Printer Friendly
The Free Library
22,728,043 articles and books

Presumed consent for organ procurement--does it have a future in the U.S.? (Ethical-Legal Perspectives).



The gap between numbers of organ donors and numbers of patients awaiting organ transplant organ transplant: see transplantation, medical.  grows larger every year. Based on Organ Procurement and Transplantation Network (OPTN OPTN Organ Procurement and Transplantation Network
OPTN Operationalizing and Professionalizing the Network
OPTN Option
) data as of June 30, 2002, the United Network for Organ Sharing United Network for Organ Sharing See UNOS.  (UNOS UNOS United Network for Organ Sharing Transplant surgery A database dedicated to optimizing the use of transplantable organs; according to UNOS statistics–1995, ± 20,000 major organs and tissues are transplanted/yr; since successful survival of ) reported that there were 80,076 names on the national patient waiting list for organ transplant. According to according to
prep.
1. As stated or indicated by; on the authority of: according to historians.

2. In keeping with: according to instructions.

3.
 OPTN data as of August 3, 2001, 5,984 cadaveric ca·dav·er  
n.
A dead body, especially one intended for dissection.



[Middle English, from Latin cad
 donors were recovered and more than 17,000 transplants from cadaveric donors were performed for the year 2000. Technological advances such as hemodialysis, cardiac assist devices, and improved pharmaceuticals have enabled people to live longer lives, but many on the waiting list still die from eventual organ failure.

One alternative for increasing the pool of potential organs is the policy of presumed consent presumed consent Transplantation The assumption that a particular action would have been approved by a person or party if permission had been sought. See Cadaveric organ transplantation, Mandated choice, Organ brokerage, Transplantation. Cf Informed consent. . Healthcare providers and ethicists continue to debate the pros and cons of such a policy change (Caplan, 1983; Cohen cohen
 or kohen

(Hebrew: “priest”) Jewish priest descended from Zadok (a descendant of Aaron), priest at the First Temple of Jerusalem. The biblical priesthood was hereditary and male.
, 1992; Dukeminier & Sanders, 1968; Erin & Harris, 1999; Moustarah, 1998; Sadler, 1992; Veatch & Pitt, 1995). What are the lessons learned from countries and states that have implemented forms of presumed consent legislation? In this article circumstances of presumed consent are explored and the implications of a policy change for neuroscience practitioners caring for potential donor patients are discussed.

Background

The Uniform Anatomical Gift Act (UAGA) of 1968 passed in 1971 in all 50 states and the District of Columbia District of Columbia, federal district (2000 pop. 572,059, a 5.7% decrease in population since the 1990 census), 69 sq mi (179 sq km), on the east bank of the Potomac River, coextensive with the city of Washington, D.C. (the capital of the United States). . It addressed various issues related to organ donation Organ donation is the removal of the tissues of the human body from a person who has recently died, or from a living donor, for the purpose of transplanting or grafting them into other persons. . UAGA sought to answer such questions as who might make legal gifts of one's body or body parts, what are the rights of next of kin The blood relatives entitled by law to inherit the property of a person who dies without leaving a valid will, although the term is sometimes interpreted to include a relationship existing by reason of marriage. Cross-references

Descent and Distribution.
 in setting aside a decedent's wishes, what are the mechanisms for making one's wishes known, and how might gifts be revoked by a donor while alive (Harris & Alcorn, 2001).

Despite a 1983 Gallup survey indicating a predominant willingness by the public to donate their organs after death (Cohen, 1992), there remained a substantial gap between those who stated their willingness and those who actually signed a donor card donor card
n.
A card, usually carried on one's person, authorizing the use of one's bodily organs for transplantation in the event of one's death.
 (Caplan, 1983). Even fewer had discussed their wishes with family members, close friends, or doctors or made note in their wills. Of those who knew about organ donation, 75% said they would give permission to donate their child's kidneys if the child was in a fatal accident, but only 25% said they would give permission to donate their own kidneys after death (Caplan).

The National Organ Transplant Act (NOTA) of 1984 endeavored to make donation more efficient and effective (Harris & Alcorn, 2001). It established OPTN within the U.S. Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979
Health and Human Services, HHS
 (DHHS DHHS Department of Health & Human Services (US government)
DHHS Dana Hills High School (Dana Point, California)
DHHS Deaf and Hard of Hearing Services
DHHS Deaf and Hard of Hearing Services
) as a coordinating body among regional organ procurement organizations (OPOs). NOTA prohibited the purchase or sale of human organs.

