Presuming consent to organ donation? Not yet

Recommendations for increasing organ donations

The United States is not ready to follow some European nations in presuming that deceased patients have consented to organ donation if they did not specifically opt out, according to the national Institute of Medicine (IOM). However, the need for donor organs calls for boosting efforts to increase donations, including using organs from patients whose deaths are determined by cardiac criteria.

The IOM released its recommendations in a report, Organ Donation: Opportunities for Action, in May (available for purchase on-line from National Academies Press at www.nap.edu).

Most organs transplanted in the United States come from deceased donors whose deaths have been determined by neurologic criteria based on the irreversible loss of activity in the brain, including in the brain stem. According to the IOM and data from the United Network for Organ Sharing (UNOS), the administrating agency of the national organ procurement program, there are at most about 16,000 eligible donors whose deaths are declared in this way each year in the United States.

But many more people are declared dead using circulatory criteria (irreversible loss of heart function and permanent cessation of circulation). The IOM estimates that at least 22,000 people who die of heart attacks outside of hospitals could be potential donors, provided certain ethical and practical issues can be resolved.

In its report, the IOM recommends that federal agencies work with states and cities that have extensive trauma centers and emergency response systems to develop demonstration projects that can determine the feasibility of increasing rates of donation after circulatory determination of death

Presumed consent rejected, for now

Right now, people in the United States must make a deliberate decision to donate their organs, or next of kin must make this choice after their deaths. Some groups have suggested enacting policies that would presume consent to donate unless a person explicitly opts out, as Spain and Italy have done. The IOM committee that prepared the recommendations examined several methods that could be pursued to increase organ donation, including the so-called "Spanish plan" of presumed consent.

"We believe that at this time the best approaches are to pursue ways to increase donations based on circulatory determination of death, to enhance public education about the value of organ donation, to increase opportunities for people to opt in, and to sustain quality improvements in the organ donation system," the committee reported.

While supporting many of the principles underlying a presumed-consent approach, the IOM determined that now is not the time to replace the current legal framework requiring explicit consent. Without broad public support, such a shift would probably reduce rather than increase the supply of organs, the report says. However, the committee encouraged those with a stake in increasing donation rates to work to create the social support necessary to make this change.

Organ donation in the United States has increased steadily over the last two decades, but the growth in donor tissues and organs is far outstripped by the increasing need. In early May, more than 92,100 people were waiting to receive organs.

Also rejected is the trend of offering financial incentives such as direct payments, coverage of funeral expenses, or contributions to the donor's choice of charity as a means of encouraging donations. Individuals who are willing to be organ donors should not be given preferential status as recipients of organs, the report adds.

So-called living donors — those who donate organs and tissues while still alive and healthy — do save lives, but the risk to their own health is considerable, and the IOM recommends additional advocacy on behalf of those donors to make sure they are fully informed when they consent to living donations. Additional study of living donation and its risks to the donor is urged by the IOM.

For more information, visit the Institute of Medicine web site at www.iom.edu.