Organ donation - presumed consent alternative

[Ivor the Engineer]

<snip>

However, there is merit to the idea of raising awareness for the tit-for-tat nature of the process. Perhaps an incentive for those who are willing to donate would be in order. For example, under my health plan, if one member of our family signs up to donate blood (even if for some reason they cannot donate or their blood is not suitable to be given to another person), then we will not be charged for blood products if any of us requires a blood transfusion.

Linda

Is that much of an incentive?

If the procedure your having requires a blood transfusion, I'd have thought the cost would most likely be eye-watering even if you deducted the cost of the blood.

 

[fls]

Is that much of an incentive?

If the procedure your having requires a blood transfusion, I'd have thought the cost would most likely be eye-watering even if you deducted the cost of the blood.

I think that we are charged for blood products like we are for drugs - that is, we bear some of the price. The cost of whatever it was that led to the transfusion would be covered under medical care (there may be a deductible).

It doesn't need to be a large incentive. It just needs to be enough to tip the balance for someone who is inclined to be apathetic, and at least get them thinking about it.

Linda

 

[Matty1973]

This is a bad idea. It would be unethical to withhold lifesaving treatment from anyone, and I don't think you would find transplant physicians willing to go along with this. You are essentially saying that it is okay to allow someone to die if they are an ******* or lazy or irrational (oops, there goes the neighbourhood ). Also, from a practical point-of-view, it seems that outcomes are maximized if organs are allocated on the basis of need, and this process would interfere with that.

However, there is merit to the idea of raising awareness for the tit-for-tat nature of the process. Perhaps an incentive for those who are willing to donate would be in order. For example, under my health plan, if one member of our family signs up to donate blood (even if for some reason they cannot donate or their blood is not suitable to be given to another person), then we will not be charged for blood products if any of us requires a blood transfusion.

Personally I would have more of an objection to giving other incentives (eg discounted charges or other financial ways), it seems more akin with buying organs from the poor which must be wrong. It sounds fairer to say if you want to receive organs then be prepared to give, and if there are some left over then those that were not prepared to give can be looked at but if not then someone has to lose out.

I agree it would complicate the issue of who gets which organs but I'm sure it is already a complicated decision process and if it helps increase the supply then it may overall decrease the total suffering.

 

[Uncayimmy]

I agree with the logic there but I think the difference is that we are not all equal with ability to donate spare cash but we are equal with ability to donate organs.

With what "logic" do you agree?

What's wrong with participation on the giving side being a factor on decisions made regarding the receiving side? There are plenty of other factors that are considered including basic geography and immigration status.

 

[fls]

Personally I would have more of an objection to giving other incentives (eg discounted charges or other financial ways), it seems more akin with buying organs from the poor which must be wrong.

How so? You can't directly profit (using the term loosely) from your decision unless you deliberately cause one of your organs to fail.

It sounds fairer to say if you want to receive organs then be prepared to give, and if there are some left over then those that were not prepared to give can be looked at but if not then someone has to lose out.

Since it violates medical ethics, I'd say it's a no-go, no matter how much personal satisfaction it gives you.

I agree it would complicate the issue of who gets which organs but I'm sure it is already a complicated decision process and if it helps increase the supply then it may overall decrease the total suffering.

How could that possibly increase the supply though? Wouldn't it suffer from all the same problems that leave us short of the ideal now? Since most people (quite correctly) will recognize that it doesn't matter whether or not they register as an organ donor, apathy will have the same effect on them as it does now (they'll get around to it later). And the discovery that their doctor will most decidedly not consider their best interests when it comes to their treatment is hardly going to allay the suspicions of those who are a bit paranoid and irrational about emergency care to begin with.

Linda

 

[Ivor the Engineer]

<snip>

And the discovery that their doctor will most decidedly not consider their best interests when it comes to their treatment is hardly going to allay the suspicions of those who are a bit paranoid and irrational about emergency care to begin with.

Linda

I bet it doesn't make them drive any more carefully* either.


*One of the reasons Spain has so many donors is because they are lousy drivers.

ETA: http://www.unece.org/trans/main/wp6/transstatpub.html

Looking at page 9 of the 2007 edition of ROAD TRAFFIC ACCIDENTS IN EUROPE AND NORTH AMERICA, it appears the Russian Federation has the most dangerous roads of those countries surveyed with almost 1 in 4000 of the population being killed in a RTA. In the US it's about 1 in 7000, Spain about 1 in 10000, the UK about 1 in 20000 and Liechtenstein about 1 in 30000.

 

[Kevin_Lowe]

But why would I care about some unknown stranger's quality of life if I don't care about the person in front of me? Alternatively, if I care about the person in front of me, why would that be superseded by consideration for some unknown stranger?

