Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
A Conscious Decision?
- Dr Joss Bray (2 February 2008)
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A lot is already presumed
- Sue R Roff (2 February 2008)
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consent and choice in organ donation
- John Saunders (4 February 2008)
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Opt out scheme must be matched by funding and education
- DAVID G SAMUEL (4 February 2008)
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Re: A Conscious Decision?
- Mary Bond (5 February 2008)
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Presumed consent is no consent at all
- Hugh V McLachlan (6 February 2008)
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A bad choice
- Sarah Boehm (7 February 2008)
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Presumed consent is too paternalistic
- Gee Yen Shin (7 February 2008)
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Presumed consent for organ donation
- Martin J Sheppard (8 February 2008)
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Re: Presumed consent for organ donation
- Hugh V McLachlan (10 February 2008)
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Presumed Consent for End-of-life Organ Donation: A Legislation Undermining Values in a Multicultural Society.
- Joseph L. Verheijde (12 February 2008)
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Presumed consent is no consent
- Roger M Goss (14 February 2008)
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Proactive opt-in already exists
- Michael Archer (19 February 2008)
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Improving donation rates without presuming anything...
- stephen black (22 February 2008)
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Dr Joss Bray, Substance Misuse Specialist Huntercombe Centre. SR2 9DJ
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There seems to be an important issue that is missing from the current debate on presumed consent for organ donation. This is the option of offering full anaesthesia for the donor even though brain death has been established by the current protocols. I recall that there was debate in the medical press a few years ago on this subject, but it has not been raised recently. It was suggested that there was a possibility of preserved pain perception in these circumstances. Personally, I would be encouraged to become a donor if there was no possibility of pain being involved - and I think this may encourage others to participate in the scheme. I suggest that there should be debate about this and the provision of a tick box to specify full anaesthesia before donation. Competing interests: None declared |
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Sue R Roff, Senior Research Fellow Dundee University Medical School
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The report of the Organ Donation Taskforce released on January 16, 2008 adovcates establishing a set of ‘clinical triggers’ of impending death (either of the heart or the brain) that would cause doctors and nurses to alert the transplant organisation and begin discussions with the family. The Taskforce accepts that this would be ‘a radical change of practice’ (1.31) that would shift the focus from the further active treatment of the patient to the type of care likely to ensure the ‘best possible retrieval of the organ or organs.’ The report acknowledges that “once a decision has been made to withdraw or withhold treatment, or once death is seen as inevitable within a short space of time, the question arises as to whether or not it is justified to treat the patient as a potential donor. This change of emphasis must be recognised as extremely challenging and potentially problematic for staff and a sensitive issue to communicate to families. Furthermore, in the case of potential non-heart- beating donors, there is a lack of legal clarity around how, if at all, a patient close to death can be treated differently in order to facilitate donation, particularly if their wishes to donate are not expressly recorded.” (4.13) It involves a shift to treating patients “in a manner that is not clearly in their medically defined best interests” because of their value as potential donors. (4.14) If the families don’t object after counselling from the expanded Transplant Coordination team, the retrieval will proceed. In other words, the Report puts in place the major clinical shift from patient to potential donor that presumed consent procedures require. The DOH press release http://www.dh.gov.uk/en/Policyandguidance/Organisationpolicy/Secondarycare/Transplantation/Organdonation/index.htmneglects to mention this central feature of the report. As Hamm and Tizzard acknowledge, there must be a widespread education campaign. As Bray notes in his Rapid Response, this should include the question of anaesthesia in retrieval since it is central to the concept of death. Many of the 40% of relatives who currently refuse retrieval may be able to accept it if they are aware of what is involved before they must make their bedside decision. But public education programmes don’t reach the marginalised, as Hamm and Tizzard acknowledge. Perhaps the model we need is in front of us, from the experience of introducing Do Not Resuscitate (DNR) decisions as a normal practice in hospital admissions. Sue Roff Centre for Medical Education Dundee University Medical School Competing interests: None declared |
