Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Unsuitable organs
- Gwendoline M Harlow (25 May 2007)
-
Presumed consent to organ donation
- David W Evans (28 May 2007)
-
It is still my body!
- Graham Kyle (28 May 2007)
-
QOF and information sharing
- Anne Holmes (28 May 2007)
-
Presumed Consent is Problematic
- Michael Potts (29 May 2007)
-
It Is Medically and Morally Correct to Presume Consent
- Gordon D Skilling, Aberdeen AB25 2ZH (29 May 2007)
-
Re: Presumed Consent is Problematic
- Richard Bartley (30 May 2007)
-
Confusion about death
- Joan McClusky (30 May 2007)
-
Presumed consent not enough
- Joannis E Vamvakopoulos (31 May 2007)
-
The acceptance of the brain death concept and organ transplants
- Calixto Machado (10 June 2007)
-
Re:Re: Presumed Consent is Problematic
- Mohamed Y Rady, Joseph L. Verheijde, Joan L. McGregor (17 June 2007)
-
The greatest good for the greatest number.
- Selina Jarvis (8 July 2007)
-
Understanding autonomy in presumed consent
- Tomasz J Pierscionek (22 July 2007)
-
Cannibalism is alive and well
- Barry A Groves (29 July 2007)
-
Organ donation: not confiscation
- Roger M Goss (31 July 2007)
-
Biological sklavery
- max bondì, Lega antipredazione organi-Bergamo PassC.Later..,22 (9 August 2007)
-
Presumptuous Content
- Nicholas P R Blyth (1 September 2007)
-
Re: Presumed Consent is Problematic
- Neil R Fell (4 September 2007)
-
A debate that misses the point
- stephen black (4 September 2007)
|
|
|||
|
Gwendoline M Harlow, Maythorp Field DN20 9HR
Send response to journal:
|
Former cancer patients are not permitted to donate blood, never mind organs. After an RTA and the subsequent rush to use organs, how would anyone know what diseases the person might have suffered? Competing interests: None declared |
|||
|
|
|||
|
David W Evans, Retired physician 27 Gough Way, Cambridge, CB3 9LN
Send response to journal:
|
To be valid in the ethical sense, whatever the legal position, consent must be fully and fairly informed and obtained without hint of coercion. For these reasons, among others, it can never be presumed. If, nevertheless, the BMA is to persist in its support for presumed consent legislation, it must accept its obligation to ensure that all those who may be presumed to have consented to removal of their organs after death were fully aware of the all the relevant facts about that procedure - as some of us pointed out 8 years ago(1). Not least in importance amongst those facts is the continuing debate about the diagnosis and certification of death for transplant purposes. 1. Hill DJ, Palmer TC, Evans DW. Presumed consent. BMJ 1999;318:1490 Competing interests: None declared |
|||
|
|
|||
|
Graham Kyle, Consultant Ophthalmologist University Hospital, Aintree, L9 1AE
Send response to journal:
|
English proposes that without evidence of prior objection, body parts could be removed from dead people for transplantation into others. There is serious error in her argument. A poll showing 90% ‘supporting’ organ donation is no basis to assume that any one respondent is in favour of donating their own organs, even assuming that the potential donor had voted! She also perpetuates the absurd idea (albeit widely held) that relatives somehow acquire a moral right to control body parts after death. Whilst any potential donor is alive, they are the sole determinant of what to do with their body, within the law. How can death change that? Competing interests: None declared |
|||
|
|
|||
|
Anne Holmes, General Practitioner Tithebarn Medical Centre, Stockton on Tees, TS19 8RH
Send response to journal:
|
Why not add possession of a donor card as a QOF target? A question about possession of a donor card is fairly simple but if the practice was requied to discuss donation, and obtain informed consent, this would require more resource. The information could be available on the NHS spine although I share concerns about awareness of contraindications to donation. Some years ago, I was appalled to discover that one of my patients had been an organ donor despite his substance misuse. Despite this being an 'in hours' donation, and a family member suggesting a problem, no attempt was made to contact the practice. Competing interests: None declared |
|||
|
|
|||
|
Michael Potts, Professor of Philosophy Methodist University, Fayettville, NC USA 28311-1498
Send response to journal:
|
Veronica English’s (1) arguments in favor of presumed consent for organ donation are flawed and ignore serious problems with the current system of organ transplantation. First, polls showing widespread approval of organ donation in the abstract do not necessarily reflect attitudes when families face a situation of potential organ donation. People who sign organ donation cards claiming that they will be donating organs “after my death” may not realize that organ donors declared dead by brain- based criteria are not dead in the usual sense. Their hearts are beating, their bodies are warm, and they do not appear to be dead. Family members may be understandably reluctant to sign a form authorizing what they believe to be the killing of their loved one by removal of vital organs. In addition, there has been widespread questioning of both the philosophical and scientific viability of brain death criteria. (2, 3) If brain death is not death, the dead donor rule is violated every time unpaired vital organs are removed from a donor, and organ donation kills the patient. Such questioning of brain death criteria by reputable physicians and philosophers should not be taken lightly, and suggests that presumed consent for a practice that may involve doctors killing patients is premature. Finally, before any notion of presumed consent can be considered, the issue of adequate informed consent to organ donation must be addressed. Forms authorizing organ donation do not currently make clear that most donors will not be dead by cardiac criteria when organs are removed, nor do they mention the controversy over brain death criteria. Without adequate informed consent, the current system of voluntary consent for organ donation is problematic. A fortiori, any system of presumed consent is also problematic. (1) English V. Is presumed consent the answer to organ shortages? Yes. BMJ 2007;334:1088 (26 May), doi:10.1136/bmj.39199.475301.AD. (2) Potts M, Byrne PA, Nilges RG (eds.), 2000. Beyond brain death: the case against brain-based criteria for human death. Dordrecht, The Netherlands: Kluwer Academic Publishers. (3) de Mattei R. (ed.), 2006. Finis vitae: is brain death still life? Rome: Consiglio Nazionale delle Richerche. Competing interests: None declared |
|||
|
|
|||
|
Gordon D Skilling, SpR Psychiatry Blair Unit, Royal Cornhill Hospital, Aberdeen AB25 2ZH
Send response to journal:
|
