As of this morning, the United Network for Organ Sharing reports that 106,371 Americans are waiting for life-saving or life-prolonging organs. Approximately eighteen of those desperate individuals die each day without a transplant. According to the National Kidney Foundation, patients who died for lack of available donor organs in 2008 included 371 patients seeking hearts, 234 needing lungs, 1,506 requiring livers, and a staggering 4,573 would-be kidney recipients. Unfortunately, despite these horrific numbers, the American political establishment has been unwilling to champion non-traditional methods of expanding the organ supply, including the mandated choice model advanced by the American Medical Association and several novel approaches that have worked with considerable success in Europe. In short, many of our leaders do not take the donor famine seriously, or they fear the wrath of lobbyists for a small but vocal fringe element in the disabled community who oppose such unconventional measures. Now an unlikely voice has targeted this unconscionable inertia. Illinois State Senator Dale Risinger, a conservative Republican from Marion County, has proposed courageous legislation that would presume consent for organ donation--but would also establish an infrastructure for allowing those not wishing to donate life-saving organs to opt out.
Under current law in all fifty states, a person is presumed not to be an organ donor upon his death unless that individual or his family takes active steps to convey his willingness to make his organs available for transplant--with the precise requirements and standards varying by jurisdiction. As a result, many cadaveric organs go to waste, not because would-be donors actively opposed giving their hearts and corneas, but because they have never thought about it. In contrast, many European nations--including Spain, France, Belgium, Austria, Denmark, Norway and Belgium--presume that a person wishes to donate her organs upon death unless she specifies otherwise. Senator Risinger's proposal would establish an Organ Donor Opt Out Registry, letting the small minority of individuals committed to burial with all their organs to log their names with the Illinois Secretary of State. Physicians would then consult this registry for matches, prior to going ahead with transplantation, much as airlines consult the Department of Homeland Security's "do not fly" list. This is precisely the sort of safeguard needed to ensure that organs are not taken over deeply-held religious or cultural objections.
Presumed consent is not the only non-traditional means of increasing the available pool of organs. An even less controversial--although possibly more expensive-- alternative is a "mandated choice" system in which all citizens are required to specify whether or not they are willing to donate organs upon death. The Royal College of Physicians proposed such a model for Great Britain last fall. A "soft" mandated choice system would also allow for a third option beyond "yes" and "no," in which respondents could instruct doctors to "ask my relatives." The advantage of mandated choices--which, in the name of full disclosure, I have advocated for in the past--is that it ensures that nobody with a strong opposition to donation slips through the cracks, as might theoretically happen in a presumed consent system. Its obvious disadvantage is the economic and bureaucratic cost of contacting and registering the entire population. The American Medical Association has for many years encouraged both mandated choice and presumed consent experiments without choosing between approaches.
A third alternative, recently adopted by Israel, grants those who register as organ donors first claim to donor organs. Such an equitable system proved necessary in that country because of the nation's religious-secular divide: Some ultra-orthodox Jews who oppose donating vital organs under any circumstances were none-the-less lining up to receive them, in essence freeloading off the generosity of their secular brethren. To the extent that similar fanatics attempt to game the system in this country, Congress should authorize UNOS to give priority in organ allocation to individuals who are themselves willing to donate--obviously making an exception for those medically unable to do so.
Finally, a fourth method of ensuring increased organ donation would involve economic incentives to potential donors. One need not establish a full-fledged organ market, such as Iran's state-coordinated program, to create such incentives--particularly if one fears exploiting would-be sellers or decreasing the availability of altruistic donor organs. However, merely offering such basic financial amenities as paid medical leave for living donors and free burial or tax breaks in return for cadaveric gifts could nudge those on the fence. While there is nothing inherently unethical in such a system--particularly if operated with meaningful safeguards--measures like "presumed consent" or "mandated choice" may obviate any need for a compensation-based initiative.
Senator Risinger's brave, bipartisan proposal, which is co-sponsored by Democratic Senator Dave Koehler of Peoria and Republican Senator Pamela Althoff of Crystal Lake, has strong support among health care providers and hospital administrators of all religious persuasions and cultural stripes. It will save lives--and that's a hard bottom-line to argue against. Nations which have adopted systems similar to that proposed by Senator Risinger have among the shortest waiting lists for organs in the world. In Belgium, for example, fewer than 2% of the population has chosen to opt out since that nation adopted presumed consent twenty-three years ago. Moreover, there is absolutely no empirical evidence that Belgians are being murdered for their organs or that any of the other fantastical abuses claimed by opponents have taken place.
Of course, evidence rarely silences ideologically-motivated nay-sayers. Already, some opponents of the proposal have attempted to cloud the issue by raising tangential questions regarding the definition of "brain death"--inadvertently revealing their own hidden agenda, the prohibition of all cadaveric organ donation. Ironically, some of these opponents even claim the mantra of being "pro-life" or favoring the rights of the disabled and the most vulnerable--even though the lives of disabled and vulnerably patients are precisely those which will be saved by the legislation proposed by Senator Risinger. I am only hopeful that other lawmakers will favor the welfare of the many silent victims of the organ famine over the apocalyptic cries of ideologues and their hollow warnings that we are somehow slipping down a slope toward killing innocent people for organs. We are not. What we are doing is addressing an epic crisis with careful and pragmatic solutions. All too rarely do I find myself on the same bioethical page as a conservative Republican politician from the heartland, so I take particular pleasure in advocating for this wise leader and his cause.
Someday, unwanted fetal organs or organs grown in laboratories from harvested stem cells may entirely eradicate the need for human-to-human organ donation. Alas, that day remains in the future. In the meantime, the desperate shortage of vital organs demands outside-the-box thinking and radical action--not merely bumper stickers and public service announcements. I am hopeful that legislators across the nation will take note of Senator Risinger's proposal and will offer similar bills for consideration in their own states. These politicians should make enactment of such programs a legislative priority, as they would with any other series of bills that could save eighteen lives a day. For the thousand of patients in need of hearts and lungs and livers, human beings who are not dead yet, but will be soon, a legislative session may prove too long to wait