BMJ  2007;334:1089 (26 May), doi:10.1136/bmj.39199.492894.AD

Feature

Head to head

Is presumed consent the answer to organ shortages? No

University Health Network and Joint Centre for Bioethics, University of Toronto, Toronto General Hospital, Toronto ON, Canada M5G 2N2

The supply of donor organs cannot keep up with demand. Veronica English argues that assuming people want to donate unless there is contrary evidence will increase availability, but Linda Wright believes the problem is more complex

Presumed consent will not answer the organ shortage. It has not eliminated waiting lists despite evidence that it increased organ donation in some countries.¹ Systems of opting out do not ensure higher rates of donation than opting-in systems.² Strategies to encourage people to donate and public education seem to help and are independent of whether people have to opt in or out. The shortage of organs has multiple causes; no single strategy is likely to solve it.

Controversy over presumed consent

Presumed consent refers to laws that permit the procurement of organs without explicit permission.³ The term is used widely in discussion of systems of opting in or opting out of organ donation. The US Institute of Medicine is concerned that the introduction of presumed consent without the appropriate public support could reduce donation rates in countries where autonomy is highly prized, such as North America.⁴ People may be more likely to donate when they feel they retain control of that decision rather than the law dictating that donation should take place. Brazil had to withdraw its system of presumed consent because it aggravated mistrust in the healthcare system.⁴

Influences on donation rates

The effect of presumed consent is hard to evaluate as it is implemented in different ways in different contexts, with different results. More organs may be available for transplantation because of the number of intensive care beds, transplant surgeons, coordinators, and specialised units or because of which organs are needed and the predominant cause of deaths.⁵ The rate of donation in France in 2005 was 22.2 donors per million population while in Spain it was 35.1 per million.⁶ Both countries operate presumed consent and routinely ask families for their consent to donation, yet their organ donation rates vary greatly. In Austria, where such permission is not routinely sought, the rate of donation was 24.8 in 2005.⁶

Spain expands its donor pool by using declarations of death based on not only neurological but also cardiocirculatory criteria—that is, declaring death when the cardiorespiratory system is believed to have stopped functioning. This system has been credited with increasing donation rates in some parts of the US, which has an opting-in system.^{7 8} Singapore's law on presumed consent makes exemptions for Muslims on religious grounds.⁹ The need for public acceptance of organ donation means that a strategy may work in one society, but not another.

Other factors that might explain Spain's enviable rates of organ donation include an environment that treats organ donation as a priority. Transplantation has a strong support system, a dedicated budget, and accountability for performance.¹⁰ Staff are trained how to approach grieving families about organ donation. Donation will not increase without the necessary equipment, trained staff, and intensive care beds to enable a potential donor to donate viable organs. These institutional factors contribute to the donation rate and seem to account for some of the variation in rates of organ availability.¹¹

Strategies to encourage donation

Currently organ donation is conceptualised as an altruistic act, and legislation exists in most countries to outlaw any material benefit for donation. However, more people might donate if they were offered financial incentives. Another possible incentive would be to give increased priority for a donor organ to people who have recorded their willingness to donate.¹² Tactics to identify those who want to donate and encouraging them to inform their families about their wishes would inform the procurement system about a donor's wishes and facilitate decision making on organ donation. Donor cards would surely help families decide whether to donate a relative's organs.¹³

We must not forget that many countries today are multicultural societies, where diverse groups view organ donation differently. Trust in the healthcare system is not universal. Presumed consent could alienate even further those groups that lack this trust, and feed negative attitudes towards organ donation. Engagement of the leaders of communities and attention to religious and cultural beliefs and practices around organ donation may help the public to build the necessary trust to favour organ donation.

Meeting demand

Given the challenge of comparing behaviours in societies with different belief systems and laws, it is imperative that we increase our knowledge of the variables influencing donation rates. Organ donation has increased in Spain, where presumed consent and additional strategies are used. Are some of these variables more effective than others? Are any or all of them adaptable and acceptable to other countries?

Finally, meeting the demand for organs may require not only increasing organ supply but also optimising prevention of disease and selection of recipients. Given the multifactorial nature of the problem, presumed consent alone will not solve the organ shortage.

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Competing interests: None declared.

References

1. Kennedy I, Sells RA, Daar AS, Guttmann RD, Hoffenberg R, Lock M, et al. The case for "presumed consent" in organ donation. International Forum for Transplant Ethics. Lancet 1998;351:1650.[CrossRef][ISI][Medline]
2. Coppen R, Friele RD, Marquet RL, Gevers SKM. Opting-out systems: no guarantee for higher donation rates. Transpl Int 2005;18:1275-9.[CrossRef][ISI][Medline]
3. Veatch RM, Pitt JB. The myth of presumed consent: ethical problems in new organ procurement strategies. In: Veatch RM, ed. Transplantation ethics. Washington, DC: Georgetown University Press, 2000:167-74.
4. Institute of Medicine. Organ donation: opportunities for action. Washington, DC: National Academies Press, 2006.
5. English V, Sommerville A. Presumed consent for transplantation: a dead issue after Alder Hey? J Med Ethics 2003;29:147-52.[Abstract/Free Full Text]
6. Council of Europe. Deceased organ donors. Transplant Newsletter 2006;11(1):4.
7. O'Connor KJ, Delmonico FL. Increasing the supply of kidneys for transplantation. Semin Dial 2005;18:460-2.[ISI][Medline]
8. Shafer TJ, Wagner D, Chessare J, Zampiello FA, McBride V, Perdue J. Organ donation breakthrough collaborative: increasing organ donation through system redesign. Crit Care Nurse 2006;26:33-42.[Free Full Text]
9. Singapore Ministry of Health. Human Organ Transplant Act. . www.moh.gov.sg/mohcorp/legislations.aspx?id=1672
10. Miranda B, Vilardell J, Grinyo JM. Optimizing cadaveric organ procurement: the Catalan and Spanish experience. Am J Transplant 2003;3:1189-96.[CrossRef][ISI][Medline]
11. Healy K. Last best gifts. Chicago: University of Chicago Press, 2006. p. 87
12. Veatch RM. Bonus allocation points for those willing to donate organs. Am J Bioethics 2004;4:1-3.
13. Abadie A, Gay S. The impact of presumed consent legislation on cadaveric organ donation: a cross country study. . http://ksghome.harvard.edu/aabadie/pconsent.pdf

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