In the UAGA of 1987, legislation mandated hospitals to establish request policies to qualify for Medicare reimbursement; healthcare providers were required to request consent from families of eligible organ donors. The Joint Commission on Accreditation of Health Care Organizations will not accredit To give official authorization or status. To recognize as having sufficient academic standards to qualify graduates for higher education or for professional practice. In International Law:  a hospital unless it has a required request policy in place. After CPOs and transplant advocacy groups spearheaded intensive educational programs to increase the public's knowledge about organ and tissue donation, a more recent survey in 1993 indicated that 75% of Americans were willing to donate an organ after death (Siminoff, Arnold, Caplan, Virnig, & Seltzer, 1995). Despite increased public support, however, these policies and programs, which were designed to address the benefits and impact of organ donation, have failed to increase the supply of organs for transplantation.

In a chart review of more than 10,000 cases at 23 hospitals, Siminoff et al. (1995) found that 81% of healthcare professionals correctly identified potential organ donors and donor families were approached in 73% of the eligible cases, yet only 47% of the families agreed to organ donation. The authors recommended educating healthcare professionals to improve their communication skills with potential donor families, because talking about donation during a family's acute grief period was uncomfortable for many healthcare professionals.

DHHS regulations concerning conditions of participation for hospitals regarding organ, tissue, and eye procurement (DHHS, 1998) stipulated that only individuals trained in requesting organ and tissue donation be allowed to make these requests. Representatives of the private OPOs that are charged with all cadaveric organ cadaveric organ Transplant surgery An organ transplanted after its owner's death. See Harvesting, Mandated choice, Presumed consent.  and tissue procurement within their specified catchment area catchment area or drainage basin, area drained by a stream or other body of water. The limits of a given catchment area are the heights of land—often called drainage divides, or watersheds—separating it from neighboring drainage  are assumed to have been trained in the consent process for organ donation.

Wendler and Dickert (2001) conducted a telephone survey of all 61 active OPOs in 1999 about their consent practices for organ procurement. They found "significant divergence" in practices (p. 332). When surveyed about their organizational practice in different scenarios, an equal "number of OPOs (19) follow[ed] the deceased's wishes as follow[ed] the wishes of the next of kin" (p. 332). Wendler and Dickert concluded that the dissimilar practices were attributable primarily to inherent ethical differences. For instance, one group may believe that following the deceased's wishes reduces the emotional effect on the family and the other group believes that it increases the effect on the family.

The current consent process, in which healthcare providers obtain express consent from a donor's recorded wishes or from family, has failed to supply the number of cadaveric organs needed to save the lives of many patients with end-stage organ disease. Is a fundamental change in public policy called for, and which alternative is the best?

Strategies to Increase the Organ Supply

Since the first successful kidney transplant kidney transplant
 or renal transplant

Replacement of a diseased or damaged kidney with one from a living relative or a legally dead donor. The former's tissue type is more likely to match, reducing the chance of rejection; but removal puts the donor at risk,
 in 1954, one of the focal points of the transplant community has been increasing the organ supply through various procurement methods. The potential reasons for the current shortage of organs in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area.  are (a) failure to identify potential donors, (b) refusal to donate, either by potential donors or families, and (c) failure to request donation (Spital & Erin, 2002). Current procurement proposals, which seek to address these concerns, include options of express donation, presumed consent through opting out, presumed consent through conscription conscription, compulsory enrollment of personnel for service in the armed forces. Obligatory service in the armed forces has existed since ancient times in many cultures, including the samurai in Japan, warriors in the Aztec Empire, citizen militiamen in ancient , mandated choice mandated choice Transplantation A mechanism suggested by the AMA's Council on Ethical and Judicial Affairs to ↑ number of cadaveric organs available for transplantation; in MC, a person would be required to choose–to donate or not while registering for a , compensation, and an organ market.

Express Donation

The process currently used in the United States to obtain organs for transplantation relies on express or voluntary donation or consent. The principles of informed consent and encouraged voluntarism voluntarism

Metaphysical or psychological system that assigns a more predominant role to the will (Latin, voluntas) than to the intellect. Christian philosophers who have been described as voluntarist include St. Augustine, John Duns Scotus, and Blaise Pascal.
 formed the basis for the UAGA of 1968 (Sadler & Sadler, 1984). According to Sadler and Sadler, who consulted in the drafting of UAGA,
   The law is doing well what it
   was intended to do: providing
   a clear mechanism for individuals
   and next-of-kin to consent
   to organ and tissue donation
   for humanitarian purposes. It
   was designed to strike a socially
   acceptable balance that facilitates
   organ donation and
   procurement without infringing
   upon other deeply held
   values and rights. (p. 6)


The advantage of express donation is that individuals or families are able to state unequivocally their wishes about organ and tissue donation. The disadvantage is that this policy has failed to procure needed organs for transplantation. Although many people agree in principle with organ donation, they may not take the necessary steps to complete paperwork or discuss the issue with their family or doctor (Caplan, 1983).