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John Saunders, hon professor, Centre for Philosophy, Humanities & Law in Healthcare, University of Wales Swansea Nevill Hall Hospital, Abergavenny NP7 7EG
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There is no such thing as "presumed consent for organ donation". Presumed consent isn't consent at all. Without consent organs are taken, not donated. I don't have a problem about my organs being taken - but many will. As section 15 of the Code of Practice of the Human Tissue Act reminds us, consent is at the heart of the Act for the removal and use of human organs - and rightly so. Compulsory voting in Australia means that all adults are mandated to choose their parliamentary representatives - it is a mandated choice by law. There is no opt in or opt out. It is accepted and it works. If we are serious about the organ shortage and serious about consent, we should mandate all adults to choose what to do with their organs. There could even be a "can't decide now" box - equivalent to a spoilt ballot paper. A policy of mandated choice would remove all debate around opt in, opt out, soft or hard, or the bureaucracy and regular publicity about registering objection. The current 'opt in' could continue for children. If we believe that citizenship creates some minimal duties to each other and if we believe in real consent, mandated choice offers us a better way forward than the deceits of "presumed consent". Please note this is a personal view and does not represent the opinion of the RCP or its Ethical Issues Committee. Competing interests: Chair,Committee for Ethical Issues in Medicine, Royal College of Physicians of London |
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DAVID G SAMUEL, MEDICAL STUDENT CF48 2AS
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Dear Sir, The gift of life Far too often the media reports of tragic tales of patients dying as a result of not receiving vital organ transplants. Fortunately last year saw an increase in the number of completed transplants, however this was coupled with an even bigger increase in the number of patients on the waiting list for transplantations. This can only mean one thing: the demand is increasing. We are an ageing population. 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. 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. Schemes such as DVLA driving applications asking whether people wish to donate organs has helped increase the amount of organs available but again, unless feelings are openly discussed, wishes are not always carried out. I feel it is therefore an appropriate time to implement the favoured “opt out” scheme where every individual will be assumed as consenting to donating their organs for transplantation after death unless they explicitly make an objection to such action. This scheme would make the public discuss the topic openly and possibly remove the stigma and Taboo nature currently attached to discussing death and relating issues. Families would have to discuss with loved ones if they intend donating organs As a medical student I have had the privilege of spending time at specialist renal units on attachment and my time with dialysis patients has inspired me to sign up to the register. 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? I call on qualified doctors to follow suit and help save lives. Encouraging public debate 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. 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. 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! 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? David Gwynfor Samuel
Competing interests: I CURRENTLY WORK ON BEHALF OF THE BMA MSC IN CONJUNCION WITH UKT TO INCREASE THE NUMBER OF REGISTERED DONORS |
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Mary Bond, Research Fellow University of Exeter EX5 5DW
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I read Dr Joss Bray's contribution with some alarm. If dead people need anaethesia to relieve the pain of having their organs removed I wonder just how dead they are; or am I missing something? Competing interests: None declared |
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Hugh V McLachlan, Professor of Applied Philosophy School of Law and Social Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow, G4 OBA
