The Guardian view on organ donation: an act of love
To give an organ for transplantation is an act of selfless generosity. It can quite literally save lives and, even when it does not do so directly, can improve immensely the quality of the recipient’s life. Paradoxically, in many cases, the donor is not directly harmed because they are dead, or at least brain dead. The big exception is kidney transplants, where donor and recipient can get by on one each. Yet here, too, the majority of donations take place after death, providing that the presumptive donor has made a clear declaration beforehand that they would like their body to be used in this way.
This requirement that people should opt in to donate has long been controversial. It seems common sense that, while no one should be compelled to have their organs used without permission, it ought to be the default position that this can happen where lives can be saved. Only those who clearly object and opt out should have their bodies preserved. Last week a bill to make organ donation in England opt-out, rather than opt-in, cleared the Commons, and at this rate it will become law in 2020. It was good to see Tory ministers and Labour MPs working together to implement the change.
Obviously, permission of some sort is essential for the practice to be ethical. China used to allow a fairly open trade in the body parts of executed prisoners – which is horrifying. Even when judicial murder is not used as a means of organ harvesting, there are poor countries where people are allowed to sell their kidneys for transplantation, and a thriving international trade in such unscrupulous surgery persists. When life is not freely given, there are always those who will seize it for themselves.
Yet in countries where the sale of organs is banned and transplants are free on the health service, the deciding factor seems not to be the state of the law. In particular, the assumption of an opt-out register, rather than the present opt-in arrangement, does not on its own lead to a greater frequency of transplants. So long as the patients’ relatives have a voice – as they should – they are able to prevent a body being used for donations. There is some evidence that they are more likely to do so if they feel they’re being bounced into a decision. What should appear as a sacrifice can seem a desecration. This is a moral reflex quite independent of religious objections.
The complications are shown by the example of Spain, which has both a very high frequency of donation and an opt-out scheme – but where the change in the law had no effect on transplant rates for 10 years. What actually improved them was a change of organisational culture: ensuring that doctors talked to relatives; that the necessary surgical skills were available everywhere; and that organs could be moved quickly to where they were most needed. Without that underlying work, the headline change was ineffective.
The altruistic character of organ donation is what makes it valuable – and also what makes it fragile. It is a deeply personal gift, which cannot be compelled. Opt-out registers can make it easier for people to do the right thing, but they have to want to do so. The real problems and difficulties are not in the regulations. Individuals and their families must be inspired with a vision of what organ donation can do: it is a way to make both life and death more valuable. Transmitting this vision is a process that takes time and demands commitment and understanding from the frontline staff of the NHS. The change in the law is welcome, but it should not be taken as a substitute for the real work that remains to be done.
