Bioethics in Faith and Practice, Volume 3, Number 1

Bioethics in Faith and Practice ⦁ 2017 ⦁ Volume 3 ⦁ Number 1 13 One important note at this point is that some object to the interchangeable use of the terms ‘presumed consent’ and ‘opt out.’ For example, T.M. Wilkinson, a political philosopher from the University of Auckland, argues that presumed consent implies the justification of non-explicit consent, while failure to opt out could instead be due to indecision or apathy. 19 This paper will use the terms interchangeably, although the ethical implications of the difference will be discussed later on. Impact of Presumed Consent Before diving into the analysis of an opt out system for organ donation based on principlist medical ethics, it is worth considering an appeal to an ethic of pragmatism. In other words, it is important to know whether or not changing to this policy would actually increase the number of organ donors in the United States. If not, maybe the ethical debate is a waste of time. Common sense would argue that since 95% support organ donation, apathy is the most obvious reason only 51% are registered. If that is the case, requiring that action be taken to be a non-donor rather than requiring a positive step to become a donor would in theory push the donor rate up near 95%. However, there could be other explanations for a lack of registration in those who support donation, such as support for the practice in general without personally being comfortable with having organs removed, fear of reduced effort on the part of medical personnel to save a donor, or the desire to default to what family members think is best. Public opinion of an opt out system would also likely impact its success, as very low approval could provoke backlash. In 2012, the US Department of Health and Human Services inquired about presumed consent in their national survey of organ donation attitudes and behaviors. They found that 51.1% either supported or strongly supported a change to presumed consent, which was up nearly 10% from their 2005 data . 20 This number is unfortunately difficult to apply to an estimated effect of enacting presumed consent. If the majority of the 46.6% of people who opposed or strongly opposed presumed consent were already registered donors, changing the system could cause some of them to change their minds on principle, but if most of the people opposed were not already registered donors, changing the policy would probably have little effect . 21 Either way, with public opinion near 50/50, it is difficult to use it as an evaluative tool. The best way to predict the results of implementing presumed consent would seemingly be to look at countries that have implemented it, compare the number of donors in that country before and after the change, and compare the numbers in that country to other countries that use explicit consent. One such study utilizes a panel of 13 presumed consent and 9 explicit consent countries to make a comparison . 22 While the straight comparison does not yield significant results, other factors must be noted. For example, commonly held religious beliefs in a certain region would likely impact donation rates, whether in a positive or negative way. Additionally, the rates of death by motor vehicle accident and cerebro-vascular diseases also vary by region and greatly impact the number of potential donors available. Controlling for these and other factors results in the statistically significant conclusion that cadaveric donation rates are 25–30% higher on average in presumed consent countries. 23 A more recent meta-analysis focuses on five studies comparing donation rates before and after the introduction of presumed consent and four studies comparing donation rates in countries with presumed consent versus explicit consent . 24 All of the before and after studies showed an increase in the number of donors; however, the authors note that these studies do not account well for other factors such as simultaneous infrastructure changes and increased publicity. Similarly, all of the comparison studies showed correlation between presumed consent and higher organ donation rates, three of which exhibited statistical significance. Again, the authors of the meta-analysis note that significant correlations also exist between higher donation rates and factors such as higher healthcare expenditure, high rates of Catholicism, and common law rather than civil law. The authors ultimately conclude that presumed consent is associated with higher donor rates, but it cannot be inferred that a change would lead to increased rates for every country.