Presumed Consent

Two versions of presumed consent policies exist: opting out and conscription. Opting out policies assume that all people consent to be organ donors upon their death unless they or their families specifically refuse or "opt out" of donation (Davis, 1999). A discussion of the logistics and ethics of adopting this option follows in the next section.

The most inflexible form of presumed consent is the idea of conscription of cadaveric organs. "All usable organs would be removed from recently deceased people and made available for transplantation; consent would be neither required nor requested and, with the possible exception of people with religious objections, opting-out would not be possible" (Spital & Erin, 2002, p. 612). Advantages are seen as obtaining cadaveric organs more efficiently; applying a simpler, less costly process to organ procurement; removing the discomfort of making requests and time delays in locating next of kin; and addressing the ethical principle of distributive justice DISTRIBUTIVE JUSTICE. That virtue, whose object it is to distribute rewards and punishments to every one according to his merits or demerits. Tr. of Eq. 3; Lepage, El. du Dr. ch. 1, art. 3, Sec. 2 1 Toull. n. 7, note. See Justice.  (Spital & Erin). This proposal is unlikely to be accepted by the American public because of apparent infringements on individual autonomy and lack of respect for the wishes of families or religious beliefs.

Mandated Choice

Mandated choice, also referred to as required or routine response, would allow people to "have the opportunity to indicate a willingness or objection to donation ... [and] the option to delegate the donation decision to his or her next of kin or designated surrogate" (Presumed Consent Subcommittee, Ethics Committee ethics committee A multidisciplinary hospital body composed of a broad spectrum of personnel–eg, physicians, nurses, social workers, priests, and others, which addresses the moral and ethical issues within the hospital. See DNR, Institutional review board. , UNOS, 1993, p. 9). Using a document that most adults would ordinarily complete, such as a driver's license application or renewal or an income tax return, people would be required to consent or object to donation prior to their death.

Advocates claim that mandated choice respects individual autonomy and might prove to be a bridging mechanism to presumed consent. They suggest that the emergence of a societal consensus on transplant donation may evolve through a policy of mandated choice (Presumed Consent Subcommittee, Ethics Committee, UNOS, 1993). Successful implementation would require that an informed, educated public understand the intent and significance of organ donation (Futterman, 1995).

Organ Donation Compensation

The 1984 NOTA made it illegal to sell any human organ for transplantation. Most Americans disapprove of payments to donors' families for organs, but the majority of people favor "some form of financial or non-financial compensation in an effort to increase the number of organs for donation" (Garcia, 1997, p. 3257). Compensation might take the form of preferred status for the donor or a relative in the event they should need a transplant or reimbursement for hospital or funeral expenses.

A more economically based approach would be to develop an organ market or make direct financial payments for donated organs. Opponents to any form of compensation object because of fears that donors might be killed or allowed to die earlier than necessary or that the poor might be exploited (Childress, 1989). However, because public opinion does not support sales of organs and physicians remain opposed to organ markets, compensation is unlikely to become public policy.

Harris and Alcorn (2001) proposed consideration of a regulated posthumous post·hu·mous  
adj.
1. Occurring or continuing after one's death: a posthumous award.

2. Published after the writer's death: a posthumous book.

3.
 organ market with "direct and indirect financial encouragement ... structured to avoid abuses, and to reserve altruism as a central motive" (p. 232). Contracts might have safeguards prohibiting relatives from selling a decedent's organs without prior consent, to be based on performance or the actual recovery of fit organs, not just promises to donate organs, exempting minors from participation, or offering bonuses for healthier lifestyles. Distribution of organs would remain under the current OPO structure.

Study of the Options

Economists Barnett and Kaserman (1993) explored six proposed organ procurement systems in the literature and evaluated them to determine the best policy. They used criteria based on the "impacts of the alternative policies on the principal stakeholders": transplant recipients, potential and actual organ donors and their families, taxpayers or other payers of transplants, and physicians or other caregivers (p. 119). Without using ethical considerations, they ranked each policy "in terms of its overall relative desirability" (p. 129). Including physicians' preferences, Barnett and Kaserman found, in terms of societal benefits or yielding the greatest number of organs for transplantation, that conscription and organ markets ranked first and second; presumed consent and express donation tied for last. They determined that mandated choice, organ markets, compensation, and express donation would be ethically acceptable because these policies would not violate any of Childress's moral and ethical principles: respect for persons, beneficence beneficence (b·neˑ·fi·s , nonmaleficence, and justice.

