Impact Ethics

Organs

Play video (above): The Body Economy: Organ Donation in the Marketplace

Overview

Organ donation and transplantation refers to the practice of removing an organ (or part of an organ) from one person’s body and transferring it to the body of another individual.

There are a wide range of individuals who require donor organs, including cancer patients, individuals with kidney or liver failure, and individuals with heart and lung diseases. At the end of 2017, there were approximately 4,300 individuals in need of donated organs in Canada; and other countries face similar significant organ shortages (a helpful overview of organ donation rates).

There are more people who need organs than donors who are able to supply organs.  Only 1.2% of all annual deaths in Canada involve individuals who could potentially be organ donors, and not all of these individuals become donors.

The organ shortage is a complex challenge. Factors contributing to the organ shortage include: the number of people surviving long enough to need organ transplants; the number of possible organ transplants that can be done; the ability to coordinate (with effective communication and efficient logistics) the transfer of organs between donors and recipients; the number of people who consent to be organ donors (living or after death), which in turn is related to public awareness and education surrounding donation; and the widespread practice of respecting families’ wishes even if they contradict an individual’s expressed desire to be an organ donor.

Individuals who want to donate their organs must fulfil specific medical and demographic requirements; and of course, some organs can only be donated after an individual has passed away. Around the world, there is legislation in place to manage organ donation, facilitate organ dispersal, and address instances of organ trafficking. Living organ donors, often but not always genetic relatives, are matched with a recipient and provide consent for their donation throughout the donation process. This means they can withdraw consent at any point. However, for organ donation that occurs after an individual has passed away, a different system of consent must be used. There are several ways to obtain consent for deceased organ donation, but the two main options are:

Opt-in organ donation (explicit consent):

In an ‘opt-in’ system, only two groups of individuals will be considered for organ donation after death: individuals who have registered their willingness to donate their organs after their death, and individuals who have not registered a desire to donate/not donate, but whose next of kin consent to the donation once the individual in question is no longer capable of consent. In this system, organ donors (or their next of kin) must explicitly agree to donation. Leading practices in opt-in systems involve initiating discussion about donation with potential donors and their families prior to death occurring.

Opt-out organ donation (presumed consent):

In an ‘opt-out’ system, all individuals are presumed to have consented to organ donation following death (and will thus be considered for organ donation), unless they have officially registered their desire not to be an organ donor. Different countries have different limitations on the category of ‘all individuals’. For example, most countries restrict the category by age and mental capacity. Other countries allow the deceased’s next-of-kin to opt-out at the time of death. In this system, individuals (or their next of kin) must have explicitly registered that they do not want to become organ donors, otherwise they will be considered candidates for organ donation.

At the present time, all provinces in Canada operate under an opt-in system, based on the need for explicit consent prior to death. However, in 2019, Nova Scotia became the first province to introduce an opt-out system to take effect sometime in 2020—The Human Organ and Tissue Donation Act.

The local context

Concerns about the Canadian organ donor shortage date back to 1999, when the House of Commons Standing Committee on Health and the National Coordinating Committee on Organ and Tissue Donation, Distribution and Transplantation each published a report acknowledging the growing demand for organs and tissues for transplantation and the increasing shortage of donors.

Since then a variety of initiatives have been launched to manage organ donation and reduce the shortage of donors. In 2001, the Government of Canada announced the creation of the Canadian Council for Donation and Transplantation which was developed to help coordinate donation. In 2009, Canadian Blood Services successfully conducted kidney transplants based on the Living Donor Pair Exchange—a donor and transplant recipient registry aiming to optimise the use of kidneys from living donors.

In 2012 the National Organ Waitlist (NOW), a real-time online listing of Canadians awaiting all organs other than kidneys was launched. NOW was developed to help transplantation programmes identify the most critical transplant needs and provide information about wait times and availability. These initiatives have all been introduced in an attempt to decrease the organ shortage. Notably these initiatives have focussed on making existing systems more effective, and addressing some aspects of the donor organ shortage.

