I support organ donation. In 2013 there were 7,250 people on the UK waiting list for a transplant. The altruistic gift aspect of donation, which arises from fully informed consent, resonates with our Christian obligation to love our neighbours as ourselves. The word ‘donate’ is derived from the Latin ‘donare’, ‘to give’. The more people willing to give in this way the better.
However I do not support policies that remove the ‘giving’ from organ donation ie. policies that remove the choice from people ‘donating’, or coerce them into donation, even if subtly, or that ‘take’.
The BMA has been driving a strong policy agenda on organ donation for several years – and is pushing it yet again in its current online newsletter – which I believe would diminish genuine choice and altruistic giving from organ donation.
Not happy with our current opt-in system, where a person has to register if they want to donate their organs in the event of their death, the BMA is advocating an ‘opt-out’ system with ‘safeguards’. An opt-out system will begin in Wales from 2015.
Under an opt-out system it is simply presumed that everyone consents to donating their organs after death unless a person has registered his or her objection in advance. If the relatives are not aware of any prior objection from the deceased, they are simply informed that donation will proceed.
As we have written previously, this policy has several pitfalls (see here, here and here. It is not nearly as clear-cut a solution to increasing donation rates as the BMA would have people believe since it is very difficult to obtain data showing the impact of any one individual factor or initiative on organ donation rates (see two articles in Transplantation here and here). Indeed, donation rates have increased by 50% since 2008 in the UK without a presumed consent system, probably due to specialist nurses. Moreover this system undermines the principle of ‘donation’. It is not an agenda that I, nor many others, support, despite our support for the principle of organ donation.
The BMA is not the only source this week of controversial proposals to increase organ donor rates.
Should donors get priority for transplants?
Also in the news, in The Times, is a call by a ‘leading doctor’ for a system of reciprocity to increase organ donation, a system that is currently used in Israel. Interestingly, this policy doesn’t even get the BMA’s support (see the 2012 BMA report on this: ‘Building on progress: where next for organ donation policy in the UK’) nevertheless it still needs highlighting and then challenging as we are bound to see it advocated elsewhere too.
Under a system of reciprocity, people are able to jump the queue for a transplant if they are on the organ donor register, on the basis that there is an inherent fairness about giving priority to people who have agreed to donate.
Therefore, those who donate organs, or sign up to a register to donate after their death, will receive priority should they themselves require a transplant.
One of the aims of a reciprocal system is to overcome the problem of so-called ‘free-riders’ – those who would be willing to accept an organ, should they need one, but are not willing themselves to donate. Surveys show that while 96% would accept an organ if they needed one, only 27% had signed up to the Organ Donor Register.
Israel is the first country to pass legislation incorporating a system of reciprocity into its organ donation system. Priority is still given to those in urgent medical need of a heart, lung or liver. However where two candidates have equal clinical need, priority is given to:
• individuals on a donor register, and their first degree relatives
• first degree relatives of people who donated organs following their death
• individuals who become non-directed living donors (ie to strangers) and their first degree relatives.
The effectiveness of the policy is not yet clear as it takes some time before any increase in people signing up for donation is reflected in increased donation rates.
However even if reciprocity does drive up donation rates, there are numerous problems with it:
- Medical care should be provided, and scarce resources allocated, on the basis of clinical need and not on the actual or perceived blameworthiness of the patient.
- This introduces allocation of organs based partly on social and moral factors, rather than solely clinical, factors.
- The offer of an incentive for donation undermines the voluntary ‘gift’ of donation. Donors are encouraged to give in order to receive some (actual or potential) benefit, therefore emphasising self-interest over pure altruism.
- Offering incentives could be considered to be coercive (even though the benefits accrue to the individual while s/he is alive while the costs are ‘paid’ exclusively after death).
- Those who do not sign up risk being penalised by having a lower priority in the event of needing an organ. This is harsh punishment for people who may have failed to sign up because of apathy, disorganisation or because they do not want to confront their own mortality.
- Children and adults lacking capacity (however defined) would have to be excluded from such a system, unless proxy advance decisions were made by relatives.
- Those whose organs are not suitable for donation – because of current illness, or past medical history, for example – would be unfairly disadvantaged.
- In Israel, it is only when two people have exactly the same clinical need that their donor status becomes relevant, thus there is less incentive to donate and, accordingly, less likelihood of the scheme impacting donor rates. A balance would need to be reached in order for the system to be fair but also to be effective.
The Christian obligation to love our neighbours as ourselves is an outworking of the Christian concept of grace, the unmerited favour that God showed us in Jesus Christ’s self-giving death for us on the cross. He gave freely and sacrificially, and asks the same of us (Matt 20: 26-28, 2 Cor 5:15). Timothy reminds us that God richly provides us with everything to enjoy and we are to ‘be rich in good works, to be generous and ready to share, thus storing up treasure for…a good foundation for the future’ (1 Tim 6: 18-19).
So, I support organ donation.
But my support is based on it being an altruistic free gift, which is not undermined through any incentives or elements of felt duty and is donated purely on the basis of clinical need. We tread a dangerous path if not.