If presumed consent was to be adopted in the U.S., there would have to be measures taken to ensure that people have access to this information in the case that they are opposed, and to understand what this means. Perhaps there is even a way for healthcare professionals to be involved in this process, such as being able to explain and answer the questions of their patients during their annual exams, and giving them reliable resources for more information should they desire it. 

In regards to other principles of ethics, the person whose organs are being donated is already dead or brain dead, so it doesn’t really affect them much at this point, but it can do a whole lot of good for someone who really needs one of those viable organs they have. To be clear, to be brain dead means that the body has completely and irreversibly lost all brain function, including that of the brain stem, and therefore all CNS and endocrine regulation. This is different than a persistent vegetative state, in which there is still some function in the brain stem and the patient may be kept on life support. When brain dead, a patient is unconscious and completely unresponsive, with no response to stimuli that would usually trigger an involuntary response, such as pupil dilation when a light is shined into the eyes. 

So what do you guys think, while there is no doubt a serious need for the U.S. to address the shortage of organ donations, are there any reasons why an opt-out system might not work for us? Do you think there’s a better way?

For more information on this topic, some interesting places for further reading include:

Johnson, E. J., & Goldstein, D. (2003). Do Defaults Save Lives? Science, 302(5649), 1338 LP-1339. Retrieved from http://science.sciencemag.org/content/302/5649/1338

Thornton, J. D., Sullivan, C., Albert, J. M., Cedeño, M., Patrick, B., Pencak, J., … Sehgal, A. R. (2016). Effects of a Video on Organ Donation Consent Among Primary Care Patients: A Randomized Controlled Trial. Journal of General Internal Medicine, 31(8), 832–839. https://doi.org/10.1007/s11606-016-3630-5