It is encouraging to read medical ethicists debating presumed consent for organ donation on the numbers rather than the ethics. Is this an indication of where the controversy lies? If so, then we can not be far off a change to a more ethically robust system that saves many more lives each year. As English highlights, the evidence that a system of presumed consent increases the number of organs available for donation is convincing. Add to her argument the fact that repeated surveys have shown more than 70% of the UK population are willing to donate their organs(1) but that only a quarter of the population have a donor card, and only a fifth of those carry it on their person(2). If we do not accept these surveys as good evidence then we can look to the experience of other countries that have been more progressive on the issue. Kennedy et al(3) used the Belgian example to illustrate the impact a system of presumed consent can have on donation rates. Belgian donation rates rose by 55% in the 5 years following the introduction of presumed consent in 1986. This was despite a concurrent decrease in the number of organs available from road traffic accidents. Wright may be correct to say that waiting lists for organ donation have not been eliminated by presumed consent but this does not mean such systems are not a substantial improvement on an opt in system. There is no convincing ethical argument against presumed consent. Of course it is a contradiction in terms. As John Harris pointed out, without the actual consent of the patient then there is no consent.(4) In theory therefore, to presume consent is an infringement of personal autonomy. Wright raises the issue that this may put people off donating altogether, using Brazil as an example. This has not been the case in the majority of countries that have adopted a system of presumed consent. It is speculation on my part, but I would predict that public opinion in the UK would be closer to that of mainland Europe than to Brazil. If we breach the autonomy of those who do not wish to donate by presuming consent, then so too do we breach the autonomy of those who wish to donate but who’s transplantable organs are not used. If surveys of public opinion are correct then to presume consent would be to breach the autonomy of 30% of the population as opposed to 70% under our current opt in system. Thus the net effect would be that people’s wishes would be respected more often if consent was presumed. It has been argued that the mistaken removal of organs is morally much worse than the mistaken non-removal of organs.(5) To give more moral weight to a decision not to donate than to a decision to donate is illogical. If either is over ruled then there is arguably a breach of autonomy. Any rational comparison would conclude that the resulting harms are greater in a case of mistaken non-removal of organs because this may result in the death, or at least significant morbidity, of another person who does not receive a transplanted organ. From a utilitarian perspective the mistaken removal is the more morally sound practice. Of course the problem of organ shortages will not be solved by one approach. The issue is complex, having cultural, spiritual and religious facets. In this regard Wright is correct to say that strategies to address public perception of the process are essential. (In fact, English and Sommerville previously observed that a desire to follow religious teachings does not preclude organ donation and most major religions positively encourage donation. (6) ) In other walks of life our society already accepts the notion that individual autonomy can be denied if it is in the public interest (think seatbelt legislation, post-mortems or jury service). The bottom line is that a system of presumed consent would save many more lives each year. In the absence of a convincing argument to the contrary, it should be the default position for organ donation in the UK. (1) Kittur DS., Hogan MM. ‘Incentives for organ donation?’ Lancet (1991); 338(8780): 1441 and New B. Solomon M. Dingwall R. McHale J. A Question of Give and Take? Improving the Supply of Donor Organs for Transplantation. Kings Fund Institute, 1994, at p66 and Written answer: organ donor register. House of Commons official report (Hansard) 2002 June 13, vol 1386, no 158: col 1445W (2) New B. Solomon M. Dingwall R. McHale J. A Question of Give and Take? Improving the Supply of Donor Organs for Transplantation, op. cit. (3) Kennedy I. Sells RA., Daar AS., Guttman RD., Hoffenberg R., Lock M., Radcliffe-richards J., Tilney N. ‘The case for “presumed consent” in organ donation’ Lancet (1998); 351(9116): 1650 (4) Erin CA., Harris J. ‘Presumed consent or contracting out’ J Med Ethics (1999); 25: 365-366 (5) Gill MB. ‘Presumed consent, autonomy and organ donation’ Journal of Medicine and Philosophy (2004); 29(1): 37-59 (6) English V. Sommerville A. ‘Presumed consent for transplantation: a dead issue after Alder Hey?’ J Med Ethics (2003); 29: 147-152 Competing interests: None declared |
|||
|
|
|||
|
Richard Bartley, Physiotherapist Denbigh, Wales
Send response to journal:
|
Michael Potts highlights an often misunderstood aspect of organ donation, i.e. death is not always what it seems, especially to relatives. However, I wonder whether his concerns are predominantly motivated by theological considerations? I suspect the key word here is prognosis, as accepted by a wide consensus of peers. The heart may still be beating, but if the prognosis is bleak in extremis, why not let someone else have a chance of a longer life? Competing interests: None declared |
|||
|
|
|||
|
Joan McClusky, Medical writer New York, NY 10003
Send response to journal:
|
Until fairly recently, the definition of death was cardiopulmonary death, not brain death. There is a vast suspicion that doctors will take organs from those who are not "really dead"--this suspicion will seem to be confirmed if the heart is still beating and there appears to be undue haste to harvest the organs. The public needs to be educated on what "brain dead" means, the difference between brain death and a coma, the need for speed in removal of the organs, and most important, the criteria that must be met to confirm that someone is indeed "dead" before organs will be removed. Competing interests: None declared |
|||
|
|
|||
|
Joannis E Vamvakopoulos, Medical student University of Birmingham Medical School, Edgbaston, Birmingham B15 2TT, UK
Send response to journal:
|
