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Should The Government Require Your Consent To Be An Organ Donor?

Paul Hsieh
This article is more than 3 years old.

In the US, there’s a significant shortage of donated organs relative to those who need them. According to the United Network for Organ Sharing (UNOS), the non-profit organization that manages the US organ transplant system, there are 117,000 waiting list candidates who need a life-saving organ transplant. Roughly 22 people a day die while waiting for a transplant.

This shortfall frustrates many physicians and organ donation advocates. UNOS notes that 95% of adult Americans support organ donation in theory — but only 54% have actually signed up to be donors.

In response to the shortage, some organ donation advocates have proposed a controversial change in US laws, switching from an “opt in” system to an “opt out” system. In the current “opt in” system, hospitals assume someone is not an organ donor unless they’ve explicitly registered to become one. In the proposed “opt out” system, everyone would be presumed to have consented to donate their organs upon death unless they explicitly “opted out.”

Supporters of the “opt out” (or “presumed consent”) model argue several benefits:

* Organ donation rates in “opt out” countries (such as Austria) can exceed 90%, whereas donation rates are typically less than 15% in “opt in” countries (such as Germany).

* An “opt out” system still respects individual preferences. Anyone with strong personal or religious convictions against organ donation is not obliged to participate. In theory, there’s no difference between given a default of A with an option to switch to B vs. being given a default of B with the option to switch to A.

* Both “opt out” and “opt in” systems impose transaction costs for those whose preferences don’t match the default option. But if 90% of adults support organ donation, then an “opt out” system imposes that cost on the minority 10%, rather than the majority 90% in an “opt in” system.

* An “opt out” system helps aligns stated preferences with actual results. If 90% of adults *say* they support organ donation, an “opt out” system yields real-world donation rates that matches their words.

Given that changing the default to “opt out” could save thousands of lives every year, I understand the appeal of such a system for its advocates. As researchers Johnson and Goldstein pointed out in a 2003 paper:

[D]efaults can lead to two kinds of misclassification: willing donors who are not identified or people who become donors against their wishes. Balancing these errors...must be made with the knowledge that defaults make a large difference in lives saved through transplantation.

However, critics of “opt out” note that changing the default runs counter to standard Western views of individual autonomy over one’s own body.

For the state to presume the authority to harvest my organs (or to allow others to do so) without my explicit consent strikes me as deep violation of my freedom and autonomy. My body and my organs are mine — not mere means to others’ ends.

All physicians swear to uphold and protect patients’ individual bodily autonomy. Although my heart goes out to patients on the waiting lists in urgent need of a transplant, they’re not entitled to anyone else’s organs.

I’ve volunteered to be an organ donor ever since I got my driver’s license. I would be delighted if my organs could help others after my own death. But all I require is that I be asked first. This affirmative decision is my call, and the default should respect that.

Moreover, other organ donors under the current system have told me that if the US changed to an “opt out” system, they would immediately opt out — and they would aggressively encourage others to do the same. Depending on how widespread this attitude was, an “opt out” system in the US could backfire badly.

By BruceBlaus (Own work) [CC BY-SA 4.0 via Wikimedia Commons

Rather than an “opt out” system, we could consider other methods to encourage voluntary organ donation, such as used in Israel:

A change of law in 2010 that prioritizes patients with a history of donation — if a family member donated his or her organs or the patient himself made a living donation or if the patient has been on the donor list for at least three years — has incentivized a significant portion of the population to register as donors.

Preliminary results, published last year, show that the annual deceased organ-donation rate increased from 7.8 organs per million people in 2010 to 11.4 organs per million people in 2011. The number of new registrations per month more than doubled and the total number of candidates waiting for a transplant fell for the first time ever.

In other words, the Israel system led to a massive increase in registered donors and a historic decrease in the size of the waiting lists.

Regarding the negative American reactions to “opt out,” UNOS spokesperson Anne Paschke noted, “Our attitudes here are very different. Individual rights are very important in this country more so than in other countries. Opt-out hasn’t been very popular because of the way that people here view government making decisions for them.”

I fully agree with Paschke's point. And I’m glad the issue of individual rights is crucial for so many Americans. The “opt in” system protects those rights, whereas the “opt out” system systematically violates them. I hope future organ donors such as myself never lose that protection.

