Hello everyone and welcome to this week's blog post. In this article, we will we discussing organ donation - specifically the new legislation in the UK which has changed organ donation to an opt-out system. I will first explain what this new legislation means and how it works, before talking about the ethics of organ donation.
Organ donation is the process by which a person gives part or all of their organ to someone else who needs it, thus saving thousands of lives every year. Organ donation can occur in most countries following the consent of the patient before they pass away (e.g by recording their decision on an organ transplant register) or by agreement of the patient's next of kin.
The types of organ that can be donated vary according to the country you are resident in. In the UK, organs that can be donated include the heart, lungs, liver, kidneys, pancreas and small bowel. In addition, tissues such as the cornea, skin, arteries and bone tissue can also be donated.
There are some restrictions on who can become an organ donor. For example, you can't donate organs if you have Creutzfeldt-Jakob Disease, Ebola virus disease or cancer. Additionally, in the UK, you also can't donate if you have HIV (although in some countries, organs from people who are HIV-positive have been successfully transplanted into others with HIV).
On the other hand, in the UK, drinking alcohol and smoking both do not necessarily prevent organ donation from occurring. This is because healthcare professionals assess all patient's who have agreed to be organ donors and decide which organs are suitable for transplantation, taking into account the patient's lifestyle. As such, everyone is encouraged to register for organ donation on the NHS Organ Donor Register.
Furthermore, the NHS has talked to religious leaders from all major religious groups and confirmed that organ donation can take place in ways which respect their beliefs and cultures.
On 15 March 2020, the Organ Donation (deemed Consent) Bill received Royal Assent and thus became law. Under this new legislation, England now uses an opt-out system for organ donation. In this system, unless you have confirmed whether you want to be an organ donor or not (by telling your friends and family or registering your decision with the NHS Organ Donor Register), then it will be assumed that you agree to donate your organs after death. The only exception to this is if you part of an excluded group (those under the age of 18, those who lack the mental capacity to understand these changes, short-term visitors to England and those who have been resident in England for under 12 months).
The Organ Donation (deemed Consent) Act is also known as Max and Keira's Law as it is named after Keira Ball and Max Johnson. Keira Ball was a young girl who tragically died in a road traffic collision in 2017. After she passed away, her parents made the decision to allow her organs to be donated to other children in need. One of these children was Max Johnson, who received a heart from Keira. Following the transplant, Max's family campaigned heavily, promoting the opt-out organ donation system. Consequently, when the government decided to change the law to an opt-out system, it was named after these two children.
Under this opt-out system, specialist nurses discuss organ donation with your family, meaning that they are still involved with the decision. Consequently, it important that they are aware of your decision so that they know that your wishes are being carried out correctly. This includes ensuring that your faith, culture and beliefs are respected after death.
Before this new legislation, England had an opt-in system for organ donation. This meant that unless consent for organ transplantation could be obtained, either through asking family members or the patient having recorded their decision on the NHS Organ Transplant Register, then consent was not given and the organ transplant did not take place.
Each year, in the UK, around 1,400 people donate their organs after passing away and a further 1,000 people donate part of their liver or a kidney while they are alive. Despite that, there are around 6000 people currently on waiting lists for organ transplants. Consequently, 3 people die on average each day waiting for an organ transplant. It is hoped that this new legislation will significantly reduce the number of people on these waiting lists by ethically increasing the number of organ donors.
According to the government, around 80% of the population of England support organ donation. However, before this new legislation, only 38% had recorded a decision on the NHS Organ Donor Register about whether they wanted their organs to be donated. As such, this shifted this difficult decision to the patient's families.
As only around half of the families made the decision to allow organ donation, this left a large proportion of the population who were unable to have their wishes carried out. The new legislation hopes to solve this problem by encouraging people to discuss their decisions with their family, making it easier for people to record their decisions before death and only assuming consent for organ donation if no other information is known.
It should be stressed that there are many safeguards in place to ensure that patient care is the same, regardless of whether you are an organ donor or not. For example, the NHS Organ Donor Register is only checked after the end of life planning has begun. In addition, death is confirmed by a doctor who is independent of the transplant team, and the same methods for confirming death are used regardless of whether the patient is an organ donor or not.
There are many ethical considerations with regards to organ transplantation. These are centred around the four pillars of ethics - autonomy, beneficence, non-maleficence and justice. In the next part of this article, I'd like to address each of these pillars in turn and suggest how they apply to organ donation.
The first of the pillars is autonomy, which says that, where possible, the patient must have the right to chose their own medical procedures. For the living donation of kidneys and parts of the liver, this can be achieved in the same way as other surgeries (by using consent forms and ensuring that the patient is aware of the risks of the operation).
When organ donation occurs after someone passes away, their right to autonomy can still be respected as much as possible. For example, people can be encouraged to register their decision with the NHS Organ Donation Register. In addition, the patient's family can also be involved in the decision to try and respect what the patient would have wanted.
Patient autonomy can be undermined, however, by other people attempting to influence the patient's decision. For example, a patient could feel pressured to accept money for a directed donation of an organ or feel pressured by a family member. To mitigate this risk as much as possible, there are many safeguards in the UK to attempt to prevent this from happening. In the UK, the sale of organs and other human tissues is strictly prohibited. Furthermore, healthcare professionals involved in organ transplantation are trained to recognise signs that the donation is occurring under duress.
The principle of autonomy is slightly different in an opt-in system compared to an opt-out system. In both systems, the patient's wishes can be carried out if they register their decisions in advance (so this should be heavily encouraged by the government). In an opt-out system, however, they will invariably be some people who aren't able to make the decision known in advance, so their organs may be used for donation even if they wouldn't have wanted them to be. On the other hand, in an opt-in system, there may be some people who would have wanted to donate but didn't make their decision known in advance.
As organ donation is an invasive procedure, I would contend that the possible harm to autonomy is much greater in an opt-out system that an opt-in system. Nonetheless, the UK system attempts to mitigate this risk as much as possible, through a massive advertising campaign to ensure that as many people as possible are aware of the new system of deemed consent. Additionally, those who would be unable to understand the new legislation and register their decision are excluded from the opt-out system.
The second and third pillars of ethics are beneficence and non-maleficence respectively. Beneficence means that a doctor should always act in the best interests of their patient, while non-maleficence means that a doctor should never harm their patient. In both these cases, provided that the patient's beliefs are respected, organ donation after someone dies does not harm the donor. Additionally, as long as the organs are checked in advance so that the operating team is reasonably sure that the organ transplant will be successful, then the operation would be in the best interests of the patient receiving the organs.
The fourth pillar of medical ethics is justice, which states that everyone should be treated equally and any actions should be good for society as a whole. The principle of justice is mostly upheld by organ donation, as everyone is treated the same under the law and, in the UK, wealth does not affect whether you receive an organ. However, in other countries, the likelihood of a patient receiving an organ does increase if they are more wealthy.
Moreover, while ethnicity is not a factor in determining whether someone should receive an organ, organ transplants work best when the tissue type is the same. Consequently, organs are often transplanted between people of the same ethnicity to increase the success rates of transplantation. As a result, it is true that ethnicity does play a role in whether a patient will receive an organ. To reduce this impact as much as possible, everyone from all ethnicities should be encouraged to donate, so that everyone has access to organs.
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