Presumed Consent Policy for Organ Procurement

Conceptual Framework For the concept in aesthetics and art criticism, see .

A conceptual framework is used in research to outline possible courses of action or to present a preferred approach to a system analysis project.
 

Having identified failure to obtain consent as a key factor in the organ shortage organ shortage Transplantation The gap between the number of organs transplanted and number needed. See UNOS. Cf Organ brokerage. , the transplant community has exerted efforts on putting policies in place that will improve the consent rate. As noted in the previous section, two versions of presumed consent policy, conscription and opting out, exist. Conscription of all usable organs from cadavers, without regard to the wishes of the deceased or family members is the stronger variation. The weaker policy of presumed consent, and the focus of this article, requires that individuals opt out of organ donation. As public policy, it
   would offer every adult the
   opportunity to express and
   have recorded by publicly
   accountable authorities his or
   her refusal to be a donor of
   solid organs and tissues. A
   clinically and legally indicated
   candidate for cadaveric
   organ and tissue recovery is
   presumed to have consented
   to organ and tissue recovery if
   he or she had not registered a
   refutal [sic]. (Presumed Consent
   Subcommittee, 1993, p.1)


Advocates (Caplan, 1983; Dukeminier & Sanders, 1968; Kennedy et al., 1998; Moustarah, 1998) claimed that a presumed consent public policy would increase the number of cadaveric organs available for transplant. It would make the donation process a routine event when an adult dies. It would respect individual autonomy. It would decrease the stress placed on requesters who must approach grief-stricken families for their consent under current policy. It would diminish the emotional pressures on bereaved families to make decisions about donation. Dukeminier and Sanders asserted that the "burden of action" would shift from healthcare providers "to the dead donor or his next of kin" (p. 418).

Opponents (Sadler, 1992; Sadler & Sadler, 1984; Veatch & Pitt, 1995) to the policy of presumed consent argued that it would not increase the number of available organs. According to U.S. surveys, less than 40% of the public, and less than 7% in another survey, support a presumed consent system (Veatch & Pitt). It would remove freedom of choice from individuals. Establishing a central registry to record objections would be problematic. It would place a burden on the individual to register his or her refusal. It would require access to the system with changes in next of kin through marriage, divorce, and death, and add a step to the organ procurement process to verify objections (Sadler & Sadler, 1984). Education would be paramount to ensure that all individuals understand the shift in policy. It would require guaranteed legal immunity for healthcare providers who act in good faith and need to be applied across state lines (Sadler, 1992).

International Policies Based on Presumed Consent

Most European nations, as well as some South American countries, Israel, and Singapore (Harris & Alcorn, 2001), have implemented public policy based A decision made by any software application that is based on the policy (rules and regulations) of the organization. See policy and COPS.  on presumed consent. To date, however, no English-speaking nation has adopted a policy of presumed consent regarding organ procurement (Stuart, Veith, & Cranford, 1981).

The laws of the different countries vary on how organs are recovered from the deceased who has not expressed a wish during his or her lifetime (Kennedy et al., 1998). In Norway, organs are removed after relatives are informed of the intent, regardless of their consent, with the exception of the nearest relative. The Italians remove organs only after ensuring the family does not object.

In Austria, organs are removed regardless of the relatives' attitudes after the physician ascertains there is no refusal in the patient's medical records. This policy has led to better rates of kidney procurement than in the United States and most other European nations, but Austria's rates of procurement for other solid organs have not improved (Harris & Alcorn, 2001).

In France, after checking medical records, physicians consult with family members to determine whether the deceased had declared a refusal. In practice, physicians then inquire about the wishes of the next of kin. This policy has essentially turned the employment of presumed consent into a voluntary donation system controlled by the family (Harris & Alcorn, 2001). The policy has had little effect in meeting the country's needs for organs.

The Belgian government passed legislation in 1986 based on presumed consent to procure organs (Roels et al., 1991). Roels et al. reported there was a significant increase in the number of cadaveric kidneys, hearts, and livers available for transplant in the 3 years following enactment of the law. Compared to Austria, another country with presumed consent policy, and to the Netherlands and ER. Germany, both with opting-in policies, they found "that only in the two countries with a presumed consent legislation, [had] multi-organ harvesting increased substantially" (p. 904).

Belgian citizens who wish to opt out of donation may do so at the local town hall. Doctors are still encouraged to contact relatives in all cases, but less than 10% of families object, compared with 20%-30% in other European countries (First, 2001). In a study of objectors to donation, Roels, Deschoolmeester, and Vanrenterghem (1997) found that the cumulative registry of objectors over the initial 8 years of the presumed consent law comprised 1.75% native Belgians and 3.23% foreigners (residing for more than 6 months in the country). Objection rates were highest for minors younger than 14 years, and higher among children of foreigners than natives, and significantly more females of all ages than males objected.

