Organ donation has long been considered an important and cost-effective treatment for a variety of conditions which lead to organ failure. For many patients suffering from such conditions, transplantation is the only chance for survival. Since 2010, approximately a million organs have been donated worldwide. Despite both the effectiveness of the treatment and the general public support for organ donation, there is a persistent global shortage of transplantable organs. In recent years, governments and regulatory bodies have been exploring a variety of ways to decrease this shortage, potentially saving hundreds of thousands of lives.
This article summarises the most significant regulatory and technological developments around the world and evaluates their effectiveness in increasing the availability of transplantable organs, focussing on the move from an ‘opt-in’ to an ‘opt-out’ system. The importance of informing the public on how states can legislate to increase the efficiency of their donation system cannot be underestimated in the fight to improve a system which saves countless lives but is capable of saving many more.
In an opt-in, or ‘informed consent’ system, organs cannot be harvested unless the donor has given explicit consent during their life. The presumption is that nobody has consented until we know otherwise. Countries which use this system include Ireland, America, the UK, Germany and Australia. Last year Ireland announced that it will join the long, and ever-growing, list of countries which use an opt-out system. By contrast, in an opt-out, or ‘presumed consent’ system, the presumption is that everyone has consented unless they have explicitly refused. Countries which use this system include Spain, Belgium, Finland, France, Greece, Hungary, Israel, Italy, Sweden and Turkey.
A highly regarded 2006 study in the Journal of Health Economics showed that countries with opt-out systems have donation rates 25-30% higher than those which require explicit consent. This makes perfect sense, especially considering evidence from the same study, which states that while 85% of US adults support organ donation, only 28% are registered donors. An opt-out system could bring those numbers much closer together.
The same pattern of widespread support for donation but low numbers of registered donors seen in the US appears around the globe. Busy lives and lack of motivation mean that many people who would consent if formally asked simply do not specify that they would like to donate, and this contributes to the shortage of transplantable organs. Would it not be better if inertia and busy lives resulted in more organs for transplantation rather than fewer?
Given that far more people support donation than not, an opt-out system also means that the presumption of the law is in line with the majority wish. A simple legislative shift has the power both to save lives and make the law more representative of how people actually feel about organ donation. Spain has been the world’s leader in organ donation for 25 years running by a significant margin. The most cited reason for this is their efficient opt-out system. Spain’s success can also be linked to better hospital protocols and the fact that they do not cap the age at which donor organs will be considered. High public awareness may also contribute to Spain’s edge over other opt-out countries.
Governments have also tried to increase the availability of organs by applying the ‘priority rule’, where people who are on the donation register are given priority when organs are being allocated. If there are two potential recipients who are in the same stage of organ failure, but only one of them is on the register, then that person will receive the organ first. The idea is that people will consent to donation on the basis that it will increase their chance of survival if they are ever in need of a transplant themselves.
While on the surface this tactic seems to appeal to self-interest, it can also be seen as a reminder of the hypocrisy of benefitting from a system to which you do not contribute. You cannot expect others to donate their organs to you if you refuse to donate your organs to others. This tactic for decreasing the shortage of transplantable organs has also proved, usually alongside an opt-out system, to be an effective tool for saving lives.
The final policy I address is controversial; in almost all organ donation systems worldwide, the family of the deceased has the power to veto the consent given by the deceased during their life. Even Spain gives families the power of veto, though high public awareness means that very few families actually do so. There is no reason, in my view, that families should be given this power. It is a violation of the donor’s autonomy and yet another obstacle between a potential recipient and the organs that could save their life. If my family has a problem with organ donation, they can choose not to donate their own organs, but what happens to my body is my call and mine alone.
According to UNOS, around 20 people die every day in the US alone due to a lack of transplantable organs. By making simple legislative changes like removing the family’s power to veto and introducing opt-out donation and the priority rule, they could in theory cut that number in half. This is not some elevated ethical debate to be discussed in classrooms. What legislators decide with respect to this issue has incalculable effects on normal people.
None of us know if and when we may require an organ transplant. We are all vulnerable to the dangers of disease, age and injury. By doing everything in our power to increase the number of organs available, not only do we save the lives of others, but we also ensure that if the time comes when we are in need ourselves, we can rest assured that there is an efficient and sensible system in place to save us.
First Published in UCD College Tribune