We should not let families stop organ donation from their dead relativesBMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e5275 (Published 07 August 2012) Cite this as: BMJ 2012;345:e5275
- David Shaw, lecturer in ethics, Faculty of Medicine, University of Glasgow, Glasgow G2 3JZ
It has recently been suggested that patients should be kept alive using elective ventilation to facilitate the harvesting of organs for donation.1 But there is a much simpler way. Veto by the family is the main impediment to an increase in organ donation,2 with at least 10% of families refusing to donate.3 However, the family has no legal grounds for over-riding the dead person’s wishes if that person clearly wanted to donate—for example, by carrying an organ donor card.4
Clinicians who heed the veto are complicit in a family denying its loved one’s last chance to affect the world. Families often regret the veto within two days, and the regret of having denied a loved one’s last wish can last for decades.5 But at the time families are in emotional distress, and clinicians must help them make the correct decision. Clinicians may be willing to respect a veto to avoid distressing families further.2 One solution is a system of so called advance commitment, where donors designate a family member in advance to confirm their decision.2
However, there is a simpler solution: get doctors to do their jobs properly.
Failure to over-rule the veto and to respect the wishes of the deceased is a classic case of clinicians giving in to psychological pressure from people close in time and space without considering the wider effects on others. The doctor’s qualms about causing more distress for the family cause deaths by omission and greater consequent emotional distress to far-off families, whose relatives will die because there were not enough organs available.
Here is an example. A doctor approaches the family of a recently dead woman who carried a donor card. The family refuses to believe that she wanted to donate her organs and asks the doctor to leave them alone. He can either do so, or persist. If he persists, and the patient’s kidneys, heart, liver, lungs, pancreas, small bowel, and eyes are donated, as many as seven people could survive who would otherwise have died. (The fact that donation saves several people rather than just one should be part of any educational campaigns aimed at increasing donation rates.6) This persistence will cause the family some short term distress, but if they follow the usual pattern, they will see within a week that the doctor was right (and of course they have no legal grounds for complaint).
If the doctor does not persist, the family will be (relatively) happy in the short term but will probably soon regret their decision, and may even be annoyed at the doctor for not persisting. Furthermore, the patient’s eyes, heart, kidneys, and other organs have gone to waste, and several people have died as a result.
The family cannot be blamed for refusing to allow donation under such stress. But can the same be said of the doctor, facing the stress of going against the wishes of a grieving family? No. Firstly, doctors are professionals with obligations to respect the wishes of the dead patient and to promote the health of the public. Giving in to the family is unprofessional and lets down the patient and potential recipients of the patients’ organs elsewhere. A doctor might argue that this family is right here in front of him, but that is simply to admit his error: it is the moral distance from those he will be complicit in bereaving (and to some extent from the dead patient) that makes it tempting to respect the veto. The family’s proximity increases the stress on the doctor, but does not change the ethics of the situation. Although we should treat the family compassionately, doctors do not have the same duty to the family as to dying patients or other patients who need organs.
Clinicians in this position should conduct a thought experiment. As well as the family that is there in front of them, they should also imagine confronting the families of those who will die as a consequence of not receiving the donor’s organs. Most doctors are reluctant to add to a family’s suffering at having lost a loved one, and families who refuse permission are rarely over-ruled. Mason and Laurie, authors of the 2006 book Law and Medical Ethics, state that “while this may be laudable sympathetic medicine, it is paradoxically doubtful medical ethics.” In fact, it may not even be sympathetic medicine because the family are not patients, but the people who will die because of the failure to donate are.
To respect a family’s veto when the patient was on the organ donor register is a failure of moral imagination that leads to a violation of the dead person’s wishes and causes the death of several people (and all the sorrow consequent to this), and many family members who stop donation come to regret their decision. Moving towards elective ventilation might alienate would-be donors and will not be necessary if doctors remember that respecting a veto of organ donation is unethical, unprofessional, and against the spirit of the law.
Cite this as: BMJ 2012;345:e5275
Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Not commissioned; not externally peer reviewed.