Presumed Consent for Organ Donation: An Expert Interview With Francis L. Delmonico, MD

[Guest guest]

Presumed Consent for Organ Donation: An Expert Interview With Francis L.

Delmonico, MD

Laurie Barclay, MD

Feb. 19, 2004 — Editor's Note: Physicians in the U.K. are backing a plan in

which everyone would be considered an organ donor unless they specifically

opt out. Although legislation mandating this plan has not yet passed, the

plan is stimulating debate in Parliament and has won the favor of the

British Medical Association (BMA). Proponents of the " Organ Donation

(Presumed Consent and Safeguards) Bill " suggest this plan would increase the

number of donors and improve the current shortage of organs for

transplantation.

The need to increase the number of available donors is highlighted by the

critical organ shortage in the U.K., where 7,278 people were on the

transplant waiting list in late December 2003. Nearly half of relatives of

patients dying in intensive care units refuse permission for organ donation,

up from 30% ten years ago.

According to the BMA, research suggests that around 90% of the population

expresses a wish to be an organ donor after death, but only 19% are on the

U.K.'s National Health Service (NHS) Organ Donor Register. In the proposed

plan, this register would record the names of those who opt out of organ

donation. In Belgium, which has already adopted a similar plan, only 2% of

the population has opted out.

To learn more about the feasibility of such a plan in the U.S., Medscape's

Laurie Barclay interviewed Francis L. Delmonico, MD, a clinical professor of

surgery and transplant surgeon at Massachusetts General Hospital and Harvard

Medical School in Boston, and a member of the National Kidney Foundation's

Medical and Scientific Advisory Board.

Medscape: How critical is the present shortage of donor organs in the U.S.?

Dr. Delmonico: As the medical director of an organ bank, I wrestle with this

issue every single day: How can we improve the donation rate to greater than

50%? It's still in the 40% to 45% range. We're all aware of the problem. The

issue is whether the U.S. society would permit the presumption that the

individual can have his organs removed. I don't believe that can take place

now. As a society, we have a responsibility to encourage everyone to become

a donor if medically suitable.

Medscape: How can our society best encourage individuals to donate organs?

Dr. Delmonico: [Department of Health and Human Services Secretary] Tommy

is doing a great job of bringing this problem to national attention

and of launching an educational program in the schools. We need to get the

message across that organ donation is a good thing to do rather than being

ghoulish. We need to identify hesitations individuals might have about

donating, like religious bias or concern about disfigurement, and overcome

them. We need to determine why we are only achieving less than 50% consent

now.

Medscape: Would having a national registry improve the rate of organ

donation?

Dr. Delmonico: In this country there is a sensitivity to opting in or out,

so we could have registries which give everyone the option of saying yes or

no, realizing that some will say no. In Texas, for example, a plan was

presented in which there were possibilities of saying yes or no, and they in

effect shot themselves in the foot because people could say no.

Medscape: Would other plans to encourage organ donation be feasible in the

U.S.?

Dr. Delmonico: In this country there is a move by Metzger of the

United Network for Organ Sharing, by the Association of Organ Procurement

Organizations, and by similar organizations recommending or at least

considering organ donor designation. When people sign up for a donor card,

this should be their final testimony as to whether they want to be a donor.

Getting the card ought to represent the carefully designated intention of

wanting to be an organ donor. That decision should not be made as a snap

decision at the time of getting a driver's license. We need to have an

initiative to get people to sign up.

On balance, that initiative seems to be the extent of where we can go in

this country. There is no possibility of presumed consent here. In Rhode

Island, for example, where a presumed consent plan was suggested, a civil

liberties group said this would cause big trouble in the state of Rhode

Island. The notion that consent would be presumed caused great difficulty.

Medscape: How could we make the donor card carry more weight?

Dr. Delmonico: I don't envision an opt-out in this country — I don't see it

unfolding in any other dimension other than moving the donor card to the

position of designating a real intention of wanting to donate organs. That

card would then represent the final say-so, and the individual's wishes

would become the final decision-making.

The states should say that the donor card cannot be overcome by any

objections the donor's relatives might have. Right now, the family's wishes

take precedence over having a donor card. With the organ donor designation

plan, having a donor card would make a difference rather than being

irrelevant if the family objects to donation.