Although both contributors to the debate on presumed consent (1) make impassioned arguments, I feel that Linda Wright's view is more, to use a fashionable term, holistic. Going by the numbers cited, it also seems to be the only reasonable response to the specific question posed. Fellow BMJ readers may find the following results of some quick calculations enlightening. Assuming a best case scenario where presumed consent was adopted in the UK resulting in an increase of 30% in organ donation rates (2), this would increase the number of donors to 16.6 per million population. According to UK Transplant's latest annual figures (3), the ratio of organ recipients to cadaveric donors stands at 2.9 (ie one donor provides about 3 organ grafts on average). The average size of the UK organ donor pool has remained roughly constant between 1996 and 2005 (-0.9% average annual growth rate) and stood at 764 at last count (Aug 2006). This corresponds to 2,195 organ grafts, a number that would potentially rise to 2,854 under presumed consent. Consider, however, that the size of the UK transplant waiting list grew by 2.9% annually, on average, between 1996 and 2005 (by 4.4% annually since 2001) and currently stands at 7,240. The immediate shortfall in meeting demand, even with an opt-out law in place, is all too apparent (and this is assuming each patient receives only one organ). Furthermore, the enduring discrepancy in donor and waiting list growth rates hints that, unless measures are taken to reverse it, organ shortages are here to stay. Presumed consent is ethically sound, has the potential to be part of the answer and the time is ripe for a public debate - but it is not a panacea for organ donation and should not be portrayed as such. Several other strategies deserve attention and among them educational initiatives, even within the medical profession, remain indispensible. We recently carried out a survey of nearly 4,000 UK doctors and medical students, which revealed a high proportion of registered organ donors but also highlighted some fundamental misconceptions about organ donation. How can we ever convince the public if we ourselves remain unconvinced? 1. English V, Wright L. Is presumed consent the answer to organ shortages? BMJ 1007;334:1088-1089 2. Abadie A, Gay S. The impact of presumed consent legislation on cadaveric organ donation: a cross-country study. J Health Econ 2006;25:599 -620 3. UK Transplant Activity Report 2005-2006 [http://www.uktransplant.org.uk/ukt/statistics/transplant_activity_report/current_activity_reports/ukt/transplant_activity_uk_2005 -2006_v2.pdf] (accessed May 30, 2007) Competing interests: None declared |
|||
|
|
|||
|
Calixto Machado, President of the Cuban Society for the Determination of Death Institute of Neurology and Neurosurgery, Apartado Postal 4268, Havana 10400, Cuba
Send response to journal:
|
Regarding the “dead donor rule”, with the advent of transplant surgery, interest in definitions and diagnosis of death based on brain formulations really acquired a new urgency.1 Nonetheless, as I have already discussed, it is important to point out that the concept of brain death (BD) as death of the individual, did not appear to benefit organ transplantation, but was a consequence of the development of intensive care. When French neurophysiologists and neurologists described the death of the nervous system and coma dépassé,2, 3 organ transplant techniques were only in the very early stages of development.4 Nonetheless, education of physicians, nurses, paramedics, and people in general, about the importance of retrieving organs and tissues from brain-dead cases, for other patients to whom transplantation surgery is a hope of life and good health is just based on the acceptance that BD means death of the individual.5,6 In a developing country like Cuba, on the contrary, education of physicians, nurses, paramedics, and the use of media to instruct the public opinion about a concept of death on neurological grounds, and the human and solidarity notion of retrieving organ and tissues for transplant surgery, have produced a low rate of family denials on authorizing organ retrievals from a brain-dead donor. In Cuba, although any person could express in his or her identity cards his or her wishes of being an organ donor, in case of being diagnosed as a brain-dead case, physicians always ask permission to patients’ relatives for organ retrieval.5 Maybe in the near future, xenotransplants, clonation, the use of stem cells, or other not yet developed methods, will allow to produce organ and tissues, replacing transplants from brain dead donors. Nonetheless, physicians will still need to face and deal with this controversial state: brain death.4,6 References 1. Siminoff LA, Burant C, and Youngner SJ. Death and organ procurement: public beliefs and attitudes. Kennedy Inst Ethics J 2004; 14: 217-234. 2. Wertheimer P, Jouvet M, and Descotes J. [Diagnosis of death of the nervous system in comas with respiratory arrest treated by artificial respiration]. Presse Med 1959;67:87-88. 3. Mollaret P and Goulon M. Coma dépassé (preliminary memoir). Rev Neurol (Paris) 1959;101:3-15. 4. Machado C, Korein J, Ferrer Y, Portela L, De la C Garcia M, and Manero JM. The concept of brain death did not evolve to benefit organ transplants. J Med Ethics 2007;33:197-200. 5. Machado C. [Resolution for the determination and certification of death in Cuba]. Rev Neurol 2003:36: 763-770. 6. Machado C. Consciousness as a definition of death: its appeal and complexity. Clin Electroencephalogr 1999:30: 156-164. Competing interests: None declared |
|||
|
|
|||
|
Mohamed Y Rady, Professor/Consultant Critical Care Medicine Mayo Clinic Hospital, Mayo Clinic Arizona, Arizona, USA, 85054,, Joseph L. Verheijde, Joan L. McGregor
Send response to journal:
|
We would like to point out that contrary to Richard Bartley views, the concerns with presumed consent are not predominantly motivated by theological considerations but rather by medical and scientific rationale. Presumed consent also violates person’s right for self-determination. It is increasingly evident that special interest groups campaigning for organ donation can profoundly influence the debate on presumed consent by misinforming the public about the differences of deceased organ procurement in brain death, cardiac death and imminent death (1). We agree that the prognosis may be a key element for organ donation; nonetheless, the lack of widely accepted criteria for the determination of medical futility among practicing physicians introduces sufficient variability in its application and risks its premature declaration for the purpose of recovering transplantable organs (2). While death is not always what it seems, especially to relatives, it is undeniable that organ donation transforms “peaceful, respectful” death to a “profanely high tech” death. The deprivation of prospective organ donors of appropriate end-of-life care is a traumatic experience for families and a morally distressing practice for other health care providers (2-4). Therefore, there is no evidence or data to support Veronica English position that a move to presumed consent would be an acceptable option in the United Kingdom (5). In the United States (US) a national survey of organ and tissue donation attitudes and behaviors (conducted by the Gallup Organization and prepared for the Division of Transplantation Health resources and Services Administration) reported most people either "opposed" (26.7%) or "strongly opposed" (30.1%) presumed consent (6). In the same survey, about 3 in 10 reported that they would opt-out of a presumed consent approach. The difficulties surrounding presumed consent and public reluctance for its support and acceptance in the US surfaced again in 2007, when an amendment was introduced to the Uniform Anatomical gift Act-UAGA drafted in 2006 (7). When addressing the effect of anatomical gift on an individual’s advance health-care directives in the 2006 draft of UAGA Section 21, it states “If a prospective donor has a declaration or advance health-care directive, measures necessary to ensure the medical suitability of an organ for transplantation or therapy may not be withheld or withdrawn from the prospective donor, unless the declaration expressly provides to the contrary” .The prospective organ donor in the UAGA is an individual who has a part that could be the subject of an anatomical gift, unless the individual had signed a refusal for organ donation. Section 21 of the UAGA presumes that for prospective donors the desire to save lives by making an anatomical gift trumps the desire to have life support systems withheld or withdrawn. Section 21 of the UAGA generated media attention and national concerns in the US that the presumption of an individual to be a prospective organ donor can override his (her) own expressed wishes about end-of-life care in either an advance health-care directive or a declaration (8). The Executive Committee on behalf of all the States Commissioners approved the amendment to Section 21 in May 2007. The amendment recognizes the conflict between the presumption of an individual to be a prospective organ donor and appropriate end-of-life care desired by an individual. The amendment states “If a prospective donor has a declaration or advance health-care directive, and the terms of the declaration or directive and the express or implied terms of a potential anatomical gift are in conflict with regard to the administration of measures necessary to ensure the medical suitability of a part for transplantation or therapy, the prospective donor’s attending physician and prospective donor shall confer to resolve the conflict. The conflict must be resolved as expeditiously as possible”. In the same amendment it is also commented that “Before resolution of the conflict, measures necessary to ensure the medical suitability of the part may not be withheld or withdrawn from the prospective donor if withholding or withdrawing the measures is not contraindicated by appropriate end-of-life care” (9). The drafting Committee of the UAGA also responded to the media criticism that they were not advocates for any special interest group but serving the public interest. It is unfortunate that public fear and distrust of the transplant community has to be suppressed by legislation of a presumed consent model, abandoning informed voluntary consent and avoiding transparency about deceased organ donation (10). Joseph L. Verheijde, Adjunct Professor of Bioethics, Arizona State University, Department of Physical Medicine and Rehabilitation, Mayo Clinic Hospital, Mayo Clinic Arizona, Phoenix, Arizona, USA Joan L. McGregor, Lincoln Professor of Bioethics, Department of Philosophy, Arizona State University, Professor of Basic Medical Sciences, Director Biomedical Ethics and Medical Humanities, College of Medicine- Phoenix, University of Arizona, Phoenix, Arizona, USA Mohamed Y. Rady, Professor/Consultant, Critical Care Medicine, Department of Critical Care Medicine, Mayo Clinic Hospital, Mayo Clinic Arizona, Phoenix, Arizona, USA References 1. Woien S, Rady MY, Verheijde JL, McGregor J. Organ Procurement Organizations Internet Enrollment for Organ Donation: Abandoning Informed Consent. . BMC Med Ethics 2006;7:14-23 Available at: http://www.biomedcentral.com/1472-6939/7/14. 2. Mandell MS, Zamudio S, Seem D, et al. National evaluation of healthcare provider attitudes toward organ donation after cardiac death. Crit Care Med. 2006;34:2952–2958. 3. Rady MY, Verheijde JL, McGregor J. Organ donation after circulatory death: the forgotten donor. Crit Care. 2006; 10:166-169. Available at: http://ccforum.com/content/10/5/166. 4. Kesselring A, Kainz M, Kiss A. Traumatic Memories of Relatives Regarding Brain Death, Request for Organ Donation and Interactions with Professionals in the ICU. Am J Transplant. 2007;7:211-217. 5. English V. Is presumed consent the answer to organ shortages? Yes. BMJ 2007;334:1088 (26 May, 2007). 6. The Gallup Organization Prepared for Division of Transplantation Health Resources and Services Administration: 2005 National Survey of Organ and Tissue Donation Attitudes and Behaviors. Attitudes Toward Presumed Consent. Available at http://www.organdonor.gov/survey2005/presumed_consent.htm 7. The National Conference of Commissioners on Uniform State Laws. Uniform Anatomical Gift Act (2006). Available at http://www.anatomicalgiftact.org/DesktopDefault.aspx?tabindex=1&tabid=63#_Toc148498125 8. Stein, R. States Revising Organ-Donation Law. The Washington Post. Wednesday, April 4, 2007; Page A01. Available at http://www.washingtonpost.com/wp- dyn/content/article/2007/04/03/AR2007040302062.html 9. The National Conference of Commissioners on Uniform State Laws. Amendment to UAGA Section 21. Available at http://www.anatomicalgiftact.org/DesktopDefault.aspx?tabindex=0&tabid=73 10. Verheijde JL, Rady MY, McGregor J. Recovery of transplantable organs after cardiac or circulatory death: Transforming the paradigm for the ethics of organ donation. Philos Ethics Humanit Med. . 2007;2:8. Available at: http://www.peh-med.com/content/2/1/8. Competing interests: None declared |
|||
|
|
|||
|
Selina Jarvis, Registeres Nurse BSc (Hons), M.A, B.A University of Hertfordshire
Send response to journal:
|
The articles entitled ‘presumed consent the answer to organ shortages?’ Yes by English and No by Wright, have triggered a number of responses which again demonstrates that there is no real ‘one size fits all’ approach to organ donation at the end of life. It is clear that in the context of multicultural society as seen here in the United Kingdom, one must be exquisitely aware of the diverse attitudes towards organ donation due the symbolism, beliefs and emotions that are associated with organs. A presumed consent approach to certain religious groups may be potentially demeaning to the deceased but also to subsequent generations of the patient’s family. In addition, as Wright points out the presumed consent approach may even lead to a lack of confidence in the medical profession as demonstrated by the example given in Brazil1. At this point, I would like to draw attention to the updated Human Tissue Act (2004) 2 in the context of organ donation at the end of life. The Act quite clearly states that an organ cannot be used for donation without patient consent. However, there is a small section of the Act, Section 43 (1) which states that the institution in legal possession of the body e.g. a hospital ‘may take steps for the purpose of preserving an organ part for use for transplantation’ if the patient’s wishes are not known at the outset. Therefore, it allows for initial organ preservation techniques to go underway until consent is confirmed or refuted. In the era of non heart beating donors, section 43 fits in with the possible organ preservation that may required promptly in these cases. Ethically, this