Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Presumed consent: primum non nocere
- R Mohindra (20 January 2008)
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Time to opt out to turn around transplant chaos
- DAVID G SAMUEL (20 January 2008)
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Better ways to increase organ donations...
- stephen black (24 January 2008)
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Opt out scheme - good but messy
- Michael G Peckitt (28 January 2008)
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R Mohindra, Consultant Cardiologist Sth Tyneside Hospital NHS Foundation Trust
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Gordon Brown has re-ignited the debate about organ donation. This time pressing upon the presumed consent question. It is important to realise that presumed consent does not remove consent. The principle operates where there is doubt about whether consent is present or not. Where there is doubt it resolves it in favour of organ donation.A good analogy is the presumption of innocence which rests on the principle of primum non nocere. The key question is whether it is better, given doubt, to remove the organs of someone who would not have wanted to donate them than to not to remove the organs of someone who would have wanted to donate them? The argument for removal is clear and simple - more lives saved. The counter argument seems weaker because it is based upon multiple pillars. These include the invasion of the wishes of the deceased, the impact upon their relatives and the ongoing impact upon the recipient and the idea that the State regards the bodies of its deceased citizens as resources for its living citizens. Despite this the counter argument is in fact powerful. Where possible the number of situations where there is doubt should be reduced. Thus there should be a legal obligation imposed upon doctors to seek to determine the wishes of the deceased in relation to organ donation by asking the relatives at the time of death. This obligation should be tempered by a therapeutic privilege. Given the power of the counter-argument above where the donor's wishes are indeterminate then donation should only proceed where the relatives agree that the patient would have desired it had they faced the question themself. Competing interests: None declared |
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DAVID G SAMUEL, 5TH YEAR MEDICAL STUDENT - CARDIFF UNIVERSITY CF48 2AS
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The success of ever advancing medical treatments and the skills of physicians are, in some ways our own worst enemy. People are now living well into their 70’s and 80’s, cured of many illnesses and infectious diseases largely eradicated. But, with this comes the increase in chronic illness and morbidity that is striking the nation. Diabetes, hypertension Bronchitis cases now engulf clinics up and down the country. Not only is this increasing the financial burden on NHS resources but is causing a sharp increase in the demand for organs for transplantation. Many of these diseases result in end organ failure and without transplant patients ace long term dialysis or suffering and even death. There is now a dire shortage of organs. As a future medic I dread the day that I WILL have to tell a patient of mine that no organ is available for them to receive as part of life saving transplant treatment for liver, kidney or heart disease. Unfortunately the demand for organs had not been met with adequate supply and donation. The donor card scheme has been in operation for many years and has proved a success in raising the profile of organ donation. However, not enough people make their wishes known to family members and, at the time of their death relatives are reluctant to allow their loved one’s to be “mutilated” in order to supply organs for others. Medics are required to obtain explicit consent from relatives before removing organs but at a time of high emotional charge and upset families may reject their request despite regretting their decision when looking back at the event in the future. Unfortunate events such as Alder Hey children’ hospital organ scandal has not helped encourage public participation and the scars of such events are long lasting. They also fear medics now acting in the best interest of those needing an organ instead of striving to save the life of the potential donor. I only hope that every doctor will continue to act in every patients best interest and to strive to preserve life if at all possible. An opt - out scheme may be required to stimulate debate and discussion regarding individual’s wishes, but this alone will not address the underlying problem: a lack of understanding, education and information regarding organ donation. I feel that, as medical students, we have a crucial role to play in meeting the demand for organs. We must all encourage each other and our families to discuss organ donation, remove the taboo nature of the subject and increase the number signing up to the current donor scheme. I also call on qualified doctors to follow suit and help save lives. Encouraging public discussion on opt out schemes is in the future, discussion between family members regarding donor issues should be encouraged now, but signing up to the register is something I believe every doctor should already have done. I believe it is the duty of the medical profession to lead the way in signing up to the registry by carrying the lifesaving card in their wallet. If we cannot help save lives after our own, how can we ever expect the public to do so? We can all benefit from organ donation and we can all contribute to it’s success. Countless stories appear in the media on how the families of many young people who are tragically killed agree to donate their organs, and how subsequently many lives are saved and the quality of those people’s lives enhanced. We must all act to defuse the ticking time tomb of organs shortages that is facing this country. Let’s not be afraid of death but turn tragedy into happiness by making our wishes known. We only have one life but lets’ make the most of it. Please donate and help many other lives when your own life comes to and end. Who knows when you may need an organ? However, if an opt out scheme is to be successful, the government must ensure that adequate resources are provided to increase the number of surgeons trained in transplantation, the number of specialist donor centres as well as increase the number of organ transplant co- coordinators. Without these, organs will continue to be wasted and the system will descend into chaos. I also fear the DOH document recommendation for trusts to be awarded financially for their transplant rates may backfire and undermine the work of medics. Public confidence will de dented and many may believe doctors will act in for the interest of their trust and financial gain instead of for what is best for the patient. I envisage complaints, accusations and horror stories of patients being declared “brainstem dead” merely to obtain organs for other – something I am sure doctors will it allow to happen but something that this recommendation and incentive allows to be suspected by the public! DAVID GWYNFOR SAMUEL
