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In Favor of Organ Donation?

June 20, 2019
In Favor of Organ Donation? June 20, 2019

by D. Joy Riley MD, MA (Ethics)

The Department of Health & Social Care of GOV.UK recently notified its email subscribers of a new law regarding organ donation in England. Beginning in 2020, “Everyone in England over the age of 18 will be considered to be in favour of donating their organs and tissues after death unless:

  • They have said they don’t want to donate their organs (they have ‘opted out’).
  • They have appointed a representative to decide for them after their death.
  • They are in one of the excluded groups – under the age of 18, ordinarily resident in England for less than 12 months before their death, or lack mental capacity for a significant period before their death.”

There are several “do not panic” assurances, however. The family will be consulted first, and if they have pertinent information regarding their loved one’s wishes not to donate their organs, they will not proceed with the organ donation. However, there is no explanation as to what that pertinent information might be. Tissue for “novel” or “rare” transplants, however, will need express consent—unless and until the decision is taken by the government to change the designation of those transplants. For now, though, face, nose, ovary, uterus, penis and testicle, along with brain and spinal cord, are excepted out of the new law. The complete list of excepted body parts is available here.

Other exceptions to the opt-out system are certain human cells or tissues: “Advanced Therapy Medicinal Products, (ATMPs), are another form of novel transplant. ATMPs are classified as medicines for human use and are based on manipulating genes, tissues or cells. They often use human cells and tissues as starting materials.”

How long will these exclusions apply? The document notes that limb transplants are already being done in Leeds, and face and uterine transplants are being developed. Already, even though the law has not yet come into effect, the exclusions are being lined up to fall. Transplants become standard practice after passing through “two assessment stages: research and service evaluation.”

Citing statistics of more than 5,100 persons waiting for transplantation, together with the past year’s removals from the waiting list (643) and deaths (339) while on the waiting list, the government is acting. With certain exceptions, upon one’s death, the government owns that person’s body.

The anguish and grief of needing a transplant, and waiting for a transplant, impact the person in need and his or her family. The donor and his or her family are also affected, often dramatically. There is no denying the distress of all parties involved.

It is intriguing, though, that the government is moving with such alacrity to possess bodies, given the numbers cited in the consultation. The numbers of persons on the waiting list or having died in the previous year pale in comparison to those affected by roadway accidents in England in a similar time frame. In the year ending in June 2018, England reported “26,610 killed or seriously injured casualties (KSIs) in road traffic accidents” that had been reported to police. There were 1,770 road fatalities reported during that year, and this represented a 3 percent increase over the previous year. Yet, the government is not claiming ownership of all motor vehicles that have been smashed, with parts to be meted out to those vehicles in need.

As chair of the U.S. President’s Council on Bioethics several years ago, Leon Kass addressed this kind of thinking. He advised asking the question, “Is the human body really like a car with completely fungible and replaceable parts?” about both medical and moral considerations:

“Medically, of course, we have the immune rejection problem which no automobile has, suggesting that there is some kind of difference between us and simply a heap of spare parts….To talk about the person that somehow survives the replacement of these parts invites the kind of person, machine or person-body dualism and one of the questions I think that we want to keep in mind is what kind of a view of ourselves are we tacitly promoting, not only in organ transplantation to begin with, but how might that view be affected by the varying proposals to increase the supply.”

It seems the government and citizenry of England, as well as those in the United States, would be well-served by carefully considering Kass’ words.

D. Joy Riley MD, MA (Ethics)

About D. Joy Riley MD, MA (Ethics)

Executive Director of the Tennessee Center for Bioethics & Culture.

2 Comments

  1. Avatar John Mulder, MD, MS, FAAHPM, HMDC on June 27, 2019 at 8:50 pm

    Thank you for addressing this issue. I must confess, however, that I have a different perspective on the topic. I find the correlation of default organ donations to spare car parts seriously in error, if not insulting and demeaning. Organs are precious, life-giving gifts of God. When donated, they have the capacity to restore life. To compare them to car parts is simply inappropriate.

    The history of default donation is rooted in the reality that most folks who have not opted in have not done so because of a moral or ethical objection to their organs being used for transplant — they simply haven’t consciously thought it through, and the only introduction to the concept they may have experienced is a question in passing from a DMV clerk. 95% of US residents approve of organ donation, and many organs ultimately donated for transplant do come from individuals who failed to check the box, but whose loved ones felt that the donation would be in keeping with the donor’s wishes. Families of default (opt-out) donors have the opportunity to decline donation in the countries where it is the practice, so consent still applies.

    I also find the concept of the “government claiming ownership” of the body to be bordering on an irrational and perhaps more political than medical. The government, to my knowledge, does not make any decisions regarding the medical aspects of transplantation. These laws, where they exist, simply serve to increase the pool of potential viable organs. The eligibility and appropriateness of donation is still solidly within the realm of the medical community. It seems to me that the fear here isn’t so much that we would have access to more organs, but rather that the government is involved in healthcare decisions. I don’t see that here. We have many “opt-out” circumstances in our health care system. In many circumstances, it’s difficult to avoid intervention, even if you don’t want it. (Simplistic example: most pregnant women when coming into the hospital in labor in the US will be required to have an IV placed and continuous fetal monitoring applied, despite the lack of evidence that such intervention is of any value to them. That’s the default, and they rarely have the opportunity to opt out.) In the case of transplant, the intermediary organizations who approach the potential donor’s family do so with humility, dignity and respect.

    I would think that an organization who firmly and unapologetically favors the sanctity of life would welcome any opportunity to preserve and restore meaningful life. If we want to engage what I believe to be a more relevant ethical conversation regarding organ transplants, we should be talking about brain death criteria and DCD.

    (Now for my unadulterated bias on this issue: I am 2 years post successful lung transplant. The gentleman in the ICU room next to mine at the time was also awaiting a lung. He is dead. I matched, he didn’t.)

    • Avatar D. Joy Riley on September 12, 2019 at 11:30 am

      Thank you for your thoughtful comment.
      Relative to this discussion, you may be interested in reading several CMDA position statements: “Human Life: Its Moral Worth” and “Imminent Death Organ Donation,” as well as the overview of human organ transplantation, and the statement on organ donation after circulatory death (DCD). These are available at https://cmda.org/position-statements/.

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