Richard Thaler and Cass Sunstein (2008) contend that mandated choice is the most practical nudge for increasing organ donation. We argue that they are wrong, and their mistake results from failing to appreciate how perceptions of meaning can influence people's responses to nudges. We favor a policy of default to donation that is subject to immediate family veto power, includes options for people to opt out (and be educated on how to do so), and emphasizes the role of organ procurement (...) organizations and in-house transplant donation coordinators creating better environments for increasing the supply of organs and tissues obtained from cadavers. This policy will provide better opportunities for offering nudges in contexts where in-house coordinators work with families. We conclude by arguing that nudges can be introduced ethically and effectively into these contexts only if nudge designers collaborate with in-house coordinators and stakeholders. (shrink)

We need to rethink our attitudes to the bodies of the dead in order to increase our willingness to donate organs and tissuesMy father died aged 87 on January 20, 1998. It was the day of his 42nd wedding anniversary. He been admitted to a major teaching hospital with jaundice of unknown origin. He died after a medical procedure and a delay in diagnosis and management of bleeding after the procedure. I believed it was important to understand why he had (...) died and what the underlying cause of his jaundice had been. I requested an autopsy.My father was not only the best father a person could have had, but my closest friend. The circumstances of his death were especially sad for me. I was on a plane while he was allowed to die of blood loss in intensive care over a period of hours, becoming progressively more delirious and experiencing the slow motion throes of death. I was told he had died while I was still in the air. My first thought was that I would never again see him or hear his deep chuckle. I would never again feel the gentle touch of his large hands. He would never see my daughter grow up as he had wanted to, playing, and laughing on the beach.I have witnessed many autopsies. As medical students, we had to attend autopsy each morning at 8.30 am as a part of pathology in fourth year medicine. Before this, we had two years of anatomy dissection, probing every crevice of the formalin fixed human body. I learnt an immense amount from these activities. But I also knew how gruesome the autopsy is. I knew that an autopsy would mean that my father would be dismembered. But I had no hesitation in requesting …. (shrink)

Cadaver organs should be automatically availableThe shortage of donor organs and tissue for transplantation constitutes an acute emergency which demands radical rethinking of our policies and radical measures. While estimates vary and are difficult to arrive at there is no doubt that the donor organ shortage costs literally hundreds of thousands of lives every year. “In the world as a whole there are an estimated 700 000 patients on dialysis . . .. In India alone 100 000 new patients present (...) with kidney failure each year” . Almost “three million Americans suffer from congestive heart failure . . . deaths related to this condition are estimated at 250 000 each year . . . 27 000 patients die annually from liver disease . . .. In Western Europe as a whole 40 000 patients await a kidney but only . . . 10 000 kidneys”1 become available. Nobody knows how many people fail to make it onto the waiting lists and fail to register in the statistics. “As of 24th November 2002 in the United Kingdom 667 people have donated organs, 2055 people have received transplants, and 5615 people are still awaiting transplants.”2Conscious of the terrible and unnecessary tragedy that figures like these represent I have been advocating for more than 20 years now some radical measures to stem this appalling waste of human life. The measure which is the subject of Hamer and Rivlin’s paper 3 concerns the automatic availability of all cadaver organs—a measure, which I first advocated publicly in 1983.4THE AUTOMATIC AVAILABILITY OF DONOR ORGANSWe need to begin by being clear about just what it is I propose and why. At the moment in the United Kingdom we …. (shrink)

No one has the right to say what should be done to their body after deathIn my opinion any concept of property in the human body either during life or after death is biologically inaccurate and morally wrong. The body should be regarded as on loan to the individual from the biomass, to which the cadaver will inevitably return. Development of immunosuppressive drugs has resulted in the cadaver becoming a unique and invaluable resource to those who will benefit from organ (...) donation. Faced with the biological reality, the moral error of any concept of property in the body, and the quantitative failure of voluntary organ donation, I believe that the right of control over the cadaver should be vested in the state as representative of those who may benefit from organ donation.How one regards the dead human body, the cadaver, is in part governed by one’s familiarity with it. At the present time, very few people ever see a cadaver which has not in some way been altered after death, and even fewer touch, handle, deal in any way with the dead human body. In developed countries, death itself most frequently occurs away from the home, in an institution, under the supervision of professional caregivers. For most people, ideas concerning the cadaver, its nature, the proper way to deal with it, are formed under these conditions.As a pathologist specialising in forensic pathology, for 50 years I have been at the other end of the spectrum of experience. In my daily work I have been privileged to examine the cadaver in all its stages after death from the immediate postmortem moments through all the stages of decomposition to bare bones. Working in a relatively small community, I have sometimes been charged with examining the body of someone I …. (shrink)

