The first time an individual is asked about organ donation, it is generally at the driver’s license center. These individuals are usually very healthy teenagers that are very excited to be able to drive, so they are surely not focusing on the decision of being an organ donor or desiring to make a decision regarding their tragic death. This is just not a topic that crosses the teenage or young adult mind. However, these are the very individuals that would present as viable organ donors if in fact, tragedy occurred. Prottas indicates that the primary obstacle in the decision to become an organ donor lies with “confronting fear of one’s own mortality”.1 Unless these individuals were in a situation where someone close was on the waiting list for a transplant, the thought of one’s own death is avoided and the idea of organ donation is nonexistent. By using the term “waiting list”, one can realize that there are not enough donors to meet the demand of the transplant patients. This insufficient number of available organs is yet another tragedy that many medical professionals and politicians have tried to address. Primarily, most of the debates have been associated with offering financial incentives in order to increase the supply of organs, but there are also many interesting arguments related to standardizing hospital procedures, offering public education, encouraging family discussion, revising the role of the donor card, addressing fears of inferior treatment, defining brain death, evaluating the distrust in the organ distribution system, and looking at implications of “free riders”.
Altruism is centrally related to decisions of organ donation. Individuals with a desire to help others are the ones that volunteer to be organ donors, both living and dead, because currently there is no financial reward for performing such an act. Wilkinson’s position for objecting to financial incentives is that the idea of offering financial rewards will eventually eliminate the practice of voluntarily donating based on altruism.2 He further argues that removal of voluntary donation without financial compensation also removes the “giving relationship that gives ethical and social value”.2 This is generally consistent and the primary argument that is associated with the not allowing financial incentives. Altruism is also used in many cases as the justification for allowing organ donation. Wilkinson argues that the primary objection to organ donation with reward is a “violation of bodily integrity” because the body is comprised of “irreplaceable and unique parts” such that removal of these parts removes the “intrinsic value” that is placed on the body.2 The only way for this violation to be overridden is by the “combination of extremely good consequences (for example the saving of an other’s life) and the pure altruism involved in the giving”.2 The concept of altruism may make an individual decide to be an organ donor, but the follow through relies on the family that is left behind amidst one’s tragic death.
Because the final decision for whether a deceased patient will become an organ donor lies with the next of kin, the method that hospitals use to request the donation of organs should be evaluated. It is often a time of tragedy and grief when the request is made; therefore, the process has to be very delicate in order to be successful. Thinking about the feelings and situation of the relatives may give rise to more empathetic approaches and lead to an increased rate of donations. In an article by DeJong, there are three reasons for lack of donation which include failure of declaration of patient being “brain dead”, failure to ask the family, and failure of family consent.3 He argues that there are three solutions to these reasons to include ensuring that the inquiry of the family be held in a private setting, separating the information regarding patient’s brain death from request for organ donation, and making the first inquiry of organ donation be made by a “hospital based health professional” with follow up from an organ procurement designess.3 All of these suggestions should be established into a standardized procedure in order to maintain the reputation of the institution as well as decrease malpractice litigation.3 Prottas includes that there are a decreased number of referrals of blacks for organ procurement.1 Standardizing a protocol that ensures that all potential donors are identified and approached may also increase the organ donation rates.
Public education could make an impact in increasing donation rates by addressing some misconceptions about the donor process and also targeting populations that have been less likely to participate in organ donations. Studies have shown that there are some race/class differences among donation rates.1 Prottas argues that black donation rates are significantly lower than whites with possible causes attributed to misconceptions that whites benefit more than blacks and fear from institutions that have primarily white staff.1 In response to these misconceptions, educating the black population about differences in the antigens between blacks and whites would show that whites are less likely to benefit from donations by blacks, blacks are more likely to suffer for decreased black donations, and blacks are more likely to benefit from increased black donations.1 Correcting these inaccuracies would lead to improved trust of the organ donation system, increased support for organ donation, and finally increased participation in the organ donation program.
Another target for methods to increase the rates of donation relies on the encouragement of family discussions. Once again, the living relatives are the ones that make the final decisions regarding the patient, so it is important that the family knows the patient’s wishes as they would be more likely to desire to uphold what the patient would have wanted. Prottas argues that there are four main reasons why a family will choose to donate including altruism, fulfilling the deceased’s wishes, mitigating the impact of death, and rehabilitating the deceased.1 In addressing the reason of fulfilling the deceased individual’s wishes, the family must be aware and have the discussion about what the person wanted. A simple donor card is not enough as the family will not truly know what the person was thinking when the decision was made. Hearing the words from the individual is much more powerful making the family more likely to honor the wish of organ donation. DeJong proposes a revision to the role of the donor card.3 The recommendation is that a family member be required to witness the completion of the donor card ensuring that someone who will make the decision knows what the patient wants.3 In addition, the system sometimes fails to determine that a patient wants to be an organ donor because the patient’s belongings may get separated from the patient when entering the hospital. There is a need for additional steps to be taken in order to ensure that a potential donor doesn’t slip through the cracks of the system with the best solution being family discussion.
