Q&A: The ethics of an opt-out organ donation system
The UK operates an "opt-in" system for anyone wishing to donate organs after death. You can opt in at the NHS Organ Donor Register, by carrying a donor card or making your wishes clear to relatives or friends.
Currently 31% of people in the UK are registered as organ donors and the NHS says 1,000 people a year die waiting for organ transplants.
An opt-out system has been under consideration across the UK and has already been approved in Wales to take effect from 2015. Consent for organs to be donated will be presumed unless people have stated otherwise, though close relatives of the deceased will have a say on the final decision.
The ethical implications of an opt-out organ donation system are discussed by Dr Greg Moorlock from the School of Health and Populations Sciences, University of Birmingham.
Are there any legitimate ethical reasons to opt out of organ donation?
Opting out: the debate
- In 2006 the government appointed the Organ Donation Taskforce to identify ways to increase organ donation
- In 2008, former PM Gordon Brown backed the introduction of an opt-out system
- Shortly after, the Taskforce published its report, which did not recommend the introduction of an opt-out system
- In 2011, Scottish Health Secretary Nicola Sturgeon said she was open to the idea of an opt-out system
- In 2012 the British Medical Association urged society to consider what more could be done to improve organ donation rates. In the report Building on progress: where next for organ donation policy in the UK, the BMA recommended the opt-out system as the best option for the UK
- The BMA has recently prepared a briefing in favour of the opt-out system for the Scottish government
- In June 2013, a consultation process was announced in Northern Ireland to ask citizens whether they support the opt-out system.
Whether it is ethically acceptable to opt out of organ donation may depend upon a person's individual sense of morality; for instance, for me as an atheist, organ donation is absolutely the right thing to do - I have no belief in an afterlife, and would view my organs as spare parts that could be used to benefit somebody else at no cost to me. If I can save/improve other people's lives at zero cost to me, then I'd feel duty-bound to do it. I suspect that many people who are pro-donation feel like this, and would perhaps think that there is no legitimate reason to opt out of organ donation.
For other people, however, the perceived cost of donation may be greater. Someone who believes in an afterlife may feel that by donating their organs they are forfeiting their access to this afterlife, and for that person it might seem unreasonable to be expected to donate their organs. Similarly, those who have other religious objections to donation may feel that they would be betraying their faith by donating. Other people may be personally pro-donation, but aware that donating would cause great upset to their next-of-kin so would choose to opt out to avoid upsetting their family.
What do different faiths think of organ donation?
Whether these are ethically legitimate reasons to opt-out is open to debate: from a strictly rational and impartial ethical perspective, donating one's organs to save someone's life seems like the right thing to do, but there's a general sense within the transplantation community that it is important to (and unethical not to) respect people's beliefs and wishes about their bodies.
Respecting people's beliefs about donation means that some organs that are medically suitable for transplantation are either buried in the ground or cremated, and this comes at a cost to those on transplant waiting lists. Broadly speaking though, society currently appears to place respecting people's wishes over saving or improving the lives of as many people as possible.
Do you think with an opt-out system donating organs becomes expected, almost an obligation?
End Quote Dr Greg Moorlock
I think that the state would be more likely to be perceived as 'taking' if a hard opt-out system was in place, but as it stands I think that soft opt-out is compatible with the idea of gifting”
I'm not convinced that the shift to an opt-out system will make much difference to this. It changes the default position: the assumption becomes that unless there is a clear indication to the contrary, a person would want to do something altruistic and try to save/improve other people's lives.
To me, it seems quite reasonable to make this assumption: it may give an increased number of people the opportunity to do a good thing. I suspect that, as opting out is introduced in Wales, the accompanying media campaigns will emphasise that organ donation remains completely optional, and that it is still a deeply personal choice. Some people have argued that there is an obligation to donate (along the lines of what I said earlier, where if one can save someone's life at little or no cost to oneself then one is morally obliged to do so), but again it may come down to the perceived cost.
I don't think that the move to an opt-out system entails that donation becomes expected though: the default position has changed, but the default need not be the expected.
Do you think the positive stigma attached to donating organs would mean people might be ashamed of opting out (even though that's really what they might want to do)?
I think there is a risk of this, but the opting-out process would obviously be confidential - it would be a different (although very interesting!) story if the organ donor register was made public. So people may feel ashamed of opting out, but by the time it actually became public knowledge they would be dead, so it would only perhaps be the memory of them or their reputation that would be affected.
Equally though, it could be argued that the positive stigma attached to donating organs would mean people might be ashamed of not opting in. There may even be some people who feel pride in opting out of donating, if they consider their actions the right thing to do. The risk of feeling ashamed is perhaps increased in those who think organ donation is the right thing to do, but are scared or worried about the process so decide to opt-out: but this may perhaps encourage more frank and open discussion about organ donation, which could be a good thing.
Do you think an opt-out system represents a shift from 'giving' organs to 'taking' them?
This is an interesting question, and one that is difficult to answer. It is a commonly accepted legal principle in the UK that a corpse cannot be considered as property, and this may also apply to organs after death, so the whole idea of donating is a bit unusual anyway: it seems difficult to be said to be donating something that you don't own anyway.
It is also not always clear who should be considered to be doing the 'giving': is it the dead person, or their next-of-kin? In the vast majority of cases currently, it is the deceased's next of kin who will make the final decision about whether to proceed with donation, and so these are ultimately making the final decision on the gift. This will remain the case, even with the switch to an opt-out system in Wales.
Given that the next-of-kin have the option to veto donation, it strikes me that they can still normally be considered to be giving whether it is opt-in or opt-out. There is a risk that the public may perceive the state to be taking organs, but transplant staff are very aware of this. It is exceedingly unlikely that organs will be taken contrary to the wishes of the next-of-kin, as transplant staff are aware of the potentially catastrophic impact upon public perceptions of transplantation.
I think that the state would be more likely to be perceived as 'taking' if a hard opt-out system was in place, but as it stands I think that soft opt-out is compatible with the idea of gifting.
Does the opt-out policy represent a shift in the values or attitude of the state vis a vis the individual, compared to the past where the choice was perhaps more geared towards individual choice?
I think it remains geared very much towards individual choice, hence the fact that people will still be permitted to opt out, and family members will have the right to veto.
I think one of the aims of the opt-out system is to combat people's tendency towards inaction: there are undoubtedly many people under the opt-in system who have no objections to donation, but simply never get around to registering. This potentially means that organs that could be donated, because the next-of-kin may be uncertain about the wishes of their loved one, or presume that their lack of registration means that they don't want to donate.
With the opt-out system, one presumes that if one is truly opposed to organ donation, then one will feel strongly enough to take the action to opt-out, or at least make it clear to one's relatives that one is anti-donation.
Dr Greg Moorlock is a Research Fellow in Medicine, Ethics, Society and History (MESH) at the University of Birmingham. His main interest is transplantation ethics, and he is currently working on a project funded by QE Hospital Birmingham Charities looking at the ethics of split liver transplantation.