Have a heart

An opt-out policy is not the solution to Ireland’s lack of organ donors, writes Philippa White

There were roughly 30,000 deaths in Ireland last year. Take this number, halve it, halve it again and then continue to do so a number of times. This will not bring you even close to the number of organ donations that were made by deceased donors in the same year. Naturally, not all of these people were suitable candidates for organ donation, yet this does not mitigate the fact that in 2010 there were, incredibly, only 58 donations of organs in Ireland.

Last week was Organ Donor Awareness Week and in spite of the sense of optimism surrounding the campaign, no amount of enthusiasm could eclipse the abysmal statistics regarding organ donation in Ireland: 2010 saw the largest drop in donations having ever been recorded in the country; there are still 650 people in the country waiting for an organ transplant and there has been a sharp increase in the number of Irish people starting dialysis treatment in the last several years.

When the statistics are that bleak, inevitably one must pose the question: how can the situation be improved? An idea that has been toyed with in the past and has now resurfaced is that of an opt-out system of organ donation. Essentially, this means that everyone would automatically be registered as an organ donor and their consent would be presumed. So unless you went out of your way and specifically requested not to be part of the system, you would be an organ donor by default.

On the surface, the idea seems both sound and altruistic – what’s not to like about having more kidneys, hearts and livers available for people who are in dire need of them? Only a minority, and dare I say a rather eccentric one, would be averse to the idea of saving more lives due to the greater supply of transplants.

Moreover, not only would it be altruistic but logical, as more organ donations are blatantly needed. The current system appears to restrict and impede our attempts to acquire the maximum amount of organs. Firstly, opt-in systems of organ donation forces one to think and even plan one’s own death, which is not something most people find easy to do. Equally, even if one is already a registered organ donor in Ireland, a next-of-kin can still refuse to allow donation after the registered donor has died.

Therefore, it seems that an opt-out system might be the solution for which we are looking.  However, on closer inspection, it becomes patent that such a policy is in fact ineffective.

An obvious case in point is the Spanish system. Spain has the highest rate of organ donation in Europe. In 1979, Spain decided to change its laws and incorporated an opt-out system where every citizen’s consent to donate their organs was presumed. Alas, there was no significant jump in organ donations that year. Amazingly, there was no significant jump in the following ten years. Suddenly in 1989 however, there was a dramatic rise in organ donation rates. The cause of this turn of events was unrelated to the new opt-out system, however.

New members of staff were being employed in Spanish hospitals. The new staff consisted of organ donor coordinators, whose sole task entailed procuring organs from deceased patients, a task which was formerly that of the doctors. The results were staggering then and to this day, Spain remains an outlier in terms of organ donations rates.

There is much to be learnt from all of this as we dissect and examine our flawed system. Like Spain prior to 1989, it is the job of intensive care unit (ICU) doctors in Ireland to choose suitable organ donors from their deceased patients. In this demanding environment, these doctors are often too preoccupied with their living patients to pay much attention to the added burden of finding suitable candidates to donate their organs, as well as getting permission from emotional relatives.

Even if Ireland did adopt the opt-out system and everyone’s consent was presumed, it is unlikely that anything would change. The doctors working in ICU would still focus on their chief task – keeping people alive – and not on assessing potential organ donors.

As a result of our system shifting too large a responsibility on to the ICU doctors, there is a gross disparity between the number of potentially willing organ donors and those who are actually chosen to donate at the time of death. Indeed, Ireland has one of the highest proportions of registered organ donors in Europe. Therefore, the issue lies in bridging this chasm between the number of people who are willing to donate and the number of people who actually donate.

In brief, from additional hospital staff to more human hearts and livers, there are many things needed to improve the current situation in Ireland. An opt-out system, however, is not one of them.