Organ donation: opt-in or opt-out?

For recipients waiting for organ transplantation, donation is a massive life-changing event. The ‘gift’ of organ donation is an admirable act of altruism for individuals who donate while living, and a beautiful gesture by family members who agree to donate organs from a close relative who has passed on.

Most organ donations occur in the setting of a previously healthy individual who suffers a catastrophic event, often an accident, and is eventually confirmed to be brain-dead while receiving full intensive care support.

At some stage during this traumatic experience, family members are asked whether they would consent to organ donation prior to the discontinuation of life support.

This is a very difficult decision, made more so when, in most cases, family members are not aware of their relatives’ wishes.

In reality, only a small percentage of the population are registered organ donors, that is, they have ‘opted-in’ by completing the relevant forms (see https://organdonation.gov.mt/) and are on the official ‘donor list’. Thankfully, most of these will live to a ripe old age and outgrow their suitability for organ donation.

Indeed, there needs to be a very large pool of registrants for the opt-in process to provide sufficient donors: very few pass away in circumstances where their organs may be suitable for donation. All those dying of old age, cancer, organ failure, infections, etc. are almost invariably not eligible and/or their organs are not suitable for donation. Hence, in reality, the opt-in process trawls too few and results in too small a pool of registrants to accommodate the great and growing need for organs.

While there is little doubt that opt-in needs to increase considerably, hopefully following enhanced education and public awareness, all those who are registered donors must ensure that their loved ones are aware of their wish and encouraged to agree to donation if the situation arises.

However, even if pushed to optimal levels, opt-in will still not provide sufficient donors.

The alternative is to assume that all citizens have no objection and agree to (their) organ donations after death. Those who do oppose would have to opt-out by formally declaring that they do not want their organs to be donated. In all probability, many who don’t agree won’t register their objection anyway. This so-called ‘hard optout’ would accommodate all those who would say ‘Yes’ anyway but would also include some whom, if asked, would decline.

For those individuals, their ‘gift’ would, therefore, be contrary to their wishes (although probably never ‘declared’) and this practice would be ethically questionable.

In contrast, a ‘soft opt-out’ would assume that all citizens are potential organ donors (as with the hard optout) but would also allow citizens the opportunity to declare their intent beforehand. In practice, this could work by the introduction of a simple but mandatory form asking the question: ‘Yes/No to organ donation in the event of (your) death.’

Replies would be officially registered at the time one signs/completes a landmark ‘event’, that could include the acquisition of a Maltese ID card, residency, driving licence, marriage certificate, life insurance, certain legal contracts, bank account, etc.

This simple exercise would ensure that a significant percentage of the adult population would have, in effect, given their consent or otherwise.

I suspect the majority would say ‘Yes’, thereby increasing the donor pool significantly and offering far greater hope to all those potential recipients languishing on some waiting list for an organ transplant.

“Only a small percentage of the population are registered organ donors

Prof. Simon Attard Montalto is head of the Academic Department of Paediatrics at the University of Malta.