small section of the Human Tissue Act (HTA) represents a social shift in our approach to end of life organ donation, but it appears to have ironically been overlooked. Bell (2005) describes how during the passage of the Human Tissue Bill through parliament, little clarification or amendment to section 43 was produced in the original explanatory notes of the bill. This implies that the current thought at that time was that initial preservation was already lawful because there was ‘no law against it’.3 Interestingly however, the BMA advocated at that time that presumed consent should apply not only to organ preservation but rather to organ donation proper.4 Therefore, despite countless debates of whether presumed consent should be instated, in the UK, initial organ preservation could legally operate under a ‘presumed consent’ umbrella. Wright defines that presumed consent refers to laws, which permit the procurement of organs without permission. Here, one could argue that we actually have the system in place since the initial preservation of an organ in a deceased patient may occur without consent. In routine medical practice, procedures may be undertaken without consent in special circumstances e.g. in the emergency situations or with incompetent patients. However, in all of these cases, one could argue that the procedure is in the best interests of the patient. In the case of an organ preserving procedure, the interests are not for the patient but rather for 3rd party benefit, thus demonstrating a Utilitarianism approach of providing the greatest good for the greatest number. If this section of the HTA was actively put into practice, one must consider that there are a large number of organs, which are not suitable for organ donation, although it is hoped that the initial preservation may reduce this in some cases. This may have consequences both logistically in replacing the organs if they are found to be unsuitable and also the emotional consequences on the relatives when the clinician must let them know that their deceased relative went through an unnecessary procedure. Many health workers may not want to jeopardise their relationship with the relatives or their professional reputation. Wright aptly mentions that presumed consent may lead to alienation of patients’ relatives from the health care profession and this could be exacerbated in these scenarios. There are a number of other implications, for example preservation of organs may interfere diagnostically with the case of death if it becomes apparent that the patient needs a post-mortem. In addition, in the era of non heart beating donors there may be an excess ‘organ preserving’ workload if taking section 43 is implicated nationally, with the need for a corresponding increase of transplant co-ordinator teams. In addition, ward staff who are not normally having at the forefront of organ donation may need specific training. English1 suggests that before a change to presumed consent, there would need to be extensive publicity advising people on how to opt-out. This is an important component to the success of a presumed consent approach. However, if one reflects on section 43 in the UK, we are half operating a presumed consent system, thus it is important that patients are aware that this can be undertaken without consent although using the organ for donation itself would need consent since this follows an opt-in system. Section 43 represents a chance for a public discussion regarding the current state of our law, which actually represents a social shift to a partially initial opt-out system in initial organ preservation if this was implemented everywhere. Publicity regarding this legislation may encourage people to give it some thought early on with their families before they first develop an illness and may promote an open discussion regarding this challenging area. 1. Institute of Medicine. Organ donation: opportunities for action. Washington, DC: National Academies Press, 2006. 2. Human Tissue Act 2004 http://www.hmso.giv.uk/acts/ acts2004/40030-a.htm 3. Bell MDD (2005) The UK Human Tissue Act and consent: surrendering a fundamental principle to transplantation needs? J Med Ethics 2003;32:283-286 4. British Medical Association (BMA) Ethics Committee (2000) Organ Donation in the 21st Century: time for a consolidated approach. BMA publishing, London Competing interests: None declared |
|||
|
|
|||
|
Tomasz J Pierscionek, medical student Newcastle Medical School Framlington Place Newcastle University NE2 4HH
Send response to journal:
|
The opposing arguments for and against presumed consent (1) have raised the importance of the ethical principle of respect for autonomy and highlighted some potential misunderstandings of its definition. The principle respects the right of a person to make their own decisions after they have been fully informed of the consequences of that decision (2). This definition does not include situations in which the individual is not asked to make a decision, has received no relevant information or, indeed, has not made any decision. To state that 70% of individuals who are willing to donate their organs have their autonomy breached (3) is to suggest that those individuals have made a decision that has not been honoured. If an individual feels strongly about donating an organ they will take steps to obtain a donor card. If they have not done so, they are either undecided, uncertain (possibly because they are not fully informed) or do not care enough about donating organs to make a decision to get a donor card. Although Dr Skilling makes an interesting point that "we breach the autonomy of those who wish to donate but whose transplantable organs are not used", for this to be correct would require a widening of our currently accepted definition of autonomy. The ethical arguments are by no means settled. To state that presumed consent is "ethically sound" is a presumption in itself (4). One of the fundamental controversies in this area revolves around whether or not presumed consent violates the respect for autonomy. Unless and until this is resolved, which may require a paradigm shift in our understanding of the limitations of autonomy, can we state with any confidence that presumed consent is ethically sound. 1. English V, Wright L. Is presumed consent the answer to organ shortages? BMJ 2007;334:1088-1089 2. Beauchamp TL and Childress, JF. Principles of Biomedical Ethics 5th edition 2001, p12 3. Skilling GD. It is medically and morally correct to presume consent. BMJ 2007 (29 May) 4. Vamvakopoulos, JE Presumed consent not enough. BMJ 2007 (31 May) Competing interests: None declared |
|||
|
|
|||
|
Barry A Groves, Independent Researcher, maintains www.second-opinions.co.uk OX7 6LP
Send response to journal:
|
