麻豆传媒

IT IS a problem faced by countries the world over. How do you close the gap between demand for human organs for transplantation and the number of people willing to donate them?

Such is the scale of the problem in the UK, where less than half of the 8000 people needing a transplant each year receive one, that the government is considering changing the law to presumed consent 鈥� so that everyone is a potential donor unless they opt out. Earlier this year, UK prime minister Gordon Brown and chief medical officer Liam Donaldson backed the idea.

However, many doctors are raising serious doubts about the proposal, partly for ethical reasons but also because of unsolved problems that mean donated organs are not always usable.

Australia, which lags behind much of the world in donation rates (see graph), is also planning changes. It will keep its system of informed consent, in which potential donors join a national registry, but aims to improve donation rates with a national network of hospital doctors trained to handle organ donation.

Both countries are considering emulating aspects of the model used by Spain, the world leader in organ donation rates. So how has Spain cracked the problem? Its policy of presumed consent is just part of the answer. While it is true that countries with presumed consent have between 20 and 25 per cent higher donation rates than those with informed consent (Journal of Health Economics, ), some countries buck this trend. Sweden, for example, which switched to presumed consent in 1996, has one of the lowest rates in Europe, and changing the law made little difference.

One of the main reasons is that in most countries the family can still veto the decision to harvest a person鈥檚 organs. 鈥淚t only provides a framework within which the organ retrieval can be organised,鈥� says Paul Michielsen of the Catholic University of Leuven (KUL) in Belgium. This means public opinion is crucial.

Spain鈥檚 high rates, though, are down to efficient transplant coordination and the way families are approached, not the law, says Rafael Matesanz, director of the country鈥檚 national transplant organisation. For example, a European opinion poll shows that in the UK, 63 per cent say they are in favour of organ donation, he says, but other research indicates that 43 per cent of families refuse permission for their relative鈥檚 organs to be removed. Strikingly, he adds, when the families of Britons who die in Spain are approached in Spanish hospitals, the refusal rate falls to 9 per cent.

鈥淪pain鈥檚 high donation rates are down to transplant coordination and the way families are approached, not the law鈥�

Indeed, Spain itself had low donation rates until a national network was set up in 1992 鈥� 13 years after presumed consent was introduced. Coordinated regional teams consist primarily of doctors working in intensive care units, who have all been trained in how to identify potential transplant organs and how to approach the families. In the UK, by contrast, training depends on hospital policy.

Evidence from the US indicates the importance of approaching families in the right way. James Rodrigue at the Beth Israel Deaconess Medical Center in Boston and his team surveyed 74 parents who had been asked to donate the organs of their recently deceased children. They found that parents were more likely to agree if they had been given information before the death; if the first mention of donation came from the child鈥檚 doctor; and if they had time to think about the decision (Pediatric Critical Care Medicine, ).

A further factor must be considered before any change in law, say some doctors: better use should be made of existing donated organs. For example, lungs are often dismissed as unusable because they are damaged during death, but giving the donor a drug called vasopressin while they are alive could prevent this damage, says Paul Corris at the Freeman Hospital in Newcastle, UK.

Presumed consent also raises serious ethical concerns, as people who are less literate are less likely to opt out, says John Fabre of King鈥檚 College London. 鈥淭he absence of an objection isn鈥檛 consent,鈥� he says. 鈥淚t will degrade the donation process from one of generosity and compassion to one where the state takes back what it believes is theirs.鈥