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Presumed consent is a very troublesome notion. Consent must be voluntarily and knowingly expressed in order to serve the function of morally authorising actions of other people towards and concerning the consenting person that otherwise would be morally wrong. (See Hugh McLachlan, ‘”Consent” at the heart of transplant debate- but what does it mean?’, The Scotsman, 6th February, 2008, See: http://thescotsman.scotsman.com/opinion/39Consent39-at-heart-of- transplant.3695556.jp Suppose that a couple have been married happily for many years. If one of them made sexual advances to the other and no reluctance to proceed was expressed when, if there was reluctance, it could have been readily indicated, it would be curious to say that a rape has taken place. Consent might reasonably be presumed in this particular sort of case but only because actions in the past were explicit manifestations of consent. If someone explicitly stated when he was young that he gave his consent to the use of his organs when he was dead, we might presume that he continues to consent if he dies as an old man without withdrawing his consent. However, if he does not ever indicate that he consents to such a use of his organs, if would be outrageous to say that we can reasonably presume that he did consent on the grounds that, when he had the chance to register the opposite of his consent, he did not take it. After all, if someone had sex with an unconscious woman and tried to justify his action by saying that, when she was conscious, she did not indicate that she did not want to have sex, we would not accept this as a reasonable argument. The notion of presumed consent to the use of our organs after our deaths is no more reasonable. To say that it can reasonably be presumed that we consent to donate our organs if we do not specifically say that we do not consent is absurd. It is a deceitful piece of sophistry. There might be a good utilitarian case for having an opt-out rather than an opt-in system of organ donation. However, this would mean that there is a case for using our organs even in the absence of our consent. If consent matters in this area, then only the explicit consent of the people concerned can justify the using of their organs after their deaths. If consent does not matter and the use of their organs can be justified without it, then consent does not matter. We should not appeal to the bogus notion of presumed consent. Professor Hugh V McLachlan
Competing interests: None declared |
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Sarah Boehm, SHO Broomfield Hospital CM1 7ET
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We are given a false choice - opt in/opt out. The current system is not good enough but opt out is not the only or the best answer. Currently the opt in system is run passively - it relies on people waking up one morning and deciding to plan the details of their death - most don't. We need a proactive approach: lets ask people - perhaps when joining a GP practice -'do you want to be an organ donor?'. If yes - it should be our responsibility to add their details to the register. This interaction could also be an opportunity to suggest this decision is discussed with the next of kin. This approach is simple and could be very effective - much more efficient than an opt out system which to remain ethically sound would require continuous and strenuous efforts to ensure the entire population is informed. Competing interests: None declared |
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Gee Yen Shin, SpR Medical Virology Department of Medical Microbiology, St George's Hospital, Blackshaw Road, London SW17 0QT
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I agree with Hamm and Tizzard that a vigorous debate on presumed consent for organ donation is overdue[1]. I do not doubt the potential benefits of presumed consent for organ donation rates. The attraction of this utilitarian approach to the perennial dilemma of a shortage of organ donors is obvious. However, I have significant reservations about the ethics of presumed consent for organ donation. It is intriguing that members of the BMA ethics department should support such an unequivocally paternalistic policy. What of the autonomy of individuals and patients? Is it acceptable or just to presume that the sick and the dying are content to surrender their organs after death? I remain to be convinced that the great British public, especially the young and the healthy, can be forced to make a properly considered, informed decision about whether or not they want to donate their organs. Death is not something most young/healthy people give serious consideration too. For example, a 2006 survey of over 2000 people found that 92% of 18 to 29 year-olds have not made a will[2]. It seems unlikely that these same people will give adequate time and effort to considering organ donation, since most people would probably consider making a will a higher priority. I believe that government, "the State", exists to serve the people, not the other way around. Harvesting organs from citizens who have died on the basis of presumed consent is the most macabre manifestation of the latter that one could imagine. Given the shortage of organs in the UK, the preoccupation with the preservation of patient autonomy may seem dogmatic and possibly eccentric, but this inconvenient concept underpins the ethics behind modern medical practice. The State brushes autonomy and free will aside at its peril. If the Government goes ahead with presumed consent for organ donation, it will irrevocably alter the relationship between the State and its citizens. It might be better to review the ability of relatives to overrule the wishes of their deceased relatives. Hamm and Tizzard's editorial stated that this occurs in about 40% of cases where the deceased have agreed to be organ donors. This is the Achilles Heel of both the status quo and the proposed policy of presumed consent. This seems to me to be the elephant in the room that looms so large in our field of vision that we are blinded to it. References: 1. Hamm D, Tizzard J. Presumed consent for organ donation. BMJ 2008;336:230 2. BBC News website: Most Britons "do not have wills" 22 Oct 06 http://news.bbc.co.uk/1/hi/uk/6065966.stm (accessed 6 Feb 08) Competing interests: None declared |