We're hopeful that organ donor designation will come to pass. If an

individual signs a donor card, this would be accepted as their intention,

and that intention could not be overcome by the objections of the

next-of-kin. We would present the family with our intention to carry out the

wishes of their relative, although of course this would have to be handled

with sensitivity.

Medscape: Why do you feel that an opt-out plan would not be feasible in the

U.S.?

Dr. Delmonico: The opt-out plan wouldn't work here because it would usurp

the consent of the individual to make a decision. Presumed consent is really

not consent at all, because the society takes the decision on itself. The

society can't presume to know the individual's wishes, so that presumption

doesn't equate with actual consent.

In this country we have a very guarded protection of the individual's

rights, especially as they pertain to someone at the time of death. We're

not promoting presumed consent because of that reality, but we're clearly in

the trenches to try to have the topic of organ donation brought forward to

young people, so that they view it as a social responsibility. When they go

to get their driver's license, they'll know what is at stake and will make a

better informed choice.

Reviewed by D. Vogin, MD

--------------------------------------------------------------------------------

Laurie Barclay, MD Freelance writer for Medscape Medical News

Medscape Medical News is edited by Deborah Flapan, assistant managing editor

of news at Medscape. Send press releases and comments to news@....

[Guest guest]

Presumed Consent for Organ Donation: An Expert Interview With Francis L.

Delmonico, MD

Laurie Barclay, MD

Feb. 19, 2004 — Editor's Note: Physicians in the U.K. are backing a plan in

which everyone would be considered an organ donor unless they specifically

opt out. Although legislation mandating this plan has not yet passed, the

plan is stimulating debate in Parliament and has won the favor of the

British Medical Association (BMA). Proponents of the " Organ Donation

(Presumed Consent and Safeguards) Bill " suggest this plan would increase the

number of donors and improve the current shortage of organs for

transplantation.

The need to increase the number of available donors is highlighted by the

critical organ shortage in the U.K., where 7,278 people were on the

transplant waiting list in late December 2003. Nearly half of relatives of

patients dying in intensive care units refuse permission for organ donation,

up from 30% ten years ago.

According to the BMA, research suggests that around 90% of the population

expresses a wish to be an organ donor after death, but only 19% are on the

U.K.'s National Health Service (NHS) Organ Donor Register. In the proposed

plan, this register would record the names of those who opt out of organ

donation. In Belgium, which has already adopted a similar plan, only 2% of

the population has opted out.

To learn more about the feasibility of such a plan in the U.S., Medscape's

Laurie Barclay interviewed Francis L. Delmonico, MD, a clinical professor of

surgery and transplant surgeon at Massachusetts General Hospital and Harvard

Medical School in Boston, and a member of the National Kidney Foundation's

Medical and Scientific Advisory Board.

Medscape: How critical is the present shortage of donor organs in the U.S.?

Dr. Delmonico: As the medical director of an organ bank, I wrestle with this

issue every single day: How can we improve the donation rate to greater than

50%? It's still in the 40% to 45% range. We're all aware of the problem. The

issue is whether the U.S. society would permit the presumption that the

individual can have his organs removed. I don't believe that can take place

now. As a society, we have a responsibility to encourage everyone to become

a donor if medically suitable.

Medscape: How can our society best encourage individuals to donate organs?

Dr. Delmonico: [Department of Health and Human Services Secretary] Tommy

is doing a great job of bringing this problem to national attention

and of launching an educational program in the schools. We need to get the

message across that organ donation is a good thing to do rather than being

ghoulish. We need to identify hesitations individuals might have about

donating, like religious bias or concern about disfigurement, and overcome

them. We need to determine why we are only achieving less than 50% consent

now.

Medscape: Would having a national registry improve the rate of organ

donation?

Dr. Delmonico: In this country there is a sensitivity to opting in or out,

so we could have registries which give everyone the option of saying yes or

no, realizing that some will say no. In Texas, for example, a plan was

presented in which there were possibilities of saying yes or no, and they in

effect shot themselves in the foot because people could say no.

Medscape: Would other plans to encourage organ donation be feasible in the

U.S.?

Dr. Delmonico: In this country there is a move by Metzger of the

United Network for Organ Sharing, by the Association of Organ Procurement

Organizations, and by similar organizations recommending or at least

considering organ donor designation. When people sign up for a donor card,

this should be their final testimony as to whether they want to be a donor.

