Organ donation after death is a contentious issue both in New Zealand and internationally. Initiating a nationwide organ donation policy invokes plentiful ethical debate as dealing with human tissue is an emotive issue that needs to be considered in the context of the varying subcultures that constitute a nation. I am not so naïve as to propose a black and white solution that will please everyone in this country over the following paragraphs. I instead intend to discuss the pros of organ donation, the ethical issue of informed consent and possible avenues for increasing the rates of organ donation in New Zealand.
It is an unrealistic situation, yet, if one was able to remove ethics, emotion and morals from the argument surrounding organ donation after death, this would be a relatively straight forward issue. The benefits of organ donation are largely irrefutable. Organ Donation New Zealand states that over 400 operations are performed a year in this country resulting in lives saved, sight restored and health dramatically improved (1). Tissues available for donation include the heart, pericardium and valves, intestines, kidneys, lungs, liver, pancreas, bones, tendons, corneas, veins, skin and sclera (2). Strict criteria for protection of immunosuppressed recipients and screening of tissues available for transplant mean tissue related infections are a relatively rare occurrence (2). In addition modern advances results in very favourable five year survival rates ranging from 40% for lung transplantation to 87% for liver and pancreatic transplants (3).
It can therefore be said with confidence that organ donation in and of itself is an important resource for increasing the quality of life of many individuals. It could also be argued that there is a trickle down affect that benefits other sectors of the health system. The cost of hospitalisation in many cases of people eligible for transplant is more than the cost of transplantation, this shows a possible avenue for more efficient appropriation of funds. One example of this is taken from a study from 1996 to 1998 conducted in the United States reports a `break-even' period of 2.7 years. This essentially shows that an organ transplant will be cheaper than dialysis in cases where the patient requires greater than 2.7 years on dialysis (4).
If it can be taken that, in principle, organ donation is an invaluable health resource then it is no great leap to assume increasing organ donation rates is a favourable concept. At present however the organ donation rates in New Zealand are suboptimal. In 2007 in New Zealand 191 transplant operations were performed, 129 from deceased donors (5). There were 38 organ donors in New Zealand (6) at a rate of 6 donors per million of population (pmp) (7), additionally there is evidence of a declining trend in donation rates as the same figure was at 9.9 pmp 4 years earlier (8). This compares very poorly internationally, Spain reports rates of 33.8 donors pmp (7). This may well be due to a different cultural make up of Spanish society but the New Zealand also compares unfavourably to the UK, at 13 donors pmp (9), and Australia at 9.8 donors pmp (7), societies with which comparisons are traditionally with some validity.
How then might a nation that feels increasing organ donation rates will benefit its citizens do so? --> Firstly it should be noted that the low rates of donation to some extent are unavoidable in order to protect the health of recipients. Only around 1% of patients who die at hospitals will offer viable tissues to donate, this is due to exclusion in cases of infection, cancer and organ failure [Author:R] (2). The two chief aspects of increasing donation rates are addressing the financial aspects of organ donation and public barriers to organ donation. In New Zealand many prominent specialists in the field of transplant medicine feel there is inadequate funding for hospitals involved in organ transplantation procedures which disadvantages any hospital providing this service, this is due to a lack of national pricing for donor care or transplant surgery (10). There also needs to be consideration paid to the financial incentive for the individuals working in this country trained in transplant medicine, the well documented `brain-drain' is a significant issue when trying to maintain a base of competent professionals (10). There is also a role of publicity in increasing organ donation rates and I feel there are two target populations this could effectively address. There is a discrepancy in the percentage of society that supports organ donation and the percent that offer consent for donation. This could be addressed by increasing information on how one goes about consenting to donation. I feel a campaign addressing those who do not support donation in New Zealand should be instigated. This should involve educating people about the process of organ donation and more importantly the positive benefits of organ donation and personal success stories of recipients.