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Martin J Sheppard, microbiologist Withybush Hopsital, SA61 2PZ
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The public presume the right to receive a donated organ. It seems to me that in this case they should also accept the responsibility of donation. It is NOT someone else's job! A central register should be created, to which people enter their consent or opposition to donation. Once this is established, donations should be restricted to those who have registered their consent. This will enhance the supply and reduce the demand: no more waiting lists. Competing interests: None declared |
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Hugh V McLachlan, Professor of Applied Philosophy School of Law and Social Sciences, Glasgow Caledonian University
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For a voluntary, private medical scheme, it might be appropriate to say that if people do not pay their membership fees, they will not receive treatment. It might be appropriate for such a private medical scheme to have a rule that if you are not an organ donor after your death, you will not receive an organ transplant during your life. However, such a principle would be inappropriate for a compulsory state system of health care provision such as the NHS. There should be no connection between the rules that regulate enforced contributions for such schemes and the rules that regulate the provision of health care. To say, for instance, that only those people who donate bed-pans to the NHS will be provided with bed-pans would be absurd. It is no less absurd to say that only those who are prepared to donate their organs will receive organs. Moral dessert might be an appropriate consideration for judicial punishment but not for the provision of health care. Competing interests: None declared |
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Joseph L. Verheijde, Adjunct Professor of Bioethics, Arizona State University, Tempe, Arizona, USA Mayo Clinic Hospital, Phoenix, Arizona, 85054 USA
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Presumed Consent for End-of-life Organ Donation: A Legislation Undermining Values in a Multicultural Society. To the Editor Governmental, private professional organizations and advocacy groups continue to mischaracterize organ donation as donation after death to make it more palatable to the general public. The two types of organ donation: heart-beating (with a confirmed diagnosis of brain death) and non-heart- beating (cardiorespiratory arrest without a prior diagnosis of brain death) are included within the legislation of presumed consent to donate organs. Both types of organ donors (brain dead or not) are resuscitated and maintained on artificial life support systems until the time when organs are procured (1, 2). Death is certain after organs have been removed from donors (3) and thus the accurate descriptor of this process is end-of-life organ donation. Hamm and Tizzard claim that presumed consent for organ donation is the way to solve organ shortage and save 1000 lives annually who die of end-stage organ disease awaiting transplantation (4). Is presumed consent to organ donation the best approach to deal with problems of end-stage organ disease in the United Kingdom (UK)? The healthcare problems related to end-stage organ disease in society can be addressed by much more cost effective and harmless alternatives. Primary and secondary preventative healthcare services can dramatically decrease the development of end-stage organ disease requiring transplantation (5). Does the legislation of presumed consent to supply more organs for transplantation practice serve the best interest of the UK population health? In 2006, the UK population was estimated at 60 million with approximately 500, 000 deaths a year (6). The legislation of presumed consent to donation will undoubtedly supply organs greatly exceeding the demand required to save 1000 lives each year. What is the fate of the surplus of organs removed? Hamm and Tizzard cite a public opinion poll showing 64% of respondents in favoring a soft system of presumed consent (4). Nonetheless, they also wonder why 90% of the UK population favors organ donation but only 24% has signed as organ donors. This discrepancy in the results of opinion polls, however, can be explained by carefully phrasing questions to obtain the desired response and findings. Therefore, how