Recently in Nova Scotia, an alternative approach has been introduced to increase rates of organ donation.  It involves legislating an opt-out system that will come into effect “on such day the Governor in Council orders and declares by proclamation.” Meanwhile, all other provinces in Canada continue to operate under an opt-in system, based on the need for explicit consent prior to death. The opt-out system introduced in Nova Scotia means that individuals will be automatically considered for organ donation after death, unless they specifically indicate that they do not want to become organ donors. This policy is not applicable to individuals under the age of 19 or those without decision-making capacity. In those instances, a parent, guardian or other legal decision maker can consent to organ donation after the death of the individual involved.

The introduction of an opt-out policy has proved controversial. There are two common critiques of this system: Firstly, it was introduced without widespread public awareness, discussion and debate, leaving several people to wonder about the politics of the move from explicit consent to presumed consent. Secondly, the policy is considered to be a radical step, when other, more measured approaches that better respect autonomy could be implemented and might be more effective. For example, with the current opt-out system, individuals have to complete a paper form and return it to the Nova Scotia health department. Something as simple as introducing an online registry could potentially increase the number of organ donors – this would better respect patient autonomy.

Alternative solutions

Although introducing an opt-out system is one possible approach to the organ shortage; there are a variety of alternative methods that could be pursued:

  • Prioritising prevention and proper management of conditions that damage organs (for example: diabetes) could reduce the demand for donor organs.
  • Improving communication and transport links could better ensure that all potential donor organs are matched and delivered to recipients in the most efficient way.
  • Revisiting the role of families and loved ones with regard to an individual’s previously prior consent to organ donation could be undertaken with a view to prohibiting or minimizing family override.
  • Increasing public awareness and education could increase the number of individuals who register as organ donors.
  • Introducing mandatory declaration (mandated choice)—a system whereby individuals are required to indicate whether they want to donate organs after their death—could be another strategy for increasing the number of individuals who register as organ donors.
  • Changing the language on organ donation consent forms (including “nudges”) might be effective in helping people consider organ donation a worthy cause they would like to support.
  • Maximising the identification of potential donors by identifying imminent deaths or brain deaths and approaching family members about organ donation (required request) could increase the number of organ donors. In some instances, this might involve mandatory referral, which requires all health care professionals to report brain deaths, imminent deaths, and possibly cardiac deaths to organ procurement organisations.

Given the number of factors that contribute to shortages of donor organs, it is likely that increasing organ donation rates in Canada will involve implementing several of these solutions.

Useful links

https://hillnotes.ca/2018/01/23/consent-for-organ-donation-in-canada/ 

https://lop.parl.ca/sites/PublicWebsite/default/en_CA/ResearchPublications/201813E 

https://www.academia.edu/12511992/Policy_Alternatives_Organ_Donation_in_Nova_Scotia 

https://nslegislature.ca/legc/bills/63rd_2nd/3rd_read/b133.htm 

Page last updated Fall 2020.

Select Impact Ethics Blogs

Select Journal Articles

  • Samia, H. (2015). The ethics of selling body parts. In J.-D.  Rainhorn & S. Boudamoussi (Eds.), New Cannibal Markets: Globalization and Commodification of the Human Body (pp.47-56). Paris: Maison des sciences de l’homme.
  • Satz, D. (2015). Ethical issues in the supply and demand of human kidneys. In H. Kuhse, U. Schücklenk & P. Singer (Eds.), Bioethics: An Anthology, 3rd ed. (pp.425-436). London: Wiley Blackwell. 
  • Radcliffe-Richards, J., Daar, A.S., Guttmann, R.D., Hoffenberg, R., Kennedy, I., Lock, M., Sells, R.A., Tilney, N., and for the International Forum for Transplant Ethics (2015). The case for allowing kidney sales. In H. Kuhse, U. Schücklenk & P. Singer (Eds.), Bioethics: An Anthology, 3rd ed. (pp.425-436). London: Wiley Blackwell.