In 1997, Brazil passed a presumed consent law despite opposition from medical organizations, only to repeal the law 1 1/2 years later (Csillag, 1997, 1998). After passage of the law, surgeons continued to ask families for consent prior to removing organs. In October 1998, the law was amended to avoid conflict between the legal mandate and practice policy to require family permission, essentially negating "presumed consent." The implementation of a national registry for transplant recipients failed, and many people feared their organs might be removed precipitously and rushed to register themselves as objectors (Csillag, 1998).

State Policies Based on Presumed Consent

A number of states have enacted legislation based on the weaker "opting out" version of presumed consent. State laws differ in the circumstances in which removal of organs may occur.

Texas, in 1991, was the first state to allow "retrieval of organs without explicit consent, albeit in limited circumstances" (Presumed Consent Subcommittee, 1993, p. 4). If a decedent's next of kin could not be found in a reasonable time, the law allowed removal of organs. When next of kin were contacted, relatives' wishes were respected unless the potential donor had indicated a donation preference in his or her lifetime. If the potential donor was older than 18 years and had indicated a desire to be an organ donor organ donor Transplantation A person/cadaver that donates his/her  organ(s) to a recipient  on the driver's license, the law supported honoring the donor's wishes without the consent of any other individual. Since that time, the Texas law has been changed to require next-of-kin consent even if a clearly documented advance directive Advance Directive

A document expressing a person's wishes about critical care when he or she is unable to decide for him or herself. However, it does not authorize anyone to act on a person's behalf or make decisions the way a power of attorney would.
 exists (The Lewin Group, 2000).

Legislative proposals followed in Maryland and Pennsylvania in 1993 (Veatch & Pitt, 1995). In Maryland, the bill would have allowed presumed consent for cases in which a decedent An individual who has died. The term literally means "one who is dying," but it is commonly used in the law to denote one who has died, particularly someone who has recently passed away.  had not opted out. It was defeated, as was a previous version of the law. In Pennsylvania, the proposed act would permit removal of organs and tissues unless the potential donor had refused.

According to the Presumed Consent Subcommittee (1993), the above proposals had similar characteristics using the language of presumed consent. For example, unless the potential donor had expressed an objection to donation, he or she was presumed to have wanted to donate. Next-of-kin objection to donation overrides the potential donor's presumed consent, if said donor had not expressed an objection. The potential donor's recorded preference for donation prevails over the objections of next of kin. Reasonable efforts must be made to contact next of kin.

Reportedly, since then, 10 states have enacted legislation that recognizes a signed driver's license as an advance directive and provides protection "to OPOs, hospitals, and tissue and eye banks when carrying out individuals' advance directives without further consent" (The Lewin Group, 2000). Pennsylvania also has initiated a pilot program that offers $300 toward funeral expenses as an incentive to donate (First, 2001). Will efforts like these lead individuals from making voluntary, humanitarian decisions or donations to making forced, mercenary mercenary

Hired professional soldier who fights for any state or nation without regard to political principles. From the earliest days of organized warfare, governments supplemented their military forces with mercenaries.
 decisions? Or does presumed consent imply a belief in community generosity?

Ethical Considerations

Scientists and ethicists debate the moral and ethical correctness of the presumed consent concept. Childress (1989) wrote a definitive piece analyzing, from an ethical perspective, various policies on organ procurement "in light of moral principles already embedded in U.S. institutions, laws, policies, and practices" (p. 87). These "embedded moral principles are respect for persons, including their autonomous choices and actions; beneficence, ... nonmaleficence, ... and justice" (p. 88). In addition, there are different views about whether human body parts are property and who has rights to use, possess, dispose, or change possession of this property.

Childress (1989) stated that to find presumed consent ethically acceptable one must view the individual's or family's wishes as "tacit consent Noun 1. tacit consent - (law) tacit approval of someone's wrongdoing
secret approval, connivance

commendation, approval - a message expressing a favorable opinion; "words of approval seldom passed his lips"
," silently or passively expressed "by omissions or by failures to indicate or signify dissent" (p. 96). He argued that this silence may only mean one lacks an understanding of the process or does not know how to register a dissent. In terms of ethical preferability, presumed consent relies on passive altruism, but does not rule out active altruism.

Veatch and Pitt (1995) spoke to the core relationship of the individual to society regarding presumed consent. Specifically, "in liberal Western society certain rights are attributed to the individual ... medical treatment is acceptable only with the consent of the individual or the individual's appropriate surrogate" (p. 1890). If one sees organ procurement as giving, as evidenced by words like "donor," presumed consent can be valid. If one sees organ procurement as taking, society will be asserting its rights over the individual without his or her permission.

