Organ donation is when an organ is given to a person, through transplantation, in order to improve or even save their life. This can either be done when you pass away (known as a deceased donation) or whilst you are still alive (known as a living donation).
There are many types of patients. The most common include heart, kidney and renal transplant patients however there can also be patients requiring an eye or limb transplant. It is estimated that in the UK, 3 people die each day while waiting on an organ which can save their life.
There are two types of opting systems which countries can choose from to adopt as their law regarding organ donation.
Opt-in organ donation is when an individual has to actively decide whether they wish to register to donate their organs after death. Their decision has to be explicit although the family are consulted too, and, as their family are deemed to know them best, can override their decision.
Opt-out organ donation is where you are automatically registered to donate your organs when you die. Several individuals are exempt from this: those under the age of 18, those lacking mental capacity to understand what this law means for them and the actions they may need to take, visitors to England, and those who have lived in England less than 12 months prior to their death. If an individual does not wish to donate their organs, they are required to make this decision clear. However, saying this, families will always be consulted as a safeguard. If an individual has not opted out but the family is aware the individual may have had an unregistered objection, and therefore the individual would not have consented, the donation will not proceed. Equally, if the patient has not opted out, but it appears organ donation would cause distress to those close to the patient, the donation will not proceed. Therefore, it is strongly advised that individuals discuss their wishes with their family.
Wales was the first country in the British Isles to switch from an opt-in system to an opt-out system in December 2015. England followed suit in May 2020 while Scotland recently adopted this approach in March 2021. Northern Ireland is currently following the opt-in method, however, after reviewing the law, they have decided to draw up plans to introduce a soft opt-out system. This means that soon the whole of the United Kingdom will follow an opt-out organ donation system.
Once the opt-out system was introduced in Wales, it was found that there was a slow increase in donations after implementing the new law, compared to England who remained in an opt-in system.
Autonomy, beneficence, non-maleficence and justice are all very important when it comes to both types of opting systems.
Autonomy, in the context of organ donations, is respecting a patient’s right to make their own decision as to whether they wish to be an organ donor or not as well as giving them the right to include whoever they would like to make that decision with (such as family). As a doctor, it is important to assess whether the patient has the capacity to make the decision (a good example is children and each country has their laws regarding this).
Beneficence is the doctor acting in the best interest of their patient. Unfortunately, the limited supply of organs means that patients who need an organ are placed on a waiting list. Therefore, in order to benefit these patients, we need to find methods of increasing organ donation.
Non-maleficence is avoiding harm to patients. Considering this in the context of organ donations: there is harm caused to patients on the waiting list if they are unable to receive an organ donation. A balance has to be made for both parties: the donors and the recipients. On one hand, to reduce numbers on the waiting list, and therefore reduce the harm caused, the number of organs donated needs to increase. But, this cannot be done against the wishes of those who are able to donate if they do not wish to.
Justice involves consideration of the law and the benefits it brings to society as the study shows for Wales. Many different people require an organ, and their condition and any other medical history can vary significantly. Decisions have to take these factors into account to bring the most benefit with scarce resources.
The pandemic has increased the burden on NHS services across the UK and also on healthcare systems worldwide. The focus on COVID-19 care and research meant that resources in other areas of healthcare have been less readily available. In addition to this, guidelines and restrictions in place to reduce the incidence of the virus led to huge changes in the provision of healthcare services. Because of this, the decision-making process has been much more complex.
The four basic ethical principles of autonomy, beneficence, non-maleficence and justice play a big part in making decisions regarding organ donation. To ensure these principles are considered and the best outcome is achieved, decisions are made by following a step by step process. The factors that have to be considered are as follows:
Decisions are made based on ethical principles for it to provide the best possible outcome and ensure patients are treated fairly. Changes in the way transplantation occurs should be clearly communicated to all patients involved, including waitlisted patients. Information should be easily accessed and understood internationally (this pandemic does not just include the NHS), which is being made easy using online platforms to provide a wealth of beneficial information.
1. What are the pros and cons of each type of opting system?
2. What are some reasons for the shortage of organs in the UK?
3. If there are a limited number of organs, how would you decide who to give the organs to?
Now apply your answer to the following question:
There are three patients in need of a kidney transplant, but only one kidney is available. One patient is a 40-year-old ex-alcoholic who is now sober, the other is an 83-year-old man with dementia and the last is a 34-year-old woman with three children under the age of 10. Rank in these patients in the order of importance of who you think should receive the kidney and explain the reasoning behind your decision.
Author: Iqra Ali
Editor: Allegra Wisking