On the one hand, my sense of concern is so deep that I would risk revocation of my license to practice medicine in order to help a stranger, while at the same time my sense of concern is so shallow that I can't be bothered to make an effort to save the life of someone under my care when given the opportunity to do so?

Linda

Two issues there.

One, money. A lot of money gets paid out to doctors, nurses and so on if they perform a transplant operation.

Two, the possibility exists that doctors might decide that because you are badly brain damaged, a racial minority, poor, stupid or whatever that your life is worth less than somebody else's.

I'm not saying doctors do kill potentially savable people for their organs, but I could see why they might be tempted to do so.

 

[Professor Yaffle]

Two issues there.

One, money. A lot of money gets paid out to doctors, nurses and so on if they perform a transplant operation.

But the doctor dealing with the potential donor won't be involved in the transplant operation.

 

[fls]

Two issues there.

One, money. A lot of money gets paid out to doctors, nurses and so on if they perform a transplant operation.

But not to the doctors/nurses making the call as to whether someone is brain dead. One team will likely have no connection to the other.

Two, the possibility exists that doctors might decide that because you are badly brain damaged, a racial minority, poor, stupid or whatever that your life is worth less than somebody else's.

"I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient;"

I'm not saying doctors do kill potentially savable people for their organs, but I could see why they might be tempted to do so.

That's my point. Where's the temptation? I can't profit from the decision to prematurely end someone's life.

Linda

 

[Ivor the Engineer]

<snip>

"I WILL NOT PERMIT considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient;"

<snip>

And there was I thinking physicians were human.

It's a nice sentiment I suppose.

 

[Matty1973]

With what "logic" do you agree?

I agreed with the logic of the post I quoted, that once you start discriminating on one basis (having opted in) you could start discriminating on many other factors. Some of these factors may be less clear cut (eg have you lead a healthy lifestyle or other) as Ivor said "where do you stop?"

What's wrong with participation on the giving side being a factor on decisions made regarding the receiving side?

I am the one arguing that it should be a factor on which decisions are based. Why are you asking me this?

 

[Matty1973]

How so? You can't directly profit (using the term loosely) from your decision unless you deliberately cause one of your organs to fail. Linda

We are talking about encouraging people to opt in. So a financial incentive would be to pay (poor) people to opt in. I am against that. Similarly I am agianst giving a discount on charges (financial incentive) to give blood. It discriminates against the poor.

Since it violates medical ethics, I'd say it's a no-go, no matter how much personal satisfaction it gives you. Linda

Then may be those medical ethics need to be looked at and updated then. Were they designed to address the situation of a lack of organs? I'm guessing they predate the issue.

How could that possibly increase the supply though? Wouldn't it suffer from all the same problems that leave us short of the ideal now? Since most people (quite correctly) will recognize that it doesn't matter whether or not they register as an organ donor, apathy will have the same effect on them as it does now (they'll get around to it later).Linda

It would increase supply by over coming apathy. At the moment there is no incentive (ie no personal benefit) but if there was (a preference if you need an organ) then more would opt in. It would matter if you register. So people would register. That is human nature.

 

[Ivor the Engineer]

If the decision to donate is coerced and the family still has the final say, those who don't really want to be donors will just enroll and tell their families to say no when asked.

What about people who find out they need an organ, enroll, get the organ they need and then take their names off the list?

 

[fls]

We are talking about encouraging people to opt in. So a financial incentive would be to pay (poor) people to opt in. I am against that.

I agree.

Similarly I am agianst giving a discount on charges (financial incentive) to give blood. It discriminates against the poor.

Well, I can guarantee you that no poor people have my health plan.

Then may be those medical ethics need to be looked at and updated then. Were they designed to address the situation of a lack of organs? I'm guessing they predate the issue.

The issue of whether or not the quality of a person's character should determine whether they live or die has always been with us. The idea has been unequivocally rejected.

It would increase supply by over coming apathy. At the moment there is no incentive (ie no personal benefit) but if there was (a preference if you need an organ) then more would opt in.

I suspect most people would get to it later unless there was some sense of urgency - i.e. they had an organ at risk. So you may see an increase in the number of registrants, but it would be of people whose organs wouldn't be of use anyway. If you need an incentive to overcome apathy, it is basic psychology to realize that reward is more effective than punishment. Plus giving preference on the basis on non-medical indicators leads to poorer outcomes.

Linda

 

[Matty1973]

The issue of whether or not the quality of a person's character should determine whether they live or die has always been with us. The idea has been unequivocally rejected.

I hadn't viewed it as a test of the person's character - more along the lines of 'have you paid your dues' in the same way private health care only treats those that have paid their premiums. Now I do see why it could be seen as unethical.

