The Big Question: Should hospitals have an automatic right to use our organs when we die?

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Why are we asking this now?

Yesterday the Government accepted a report from a group of expert medical advisers which recommended against Britain adopting an "opt-out" system of organ donation, to boost transplant rates. Although widely trailed in advance, the decision is a surprise because an opt-out system has received vigorous backing from the Prime Minister, Gordon Brown, and the Chief Medical officer, Sir Liam Donaldson, as well as other organisations such as the British Medical Association.

What is an 'opt-out' system?

Under an opt-out system, there would be a presumption that a person's organs would be available for transplant after their death, unless they had registered an objection while still alive, or their relatives objected. Under the current "opt-in" system, the public are encouraged to indicate their willingness to donate their organs after death by adding their names to the UK Transplant donor register, and to tell their relatives of their wishes. But only 25 per cent of adults have done so whereas 65 per cent say (in surveys) they would be prepared to donate their organs.

What is the case for a change?

It rests on the critical shortage of organs available for transplant, and the fact that people are dying avoidable deaths as a result. Organ transplantation began half a century ago but has only become widespread in the last 30 years.

According to UK Transplant, in 2007-8 there were 809 deceased donors whose organs were used to help 2,381 patients, and a further 856 living donors (who gave, for example, one kidney) who boosted the total number of recipients to 3, 235. However, this was half the number on the active transplant waiting list (7,655), and 506 patients died waiting for an organ. The number of deceased donors has been falling for years because of a decline in fatal road accidents – the victims of which have been a prime source of organs.

Wouldn't an opt-out system work?

Not according to the expert members of the Organ Donation Taskforce whose report was published yesterday. Even though 60 per cent of the public say they would support a change, the taskforce concluded, after looking at the evidence, that on its own an opt-out system would not have a significant impact.

"Many other factors affect donation rates," they say. They list 10 countries with some form of opt-out system, but with widely varying donation rates. Sweden switched to an opt-out system in 1996 but still has a lower donation rate than the UK and one of the lowest in Europe. The report says the arguments are "finely balanced", but that while its members started with a varying views, pro and anti, they had reached a clear anti consensus by the end.

What about the Spanish experience?

Spain is always cited as a success in organ donation because its donor rates are almost three times higher than the UK (34.4 per million population in 2007 compared with 13.4). But while the law introducing presumed consent – an opt-out system – was passed in Spain in 1979, donor rates did not begin to rise until a decade later in 1989 when the Spanish National Transplant Organisation was founded, which boosted the number of transplant co-ordinators and other measures.

Dr Rafael Matesanz, the organisation's president, told the taskforce that Spain's success had nothing to do with the change in the law. "The families are always approached. They always have the last decision and there are great variations from region to region," he said. When Britons living in Spain were approached, their families refused in 9 per cent of cases, compared with 43 per cent in the UK, he said.

Are there objections to an opt-out system?

Yes. The task force says they heard "persuasive arguments" from doctors about the potentially negative implications of an opt-out system which they said could damage the "vital relationship of trust" between patients and doctors. The concern is that patients (and their relatives) might come to see doctors as more interested in saving others with their organs than in saving them.

Some intensive care doctors threatened to opt out themselves from participation in such a programme. The report notes that this would be "disastrous" because the donor programme is dependent on intensive care doctors for its success.

Patients also felt an opt-out system could be regarded as paternalist, that it did not accord with the current emphasis on choice, and that it might undermine the gift relationship that many felt was a crucial element of organ donation.

Are there cases where an opt-out system had a negative impact?

Yes. Brazil introduced an opt-out law in 1997 but had to repeal it in 1998 because of a mistrust of government and allegations of body-snatching. France was hit by a wave of bad publicity in 1992 surrounding the case of a 19-year-old killed in a car accident whose corneas were removed from his body although his parents had only consented to limited organ retrieval. Although the law was not breached, public trust in the system was damaged for some time.

How will Gordon Brown react to the report?

With disappointment. He spoke earlier in the year of the "aching gap" between the supply and demand for organs and the urgent need to close it. In response to suggestions that an increase in transplant co-ordinators would be more effective than a change in the law, Sir Liam Donaldson, chief medical officer, said at the weekend that both measures were needed. The British Medical Association agreed. It said an opt-out system could boost donor rates by 10-15 per cent.

What is the Department of Health doing?

Making the best of the existing system. Yesterday, Alan Johnson, the Health Secretary, announced a £4.5 million campaign to begin next March aimed at boosting the numbers on the donor register to 25 million, almost half the population, over the next five years. The aim is to increase donor rates from 800 a year to 1,400 a year which would put us on a par with the best in Europe, Mr Johnson said.

On average, three people benefit from each donor so this would increase the numbers helped by 1,800 a year. The Government is also appointing 63 new donor transplant co-ordinators, and each Trust will have an organ donation champion to discuss the issue with families.

What happens ifit doesn't work?

Efforts to increase the number of donors have not worked in the past, and they remain little changed. Similarly, there has been no change in the proportion of families – 60 per cent – who agree to the use of their relatives organs when approached. Ministers said yesterday that they were not ruling out a future change in the law "if progress against national objectives is not as swift as it should be".

Should presumed consent to organ donation be enshrined in law?

Yes

*Countries which have a system of presumed consent have higher organ donation rates.

*Two thirds of the British public say they would be in favour of a change in the law.

*Over 500 people die each year on the waiting list for a transplant in the UK.

No

*Switching to a system of presumed consent would not itself boost organ donor rates.

*Many other changes are required, including an increase in transplant co-ordinators.

*It could undermine trust in doctors and cause damage to the transplant programme.

j.laurance@independent.co.uk

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