One of the obstacles that must be addressed is fear to receive inferior treatment if the patient agrees to be an organ donor. This relies mainly on the lack of information and ultimately distrust in the system. These patients feel that they will be sacrificed and not receive the required attention to preserve life just because of the decision to become organ donors. This is a huge misconception that can be addressed by educating the public on the process that is taken when requesting organs. Because the living relatives make the decision, it doesn’t matter if a patient wants to be a donor as this decision can be overridden. In addition, because the system doesn’t work efficiently, the team providing treatment wouldn’t know that the patient desires to be a donor.
Another questionable practice is determining brain death and the implication this makes on donors. Brain death is defined as the “death of brain stem with lack of functioning nerves originating in the brain stem”.4 This term allows for a patient to be declared dead but still have a heartbeat which is important to continue perfusion to organs until harvesting for donation. In addition, this term was created primarily for the process of organ donation in order to allow removal of organs without implying murder.4 The argument most commonly made is that there is still some brain function that exists; therefore, the patient isn’t dead until irreversible circulation ceases.4 Since the term brain death does not indicate actual death, some feel that this allows for lack of treatment and hastening of death in order to procure organs. Kerridge argues that the term brain death is a fictional state that indicates that removing organs in this state is actually killing the patient and organ donation programs should state the truth to sustain support for the program dealing with the moral implications that arise.4
Corruption in the distribution of organs also causes some to not support the process of organ donation. Whether it is a racial distrust or class distrust, misconceptions that organs go to the higher bidder or to another race influences the decision donations. Annas presents several approaches for organ distribution including the free market approach, a committee selection approach, a lottery approach, and a customary approach. All of these have advantages and disadvantages, but determining which approach or combination of approaches to use is necessary. This process needs to be fair, as free from bias as possible, and fully explained to the public. The organ donation programs must be prepared to deal with the implication of this distribution system on organ donation rates; however, being truthful about how the process works will remove this obstacle in the decision to become or not become an organ donor. One of the biggest considerations should be the matching required to ensure the most successful transplantation to decrease the likelihood of rejection and ultimately the wasting of a scarce resource.
Free riders are individuals that are against donating organs but would want an organ if requiring a transplant. Eaton argues that “free riders” are implications to instituting an opting out system for organ donation.6 Individuals have a tacit consent that one would want a transplant if needed; therefore, if the individual opts out of organ donation, then one is willing to accept the generosity of a donor but not willing to pay by being a donor.6 In addition, these individuals would not receive priority when organs are available unless there is the best chance for successful use of the organ with one of these individuals.6
The most emphasis for increasing donation rates includes provision of financial incentives. Harvey argues that the main objection to offering financial incentives is the financial pressure that may affect a free, informed, and voluntary decision, especially with those that are in poverty, indicating possible coercion.7 The objection is whether this financial pressure actually changes the decision of an individual to be or not to be an organ donor with the response purely related to need for the money.7 The objection could be extended to show that the decision is not entirely free, voluntary with donations by relatives due to the emotional and psychological pressures without the involvement of money.8 Harvey responds to financial pressures by stating that even if money is offered, the decision is still made by the individual; therefore, the responsibility lies with the individual.7 Another main objection to allowing financial incentives involves the potential for commercialization and morally wrong exploitation of the poor by buying organs at a low price from individuals in poverty and selling to the highest bidder for a large profit. However, it could still be argued that hospitals profit from the donation already causing even free organ donation as exploitation. Joralemon offers suggestions for helping public opinion accept some financial incentives to organ donation including the changing language to soften the blow of the message, using statistics, and using small scale models to measure impact.9
After reading many articles regarding organ donation and the methods to address the limited supply of organs donated, the suggestions of improving public education, standardizing hospital procedures, and offering small rewards for donation have merit. First of all, improving public education about organ donation should include several points. Letting the public understand the donation process including the distribution of organs, defining the use of brain death including the implications of this state, and addressing the race/class misconceptions of preference could provide vital information for individuals making the decision on whether to be or not to be a donor. Giving all of this information empowers the individual to make an informed decision with all the facts on the table. Another huge impact can be made by hospital protocols ensuring that there is no bias in the individuals asked to be donors, involving a sense of understanding, empathy, and care when requesting organ donations, and removing any conflicts of interest.