Erin and Harris (1999) argued for presumed consent because they "believe it is the right thing to do because ... it is in the best interests of those patients in need of an organ, and that not to remove these organs would be to harm those patients" (p. 365). They agreed that the presumption of consent directly contradicts the principle of respect for individual autonomy. However, "if we are to presume anything, we should presume that people would wish to do the morally right thing" that is, to make cadaver cadaver /ca·dav·er/ (kah-dav´er) a dead body; generally applied to a human body preserved for anatomical study.cadav´ericcadav´erous

ca·dav·er
n.
 organs "available for life-saving or life-enhancing use" (p. 366).

Other advocates (Caplan, 1983; Cohen, 1992; Kennedy et al., 1998; Moustarah, 1998) followed similar lines of reasoning. Presumed consent policies will uphold the principle of beneficence; saving lives is good. Cohen (1992) wrote that consent or refusal may be required to opt in or opt out of donation, but a presumption must be made with the burden falling "upon those for whom the presumption made is incorrect" (p. 2172).

Although there is no consensus that presumed consent policies are ethically or morally correct or even more effective in procuring organs, all parties agreed that certain measures must be in place if a transition is made from a public policy of expressed to presumed consent for organ procurement.

Effect of Enacting a Public Policy of Presumed Consent

Changing national policy from opting in to opting out of organ donation would require societal changes in attitude of both healthcare providers and the public. Technically, policy change would require the formation of a central registry, an efficient means for individuals to register their objections, and a consistent, reliable method of accessing, entering, updating, and respecting this data (Futterman, 1995). It would necessitate a massive public education program about organ procurement and the new program requirements.

Opponents of presumed consent argue that there is no mechanism in place to consolidate and safeguard objections to donation and that this could be a cumbersome nightmare to achieve. Proponents of presumed consent refute this stance. The United States has large databanks in place for various other nationally required programs such as income tax, Social Security, and the selective service system. Surely with technological capabilities and assistance from countries with effective registry programs in place, these technical difficulties could be overcome (Moustarah, 1998).

Many states currently do not have databases of individuals who have indicated their willingness to be donors. Of the states that do maintain registries, most of these programs involve driver's license/motor vehicle departments and some state health departments, but round-the-clock access is rare (The Lewin Group, 2000).

State legislative efforts on organ procurement vary. Is a national consensus possible? Singapore enacted presumed consent policy for kidney procurement in 1987. Their plan of action was twofold, using presumed and voluntary consent. Muslims were "automatically considered objectors ... on religious grounds" under the presumed consent policy but, "they could voluntarily pledge" by signing a donor card (Teo, 1991, p. 10). Despite ethical questions, the government made "very laudable laud·a·ble
adj.
Healthy; favorable.
 efforts to make its presumed consent policy ethically defensible" by supporting public knowledge prior to passage of the law (p. 13). They conducted extensive media programs, had well-publicized public and parliamentary discussions, and sponsored public awareness programs and hearings.

Perhaps the greatest hurdle to enacting a presumed consent policy in the United States is the ethical debate. Presumed consent belies the American value of respect for individualism. Diversity in age, culture, education, and economics, and individual responses to bereavement Bereavement Definition

Bereavement refers to the period of mourning and grief following the death of a beloved person or animal. The English word bereavement
 must be considered is making such a dramatic change in organ procurement policy (Futterman, 1995). How will healthcare providers be affected if a presumed consent policy is established?

Implications for Healthcare Professionals

As any bedside nurse, advanced practice nurse, physician, or therapist recognizes, knowledge of a particular healthcare issue and personal insight into one's own knowledge, beliefs, and values about that issue are key to communicating effectively with patients and families. When presumed consent policies are debated in the healthcare or public venues, practitioners have the opportunity to explore their own values and beliefs and make decisions about how to interact with families and patients who may be potential donors or recipients of organs. If a policy transition were to occur, providers would need extensive self-education before educating the public.

It is essential that professionals in the neuroscience, trauma, or critical care domains understand the concepts of brain death and the procedure for procurement of organs for transplantation. If public education campaigns have been successful, in the event of a policy change, families should come to expect the routine recovery of any usable organs from their deceased family member. However, support for the grieving family should be available as well as resources to explain the procurement process if any questions arise.

For professionals in family or primary care, it would be important to understand the changes in process and laws on registering objections to organ donation. Patients may ask questions about the technicalities, their medical care, or the morality of presumed consent. Practitioners may need to learn more about advance directives and become more comfortable addressing the issues of death and dying.