For a couple of hundred years we sent explorers, anthropologists, doctors, and medical missionaries around the world to contact primitive peoples, learn about their ways, convert them to a variety of types of Christianity, and bring them the 'benefits' of our civilisation. The one thing that concerned these men and women most was cannibalism. Even today we talk of primitive cannibals, and westerners such as plane-crash survivors, forced by circumstance to eat other humans to survive, with similar horror. And yet we as a society regularly practise cannibalism. Not only do we practise it, we actually make a virtue of cannibalism, to the extent that it seems that before long offering oneself to be cannibalised may well become mandatory. To compound this, the cannibals even want our bodies for free! I look upon the whole business as extremely distasteful, and the way the medical professsion is going about forcing us to succumb as tyrannical. It's enlightening that, according to those earlier anthropologists and men such as Weston A Price and Vilhjalmur Stefansson, both of whom were working in the 20th century, those peoples who did not have our 'benefits' did not suffer any medical conditions that would have necessitated organ transplants. Why do we not put more effort into ensuring that people do not get ill enough to need transplants in the first place rather than resort to a distasteful practice we so deplored in others? Competing interests: None declared |
|||
|
|
|||
|
Roger M Goss, Co-director Patient Concern, London SW5 9FY
Send response to journal:
|
Patient Concern supports Liam Donaldson’s, the BMA’s and the BMJ editor’s goal 100% but like many, including plenty of BMJ readers, views the call as misguided and unethical. Not agreeing to something cannot constitute agreeing. Only some doctors and the Department of Health don’t seem to find this contradictory nonsense. The latter are assuming consent to an electronic patient care record. Where next? Presumed consent to any medical research, therapeutic or non-therapeutic, unless the patient has anticipated the possibility and formally opted out? The approach is expediency over principle. It is trying to exploit human inertia for a desired good. The end justifies the means. We beg to differ. It will be a bad day if people are deprived of their right to make a positive altruistic gift of their organs, instead confiscating them in the absence of a formal objection. This approach goes against the Department of Health’s own ‘Good Practice in Consent’, the spirit of the Mental Capacity Act, the objective of the Human Tissue Act, and the principles in the GMC’s new draft document on ‘consent’. Patient Concern supported all these advances. Pay GPs and hospital doctors for every patient they sign up. Require them to publicly display the percentage of their staff on the donor register in their surgeries and out-patient departments compared with the national average for healthcare employees. Lead by example. Make anaesthetising all beating heart donors mandatory. That should reduce relatives’ 40% refusal rate. Many fear consent may condemn their loved one, manifestly dying rather than actually dead, to the risk of more suffering. These are practical and honourable ways forward. If the opinion polls showing 80% willing to donate are true, such measures will deliver what we all want – better availability of organs. We respectfully suggest that this is the morally right approach to such a sensitive subject. Competing interests: None declared |
|||
|
|
|||
|
max bondì, general surgeon Italy-Roma-39, Lega antipredazione organi-Bergamo PassC.Later..,22
Send response to journal:
|
BIOLOGICAL SLAVERY While in the phagocytic process and in the cannibalism the phagocytized subject is digested and therefore destroyed and only remains the energy deriving from his fission, it is quite different what happens in the explant-transplant process. Organs and tissues taken off from the alive and breathing Subject are replaced in another organism and obliged to work in extremely difficult conditions ( rejection with the anti-immune- depression treatment) . In this way two very important actions against Nature are perpetrated. The first one is the explant which determines definitely the death of the subject. The second is the chronic pathological state of the transplantated subject in a permanent rejection situation . Two extremely grave actions against Nature for the actors of this drama, that should be forbidden by Law. So Humanity in his ignorance exceeds considerably the Immorality of Nature(Mors tua vita mea) through the Biological Slavery application. An organ is compelled to work for another subject with all the annexed implications of cellular and genetic suffering. In fact the Genetics of the explant-transplant is still unknown; we do not know absolutely what may happen joining different DNA in the long run and in the following generations. It is likely to think that joining different DNA some negative interactions may occur in the long run. prof.dr. Max Bondì l.d. Pat.chir.prop.clin.Univ.La Sapienza-Roma Pathologist General surgeon Sydney Chief scientific committee of League against the predatory organs and the beating heart death. President; Nerina Negrello-24100 Bergamo-Pass.C.Lateranensi,22 -Italy Ph.-fax-035-219255 Competing interests: None declared |
|||
|
|
|||
|
Nicholas P R Blyth, Publishing Manager Today Media Ltd., Inwood House, 1 - 3 Elliott's Place, Islington, London N1 8HX
Send response to journal:
|
Dear Sir, I was interested in the articles I read relating to “presumed consent” and submit a layman’s point of view. Regarding Veronica English’s contribution, I was arrested immediately ( and angered ) by the sheer lack - absence, almost - of either intellectual rigour or logical thought. From the very start, I was alarmed by a kind of facile assumptiveness - implicit in phrases such as “it seems likely that”, “we all have the same aim”, “changing the default position”, “assuming…unless there is evidence to the contrary”, “analyses seem to indicate” et al. They set the tone for the whole piece. Add to those the ones that spell danger because they conceal ( albeit under a thin disguise ) some sinister sub-texts and there’s a cause for grave concern. I always worry when something is presented as being “easier for all concerned” ( as though convenience were the main - even the sole - criterion ). It alerts me immediately to the probability that something is being slipped in and that an attempt is being made to disarm or anaesthetise my critical faculties! Looking at the essay more closely, I found roughly what the cursory reading had led me to expect: the ethical issue is simply not dealt with at all! The entire ‘argument’ ( to call it that ) is based on convenience and on the assumption that any system which increases the number of donations requires, ipso facto, no further justification. Countries where the donation rates are highest are thus presented as ‘evidence’ that a ‘presumed consent’ policy is ‘better’. I found the first major assumption of the piece both baffling and disgraceful: that bodies had been buried or cremated “intact” ( rather than used for organ transplantation ) “not because people objected to donating their organs