Changing the tune on organ donation? Presumed consent and the BMA

by Joseph Markus

A piece of good news this week—in and amongst all the rather bad news for the Greek public—is that the British Medical Association has reasserted its support for an ‘opt-out’ system in organ donation. This is the idea that an individual’s consent to organ donation after death is presumed, unless that person explicitly opts out of the system. It is credited, in other countries, with leading to massive rises in donation rates.

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The report, which also covers a range of other matters such as elective ventilation, strengthens the older BMA position on the issue. By way of contrast, David Cameron has previously positioned himself staunchly on the other side. (And, as an aside, using the language of “harvesting” organs “without permission” (as he does) really isn’t right, making the whole process seem less like a legitimate medical procedure—one that will usually save or greatly improve the life of a still-living person with parts of a dead (unfeeling, and otherwise socially useless) body—and more like a bad horror film.)

Foremost in the report, and rightly so, is one of the realities within which organ donation has to be considered. This is the dearth of willingly donated organs—and I mean ‘willingly’ in the sense of a positive decision taken during life.

It might be rather distasteful to see the recently deceased human body as a ‘toolkit’ or resource, but this is what the twin medical imperatives of preserving life and increasing donation rates require.

Another factor—jarring in the context—is the cost of maintaining a patient on, for instance, indefinite dialysis while waiting for a transplant. Increasing the number of transplants will drastically reduce the strain on the NHS of caring for chronic cases of organ failure.

A number of government initiatives over the past few years, including the Organ Donation Taskforce from 2006, have sought to address the disparity between supply and demand in the area. The Taskforce recommended against moving to an ‘opt-out’ system, instead proposing the unfortunately vague processes of ‘raising awareness’, ‘addressing misinformation’, and boosting infrastructure. These are by all means fine objectives, but they demonstrably have not met the organ deficit.

In my mind there are only a very few statistics that really need to be absorbed. First, as many as 90% of the public (according to some estimates) support the broad idea of donating organs and up to 65% say that they would donate an organ after their death. This contrasts with the much lower number of 25%. That is the proportion of the population registered on the Organ Donation Register. At March 2011 the precise number of registrants was 17,751,795.

What causes this gulf between action and intention? There are only a few realistic options. Maybe a large number of people lie (or twist the truth) to impress the interviewer or pollster. Or maybe this is simply the reflection of a more general malady—paralysing apathy. My view is that it is more likely to be apathy. But in any event it really shouldn’t be too significant. I, and the BMA, agree that now is the time to call the bluff of that 45%.

I’m not suggesting that a system of presumed consent would be some sort of panacea: it can only ever be one limb of a unified strategy to increase donation rates. But, that said, it’s hard to think of a single measure that is likely to have such a great impact on public health provision which, at the same time, still respects (and if it eradicates some of the effects of apathy and laziness, positively supports) the idea of individual choice.

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