For professionals in organ transplantation The transfer of organs such as the kidneys, heart, or liver from one body to another.

The transplantation of human organs has become a common medical procedure. Typical organs transplanted are the kidneys, heart, liver, pancreas, cornea, skin, bones, and lungs.
, the implementation of a presumed consent policy may improve their patients' chances of receiving a life-enhancing or lifesaving transplant. Practitioners may encounter these individuals when they are discovering they need a transplant, during the evaluation and selection as a transplant candidate, during the waiting period, or after the transplant. Until an increase in available organs becomes more apparent, practitioners need to continue to support the physical and emotional needs of these patients.

Summary

Policies of presumed consent to procure organs for transplantation have stimulated discussion of success/failure in increasing organ availability, technical pitfalls, and ethical dilemmas. The presumption of consent has made inroads inroads
Noun, pl

make inroads into to start affecting or reducing: my gambling has made great inroads into my savings

inroads npl to make inroads into [+
 in public policy internationally and influenced some state policies. A policy of presumed consent remains unlikely in the face of American attitudes of freedom of choice and respect for individual autonomy but healthcare providers need to be aware of potential policy changes and how these changes may affect their practices.

References

Barnett, A., & Kaserman, D. (1993). The shortage of organs for transplantation: Exploring the alternatives. Issues in Law & Medicine, 9(2), 117-137.

Caplan, A. (1983). Organ transplants: The costs of success. Hastings Center The Hastings Center, founded in 1969, is an independent, nonpartisan, non-profit bioethics research institute dedicated to examination of essential questions in health care, biotechnology, and the environment.  Report, 13(6), 23-32.

Childress, J.F. (1989). Ethical criteria for procuring and distributing organs for transplantation. Journal of Health Politics, Policy and Law, 14(1), 87-113.

Cohen, C. (1992). The case of presumed consent to transplant human organs after death. Transplantation Proceedings, 24, 2168-2172.

Csillag, C. (1997). Brazil's law on organ donation passed. Lancet, 349, 482.

Csillag, C. (1998). Brazil abolishes "presumed consent" in organ donation. Lancet, 352, 1367.

Davis, R. (1999). Meeting the demand for donor organs in the U.S. British Medical Journal The British Medical Journal, or BMJ, is one of the most popular and widely-read peer-reviewed general medical journals in the world.[2] It is published by the BMJ Publishing Group Ltd (owned by the British Medical Association), whose other , 319, 1382-1383.

Department of Health and Human Services Standards and Certification Conditions of Participation for Hospitals: Organ, Tissue, and Eye Procurement, 42 C.F.R. [section] 482.45 (1998).

Dukeminier, J., & Sanders, D. (1968). Organ transplantation: A proposal for routine salvaging of cadaver organs. New England Journal of Medicine The New England Journal of Medicine (New Engl J Med or NEJM) is an English-language peer-reviewed medical journal published by the Massachusetts Medical Society. It is one of the most popular and widely-read peer-reviewed general medical journals in the world. , 279, 413-419.

Erin, C., & Harris, J. (1999). Presumed consent or contracting out. Journal of Medical Ethics medical ethics The moral construct focused on the medical issues of individual Pts and medical practitioners. See Baby Doe, Brouphy, Conran, Jefferson, Kevorkian, Quinlan, Roe v Wade, Webster decision. , 25, 365-366.

First, M. (2001). The organ shortage and allocation issues. Transplantation Proceedings, 33, 806-810.

Futterman, L. (1995). Presumed consent: The solution to the critical organ critical organ
n.
The organ or physiological system that would first be subjected to radiation in excess of the maximum permissible amount as the dose of a radioactive material is increased.
 donor shortage? American Journal of Critical Care, 4, 383-388.

Garcia, V.D. (1997). Financial and legislative issues. Transplantation Proceedings, 29, 3256-3257.

Harris, C., & Alcorn, S. (2001). To solve a deadly shortage: Economic incentives for human organ donation. Issues in Law and Medicine, 16, 213-233.

Kennedy, I., Sells, R., Daar, A., Guttmann, R., Hoffenberg, R., Lock, M., et al. (1998). The case for "presumed consent" in organ donation. Lancet, 351, 1650-1652.

Moustarah, F. (1998). Organ procurement: Let's presume consent. Canadian Medical Association Journal The Canadian Medical Association Journal (CMAJ) is a general medical journal that is published biweekly by the Canadian Medical Association (CMA).

It is considered to be one of the top six general medical journals; the others being the
, 158, 231-234.

Presumed Consent Subcommittee, Ethics Committee, UNOS. (1993, June). An evaluation of the ethics of presumed consent and a proposal based on required response. Richmond, VA: Author.