but simply because they never got around to making their wishes known”! That anyone should present such an obviously self- serving proposition on the basis, merely, that it “seemed likely” was, I thought, staggering. The rest of the piece is riddled with logical falsehoods and ineptitude. The idea that because some people may “support organ donation” as a principle they will necessarily be willing to give pre-emptive consent to the use of their own organs - and that without being made fully aware of the conditions under which this will happen ( and understanding / accepting those conditions ) - is preposterous. I’ve no doubt, of course, that the idea that an assumption that people want to donate unless there is evidence to the contrary will cause an increase in availability. That’s obvious. But - as in the whole of Ms. English’s thesis - this makes not the slightest attempt to confront ( even to touch on ) the moral issues. Mostly, throughout her entire essay, moral considerations are simply ignored. As far as she’s concerned, increased availability = success = justification; which even a naïve moral philosopher like myself can see to be nonsense. It’s back to the old end- justifies-the-means debate. And when she questions the validity of “current law” because it “assumes, when people die, that they are in the minority who do not wish to donate”, she is on equally thin ice; in fact, on no ice at all. Dead in the water! Of course the law assumes that! It ‘assumes’ that unless I make it clear before my death that when I die I wish to ‘donate’ something that belongs to me to a specific cause or for a specific purpose, then I do not so wish. Otherwise, all kinds of ‘assumptions’ could be made about how I might want to dispose of my possessions ( including my own body ): e.g., that I wanted ( in the absence of any clear indication to the contrary ) to donate my body to medical research or that I wished the proceeds of my estate to be donated to the Battersea Dogs’ Home! Once we start ‘assuming’ what people want, we’re already part way down a very slippery slope. It soon becomes an assumption of authority to decide what people ought to want. As if that were not enough, the people “who do not wish to donate” are implicitly derogated as a “minority”. ( I’ve noticed before that when people want to foist otherwise untenable notions on others, they often use the ‘minority’ idea as an argument. It’s typical, I’ve found, of such people to assume that the majority is always right; which is something no intelligent and honest person would ever claim! ) I’m amazed, too ( though perhaps not ), that the basis itself for establishing that people who do not wish to donate are a minority is so ill-defined. “Surveys show…”!! It’s one of those corny old expressions - like “research on both sides of the Atlantic has established…” or “A highly-placed Government source assures me that…” ( I note, in this case, that the only reference to any actual survey is distinctly anonymous and general: a “UK Transplant Survey”. If such a survey existed, I would be very interested to see and analyse the questions on which its conclusions were based. I would anticipate much of the kind of box-ticking that manoeuvres respondents into false positions by cutting off their options ( probably without anaesthetic! ). As regards her claim - and apparent surprise at the fact - that “although 90% of the population supports donation, only 23% have registered their wish to donate”, one can only register surprise oneself that Ms. English is surprised. The questions to be asked are, surely, a) if this is so, why is it so? and b) why have people like Ms. English not asked ( and found the answer to ) this obvious question? The obvious answers, it seems to me, are: a) that a general support for the idea of organ ‘harvesting’ is very different from a willingness to give permission for one’s own organs to be used; b) that without far more - and far more precise - information concerning how and under what circumstances one’s organs might be removed and re-distributed and one’s death defined, one would, of course, be reluctant to make any commitment whatsoever. And one has only to consider the “efforts” ( e.g. strategies ) “to improve transplantation rates over the last decade” to see even more clearly where Ms. English is coming from. For “publicity” read ‘propaganda’, for “education” ( with its facile and patronising implications - that if only we can explain to these simpletons ( the 90% ) just how silly and selfish their point of view is, they will fall in line and thank us for it - ) read, effectively, ‘coercion’. For “simplifying the process” read ‘falsifying the reality’ through carefully contrived box -ticking questionnaires that manipulate the respondents into compromising positions by offering limiting alternatives which discourage both freedom of thought and accuracy of response. Nor would I have a jot of confidence in “extensive publicity advising people how to opt out”. We’ve most of us, at some time or other, been supplied with ‘opt-out’ information, or been offered opportunities to ‘register objections’. Those of us who’ve attempted these complicated and often ( I suspect deliberately ) baffling procedures would, in most cases, I think, be very sceptical; if for no other reasons than that the people offering the opportunity don’t want you to opt out! Paragraph 5 seems to me to be the most offensive of all. The idea that the relative of a dead or dying ‘target’ person who has not opted out should be asked if they know of any “unregistered objection” is bizarre - and, in a sense, wicked. The terminally sick or deceased person not having opted out ( confusion, mental fatigue, the near-to-death physical condition itself, not even having considered the matter, etc. ), the relatives, if they fail to declare knowledge of an unregistered objection, “are informed of the intention to proceed”! The only reservation allows the possibility of the process causing the relatives “severe distress”. Well - we’ve all seen how expressions like that have helped to open the flood gates to literally millions of abortions whose justification depended on ‘severe mental distress’ being caused to the ‘mother’ and have created a climate in which mass-murder presents itself as social concern. Ms. English goes blithely on to show - though the phrases describing her frames of reference ( “careful analyses seem to indicate” ) ring immediate alarm bells - that in countries where the policy of “presumed consent” has been implemented there have been “higher donation rates”. This is one of the few assumptions she makes that I would not be disposed to doubt. It’s the one thing about which I’m sure she’s right. But in spouting these statistics she is only coming up with the answer that most people would expect. She has still not even begun to address the moral issue that would concern most people; and clearly doesn’t see that there is one. Firstly, she implies that the government argues lack of support for “presumed