Too Many Preventable Deaths
Putting Donors First

Lisa Nyberg, MD, and Steve Heilig, MPH | San Francisco Medical Society

The year 2010 marks the fifty-sixth anniversary of the advent of transplantation of human organs. Organ transplants are one of most striking modern medical miracles. Only a generation ago, using another person's heart, liver, kidney, or other organ to save or at least improve another's life was a science-fiction dream; once transplants began to occur, they were front-page news worldwide. In a relatively short period of time, transplantation has become common, if not routine. Such surgeries are a wonder of our time, supported by the vast majority of people as a modern boon to humanity.

The full promise of these breakthroughs has not been realized, however, no matter how fast clinical advances take place. For although about 56 percent of Americans state that they wish to donate their own organs upon their death, only about a third take the procedural steps needed to ensure that this occurs.
Demand for organs, however, keeps rising. Thus a chronic and tragic shortage of organs relative to need results in much unnecessary suffering and death. More than 100,000 Americans are on waiting lists for organs; more than 6,500 per year die while waiting—almost 18 such deaths per day. The waiting lists grow by an average of 19 percent annually. The problem is getting worse rather than better, with pessimistic projections.

However, there is increasing advocacy for changes that might increase the supply of organs. The most sweeping such policy is that of "presumed consent," which reverses the default for donation to one where an individual must specify that they do not want to donate their organs. This has become the policy in at least five European nations, with marked increase in usable organs there. A similar policy has been proposed in New York State. Under the proposed legislation, an applicant for a driver’s license is automatically enrolled as an organ donor unless he or she opts out of the program. The American Medical Association has formally noted that a presumed consent system is not unethical as long as there is a clear opt-out provision for anyone who does not want to donate their organs

Another recent proposal is California Senate Bill 1395, which would establish a registry of individuals who identify themselves as potential organ/tissue donors after death and the establishment of an altruistic living donor registry for persons who would like to identify themselves as potential kidney donors during their lifetime. The bill would also require the department of motor vehicles to verbally ask each driver’s license/I.D. card applicant if he or she wishes to enroll in the registry.

Presumed consent still offers the greatest promise for improvement in organ donation rates. However, it may be unlikely that this sweeping change of the default for donation will be enacted in the USA any time soon. There may, however, be a more moderate option that could also significantly increase organ donation without raising many of the objections to presumed consent.

We believe that a "donor-first/confirmed consent" incentivized system can be implemented with minimized logistical and ethical problems. This system would offer priority[PRIORITY FOR WHAT?] to those individuals who have previously committed to organ and tissue donation at the time of their own death. After development and adoption of a suitable policy and program, a widespread public education effort would be needed to inform people about their newly heightened interests in donating their organs. Ideally, the program could effectively nullify itself if many new donors respond to the new incentive. Only a fraction of those who have not yet offered organs but who say they would intend to would need to so respond in order to fulfill current demands for organs. Thus, the waiting lists could diminish so much as to make the "triaging" inherent in current practice, and this proposed policy, moot. Although this is a lofty goal, it could be attained with a full commitment to implementation of and education about this policy. Indeed, a similar model was implemented in Israel in January 2010 (Israel Parliament clause 9[B]4). The effect of the new policy on organ donation rates will be monitored and a public report will be submitted two years after its implementation.
An ever-increasing number of families and friends are suffering the emotional anguish of seeing their loved ones suffer and sometimes die while thousands of potentially life-saving organs are being discarded. Additionally, the possibility of giving “the gift of life” often offers some solace for the survivors, as they may feel that a part of their loved one lives on. Finally, a large number of potential donors would have consented if the issue had been adequately discussed prior to their deaths. The “donor-first/confirmed consent” incentivized program will encourage discussion of choices and attitudes regarding organ and tissue donation and thus could potentially save thousands of lives. Even if there are problems with the policy, they are unlikely to be as tragic as the existing number of preventable cases of suffering and death.


Lisa Nyberg is a gastroenterologist and transplant specialist/researcher at Kaiser Permanente in San Diego. Steve Heilig is on the staff of the San Francisco Medical Society and is coeditor of the Cambridge Quarterly of Healthcare Ethics.