Getting the card ought to represent the carefully designated intention of

wanting to be an organ donor. That decision should not be made as a snap

decision at the time of getting a driver's license. We need to have an

initiative to get people to sign up.

On balance, that initiative seems to be the extent of where we can go in

this country. There is no possibility of presumed consent here. In Rhode

Island, for example, where a presumed consent plan was suggested, a civil

liberties group said this would cause big trouble in the state of Rhode

Island. The notion that consent would be presumed caused great difficulty.

Medscape: How could we make the donor card carry more weight?

Dr. Delmonico: I don't envision an opt-out in this country — I don't see it

unfolding in any other dimension other than moving the donor card to the

position of designating a real intention of wanting to donate organs. That

card would then represent the final say-so, and the individual's wishes

would become the final decision-making.

The states should say that the donor card cannot be overcome by any

objections the donor's relatives might have. Right now, the family's wishes

take precedence over having a donor card. With the organ donor designation

plan, having a donor card would make a difference rather than being

irrelevant if the family objects to donation.

We're hopeful that organ donor designation will come to pass. If an

individual signs a donor card, this would be accepted as their intention,

and that intention could not be overcome by the objections of the

next-of-kin. We would present the family with our intention to carry out the

wishes of their relative, although of course this would have to be handled

with sensitivity.

Medscape: Why do you feel that an opt-out plan would not be feasible in the

U.S.?

Dr. Delmonico: The opt-out plan wouldn't work here because it would usurp

the consent of the individual to make a decision. Presumed consent is really

not consent at all, because the society takes the decision on itself. The

society can't presume to know the individual's wishes, so that presumption

doesn't equate with actual consent.

In this country we have a very guarded protection of the individual's

rights, especially as they pertain to someone at the time of death. We're

not promoting presumed consent because of that reality, but we're clearly in

the trenches to try to have the topic of organ donation brought forward to

young people, so that they view it as a social responsibility. When they go

to get their driver's license, they'll know what is at stake and will make a

better informed choice.

Reviewed by D. Vogin, MD

--------------------------------------------------------------------------------

Laurie Barclay, MD Freelance writer for Medscape Medical News

Medscape Medical News is edited by Deborah Flapan, assistant managing editor

of news at Medscape. Send press releases and comments to news@....

[Guest guest]

Presumed Consent for Organ Donation: An Expert Interview With Francis L.

Delmonico, MD

Laurie Barclay, MD

Feb. 19, 2004 — Editor's Note: Physicians in the U.K. are backing a plan in

which everyone would be considered an organ donor unless they specifically

opt out. Although legislation mandating this plan has not yet passed, the

plan is stimulating debate in Parliament and has won the favor of the

British Medical Association (BMA). Proponents of the " Organ Donation

(Presumed Consent and Safeguards) Bill " suggest this plan would increase the

number of donors and improve the current shortage of organs for

transplantation.

The need to increase the number of available donors is highlighted by the

critical organ shortage in the U.K., where 7,278 people were on the

transplant waiting list in late December 2003. Nearly half of relatives of

patients dying in intensive care units refuse permission for organ donation,

up from 30% ten years ago.

According to the BMA, research suggests that around 90% of the population

expresses a wish to be an organ donor after death, but only 19% are on the

U.K.'s National Health Service (NHS) Organ Donor Register. In the proposed

plan, this register would record the names of those who opt out of organ

donation. In Belgium, which has already adopted a similar plan, only 2% of

the population has opted out.

To learn more about the feasibility of such a plan in the U.S., Medscape's

Laurie Barclay interviewed Francis L. Delmonico, MD, a clinical professor of

surgery and transplant surgeon at Massachusetts General Hospital and Harvard

Medical School in Boston, and a member of the National Kidney Foundation's

Medical and Scientific Advisory Board.

Medscape: How critical is the present shortage of donor organs in the U.S.?

Dr. Delmonico: As the medical director of an organ bank, I wrestle with this

issue every single day: How can we improve the donation rate to greater than

50%? It's still in the 40% to 45% range. We're all aware of the problem. The

issue is whether the U.S. society would permit the presumption that the

individual can have his organs removed. I don't believe that can take place

now. As a society, we have a responsibility to encourage everyone to become

a donor if medically suitable.

Medscape: How can our society best encourage individuals to donate organs?