In the UK, the legal processes underpinning the procurement system for cadaveric organs for transplantation and research after death are under review. The review originated after media reports of hospitals, such as Alder Hey and Bristol, retaining organs after death without the full, informed consent of relatives. The organ procurement systems for research and transplantation are separate and distinct, but given that legal change will be applicable to both, some have argued now is the time to introduce alternative organ transplant (...) procurement systems such as presumed consent or incentive based schemes . Findings are reported in this paper from qualitative and quantitative research undertaken in Scotland in order to ascertain the public acceptability of different procurement systems. Nineteen in depth interviews carried out with donor families about their experiences of donating the organs of the deceased covered their views of organ retention, presumed consent, and financial incentives. This led onto a representative interview survey of 1009 members of the Scottish public. The originality of the triangulated qualitative and quantitative study offers exploration of alternative organ procurement systems from different “sides of the fence”. The findings suggest that the legal changes taking place are appropriate in clarifying the role of the family but can go further in strengthening the choice of the individual to donate. (shrink)

This article explores how the type of consent given for organ donation should affect the judgement of a patient's overall benefit with regards to donation of their organs and the pre-mortem interventions required to facilitate this. The findings of a qualitative study of the views of 10 healthcare professionals, combined with a philosophical analysis inform the conclusion that how consent to organ donation is given is a reliable indicator only of the strength of evidence about views on donation and subsequent (...) willingness to undergo pre-mortem interventions. It is not an indicator of the strength of actual desire to donate. Clinical management of living patients prior to donation after circulatory death must therefore respect the values, wishes and beliefs of the potential donation after circulatory death donor. Our participants, however, suggested that the information currently provided is sufficient to authorise donation and that this consent, however provided, was sufficient to proceed with pre-mortem interventions. Respect for autonomy underpinned this ‘all or nothing’ approach. Although the legal requirements for donation authorisation and the protection of patients without capacity are clear, practice and policy regarding consent in donation after circulatory death may be based on donation following brainstem death where the patient is already dead when the family is approached. Custom and practice in donation after circulatory death may need to be revised to protect the interests of the dying potential donor. (shrink)

advanced directivesend-of-life decisionsharming the deadposthumous reproductiontransplant ethics.

ZusammenfassungIn zahlreichen Ländern nimmt die Zahl von Organspenden nach Kreislaufstillstand zu, obwohl in der Medizinethik verschiedene Aspekte der DCDD kritisch diskutiert werden. In unserer Arbeit identifizieren wir ethisch relevante Aspekte der DCDD basierend auf einer umfassenden Literaturanalyse. Wir fokussieren dabei insbesondere auf zwei Aspekte: vorbereitende Maßnahmen und Irreversibilität des Todeskriteriums. Danach untersuchen wir in einer weltweit durchgeführten Auswertung von Webseiten von Organspende-Organisationen und einer begleitenden Umfrage, inwieweit diese ethisch relevanten Aspekte von DCDD in der Information potenziell spendewilliger Personen eine Rolle (...) spielen. Es zeigt sich, dass in der Mehrheit der Webseiten der Organisationen auf die Thematik DCDD nicht oder kaum eingegangen wird, die befragten Verantwortlichen der Organisationen aber die Wichtigkeit der Aufklärung bei spendewilligen Personen betonen. Wir diskutieren diese Diskrepanz und weisen auf zentrale Punkte hin, über welche spendewillige Personen informiert werden sollen, wenn diese Form der Organspende in ihrem jeweiligen Land praktiziert wird. Zudem plädieren wir dafür, dass das Todeskriterium und die Prozeduren zur Todesfeststellung in der Transplantationsmedizin einheitlich sein sollen, um kritisch diskutierte Aspekte im Kontext der DCDD entschärfen zu können. (shrink)

The question of whether individuals retain interests or can be harmed after death is highly contentious, particularly within the context of deceased organ retrieval, retention and use. This paper argues that posthumous interests and/or harms can and do exist in the Konkomba traditional setting through the concept of ancestorship, a reputational concept of immense cultural and existential significance in this setting. I adopt Joel Feinberg’s account of harms as a setback to interests. The paper argues that a socio-culturally sensitive regulatory (...) framework does not necessarily exclude the donation of human biomaterials for transplant and science research. Indeed, when customary values are explored with open-mindedness and sensitivity it may be shown that such donation can form part of the important customs of some communities in this jurisdiction. Accordingly, a context-appropriate governance framework could utilise the cultural value of ancestorship as an incentive to encourage organ donation in the Ghanaian traditional setting. (shrink)