Organ Donation Opportunities for Action (2006) / Chapter Skim
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7 Presumed Consent
7 Presumed Consent
Pages 205-228
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From page 205... ...
. Under such a policy, organs from deceased individuals could be removed for transplantation unless the decedents -- or their families, after their deaths -- had followed the prescribed measures for opting out.
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From page 206... ...
Instead, state or societal ownership of or authority over the bodies of deceased individuals (or individuals' and families' enforceable social obligations) ground the law and social practices of implementation (Childress, 1997)
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Several factors militate against the adoption of this routine-removal model for solid-organ recovery in the United States. First, the current policies of routine removal apply only to the relatively small number of deceased bodies that come under the authority of the medical examiner.
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From page 208... ...
Instead, the chapter focuses on presumed consent, which, although also controversial, would be more acceptable because it affirms the principle that dispositional authority rests with individuals while they are alive or with their next of kin after they have died. PRESUMED CONSENT The presumed-consent policy for the recovery of organs from deceased individuals has been explained in the following manner: Public policy based on presumed consent would offer every adult the opportunity to express and have recorded by publicly accountable author ities his or her refusal to be a donor of solid organs and tissues.
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From page 209... ...
It appears in the Uniform Anatomical Gift Act's framework for organ donation as well as in rules of voluntary, informed consent in both therapy and research involving human participants. However, express consent is not the only kind of consent that can be valid and effective.
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. It is possible, perhaps even probable, that new social practices, particularly increased levels of public education regarding donation, could make it more reasonable in the future.
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organ recovery teams do not have to check with the family, either about the family's knowledge of the decedent's preferences or about the family's own preferences. In the weak version, organ recovery teams must consult the next of kin after an individual's death.
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The following discussion analyzes the array of arguments that have been presented on both sides of the debate and offers the committee's comments on presumed-consent policies. Effectiveness and Cost-Effectiveness Effectiveness in Increasing the Number of Transplantable Organs The primary argument in favor of presumed consent is that it would increase the availability of transplantable organs and that such an increase could save lives and enhance the quality of the lives of transplant recipients.
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From page 213... ...
. Although several of these factors account for much of the international variation in the rates of organ recovery, opt-out legislation "has a positive and sizeable effect on organ donation rates"; and after accounting for other determinations of donation rates, "presumed-consent countries have roughly 25 percent to 30 percent higher donation rates than informed-consent countries" (Abadie and Gay, 2004, p.
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From page 214... ...
These scenarios led to very different responses. "Revealed donation rates were about twice as high when opting-out as when opting-in.
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From page 215... ...
. The following is a line of argument that expresses the concern that adoption of a presumed-consent policy might be counterproductive in the United States: some individuals now fail to sign donor cards because of their distrust of the system, including their fears that they might not receive the best possible care or that their deaths might even be hastened if they were on record as organ donors, but they may not be opposed to a family decision to donate their organs after their death.
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From page 216... ...
After all, to be valid, presumed consent requires understanding; and public understanding entails vigorous and extensive public education. In addition, there must be clear, easy, nononerous, and reliable ways for individuals to register their objections to being organ donors, as well as multiple opportunities to do so.
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From page 217... ...
In the United States and the United Kingdom, both of which have optin policies, approximately 50 percent of the requests for organ donation directed at the decedent's next of kin, in the absence of a signed donor card, are turned down. The turn-down rate is much lower in countries with optout policies: in Spain the rate is about 20 percent, and in France it is about 30 percent (Abadie and Gay, 2004)
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From page 218... ...
Autonomy-Based Arguments Different arguments based on autonomy and respect for autonomy can support or oppose presumed-consent policies. Some arguments for presumed-consent policies stress that the majority of respondents in public opinion surveys indicate that they would be willing to donate their organs or to have their organs donated but that less than 50 percent actually sign donor cards.
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. These social practices would include both improved and extended public education and mechanisms for the clear, easy, nonburdensome, and reliable registration of objection to organ donation.
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From page 220... ...
.6 Such an argument would be even more powerful in a system that presumes consent to organ donation by all who do not expressly dissent. It is arguably unfair and exploitative to include in a policy of presumed organ donation individuals who would not be able to obtain a transplant if needed 6By contrast, renal transplants are generally covered by the End-Stage Renal Disease Program of Medicare, at least if the individual's primary health insurance does not provide coverage, although immunosuppressive medications for many transplant recipients are covered for only 3 years posttransplantation.
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. Under this approach, people who want to be eligible to receive organs or to have priority on the waiting list would be required to document their willingness to be organ donors (Chapter 8)
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Although it is difficult to ascertain their views and attitudes in a systematic way, the evolving opinions of the Council on Ethical and Judicial Affairs of the AMA provide some clues. In 1994 the AMA Council adopted the following statement: "a system of presumed consent for organ donation, in which individuals are assumed to consent to be organ donors after death unless they indicate their refusal to consent, raises serious ethical concerns" (AMA, 1994, p.
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From page 223... ...
Response: To reduce mistakes, vigorous public education would be essential, along with various safeguards, includ ing clear, easy, reliable, and nonburdensome ways to register dissent and perhaps also notification of the next of kin. · Possible ineffectiveness and counterproductivity.
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From page 224... ...
. A policy of presumed consent will fail without the support of the public and of the relevant healthcare professionals.
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From page 225... ...
, the first step is to build sufficient social support before introducing presumed consent in the United States. This can be accomplished through intensified public education regarding organ donation, building greater trust in the healthcare system, and encouraging a general shift in societal understanding of the value and moral grounding of donation.
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From page 226... ...
Policies of routine removal assume that the state or society has a right of access to decedents' organs, whereas presumed-consent policies presuppose the individual's or family's dispositional authority over the decedent's body and organs. In the committee's judgment, a routine-removal policy, even when it allows individuals or families to opt out, represents such a radical departure from the principle of individual and family control over the bodies of deceased individuals that it could not and should not be adopted in the United States.
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From page 227... ...
1994. Strate gies for cadaveric organ procurement: Mandated choice and presumed consent.
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From page 228... ...
1992. The Rights and Responsibilities of Potential Organ Donors: A Com munitarian Approach.
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