How does a private doctor get around the ethics of not treating someone who is not covered. Could the same reason not be given for treating someone not opted in?

I suspect most people would get to it later unless there was some sense of urgency - i.e. they had an organ at risk. So you may see an increase in the number of registrants, but it would be of people whose organs wouldn't be of use anyway. If you need an incentive to overcome apathy, it is basic psychology to realize that reward is more effective than punishment. Plus giving preference on the basis on non-medical indicators leads to poorer outcomes.

Ocelot mentioned a 'length of service' factor to make the benefit only available if you have registered well in advance of needing treatment. This would ensure the additional registrants would be of people whose organs would be of useful.

I do view this as a reward rather than a punishment. A reward of 'preference' for opting in.

I agree this would lead to some poorer outcomes due to the non-medical basis of the decision - but hopefully that would be out weighed by the overall increase in organ donations.

 

[fls]

How does a private doctor get around the ethics of not treating someone who is not covered. Could the same reason not be given for treating someone not opted in?

A private doctor isn't preventing someone from getting treatment though, even if the treatment doesn't come from them specifically.

I don't see why the additional registrants would be of people whose organs wouldn't be of use.

If they have an illness that affects one organ, there's a good chance they wouldn't be suitable donors of other organs. For example, if a patient has a kidney that fails from diabetes, their heart won't be in good shape either. Plus the average age of recipients is higher than the average age of donors.

I do view this a reward rather than a punishment. A reward of 'preference' for opting in.

Imminent death is hardly a neutral non-reward, though.

I agree this would lead to some poorer outcomes due to the non-medical basis of the decision - but hopefully that would be out weighed by the overall increase in organ donations.

Decrease quality in the hope that it will increase supply? If you're lucky you'll regain your losses? Do you really think anyone would go for this?

Linda

 

[fls]

I see you added another paragraph to your post while I was replying.

Ocelot mentioned a 'length of service' factor to make the benefit only available if you have registered well in advance of needing treatment. This would ensure the additional registrants would be of people whose organs would be of useful.

So how would that work? If you're young and you need an organ, tough ****** You haven't been registered for long enough?

Linda

 

[Matty1973]

Sorry - I added that paragraph because I didn't read your answer properly the first time.

I don't think I have explained when opt in would occur clearly enough. You seem to think this opt in incentive is for ill people who have discovered they need a organ donation and so now they opt in to get one. This is not how it would work. The opt in would be at 18 years old (or some similar age - children would be treated as they are now).

So if at 18 you opt in then fine you are given preference if at some later stage you need a donation. If you don't opt in then you don't get the preference. Your choice.

If at some stage later in life you decide to opt in then after a period (5 years? gradually staggered) you get preference too. Obviously when the scheme starts initially anyone opting in straight away gets equal preference regardless of age.

This ensures that
a) there is a reward to opt in early.
b) the people opting in are as healthy as average.


So the opt in is not aimed at ill people. There is no punishment of imminent death.

For ill people who have not opted in then I'm afraid it is tough. You made your choice. If there are no organs left over once the preference people have been treated then you miss out. Opting in now is too late to get a preference

As for decreasing quality for increased quantity - that is definitely a calculation that needs to be made. I'm sure that calculation is made in many situations in health care on many different scales every day.

 

[fls]

I don't think I have explained when opt in would occur clearly enough. You seem to think this opt in incentive is for ill people who have discovered they need a organ donation and so now they opt in to get one.

No, just that if you're apathetic, it may not occur to you to opt-in until you discover that this choice will affect your future.

So the opt in is not aimed at ill people. There is no punishment of imminent death.

I meant that the point at which your receive your reward (preference) is the point at which the lack of the receipt of that reward is imminent death.

Linda

 

[Matty1973]

No, just that if you're apathetic, it may not occur to you to opt-in until you discover that this choice will affect your future.

It can be part of the school curriculm. You get taught that you have the choice to opt in at 18. If you're apathetic you don't get the preference. That's the consequence of being apathetic - you miss out on the things in life that you don't take an interest in.

May be to be fair to apathetic people who are already over 18 the scheme should start from now with 18 year olds. To make sure people have definitely been educated how it works.

I meant that the point at which your receive your reward (preference) is the point at which the lack of the receipt of that reward is imminent death.

Yes but the offer of reward is the incentive at the point of opting in (normally age 18).

As you said yourself:

If you need an incentive to overcome apathy, it is basic psychology to realize that reward is more effective than punishment.

The 'punishment' of imminent death is not a factor for getting people to opt in - those that are already ill are not the target group. When you originally brought up imminent death I believe you were under the impression ill people were the likely people opting in, so it is a bit out of context now.