Competing interests: BMA Medical Students Committee Deputy Chairperson, currently cooperating with UK Transplant to increase student donor register numbers |
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stephen black, management consulting london sw1w 9sr
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The majority of the medical profession and (possibly) the majority of people may well be convinced that we need presumed consent to improve the rate of organ donation in the UK. But, there may be problems making it work and there may be better ways to increase the donor rate. Problem number one is passing the required legislation. It has failed before and even health secretaries have voted against. It is unclear whether any of the logic behind presumed consent will persuade its implacable opponents. Problem number two is the NHS’s ability to cope with more donated organs. Somebody should have enough statistics to determine whether the real bottleneck is the consent step or the extraction and use step. I find it mildly disturbing that the issue has been raised without any convincing evidence being brought to bear. It would be ironic if we dramatically increase the number of willing donors only to find no increase in the number of actual donations because we misunderstood where the bottleneck was. Then there are two issues that emerge from the opinion polling: one pointing to a better solution; the other to a potential problem with presumed consent. The biggest mystery in the whole debate is why so many people (8 or 9 out of 10) say they are willing to donate, but so few (maybe 2 out of 10 of the population) are on the register. The second observation is that relatives are significantly less likely to object if they know the donor has expressed a wish (conversely more may object if consent is merely presumed). What is significant is that we know why so few people sign up. In the UK we provide some, but not many, opportunities to apply for a donor card. But all the opportunities require active involvement: the default action is not to be on the register. The problem is that when they are faced with choices the default option is the one the majority will pick regardless of the costs or benefits. Even when faced with a costly default (eg a more expensive type of insurance or a torrent of email spam from “carefully selected partners”) the majority will choose the default. Some telling experiments are reported in Gerd Gigerenzer’s recent book “Gut Feelings” (Allen Lane, 2007). In one experiment groups of north americans were asked to imagine they were moving to a new state. The different groups were given differently worded questions. One group were told they were moving to a state with a default that you would be a donor: they were given a chance to opt out. Another were told the default assumption was not be a donor unless they opted in. The third were required to make a choice with no default. Even though the decision costs were exactly the same, the opt- out group had twice as many donors (>80% or the group) compared to the opt-in. The no-default group (ie those forced to choose but with no default assumption) had only a slightly lower number of donors than the opt-out group. This suggests to me two simple ways to get a high rate of sign-up without presuming anything: force people to choose. Take some official form people have to fill in regularly (eg voting registration forms) and add a default sign-up for the donor register. Anyone who doesn’t actively opt out goes on the register. This exploits the psychology of choosing the default option without raising any of the objections to presuming consent. It also neutralises the barrier of relatives’ objections in cases where the donor had not expressed an opinion (everyone will have chosen an option). As far as I can tell this option avoids the objections some have raised to presumed consent but should get us just as far is terms of available donors. So, why don’t we try it instead of pushing for presumed consent and risking failure to make any progress in Parliament? Competing interests: PA Consulting has commissioned opinion polling on the topic but the author's views are his personal opinions |
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Michael G Peckitt, Student Philosophy Dept, University of Hull, Cottingham Rd, Hull, East Yorkshire, HU6 7RX
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The government's proposed organ donation opt out scheme is one I support but it does present some hurdles which lawyers may or may not be able to overcome. These hurdles essentially boil down to one issue, informed consent, that there may be some people who may not understand what "opting out" means or not be given chance to do so. New born children cannot declare their intentions, so presumably some form of loco parentis clause has to be worked into the law. Secondly, there will be some people with degenerative disorders which affect memory and judgment, and can we say honestly that they truly understand what they are agreeing to, and the same can be said of some people with cognitive impairments, so again some form of power of attorney clause is needed. However, even with these clauses worked in, we can ask have we the moral right to make this decision, a decision about one's after death for another person. This is a messy issue that needs a far longer discussion. Competing interests: None declared |
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