Essay question

“An opt-out or presumed consent system for deceased organ donation would be preferable to the current opt-in regime in England.” Discuss.

Outline answer

As a starting point, you might wish to consider (briefly) why organ donation is important. For example, kidney transplantation has been a very effective therapy for people with kidney failure.  Not only does kidney transplantation improve quality of life but it is also cost effective. It is estimated that following a kidney transplant overall savings (over ten years) will amount to £250,000.  

Unfortunately the rate of procurement of deceased organs is particularly low in the UK compared with other European countries. You might wish to read “Taking organ transplantation to 2020” which outlines the main recommendations of the Organ Donation Task Force (2008). Some of these recommendations include early testing for brainstem death, increasing the number of transplant co-ordinators, high profile media campaigns and well-supported co-ordination initiatives between domestic and overseas centres to enhance successful organ retrieval and use.

The current system in England for deceased organ donation is “opt-in”. This means that people who wish to donate their organs and tissues must make these wishes known proactively and prior to their death (while they have capacity).  This can be achieved by carrying a donor card and registering intentions, or by instructing a nominated representative. The concept of appropriate consent is provided for in section 3(6) of the Human Tissue Act 2004 (HTA 2004).  Removal of organs or tissues without appropriate consent is an offence under section 5(1) of the HTA 2004 and the penalty for conviction is up to three years of imprisonment, a fine, or both (section 5(7) HTA 2004). Don’t forget to compare with Wales (Human Transplantation (Wales) Act 2013).

According to the HTA 2004 Code of Practice 1 (2009: paragraph 74) if adults have given valid consent for post mortem donation, removal and storage of their organs or tissues, then that is sufficient in law. However, it is customary to ask for consent from near relatives of the deceased. Paragraph 75 states that if those who are close to the deceased object to donation, then they should be encouraged to accept the deceased’s wishes. They do not have the right to overrule these wishes. Nevertheless, paragraph 76 guides healthcare staff to consider the potential negative effects of proceeding with removal of organs when there is strong opposition from relatives. In practice, therefore, even if pre-mortem consent has been given, the consent of close relatives will still be sought and this could be either from a nominated representative (section 4 of HTA 2004) or someone who stands in a qualifying relationship (section 27(4) of the HTA 2004). Note that those who are in a qualifying relationship are ranked in hierarchical order.

The current opt-in system in England presents considerable hurdles to the post mortem removal of organs. First the deceased would have had to make her wishes known proactively before death and second, in practice, relatives’ consent needs to be obtained. This can often be difficult, especially as relatives are in a grieving state immediately after the death of their loved ones. It has therefore been proposed that an opt-out system should be used.  Opt-out systems are based on the concept of ‘presumed’ consent, namely it is presumed that a person would consent to have her organs removed after death unless that person has registered his or her objections to posthumous donation. This is based on the assumption that most people would act altruistically and wish to donate their organs after death.   Several countries, such as Belgium, Austria and Spain, use an opt-out system and have considerably increased the supply of organs. There are two main variations to this regime. In a soft opt-out system, if there is no evidence of the person’s refusal to donate, relatives may override the policy if they object. Under those circumstances, organ donation cannot proceed. In the hard opt-out system, relatives’ wishes do not override the policy and organ donation can proceed. You may wish to consider the ethics of employing an opt-out system. For example, would everyone wish to act altruistically? Are there other specific beliefs and wishes that the deceased may have had that should be taken into account? Is a soft opt-out system preferable to a hard opt-out system in that there is at least some power that relatives may exert if they object to organ retrieval from their deceased loved one?

Both systems described are based upon a willingness for organ donation to proceed, either through actual consent (or authorisation), or presumed consent, of the deceased and/or endorsement by relatives (in the opt-in and soft opt-out systems). Remember, however, that there are alternative sources of organs (living donation and xenotransplantation (organs obtained from animals) although to date the latter has had a relatively small part to play. The developments of medical technology are now producing artificial organs and it is possible that within a few decades, artificially produced organs might dominate the scene meaning that there will be less need for voluntary human donation.  Remember to support your answer with reference to the academic literature.  For example, reference to the idea that presumed consent is no consent at all. Finally, remember to provide a conclusion to your answer, linking this back to the essay question.