consent” without any serious attempt to test this assertion ( where, I wonder, does that idea come from? ), then claims - with the arrogant assumptiveness that one has now come to expect of the whole piece - that “We all have the same aim: to improve donation rates.” That, I think, caps everything! Any other criterion is irrelevant. People who do not agree are committed to a “strategy that has failed” but which they “doggedly pursue”. It’s all pretty insulting - and one of the most facile pieces I think I’ve read. The lack of logic, even, coupled with the over- confident, hectoring tone is itself an insult. Whatever one’s moral instincts concerning this issue, one would have to be no more than a half- intelligent person to feel disquieted by it. The “strategy” that she condemns can be judged a failure only if you agree with its fundamental premise: that to “improve donation rates” is the sole criterion of success. The bullet points with which she concludes are an appropriate summary of her method and of the sloppiness of her thought. Gordon Skilling’s article accepts, almost without demur, Ms. English’s whole thesis, while throwing a casual sop to conscience by accepting that “The issue is complex” ( Wow!! ) “having spiritual and religious facets”, but sees the only way forward ( i.e. to the achievement of the stated aims ) as devising “strategies to address public perception” ( i.e., to show dissidents that they’re wrong ). Well - one would hardly expect a balanced argument from someone who maintains “there is no convincing ethical argument against presumed consent” and accepts English and Somerville’s claim that “most major religions positively encourage donation”. What he understands by a ‘religion’, I’m not clear. All the ‘inspired’ documents that form the bases of the world’s major religions came into being, obviously, centuries before the idea of organ transplantation was even seriously imaginable. I don’t think he - or Veronica English - have any real intention to grapple with the ethical or religious issues. He asserts blandly: “The bottom line is that a system of presumed consent would save many more lives each year”. If that’s the case, then there’s no point in any argument at all; except to say “No! It simply isn’t. That is not the ‘bottom line’ ”. As for his ideas about the infringement of personal autonomy - they seem to me to be intellectually puerile. “If we breach the autonomy of those who do not wish to donate by presuming consent”, he writes, “then so too do we breach the autonomy of those who wish to donate but whose organs are not used.” I could hardly believe I read that. Is he really saying that a person who has donated organs but whose organs are either unsuitable or surplus to requirements has had his ‘autonomy’ breached? Would he use the same ‘logic’ in support of the use of all organs offered - including diseased ones - for fear of breaching someone’s ‘autonomy’? ( See Gwendoline Harlow’s comment about former cancer patients, who are “not permitted to donate blood, never mind organs”! ) It doesn’t surprise me, therefore, that he should come up with “To give more moral weight to a decision not to donate than to a decision to donate is illogical.” What a muddle! The point has to do not with donating or not donating but with donating freely, on the one hand, or being pressured into donating on the other, or having one right to decide whether or not to donate unfairly influenced or actually abrogated. And that the notion of infringement of autonomy can be proved to be ‘already accepted in our society’ by comparing the legal requirement to wear safety belts in cars with ‘presumed consent’ is, frankly, risible! Not surprisingly, I liked Michael Potts’s article and the contributions by Graham Kyle ( not, I hope, merely because I agree with their ethical premises ) and - in a slightly modified form - Barry Groves’s provocative and feisty comment on human ‘cannibalism’. Also, the contribution by Dr. David W Evans had, I found, a strength and a depth of focus that the others did not. I particularly appreciated a) its undistracted concentration on the central issue, b) its closely reasoned logic, c) its calm non-rhetorical delivery, d) its precision of statement. Yes - “The fundamental ethical issue…is that of truth and its telling.” I believe, too, ( as argues earlier ) that he is absolutely right in his judgement concerning the attitude that “may well explain the difference in numbers of those declaring support for organ transplantation in the general, impersonal, sense and those prepared to register as “opt- in” potential donors…” Competing interests: None declared |
|||
|
|
|||
|
Neil R Fell, Senior House Officer West Sussex PCT. BN12 6BT
Send response to journal:
|
Michael Potts may disagree with English’s views on informed consent however it should be noted that in the UK families are always counselled about their relatives’ medical situation and the expectation for recovery before a decision is made about organ donation. Implying that doctors ‘kill loved ones’ is erroneous. Competing interests: None declared |
|||
|
|
|||
|
stephen black, management consultant london sw1w 9sr
Send response to journal:
|
This whole debate seems deeply entrenched in strongly held views that are unlikely to change. Both the pros and cons seems to miss an obvious solution that depends on not making assumptions about the fuzzy majority of the public who don't appear to have expressed a view actually believe. The real issue is not that the fuzzy majority hold to the anti-donor view: its that they don't care enough either way to take an active step to express their views and carry a donor card (is their an anti-donor card?). The presumed consent lobby assume this group consents and wants to enroll them; their opponents assume many of this group hold strong anti-donor views. Rather than making presumptions about the fuzzy majority, perhaps we should force them to choose. Make having a donor card an opt out rather than opt in action (every time you fill in an official form--driving licence, passport etc--you have tick a box so you don't end up with a donor card as well). Nobody who harbours serious objections to donating would be presumed to consent by this: they would all tick the box. But the system would catch those who have no objection but are too lazy to volunteer. Such approaches are well known to be effective. The requirement to take even a small action often reduces takeup by 60% or more. I recently lost a cashback offer on my credit card because I didn't fill in and return a form on time. Employers who have switched pension enrollment from opt-in to opt-out have seen takeup rate skyrocket (even where the conditions and benefits are the same). I don't know whether such approaches have been tried in the UK for donor-cards, but the (opt-out rather than opt-in)principle seems to work well in other areas. And its hard to see why making it easy for the lazy to make a choice is morally problematic. Competing interests: None declared |
|||