Overview

Play video (above): The Body Economy: Organ Donation in the Marketplace

Overview

Organ donation and transplantation refers to the practice of removing an organ (or part of an organ) from one person’s body and transferring it to the body of another individual.

There are a wide range of individuals who require donor organs, including cancer patients, individuals with kidney or liver failure, and individuals with heart and lung diseases. At the end of 2017, there were approximately 4,300 individuals in need of donated organs in Canada; and other countries face similar significant organ shortages (a helpful overview of organ donation rates).

There are more people who need organs than donors who are able to supply organs.  Only 1.2% of all annual deaths in Canada involve individuals who could potentially be organ donors, and not all of these individuals become donors.

The organ shortage is a complex challenge. Factors contributing to the organ shortage include: the number of people surviving long enough to need organ transplants; the number of possible organ transplants that can be done; the ability to coordinate (with effective communication and efficient logistics) the transfer of organs between donors and recipients; the number of people who consent to be organ donors (living or after death), which in turn is related to public awareness and education surrounding donation; and the widespread practice of respecting families’ wishes even if they contradict an individual’s expressed desire to be an organ donor.

Individuals who want to donate their organs must fulfil specific medical and demographic requirements; and of course, some organs can only be donated after an individual has passed away. Around the world, there is legislation in place to manage organ donation, facilitate organ dispersal, and address instances of organ trafficking. Living organ donors, often but not always genetic relatives, are matched with a recipient and provide consent for their donation throughout the donation process. This means they can withdraw consent at any point. However, for organ donation that occurs after an individual has passed away, a different system of consent must be used. There are several ways to obtain consent for deceased organ donation, but the two main options are:

Opt-in organ donation (explicit consent):

In an ‘opt-in’ system, only two groups of individuals will be considered for organ donation after death: individuals who have registered their willingness to donate their organs after their death, and individuals who have not registered a desire to donate/not donate, but whose next of kin consent to the donation once the individual in question is no longer capable of consent. In this system, organ donors (or their next of kin) must explicitly agree to donation. Leading practices in opt-in systems involve initiating discussion about donation with potential donors and their families prior to death occurring.

Opt-out organ donation (presumed consent):

In an ‘opt-out’ system, all individuals are presumed to have consented to organ donation following death (and will thus be considered for organ donation), unless they have officially registered their desire not to be an organ donor. Different countries have different limitations on the category of ‘all individuals’. For example, most countries restrict the category by age and mental capacity. Other countries allow the deceased’s next-of-kin to opt-out at the time of death. In this system, individuals (or their next of kin) must have explicitly registered that they do not want to become organ donors, otherwise they will be considered candidates for organ donation.

At the present time, all provinces in Canada operate under an opt-in system, based on the need for explicit consent prior to death. However, in 2019, Nova Scotia became the first province to introduce an opt-out system to take effect sometime in 2020—The Human Organ and Tissue Donation Act.

The local context

Concerns about the Canadian organ donor shortage date back to 1999, when the House of Commons Standing Committee on Health and the National Coordinating Committee on Organ and Tissue Donation, Distribution and Transplantation each published a report acknowledging the growing demand for organs and tissues for transplantation and the increasing shortage of donors.

Since then a variety of initiatives have been launched to manage organ donation and reduce the shortage of donors. In 2001, the Government of Canada announced the creation of the Canadian Council for Donation and Transplantation which was developed to help coordinate donation. In 2009, Canadian Blood Services successfully conducted kidney transplants based on the Living Donor Pair Exchange—a donor and transplant recipient registry aiming to optimise the use of kidneys from living donors.

In 2012 the National Organ Waitlist (NOW), a real-time online listing of Canadians awaiting all organs other than kidneys was launched. NOW was developed to help transplantation programmes identify the most critical transplant needs and provide information about wait times and availability. These initiatives have all been introduced in an attempt to decrease the organ shortage. Notably these initiatives have focussed on making existing systems more effective, and addressing some aspects of the donor organ shortage.

