When Christiaan Barnard transplanted the first human heart in South Africa on 3 December 1967, it was hailed as a triumph for modern medicine. According to the British Heart Foundation [Ref: British Heart Foundation], more than 5,328 heart transplants have been conducted in the UK, and patients can go on to live very active lives, some even running marathons [Ref: Heart Transplants]. The latest NHS figures list 3,087 people [Ref: UK Transplant] as having their lives saved or improved by an organ transplant in 2006/07, benefiting from kidney, pancreas, lung and liver transplants as well as hearts. However, despite being a pioneer of transplantation, the UK has one of the worst records for organ donation in Western Europe. More than 1,000 patients die annually due to a lack of available organs at a time when the number of patients registered for a transplant is rising, up by 8 per cent on the previous year to 7,235. In response to this situation, in 2006 the government established the UK-wide Organ Donation Taskforce [Ref: Department of Health] to identify barriers to organ donation and procurement. In July 2007 the Chief Medical Officer, Sir Liam Donaldson, argued for changing the legal framework governing organ donation and abandoning the UK’s ‘opt-in’ system in favour of a system of ‘presumed consent’, where individuals would have to actively ‘opt-out’ if they do not wish to be considered donors upon death [Ref: Department of Health]. In an article published in the Sunday Telegraph in January [Ref: Telegraph], Gordon Brown indicated his sympathy for this proposal and kicked-off a nationwide debate.

Are we just too lazy to register?
Supporters of presumed consent point to the far higher donation rates achieved in countries that operate some form of opt-out system. For example, Spain, which operates a ‘soft’ opt-out system [Ref: UK Transplant] where the views of relatives are still sought, has 35.5 organ donors for every million people of its population – three times the UK rate of 12.9 per million. One reason for this differential is that in the UK only 25 per cent of the population have signed up to the donor register, despite surveys showing up to 90 per cent support donation [Ref: UK Transplant]. The broadcaster Vanessa Feltz argues all Gordon Brown wants ‘is to make it easier for those of us too ditzy, dopey or with our heads buried too deeply in the sand to make a difference in death’ [Ref: Express]. The British Medical Association points out that presuming consent rather than presuming objection is more likely to achieve the aim of respecting the wishes of the deceased person, and would relieve relatives of the burden of making the decision in the absence of any indication of the deceased person’s wishes [Ref: British Medical Association].

What about personal autonomy and respect for individual beliefs?
Critics of the proposal argue it turns volunteers into conscripts and demonstrates disdain for ordinary people. Katherine Murphy of the Patients Association charity [Ref: Patients Association] told the Daily Telegraph: ‘We don’t think a private decision, which is a matter of individual conscience, should be taken by the state’ [Ref: Telegraph]. Mick Hume, the Times columnist, has written about the importance of personal autonomy, arguing that whilst ‘the dead body is no longer a person’ neither ‘should it automatically be assumed to be a national asset’ [Ref: spiked]. Hume further notes the proposal has the potential to undermine trust in the medical profession whereas a high profile campaign to persuade patients this is the humane thing to do could win widespread public support. Polly Toynbee, the Guardian columnist, counters that opposition is based on superstition and scaremongering led by ‘a few vociferous people’s misguided and primitive instincts about the sanctity and integrity of corpses’ [Ref:  Guardian].

Will planned safeguards address concerns and objections?
Gordon Brown stated ‘in cases where the potential donor is not on the register’ it would be ‘only right and proper’ to ‘leave the final decision with the family’ [Ref: Telegraph]. Liam Donaldson emphasised that the right to opt-out must be ‘inalienable’ [Ref: Guardian]. But does this address the point that an opt-out system is not voluntary and that the onus should be on the medical profession and the NHS to win public support rather than rely on conscription? Dr Kevin Gunning, an intensive care consultant at Addenbrooke’s Hospital, is concerned about conflicts of interest when tending someone considered a potential donor [Ref: Telegraph]. Donaldson insists there will be rigorous clinical protocols, including the brain stem death test [Ref: UCL Institute of Child Health], to determine when someone can be considered for donation.

Is presumed consent the best way to achieve higher donation rates?
In November 2008 the Organ Donation Taskforce unanimously rejected [Ref: Guardian] presumed consent, on the grounds there was no clear link to improving donation rates. Instead, they argued in an earlier report, the government should focus on an improved centralised system of organ procurement, involving a doubling of the number of transplant coordinators within the NHS to 200. Spanish medica argue this was the key to their success [Ref: BBC News]. Yet Gordon Brown has not ruled out introducing presumed consent [Ref: BBC News] if the latest publicity drive fails. If this is the true basis for Spain’s success, is the UK government in danger of missing the point and alienating doctors from the public? Or is a system of presumed consent what the public really want anyway? Meanwhile, pioneering stem cell research [Ref: Guardian] offers a potential technological solution– but that is no less problematic [Ref: Guardian].