Coursework: Should England Change to an “Opt-Out” Organ Donation System? (February 2014)

In February 2014, for my GCSE English language coursework, I chose to discuss whether England should change to an opt-out organ donation system.

I decided to write my article for a predominantly adult audience who hadn’t given much thought to the topic beforehand, but to whom the issue of organ donation would apply. Therefore, I wrote in a formal style, but refrained from using complicated scientific terms, in order to give the reader a deep understanding of the topic and the arguments for and against an “opt-out” system. Moreover, where possible, I backed up my arguments with carefully chosen relevant statistics and quotes that gave my work credibility. I sought to make my article informative and unbiased, presenting the salient arguments for and against an “opt-out” system succinctly before coming to a clear judgement in the conclusion.

Here is a copy of it (footnotes removed for reasons of layout):

Should England Change to an “Opt-Out” Organ Donation System?

Currently, the whole of the UK operates an “opt-in” organ donation system, whereby only people who have explicitly given consent are able to donate their organs. However, this will all change. On 10 September 2013, the Human Transplantation Wales Act received Royal Assent, meaning an “opt-out” system will come into place on 1 December 2015. This means that anyone who hasn’t refused to donate their organs is automatically a donor. This is a hugely controversial move, sparking both praise and uproar alike from the UK: although many have commended it, it is also criticised by a great proportion of the UK. This change of system is a very contentious move, as it brings with it a plethora of social, political and ethical complications. However, more people on the donor list sequentially leads to more organ transplant, and thus more lives saved.

The first salient point to consider is the impact an “opt-out” system would have on the rates of organ donation. In the vast majority of cases, an “opt-out” system does dramatically increase the rate of organ donation; this is coined the default effect. Take Austria and Germany, for example, two countries of similar economic development and culture. Whilst Germany, which employs an “opt-in” system, has a consent rate of 12%, Austria, with an “opt-out” system, has a rate of 99.98%. This is a dramatic difference between the two countries, and suggests that an “opt-out organ donor system ‘would increase transplants’”. In a broadened sense, Neto et al., 2007, explored data from thirty-four countries over five years and concluded that countries with “opt-out” systems had 21 to 26% higher organ donation rates than their counterparts with “opt-in” systems. This equates to 2.7 to 6.14 more donors per million population.

Of course, the huge advantage of an “opt-out” system is that far fewer people die whilst waiting for a suitable organ donor. At present, around 400 people per year die whilst on the organ transplant waiting list. Sheila Bird from the Medical Research Council Biostatistics Unit in Cambridge and John Harris from the Institute for Science, Ethics and Innovation in Manchester argued that had there been an opt-out system in place during the last ten years then there would have been an extra 2,880 organs available for transplantation. Moreover, Professors Bird and Harris – writing in the BMJ – said that an “opt-out” system “should ultimately cut costs, add life, and save bereaved families from . . . deliberation”. Consequently, the NHS would potentially save much money, as fewer people would need to spend less time in hospital, on dialysis machines for instance, and so more money could be used instead to improve the health system. In turn, this would lead to fewer deaths and a more efficient health system, and so the domino effect continues ad infinitum.

Furthermore, the gulf between the number of organs available and the number of people awaiting an organ transplant is extending, due to an insufficient supply of donor organs. The organ donation transplant waiting list is growing by around 8% per annum, and this is likely to be exacerbated by the ageing population and increasing prevalence of type 2 diabetes. This argues that a new organ donation system is required, “and fast”. In addition, an “opt-out” policy could reduce, and possibly get rid of, the black market where organs are sold illegally. This is because there would be fewer people desperately needing an organ transplant, due to an insufficient organ pool, and so they would not need to resort to the black market.

However, on the other hand, high rates of consent do not necessarily convert into high organ donation rates, due to a number of important factors. In soft “opt-out” systems, such as that in place in Australia, the family members of the donor are required to make a final judgement as to whether the donor’s organs will be donated; they may veto or approve the proposed donation. For instance, the USA with an “opt-in” system has 25.97 donors per million population, whereas Austria, who use an “opt-out” system, have a rate of 21 people per million population. This illustrates that organ donation rates depend on a vast number of other factors as well as consent rates. Despite Spain’s prodigious organ donation rates – 33.4 per million population – Dr Rafael Matesanz, president of the Spanish National Transplant Organisation, explicitly states it’s “not likely” that Spain’s success was a consequence of their “opt-out” system. He underlines the point that a number of elements have to be right to achieve an increase in organ donation rates, such as optimum medical infrastructure and educating young people about the issues to do with organ donation in the school curriculum.

Moreover, in his interview, Dr Barry Morgan made reference to Chile as an example of an opt-out system failing and decreasing organ donation rates. Having switched to an “opt-out” system, organ donation rates in Chile fell from 6.5 per million population in 2009 to 5.4 in 2010, and a 29% decrease from 2010 to 2016. In this circumstance, the “opt-out” system had a detrimental and deleterious effect on donation rates, as a result of both family refusals and a greater hostility towards organ donation. From this one can infer that different counties and communities will have conflicting attitudes towards an “opt-out” system, and whilst some will be obliged to be a donor, others may be opposed to it.

One fear of a potential “opt-out” system is that people such as the elderly or those who don’t have access to a computer won’t be able to register an objection to donating their organs. Most people find it very difficult to discuss their death. Unless someone either carries a donor card or has registered with the ODR, the family may not be aware of their views when they die. This could result in a sense of ambiguity, leading to unnecessary anguish and distress for the family. The family may struggle to make the “right” decision at a time of immense pressure and distress, and instead assume the “safest” course of action is to refuse organ donation. A central political complication is whether an “opt-out” system would increase or reduce autonomy. Opposition to an “opt-out” system could argue that the decision is being removed from the hands of the people, and instead the government is taking and using the donors’ organs without their permission or consent. Some may assert that an “opt-out” system “could imply that our bodies are owned by the state”.

Barry Morgan, Archbishop of Wales, describes the “opt-out” system as “no kind of consent”; he says that it relies on the basis of “taking rather than gifting”. Currently, the “opt-in” system is dependent on altruism, making every organ a “gift”. However, an “opt-out” policy could nullify the sense of generosity associated with organ donation at the moment. “Giving something as precious as an organ is a deeply personal matter” that could be negated by an “opt-out” system, almost rendering organs worthless.

To conclude, England should not change its organ donation system to an “opt-out” system. This is because there have been a number of countries in which an “opt-out” system has had a negative effect on organ donation rates: with the huge demand for donations, it is not worth running the risk of decreasing the number of donors. Furthermore, the “opt-out” system raises a number of controversial issues such as autonomy and consent. However, in England, more should be done to increase the organ donation rate without turning the current system on its head. This includes investing more money in better medical infrastructure and raising awareness about the issue, whether being education in school or adverts on television. Although it is arguable that an “opt-out organ donor system ‘would increase transplants’”, the potential “ethics and implications” of it are too grave.

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