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Organ donation: balancing patient duties and public health

Ethical considerations to weigh when broaching the issue of organ donation

From the June ACP Observer, copyright 2006 by the American College of Physicians.

By Deborah Gesensway

When it comes to organ donation, physicians must balance their primary duty to serve their patients with a secondary responsibility to promote public health, according to an Annual Session panel. But how do they pull off that balancing act?

Internists can start by explaining to patients that after they die, their body belongs to their beneficiaries, usually family, explained Virginia L. Hood, FACP, of Burlington, Vt., a member of ACP’s Board of Regents. That's why it is critical to write living wills, draft health care powers-of-attorney and other forms of advance directives—including signed organ donor cards—to ensure that others follow their wishes about medical care when they are alive and organ donation after they die.

“If your family doesn’t agree,” Dr. Hood pointed out, “you will not be an organ donor.”

It's also up to physicians to remind family members that they have the right to say “no” to a request for organ donation if it is not right for them, she said during the panel presentation on ethical challenges surrounding organ donation.

However, it's not physicians' job to talk to family members about organ donation after a patient has died. Telling a family that their loved one has just died and then quickly asking for permission to harvest the newly deceased’s organs can raise potential conflict-of-interest questions in people’s minds.

“The ethical conflict is that donating organs is really an issue of social justice,” Dr. Hood explained, “and in our interchange with our patients, we are not primarily concerned about social justice, but about the immediate needs of the individual we are caring for.”

Instead, physicians need to call in a local organ procurement organization that has workers trained in legal issues and in how to talk to families about this delicate subject. Organ procurement agencies have more success in gaining a family’s permission for organ donation.

“It may seem awkward sometimes,” said David C. Dale, FACP, of Seattle, ACP’s President-Elect and another panel member, “but it’s good to call in the expert.” Panelists pointed out that nearly 27,000 Americans received organ transplants in 2004. About 90,000 people in the U.S. are now waiting for organ transplants, mostly kidney and liver, followed by lung and heart.

Relieving concerns

Doctors also have a big role in addressing some common patient concerns about organ donation. Those include:

Myth: Patients who are designated organ donors won’t get the same care.

Fact: Physicians need to assure patients that dying organ donors will receive as much potentially life-saving medical care as those who have not declared their wish to donate organs.

Myth: Transplant teams decide who's "brain dead."

Fact: In reality, usually two physicians not connected with the case in any way and with no conflicts of interest make the determination of brain death. Physicians also should be prepared to explain how someone who is still breathing can be "brain dead."

Myth: Someone is going to make money from the organ donation.

Fact: Patients should know that in the U.S., as in most other countries, it is illegal for anyone to benefit financially from organ donation. Although there is the occasional news story about illegal trafficking in live organs, approved transplant units are forbidden from using any organ that doesn’t go through the Organ Procurement and Transplantation Network. Organ sales for transplant have been illegal in the United States since 1984 and many other countries have similar statutes.

Although there is some debate over whether paying for organs could increase the number of organs available for transplant, Dr. Dale said the experience of paying blood donors has had just the opposite result: donation rates went down. (ACP has endorsed recently introduced federal legislation that would create tax credits for living organ donors—but the incentive pertains only to indirect costs of transplantation, such as lost wages from time missed from work and transportation expenses.)

Myth: Hospitals can take people’s organs despite their wishes.

Fact: Some countries, mostly in Europe, have passed laws allowing “presumed consent”—but not the U.S. or Canada. Presumed consent allows hospitals to assume patients are organ donors unless they have “opted out” before their death.

Dr. Hood said she has found that some patients and families are also concerned that their organs will go to non-Americans.

While that is true, she said, it also is fair because foreign visitors who die in the U.S. donate organs to Americans. Although non-resident aliens here can receive American organs, they must wait on the transplant lists just like everyone else. According to the Department of Health and Human Services, non-resident aliens accounted for only about 1% of the more than 20,000 transplants performed annually between 1995 and 2002.

Deborah Gesensway is a freelance health care writer in Toronto.

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.

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