people respond and behave in real life situations can be notoriously misrepresented in opinion poll results. So why is there so much interest to legislate presumed consent for organ donation in the UK? Traditional sociocultural concepts about human life are systematically being altered to accommodate for maximizing deceased organ donation and transplantation practice (7). Introducing presumed consent for organ donation has much deeper societal consequences that are not readily apparent to the general public. Through the process of legitimizing presumed consent to donate organs at the end of life, this legislation is silently dismantling the traditional boundaries of the legal norms pertaining to death. The transplant community has reinterpreted enacted laws in many countries to defend disputed end-of- life practices in organ donation (8-10). Arbitrarily defining death (3), wrongfully declaring brain death (11), and hastily determining unsalvageability of patients are a few of the convenient end-of-life vehicles to supply more human organs for transplantation. While certain end-of-life practices in organ donation are inconsistent with existing laws (10), they remain uncontested in many countries. It can be argued that organ procurement practice is no different from other acts of physician-assisted death or homicide except for its ability to circumvent current prohibitive laws (12, 13). Legislating presumed consent for organ donation implicitly denies individuals the right of autonomy over their bodies and personal views about end of life emanating from religious and cultural values and beliefs. Consequently, this legislation also undermines the plurality of religious and cultural differences about end-of-life practices in society. Mandating procurement of organs through presumed consent breaches the boundaries of forbidden areas of rituals about death and handling of the deceased body in many religions and cultures. Several cultures and religions object to practices that actively shorten the dying process (14). Bodily mutilation and removing organs to save another life may not be of a higher priority than offering dignity, peace and respect to grieving families of the recently deceased (15). Presumed consent for organ donation is also most likely to affect certain vulnerable groups in society such as those with severe cognitive and/or physical disabilities, the chronically institutionalized, the very sick, the poor and the homeless who are without families or surrogates that can stand up to defend them at the end of life. Society becomes a participant in potentially sacrificing these vulnerable groups on the premise of supplying organs to save others. Presumed consent to donate organs infringes on the fundamental human right of individuals to autonomously decide what happens with their bodies (16). Through marginalizing traditional societal values, the subtext of presumed consent to organ donation has much more dire consequences than advocates are willing to disclose to the general public. Joseph L. Verheijde, PhD, MBA, PT Department of Physical Medicine and Rehabilitation Mayo Clinic Hospital, Phoenix, Arizona, USA Adjunct Professor of Bioethics, Arizona State University, Tempe, Arizona, USA Mohamed Y. Rady MD FRCS (Ed.) FRCS (Eng.) FRCP (UK) FCCM Professor, Mayo Clinic Arizona, Consultant, Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix, Arizona, USA Joan L. McGregor, Ph.D. Lincoln Professor of Bioethics Professor, Department of Philosophy, Arizona State University, Tempe, Arizona, USA Reference: 1. Snoeijs MGJ, van Heurn LWE, van Mook WNKA, Christiaans MH, van Hooff JP. Controlled donation after cardiac death: a European perspective. Transplant Rev 2007;21:219-229. 2. Adrie C, Haouache H, Saleh M, et al. An underrecognized source of organ donors: patients with brain death after successfully resuscitated cardiac arrest. Inten Care Med. 2008;34:132-137. 3. Joffe AR. The ethics of donation and transplantation: are definitions of death being distorted for organ transplantation? . Philos Ethics Humanit Med. . 2007; 2:18. Available at: http://www.peh- med.com/content/2/1/28. 4. Hamm D, Tizzard J. Presumed consent for organ donation. BMJ. 2008;336:230. 5. Health Resources and Services Administration of the US Department of Health & Human Services. Reduce the Risk for Needing a Transplant. http://organdonor.gov/reduce_risk/index.htm. Accessed February 9, 2008. 6. Office for National Statistics. UK National Statistics online. http://www.statistics.gov.uk/. Accessed February 7, 2008. 7. Matesanz R, Dominguez-Gil B. Strategies to optimize deceased organ donation. Transplant Rev 2007;21:177-188. 8. Shemie SD. Clarifying the paradigm for the ethics of donation and transplantation: Was 'dead' really so clear before organ donation? Available at http://www.peh-med.com/content/2/1/18 Philos Ethics Humanit Med. . 2007; 2:18. 9. Rady MY, Verheijde JL, McGregor JL, et al. Organ donation after cardiac death: legal and ethical justifications for antemortem interventions. eMJA. 2008;188:186-188. 10. McGregor JL, Verheijde JL, Rady MY. Do Donation After Cardiac Death Protocols Violate Criminal Homicide Statutes? Medicine and Law. 2008;27:in Press. 