The primary issue f[Author ID1: at Mon May 19 14:51:00 2008 ]acing the New Zealand government is the decision whether or not to implement a nationwide scheme of presumed consent for organ donation. In short this system would entail everyone in New Zealand being organ donors by default. If under this system one desired, for any reason, to not be an organ donor then they would need to opt out of the system of organ donation. I feel the general opinion is that a presumed consent system of organ donation would effectively increase the rates of donation. I'm inclined to agree with this stance. For this it is useful to artificially segregate our public into groups for, against and indifferent to the issue. In general it's difficult to assess the level of indifference to a contentious issue such as this. I believe the facet of population who have no particularly strong views either way will as a sub group greatly increase their rates of organ donation. It should be noted that a percentage of this group may develop views in response to the publicity surrounding a change in donation systems. Any individual who doesn't support donation would be likely to opt off in this proposed scheme but this will not have the effect of reducing donation rates. The only situation I can envisage that may decrease rates would be if the numbers of people currently consenting to donation were to fall. This strikes me as highly unlikely, yet there is the possibility that they may take offence to the ethics of this new system. The most logical conclusion to draw is that there would be a rise in donation for those indifferent to the issue and relatively static rates of those for or against.
Presumed consent is the system of organ donation in Austria, Spain, Portugal, Italy, Belgium, Bulgaria, France, Luxembourg, Norway, Denmark, Finland, Sweden, Switzerland, Latvia, Czech Republic, Slovak Republic, Hungary, Slovenia, Poland, Greece, and Singapore. The rates of people opting out of the system have been around 2% in these countries (11). This seems to have worked well in these countries yet there still remains a majority of countries who have chosen not to implement this system. It is thought that this system places more emphasis on [Author ID1: at Mon May 19 14:53:00 2008 ]beneficence than autonomy. That is to say that the idea of using these organs to help others is placed at a higher value than the rights of a person to make there own decisions. Another suggestion is that following a serious brain injury there may be the temptation to view the patient as a mass of potential organs available for transplantation as opposed to a patient in need. I refute both these suggestions. I believe autonomy is fully preserved in the system of presumed consent providing sufficient education, it is merely changing the way one must make there own decisions. I also find the suggestion that the care of patients that are potential donors would suffer preposterous.
Is presumed consent/ opting out a viable system of consent for organ donation in New Zealand? I'm going to offer a contingent yes. I'm convinced of the benefits of organ donation and I'm also fairly confident that this system will increase donation rates. The ethics of this system unquestionably has dubious aspects to it. I believe informed consent is a basic right. As such I would need to be sufficiently convinced that everyone was sufficiently informed about the change in the system, and the process of opting out if the chose to do so. I think this task should fall to an independent party that would have nothing to gain from insufficiently informing people either by way of conserving money or increasing donation rates. Their task would involve publicity with a goal of 100% coverage including the illiterate, intellectually impaired or those without access to television and also for subsequent generations. I feel autonomy would not be affected under these circumstances.
The result of this is that, as is typically unavoidable, the issue of justice is raised. Although I agree in principle to this proposed system it is important to recognise the limitations of my own expertise, essentially representing Joe Public, in making decisions of this magnitude. How much will this publicity campaign cost the taxpayer? How effective it is likely to be? What other public sectors will suffer as a result of funds spent on this? Are they more important to the overall health of the country? Health economics is outside the scope of my knowledge but these questions certainly need to be addressed by the appropriate people.
If this system were to be instigated a further ethical issue of note is that of advocacy for the deceased remains, in particular how should the situation be approached where the family opposes the deceased decision to donate. It is my opinion that if in an opt out system it is felt that the deceased was not able to make this decision due to intellectual impairment then it is appropriate for the family to make decisions on their behalf. This is essentially an extension of the system in place whereby a person is incapable of informed consent whilst alive has there decisions made by an appropriate advocate. If a person fully capable of making decisions for themselves has family members with opposing views there views are immaterial and the patients' decision is respected. I believe this should extend to organ donation also. This is not to say there won't be conflict within families and this needs to be addressed within families. There should also be publicity to inform people of the role of families views on this issue and should aim to encourage discussion about this topic. It will ultimately be the individuals' decision to either maintain their autonomy or compromise their views to help appease family members coping with their passing away.