Recently in Nova Scotia, an alternative approach has been introduced to increase rates of organ donation.  It involves legislating an opt-out system that will come into effect “on such day the Governor in Council orders and declares by proclamation.” Meanwhile, all other provinces in Canada continue to operate under an opt-in system, based on the need for explicit consent prior to death. The opt-out system introduced in Nova Scotia means that individuals will be automatically considered for organ donation after death, unless they specifically indicate that they do not want to become organ donors. This policy is not applicable to individuals under the age of 19 or those without decision-making capacity. In those instances, a parent, guardian or other legal decision maker can consent to organ donation after the death of the individual involved.

The introduction of an opt-out policy has proved controversial. There are two common critiques of this system: Firstly, it was introduced without widespread public awareness, discussion and debate, leaving several people to wonder about the politics of the move from explicit consent to presumed consent. Secondly, the policy is considered to be a radical step, when other, more measured approaches that better respect autonomy could be implemented and might be more effective. For example, with the current opt-out system, individuals have to complete a paper form and return it to the Nova Scotia health department. Something as simple as introducing an online registry could potentially increase the number of organ donors – this would better respect patient autonomy.

Alternative solutions

Although introducing an opt-out system is one possible approach to the organ shortage; there are a variety of alternative methods that could be pursued:

  • Prioritising prevention and proper management of conditions that damage organs (for example: diabetes) could reduce the demand for donor organs.
  • Improving communication and transport links could better ensure that all potential donor organs are matched and delivered to recipients in the most efficient way.
  • Revisiting the role of families and loved ones with regard to an individual’s previously prior consent to organ donation could be undertaken with a view to prohibiting or minimizing family override.
  • Increasing public awareness and education could increase the number of individuals who register as organ donors.
  • Introducing mandatory declaration (mandated choice)—a system whereby individuals are required to indicate whether they want to donate organs after their death—could be another strategy for increasing the number of individuals who register as organ donors.
  • Changing the language on organ donation consent forms (including “nudges”) might be effective in helping people consider organ donation a worthy cause they would like to support.
  • Maximising the identification of potential donors by identifying imminent deaths or brain deaths and approaching family members about organ donation (required request) could increase the number of organ donors. In some instances, this might involve mandatory referral, which requires all health care professionals to report brain deaths, imminent deaths, and possibly cardiac deaths to organ procurement organisations.

Given the number of factors that contribute to shortages of donor organs, it is likely that increasing organ donation rates in Canada will involve implementing several of these solutions.

Useful links

https://hillnotes.ca/2018/01/23/consent-for-organ-donation-in-canada/ 

https://lop.parl.ca/sites/PublicWebsite/default/en_CA/ResearchPublications/201813E 

https://www.academia.edu/12511992/Policy_Alternatives_Organ_Donation_in_Nova_Scotia 

https://nslegislature.ca/legc/bills/63rd_2nd/3rd_read/b133.htm 

Page last updated Fall 2020.

Media Articles

Further Reading

Select Impact Ethics Blogs

Select Journal Articles

  • Samia, H. (2015). The ethics of selling body parts. In J.-D.  Rainhorn & S. Boudamoussi (Eds.), New Cannibal Markets: Globalization and Commodification of the Human Body (pp.47-56). Paris: Maison des sciences de l’homme.
  • Satz, D. (2015). Ethical issues in the supply and demand of human kidneys. In H. Kuhse, U. Schücklenk & P. Singer (Eds.), Bioethics: An Anthology, 3rd ed. (pp.425-436). London: Wiley Blackwell. 
  • Radcliffe-Richards, J., Daar, A.S., Guttmann, R.D., Hoffenberg, R., Kennedy, I., Lock, M., Sells, R.A., Tilney, N., and for the International Forum for Transplant Ethics (2015). The case for allowing kidney sales. In H. Kuhse, U. Schücklenk & P. Singer (Eds.), Bioethics: An Anthology, 3rd ed. (pp.425-436). London: Wiley Blackwell.