Roels, L., Deschoolmeester, G., & Vanrenterghem, Y. (1997). A profile of people objecting to organ donation in a country with presumed consent law: Data from the Belgian national registry. Transplantation Proceedings, 29, 1473-1475.

Roels, L., Vanrenterghem, Y., Waer, M., Christiaens, M., Gruwez, J., & Michielsen, P. (1991). Three years of experience with a 'presumed consent' legislation in Belgium: Its impact on multi-organ donation in comparison with other European countries. Transplantation Proceedings, 23, 903-904.

Sadler, A.M., & Sadler, B.L. (1984). A community of givers, not takers. Hastings Center Report, 14(5), 6-9.

Sadler, B.L. (1992). Presumed consent to organ transplantation: A different perspective. Transplantation Proceedings, 24, 2173-2174.

Siminoff, L., Arnold, R., Caplan, A., Vernig, B., & Seltzer, D. (1995) Public policy governing organ and tissue procurement in the United States. Annals of Internal Medicine Annals of Internal Medicine (Ann Intern Med) is an academic medical journal published by the American College of Physicians (ACP). It publishes research articles and reviews in the area of internal medicine. Its current editor is Harold C. Sox. , 123, 10-17.

Spital, A., & Erin, C. (2002). Conscription of cadaveric organs for transplantation: Let's at least talk about it. American Journal of Kidney Diseases, 39, 611-615.

Stuart, F., Veith, E, & Cranford, R. (1981). Brain death laws and patterns of consent to remove organs for transplantation from cadavers in the United States and 28 different countries. Transplantation, 31, 238-244.

Teo, B. (1991). Organs for transplantation: The Singapore experience. Hastings Center Report, 21(6), 10-13.

The Lewin Group, Inc., for the Office of the Assistant Secretary for Planning and Evaluation. (2000, January 4). Analysis of state actions regarding donor registries. Retrieved April 5, 2002, from http://aspe.hhs.gov/health/orgdonor/stat e%20organ%20donor%20registries.htm

Veatch, R., & Pitt, J. (1995). The myth of presumed consent: Ethical problems in new organ procurement strategies. Transplantation Proceedings, 27, 1888-1892.

Wendler, D., & Dickert, N. (2001). The consent process for cadaveric organ procurement: How does it work? How can it be improved? Journal of the American Medical Association JAMA: The Journal of the American Medical Association is an international peer-reviewed general medical journal, published 48 times per year by the American Medical Association. JAMA is the most widely circulated medical journal in the world. , 285, 329-333.

Questions or comments about this article may be directed to: Carol J. Roberts, MSN (1) (MicroSoft Network) A family of Internet-based services from Microsoft, which includes a search engine, e-mail (Hotmail), instant messaging (Windows Live Messaging) and a general-purpose portal with news, information and shopping (MSN Directory).  RN CCRN CCRN Critical Care Registered Nurse
CCRN Certification In Critical Care Nursing
, by phone at 804/828-9244 or by e-mail at cjrobert@hsc.vcu.edu. She is a clinical nurse IV in the neuroscience intensive care unit at VCU Health System, MCV MCV mean corpuscular volume.

MCV
abbr.
mean corpuscular volume


Mean corpuscular volume (MCV)
A measure of the average volume of a red blood cell.
 Hospitals and Physicians, Richmond, VA.
COPYRIGHT 2003 American Association of Neuroscience Nurses
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2003 Gale, Cengage Learning. All rights reserved.

 Reader Opinion

Title:

Comment:



 

Article Details
Printer friendly Cite/link Email Feedback
Title Annotation:neuroscience nursing research
Author:Roberts, Carol J.
Publication:Journal of Neuroscience Nursing
Geographic Code:1USA
Date:Apr 1, 2003
Words:5207
Previous Article:Longitudinal analysis of illness uncertainty, coping, hopefulness, and mood during participation in a clinical drug trial.
Next Article:Neuroprotection for ischemic stroke. (Pharmacology Update).
Topics:



Related Articles
Organ procurement: various legal systems and their effectiveness.
Frist, Durbin transplant bills would remove financial disincentives for live donation, create donor medal.
AMA board to review changing US donor system to presumed consent.
British government rejects recommendation to change current consent system for organ donation.
Legal solutions to Ontario's organ shortage: redrawing the boundaries of consent.
Finding the winning combination: how blending organ procurement systems used internationally can reduce the organ shortage.
DAILY POST YOUR VOICE IN WALES: Law change would mean new hope for so many.
You get what you pay for? Rethinking U.S. organ procurement policy in light of foreign models.

Terms of use | Copyright © 2014 Farlex, Inc. | Feedback | For webmasters