Dr. Delmonico: [Department of Health and Human Services Secretary] Tommy

is doing a great job of bringing this problem to national attention

and of launching an educational program in the schools. We need to get the

message across that organ donation is a good thing to do rather than being

ghoulish. We need to identify hesitations individuals might have about

donating, like religious bias or concern about disfigurement, and overcome

them. We need to determine why we are only achieving less than 50% consent

now.

Medscape: Would having a national registry improve the rate of organ

donation?

Dr. Delmonico: In this country there is a sensitivity to opting in or out,

so we could have registries which give everyone the option of saying yes or

no, realizing that some will say no. In Texas, for example, a plan was

presented in which there were possibilities of saying yes or no, and they in

effect shot themselves in the foot because people could say no.

Medscape: Would other plans to encourage organ donation be feasible in the

U.S.?

Dr. Delmonico: In this country there is a move by Metzger of the

United Network for Organ Sharing, by the Association of Organ Procurement

Organizations, and by similar organizations recommending or at least

considering organ donor designation. When people sign up for a donor card,

this should be their final testimony as to whether they want to be a donor.

Getting the card ought to represent the carefully designated intention of

wanting to be an organ donor. That decision should not be made as a snap

decision at the time of getting a driver's license. We need to have an

initiative to get people to sign up.

On balance, that initiative seems to be the extent of where we can go in

this country. There is no possibility of presumed consent here. In Rhode

Island, for example, where a presumed consent plan was suggested, a civil

liberties group said this would cause big trouble in the state of Rhode

Island. The notion that consent would be presumed caused great difficulty.

Medscape: How could we make the donor card carry more weight?

Dr. Delmonico: I don't envision an opt-out in this country — I don't see it

unfolding in any other dimension other than moving the donor card to the

position of designating a real intention of wanting to donate organs. That

card would then represent the final say-so, and the individual's wishes

would become the final decision-making.

The states should say that the donor card cannot be overcome by any

objections the donor's relatives might have. Right now, the family's wishes

take precedence over having a donor card. With the organ donor designation

plan, having a donor card would make a difference rather than being

irrelevant if the family objects to donation.

We're hopeful that organ donor designation will come to pass. If an

individual signs a donor card, this would be accepted as their intention,

and that intention could not be overcome by the objections of the

next-of-kin. We would present the family with our intention to carry out the

wishes of their relative, although of course this would have to be handled

with sensitivity.

Medscape: Why do you feel that an opt-out plan would not be feasible in the

U.S.?

Dr. Delmonico: The opt-out plan wouldn't work here because it would usurp

the consent of the individual to make a decision. Presumed consent is really

not consent at all, because the society takes the decision on itself. The

society can't presume to know the individual's wishes, so that presumption

doesn't equate with actual consent.

In this country we have a very guarded protection of the individual's

rights, especially as they pertain to someone at the time of death. We're

not promoting presumed consent because of that reality, but we're clearly in

the trenches to try to have the topic of organ donation brought forward to

young people, so that they view it as a social responsibility. When they go

to get their driver's license, they'll know what is at stake and will make a

better informed choice.

Reviewed by D. Vogin, MD

--------------------------------------------------------------------------------

Laurie Barclay, MD Freelance writer for Medscape Medical News

Medscape Medical News is edited by Deborah Flapan, assistant managing editor

of news at Medscape. Send press releases and comments to news@....

[Guest guest]

Presumed Consent for Organ Donation: An Expert Interview With Francis L.

Delmonico, MD

Laurie Barclay, MD

Feb. 19, 2004 — Editor's Note: Physicians in the U.K. are backing a plan in

which everyone would be considered an organ donor unless they specifically

opt out. Although legislation mandating this plan has not yet passed, the

plan is stimulating debate in Parliament and has won the favor of the

British Medical Association (BMA). Proponents of the " Organ Donation

(Presumed Consent and Safeguards) Bill " suggest this plan would increase the

number of donors and improve the current shortage of organs for

transplantation.

The need to increase the number of available donors is highlighted by the

critical organ shortage in the U.K., where 7,278 people were on the

transplant waiting list in late December 2003. Nearly half of relatives of

patients dying in intensive care units refuse permission for organ donation,

up from 30% ten years ago.

According to the BMA, research suggests that around 90% of the population

expresses a wish to be an organ donor after death, but only 19% are on the

U.K.'s National Health Service (NHS) Organ Donor Register. In the proposed

plan, this register would record the names of those who opt out of organ

donation. In Belgium, which has already adopted a similar plan, only 2% of

the population has opted out.