11. Laureys S, Fins JJ. Are we equal in death?: Avoiding diagnostic error in brain death. Neurology. 2008;70:e14-e-15. 12. Truog RD. Brain death - too flawed to endure, too ingrained to abandon. J Law Med Ethics. 2007;35:273-281. 13. Verheijde JL, Rady MY, McGregor JL, Truog RD. “Brain Death – Too Flawed to Endure, Too Ingrained to Abandon” Letter to The Editor and Author Reply. J Law Med Ethics. 2007;35:515; author reply 515-516. 14. Sprung C, Maia P, Bulow H-H, et al. The importance of religious affiliation and culture on end-of-life decisions in European intensive care units. Intensive Care Med. 2007;33:1732-1739. 15. Sque M, Long T, Payne S, Allardyce D. Why relatives do not donate organs for transplants: ‘sacrifice’ or ‘gift of life’? J Adv Nurs 2008;61:134-144. 16. Verheijde JL, Rady MY, McGregor JL. The United States Revised Uniform Anatomical Gift Act (2006): New challenges to balancing patient rights and physician responsibilities. At http://www.peh- med.com/content/2/1/19. Philos Ethics Humanit Med 2007;2:19 Competing interests: None declared |
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Roger M Goss, Co-director Patient Concern SW5 9FY
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The BMA' ethics committee's ethics are those of the ends they want justifing any means, however unprincipled. They don't like the threat to patients' trust in doctors inherent in presumed consent to accepting electronic healthcare records. So they oppose this. They are right. Capital punishment may reduce the incidence of murder. Public support for its re-introduction may well exceed 64%. That doesn't make it right. Torture of prisoners may extract information that saves innocent lives. That doesn't make it right. Presuming consent though you don't have it, may increase the availability of organs. That doesn't make it right. Organ donation is the ultimate altruistic gift. Converting everyone into conscripts, save for conscientious objectors, would be disgraceful and counter-productive in terms of public confidence in the medical profession, given our history of doctors taking whatever they fancied without attemting to obtain consent. The government unequivocally opposed such a change only 3 years ago passing the Human Tissue and Mental Capacity Acts to maximise individuals' opportunities to make positive informed choices about how their bodies are treated. Explicit consent is a core principle of all medical regulators' 'good medical practice'. Long may it remain so. Competing interests: None declared |
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Michael Archer, General Practitioner Grimston Medical Centre, King's Lynn, Norfolk PE32 1DW
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Boehm advocates a proactive approach by asking people whether they want to be an organ donor when they join a general practice[1]. In fact, this question has been included on the form for registration with a general practitioner for many years. According to the UK Transplant website[2], people are also given the opportunity to opt in to organ donation when completing an application for a passport, driving licence, European Health Insurance Card or Boots Advantage card. The system that Boehm proposes is thus precisely the one that is in current use and that she says is not good enough. Simple it may be, but this approach has been tried and found wanting. 1 Boehm S. A bad choice. BMJ 2008; 336: 345 2 http://www.uktransplant.org.uk/ukt/how_to_become_a_donor/registration/routes_to_registration.jsp Competing interests: None declared |
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stephen black, management consultant london sw1w 9sr
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It seems to me that this debate has managed to miss the critical issues around donation and in doing so has failed to spot an alternative to presumed consent that could achieve high rates of donation. The key problem presumed consent is supposed to tackle is the large gap between those who say they are happy do donate when asked (80-90%) and those who actually sign up to the register (20-30%). This gap exists for two key reasons: people are not often asked to make this choice; and the default option when asked is not to donate. The default option--whatever the choice--is the one most people pick (even if it is more costly or has a lower reward than the alternative--I discussed some evidence for this in a reply on a previous thread: http://bmj.com/cgi/eletters/336/7636/111-a#188146, 24 Jan 2008) This suggests a solution that avoids any presumption: pose the donation question more regularly (eg electoral registration forms filled in by adults once a year) and make the default option to join the donor register. By exploiting what we know of the psychology of human decision making, we can avoid presuming anything, make it easy for objectors to stay off the register and (probably) get a registration rate three times the current level. Competing interests: PA Consulting has commisioned opinion polling on attitudes to donation. The author's views are, however, his own. |
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