England has initiated public consultation to change legislation to an opt-out system for organ donation.
Notionally, this appears a reasonable proposal to increase the number of deceased donor organs for use in transplant operations. However, the move towards an opt-out system for organ donation fails to address profound ethical, moral and professional concerns among some nurses.
“The perception that legislative change alone can ‘fix’ the critical shortage of donated organs is contentious”
While any political decision or discourse which leads to more lives being saved should be encouraged, the perception that legislative change alone can ‘fix’ the critical shortage of donated organs is contentious. Moreover, there is no solid evidence from anywhere in the world that legislative changes dramatically increases donor numbers.
The current system in England observes a soft opt-In system for organ donation. This model relies on individuals to sign up to the Organ Donor Register (ODR) or carry an organ donor card.
Furthermore, the Human Tissue Act 2004 interprets lawful consent to organ donation as a person verbalising organ donation wishes to relatives during life. Critically, the current legal framework allows lawful consent from relatives in situations when wishes are not known.
First, most deceased donor organs originate from patients in critical care areas that lack capacity. Typically, a potential organ donor is a patient who has experienced a neurological insult leading to brain stem ischaemia.
In an attempt to protect the airway, clinicians insert an endo-tracheal tube into the trachea and add sedatory drugs to promote compliance with mechanical ventilation. This generates a situation whereby the patient lacks capacity to consent due to their unconscious state.
Indeed, some commentators argue that the autonomy of the person has been relinquished, which produces a complex situation as the patient is unable to express personal need, desire or belief.
This stimulates a myriad of emotional and moral dilemmas for nurses. That is to argue if 65% of the population are not on the ODR then the opt-out debate and ‘presumptive’ consent for organ donation is difficult.
Second, the public can elect to opt-out of the proposed organ donation system on inaccurate or limited information. High-profile media cases have proven to disrupt public confidence in organ donation and transplantation.
For example, in 2015 The Telegraph reported that the NHS had endorsed plans to use ‘high-risk’ donor organs. Without contextualising the concept of ‘high-risk’, such articles damage public confidence about the safety of organ transplantation.
“Practitioners need to apply a note of caution”
Finally, practitioners need to apply a note of caution as legislative change alone is not a panacea to the critical shortage of donor organs. Possibly some are attracted to donate organs to help others as ‘altruistic gifting’ and perhaps the obligation attached to an opt-out system is uncomfortable for some.
Wales has moved to an opt-out system for organ donation. However, the Welsh opt-out law changes in 2015 failed to dramatically increase the number of organ donors. Hawes (2017) notes that even with an opt-out system for organ donation ”the agreement of next of kin must still be sought, a condition missed by many”.
Dr Greg Bleakley RN is lecturer in adult nursing, University of Manchester
Hawes N (2017) Welsh opt-out law fails to increase organ donations. British Medical Journal; 359: j5659 doi: 10.1136/bmj.j5659.