To learn more about the feasibility of such a plan in the U.S., Medscape's

Laurie Barclay interviewed Francis L. Delmonico, MD, a clinical professor of

surgery and transplant surgeon at Massachusetts General Hospital and Harvard

Medical School in Boston, and a member of the National Kidney Foundation's

Medical and Scientific Advisory Board.

Medscape: How critical is the present shortage of donor organs in the U.S.?

Dr. Delmonico: As the medical director of an organ bank, I wrestle with this

issue every single day: How can we improve the donation rate to greater than

50%? It's still in the 40% to 45% range. We're all aware of the problem. The

issue is whether the U.S. society would permit the presumption that the

individual can have his organs removed. I don't believe that can take place

now. As a society, we have a responsibility to encourage everyone to become

a donor if medically suitable.

Medscape: How can our society best encourage individuals to donate organs?

Dr. Delmonico: [Department of Health and Human Services Secretary] Tommy

is doing a great job of bringing this problem to national attention

and of launching an educational program in the schools. We need to get the

message across that organ donation is a good thing to do rather than being

ghoulish. We need to identify hesitations individuals might have about

donating, like religious bias or concern about disfigurement, and overcome

them. We need to determine why we are only achieving less than 50% consent

now.

Medscape: Would having a national registry improve the rate of organ

donation?

Dr. Delmonico: In this country there is a sensitivity to opting in or out,

so we could have registries which give everyone the option of saying yes or

no, realizing that some will say no. In Texas, for example, a plan was

presented in which there were possibilities of saying yes or no, and they in

effect shot themselves in the foot because people could say no.

Medscape: Would other plans to encourage organ donation be feasible in the

U.S.?

Dr. Delmonico: In this country there is a move by Metzger of the

United Network for Organ Sharing, by the Association of Organ Procurement

Organizations, and by similar organizations recommending or at least

considering organ donor designation. When people sign up for a donor card,

this should be their final testimony as to whether they want to be a donor.

Getting the card ought to represent the carefully designated intention of

wanting to be an organ donor. That decision should not be made as a snap

decision at the time of getting a driver's license. We need to have an

initiative to get people to sign up.

On balance, that initiative seems to be the extent of where we can go in

this country. There is no possibility of presumed consent here. In Rhode

Island, for example, where a presumed consent plan was suggested, a civil

liberties group said this would cause big trouble in the state of Rhode

Island. The notion that consent would be presumed caused great difficulty.

Medscape: How could we make the donor card carry more weight?

Dr. Delmonico: I don't envision an opt-out in this country — I don't see it

unfolding in any other dimension other than moving the donor card to the

position of designating a real intention of wanting to donate organs. That

card would then represent the final say-so, and the individual's wishes

would become the final decision-making.

The states should say that the donor card cannot be overcome by any

objections the donor's relatives might have. Right now, the family's wishes

take precedence over having a donor card. With the organ donor designation

plan, having a donor card would make a difference rather than being

irrelevant if the family objects to donation.

We're hopeful that organ donor designation will come to pass. If an

individual signs a donor card, this would be accepted as their intention,

and that intention could not be overcome by the objections of the

next-of-kin. We would present the family with our intention to carry out the

wishes of their relative, although of course this would have to be handled

with sensitivity.

Medscape: Why do you feel that an opt-out plan would not be feasible in the

U.S.?

Dr. Delmonico: The opt-out plan wouldn't work here because it would usurp

the consent of the individual to make a decision. Presumed consent is really

not consent at all, because the society takes the decision on itself. The

society can't presume to know the individual's wishes, so that presumption

doesn't equate with actual consent.

In this country we have a very guarded protection of the individual's

rights, especially as they pertain to someone at the time of death. We're

not promoting presumed consent because of that reality, but we're clearly in

the trenches to try to have the topic of organ donation brought forward to

young people, so that they view it as a social responsibility. When they go

to get their driver's license, they'll know what is at stake and will make a

better informed choice.

Reviewed by D. Vogin, MD

--------------------------------------------------------------------------------

Laurie Barclay, MD Freelance writer for Medscape Medical News

Medscape Medical News is edited by Deborah Flapan, assistant managing editor

of news at Medscape. Send press releases and comments to news@....