The law relating to organ transplantation

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Organ transplants can vastly improve patients’ quality of life and benefit their families and society in general by restoring an ill and dependent individual to health. On cost benefit analysis transplants prove ultimately cheaper than long-term dialysis by £191,000 per patient on average. However, there are fewer donors than there are needy patients although this should not be the case, because the percentage of willing donors lie in the 70s. Nonetheless, actual donations languish in the 20s. I argue that this is due to the misdirected and incoherent legal structure in place. I suggest that to increase the number of organs for transplantation a presumed consent system should be implemented to close the gap between willing and actual donations. In conjunction with improved coordination this will ameliorate the severe shortage. Such a system is ethically and morally justified. I consider other options under cadaveric donation such as increased investment in coordination without a change in the default position of deference to relatives (in the footsteps of Spain), as well as alternatives to cadaveric donation, such as live donations and xenotransplantation. They are however problematic both ethically and practically, such that even if the law formally and effectively ensures that all who need organs get them, it would be normatively wrong.

1        The law relating to organ transplantation

The terms of the relevant law must be subject to critique, because ultimately healthcare workers must work within the existing common law and legislation, even as they seek to save patients from an avoidable early death.

The definition of death is problematic. Today the concept of brain death has been adopted by most Western countries. Others suggest however that when the capacity for sentience is irrevocably absent, the minimum criteria for personhood no longer exists, despite the presence of a functioning brain stem. Perhaps it is best to admit that it is impossible to define the moment of death with any certainty or precision, and that the important task therefore is to determine at what point in the process of dying organ retrieval becomes legitimate.

In the UK, s1(4) of the HTA61 specifies that the doctor be satisfied that life is extinct before organ retrieval may take place but there is no statutory definition of death, leaving that to a matter of clinical judgement. Standard practice is for two independent doctors to perform two sets of tests to determine brain stem death.

The HTA61 outdated and prevents the facilitation of a successful programme. The current system tries to allow for all possible scenarios. S1(1) approximates an opt-in system, but there is no definition of who the person ‘lawfully in possession of the body’ is, and a verbal intention is only legally valid when it is made in the course of the last illness. Further, according to HSC 1998/035, 8.2, if a patient is a recorded willing donor, there is no legal requirement to establish a lack of objection on the part of relatives, but in practice it is good practice for any objectives raised by relatives to take priority over donors’ wishes.

S1(2) approximates a weak ‘opt-out’ scheme applying where the deceased has left no recorded expression of his or her wishes. The person lawfully in possession of the body is authorised to remove organs for transplantation if reasonable enquiry shows that the deceased did not object to organ removal or that the surviving spouse or any surviving relative has no objection to the use of the organs. Although it is fairly evident why spouses should be invited to express their views, this does not reflect the reality of the situation in which many adults now live – cohabitees or long term partners now fulfil this role.

The system is on aggregate incoherent and piecemeal, and when an organ is taken, no one knows for sure why – is it because the medical team has requested, or is it because the medical team has procured it under s1(2) of the HTA61? McLean opines that the current legislation is more of a hindrance than an assistance to an effective transplantation programme. So, to increase the number of organs for transplantation a presumed consent system should be implemented in conjunction with improved coordination to ameliorate the severe shortage. Such a system is ethically and morally justified.

2        Dead Donors

Presumed Consent

Historically doctors were thought reluctant to ask families of the deceased about the possibility of donating their relative’s organs. However, Gentleman et al. found that in fact request rates were reasonably high such that the belief that a failure to request is the cause for organs shortage is no longer sustainable. Rather, the problem with the opt-in system is its inability to enforce deceased individuals’ preferences because the family vetoes it, in part because they were never made known. For a grieving and bereft family, a request for organ donation is difficult to agree to because they can only guess at the wishes of the deceased and if there were any doubt at all, would not the natural answer be a rejection? If relatives had severe objections, they should be taken into account for to do otherwise raises the spectre of the swastika, but the point remains that by changing the default position of organ donation it is a veto clearly against the deceased’s wishes, which would be rather more unlikely to take place than the current veto due to a simple lack of information. It is not that the PC system is ethically unsound.

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I argue that presumed consent is superior to the opt-in system because it truly ensures autonomy by giving effect to choices each person makes. It gives legal effect to individual autonomy and it ensures truly informed consent when accompanied by public education and information, instead of intuitive responses to organ donation.

Nonetheless, some problems with presumed consent have been pointed out.

Patient autonomy lies at the very heart of modern medicine and medical research . This is partly a reaction against medical paternalism and an increasing awareness of the integrity of the individual. It may ...

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