AMA: More pilot studies to boost organ donation

Presumed intent, mandated choice among options

The American Medical Association (AMA) is urging its members to support pilot studies of whether presumed consent and mandated choice policies could increase organ donations, while the nation’s organ matching system continues to be skeptical of the success of such programs in the United States.

AMA delegates approved a policy in June seeking more information about presumed intent, in which a person is assumed to be a willing organ donor upon death unless he or she specifically withdraws consent, and mandated choice, which requires people to specifically express their preferences for or against organ donation.

Trustees of the AMA said there currently is not enough data to support a national plan of presumed consent or mandated choice, but that because more than 7,000 patients on the national organ transplantation wait list died in 2004 because of lack of organs, the two methods should be studied to determine if they could be effective in generating more organs for transplant in the United States.

Could Spanish model’ work here?

Advocates of presumed consent point out that Belgium, Austria, Singapore, the Czech Republic, and most famously, Spain have experienced marked increases in organ donation through use of the presumed consent process.

The AMA’s ethics policy addressing presumed consent, adopted in 1993, says presumed consent "raises serious ethical concerns" because to be ethically acceptable, the process should include effective means of documenting and honoring refusals to donate. When there is no documented refusal, AMA ethics canons require the family of the deceased be contacted to verify that they know of no objections to organ donation expressed by the patient before he or she died.

Advocates of presumed consent often cite the "Spanish model" as a successful example of that approach. In one decade, the rate of organ donation in Spain rose more than 145%, topping the rest of the world in the rate of organ donations per million population.

Under Spanish law, organs only can be retrieved after obtaining consent from the family, and the country’s national network of specialist physicians who work as hospital transplant coordinators identify potential donors, approach the families, and manage the donors.

Doubt cast on U.S. model

Despite the success of the Spanish model, at least one study casts doubt on how well that approach would work in the United States (Matesanz R. Factors influencing the adaptation of the Spanish model of organ donation. Transplant International:Springer-Verlag; 2003), because the part-time physician transplant coordinator, considered to be key to the Spanish program’s success, would be difficult to tailor into physician practices in the United States.

At the AMA meeting in June, several black physicians spoke against endorsing presumed consent, saying it could worsen minority distrust of a health care system many Hispanics and blacks believe undervalues them as it is.

AMA trustees indicated more support for mandated choice, in which people would be required to declare their choice when getting a driver’s license or other government-issued document.

Other strategies for boosting organ donations that the AMA has expressed interest in are not letting families overrule a dying patient’s previously expressed desire to donate and better treatment of hypertension and diabetes patients, to prevent organ failure and thereby reduce the need for transplants.