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Should organ donation registers move from an opt-in to an opt-out system?

Background and context

In the UK there is a presumption that individuals have not given consent to the use of their organs for transplantafter their death. Individuals can opt in to becoming donors by signing the NHS organ donor register. The final

decision on whether a suitable organ may be used for transplant rests with the potential donors family. In other

European countries including France, Belgium, Denmark, Finland, Italy, Sweden, Norway and Spain, there is an

opt-out system where individuals are presumed to have consented to have their organs used for transplant

unless they specifically object. This may have a significant impact on the total pool of potential donorsin

Belgium, for example, only 3%-4% opt out of donation. The British Medical Association has indicated itssupport for an opt-out system of presumed consent.

Argument #1

Yes

There is a serious shortage of organs for transplant in

the UK, with about 5,600 people on the transplant

waiting list but fewer than 3,000 transplant operations

carried out every year. Although about 70% of thepublic say in surveys that they would be willing for

their organs to be used by others after their death, only

around 15% have signed the NHS organ donor

register. Many organs are therefore buried or cremated

when their owners would have wanted them to be usedagain, if possible. Moving to a system of presumed

consent would enable those who object to the use of

their organs to have their views respected, while

ensuring the maximum possible donation rate from the

rest of the population. Similar systems work in

Sweden, in Spain (which has a "soft opt-out" systemwhere the views of close relatives are taken into

account) and in Austria (which has a "hard opt-out"

system where relatives views are ignored). Spain has

a higher number of donors than the UK and is the only

country to have sustained a year-on-year increase in

organ donation for the last ten years.

No

Withholding of consent is not the most significant

factor in the current UK organ shortage. Seven out of

every ten families approached do give their consent to

the use of their relatives organs for donation; refusal

of consent where the donor has previously indicated a

willingness to donate, such as with a donor card, is

extremely rare. The biggest single factor in national

organ donation rates is road safety: most donors areaccident victims, as people who die of old age or

disease tend not to have suitable organs for donation.

Road accident statistics account for the much higherrate of organ donation in Spain than in Britain, for

example. Other important factors, which this policy

does nothing to address but which account for wide

disparities between donation rates in different

countries, include cultural attitudes to the disposal of

bodies and the provision of intensive care beds. Thesenational differences are reflected in the fact that, for

example, Sweden has a lower donation rate per million

population than the UK, despite the fact that it has an

opt-out system.

Argument #2

Yes

Under the current system, the final decision over

whether an organ is donated is made by the potential

donors family. In many cases, family members may

not know their relatives wishes, and may offer anobjection which the donor would not support - for

example, they may hold beliefs about the importanceof bodily integrity before burial which their relative

No

Presuming consent and ignoring the wishes of the

potential donors family could cause major distress to

relatives and partners. This could lead to adverse

publicity for the cause of organ donation. Offendingthe familys feelings could also adversely affect their

trust and respect for the medical profession. At death,the wishes ofthe victims family should be more

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rejected. Consulting the family is a denial of the

donors autonomy.

important than those of the victim - they are, after all,

still alive, and have to live with the consequences of

any decision taken.

Argument #3

Yes

The death of a relative is always extremely traumatic.

At this difficult time, families are not best placed tomake the right decision on their relatives behalf. It is

wrong to place such a heavy extra burden on them,

and better to leave it to the donor herself.

No

There could be medical risks with removing organs for

donation without discussion with relatives. Relativesare an important source of information about the

potential donors previous health, and are currently

routinely questioned as part of the screening process.

Argument #4

Yes

Of course it is important to publicise this change in the

law and make sure it is clearly understood. However,

the nature of the new law is that it is the individuals

responsibility to make her own decision, and thereforeher responsibility to acquaint herself with the way the

law works - as with absolutely every other law.

No

An individuals failure to withhold consent may

indicate a lack of understanding of the procedure

rather than agreement with the policy. There is

therefore a danger that an individual may end uphaving her organs removed and used for transplant

despite a real objection to such a procedure.

Argument #5

Yes

The number of donors in the USA has declined following aninitial increase on the introduction of the "required request"

rule. The key point about Spain is that, despite the fact that it

routinely consults relatives, it operates an opt-out system andthe wishes of the donor are key - it is an example on theproposition side. The only way of ensuring the maximisation

of donated organs is to operate a strict opt-out system so thatevery suitable organ can be used for donation unless thedonor specifically objects

No

There is no need to adopt this policy in order to achieve anincrease in donated organs. In the USA the "required

request" rule makes it mandatory to make enquiries into thepossibility of organ donation before a life-support machine isswitched off. This makes it less likely that opportunities fordonation will be overlooked, but ensures that families

continue to be involved in the process. In Spain, where a"soft opt-out" policy is in force, relatives are alwaysconsulted by a trained professional to ensure that they areaware of the possibility and implications of organ donation -

this increases relatives willingness to allow the use of their

loved-ones organs, and their support for the donationprogramme.