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Organ Donation Should Be Compulsory Unless You Opt Out

When I flipped open my laptop to start typing up a piece on organ donation, it was going to be a no brainer: Australia should, surely, move to an opt-out system. This, I assumed, would widen the pool of donors and save lives.

Opt-out operates on ‘presumed consent’ -- your organs are permitted to be removed when you die, unless you opt out. The current system means that organs can only be taken from those who opt in.

But a closer look at all the evidence has led me to realise it isn’t quite the no-brainer many think it might be (a brief, quick poll of my Twitter followers found that 80 percent support moving to an opt out model.)

While there may not be a totally straightforward answer, I still believe that compulsory organ donation, unless you opt out, if implemented effectively, could save many more lives than our current system.

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I researched other countries’ policies and spoke to doctors, the Australian Medical Association, charities, donor recipients and the government’s organ transplant division. The findings might surprise you.

First up, it’s important to acknowledge that there are still good, solid reasons for Australia to move to an opt-out model. Fourteen hundred Australians are currently waiting for a transplant, and about 12,000 people are on kidney dialysis. That’s a lot of people waiting around to see if they’ll live healthy lives, or become ill and potentially die.

Kidney dialysis patients in Australia number more than 12,000.  (Image: Getty)

Opt-in simply isn’t returning many organs in Australia. In 2017, the organs of just 510 deceased donors were transplanted into Australian recipients. This amounts to 20.7 donations per million people. More than 1500 people received a life-saving transplant last year -- an improvement, but still a small number.

The marketing for opt-in could do with being more aggressive. While 69 percent of Australians believe organ donation is important, only one in three people are registered as organ donors. Perhaps there’s some risk averseness there, tip-toeing around the ultimate taboo that is death.

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Doctors themselves are keen to move to opt-out. Dr Dee Chohan, a Sydney emergency specialist, said:

“It definitely think it should be opt-out. It’s tragic people are dying waiting for organ transplants. We don’t need our organs after death and transplants save lives, so it’s ridiculous that it’s not opt-out.

"Families can also refuse organ donation, even if the person wanted to donate, which is even more tragic. I understand people are in shock when told a loved one is dying, but that is also not the time to make these decisions. It’s really important your family and next of kin know your wishes.”

It’s true that, in the current opt-in model, your family can override your wishes, even if you expressly said how important organ donation was to you. This further depletes supply.

Florida liver transplant recipient Trine Engebretsen speaks about her love of her donor family and doctors who have cared for her over the years. (Image: Getty)

Dr Aifric Boylan, CEO of Qoctor, says an opt-out system “makes sense” -- but with caveats: “It needs to be preceded by a very comprehensive public information campaign and ongoing education. Respect for individual choice is paramount.”

The Australian Medical Association is on the fence: Dr Kate Stockhausen, Manager of its Ethics Section, said the organisation doesn’t have a position on opt-in/opt-out either way. It suggests the jury is very much still out.

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Donors themselves are divided on the issue. Sydney’s Racquel Sherry, 47, received a life-saving kidney transplant in 1996, after childhood cancer. She’s passionately in favour of opt-out:

“At any time, when a person requires any other form of medical treatment, it is available to them. It’s not up for debate. However if your organs are dying you wait, and often die.

"It’s astonishing to me that people die with organs that could be given to a sick person. Organ donation is out there as one of those weird public discussions that I don’t think should be a public debate. It should be a given.

"There are people who won’t tick yes to donating their organs but will fully expect an immediate and exceptional level of care when they go to hospital.”

On that last point, Israel has an answer. It has a ‘priority incentive scheme,’ which means those who’ve agreed to donate their own or a deceased family member's organs are given priority on transplant lists should they themselves need an organ in the future.

Israel gives registered donors priority if they themselves require an organ transplant. (Image: Getty)

Patricia Scheetz, 35, from Sydney, received two organs (kidney and pancreas) eight years ago. She’s sceptical about moving to an opt-out system:

“It’ll only lead to misinformation, mistrust and community confusion -- look at what happened with My Health Record. We'd have Australians, who are usually a generous bunch of people, opting out in droves, simply because they can.”

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In December 2018, a parliamentary committee report on organ donation made a number of recommendations for the Australian government, including investigating whether an opt-out system of organ donation could help increase donation rates. This review will inform the development of a long-term strategy for organ retrieval / transplantation.

Tellingly, the government’s own organ transplant division, DonateLife, doesn’t support a move to opt-out, saying that there’s “no clear evidence that it contributes to achieving a higher donation rate.” Kidney Health Australia said it aligns with this position too.

It bases this on international evidence: In France and Brazil, variations on a "presumed consent" (opt-out) system actually led to a decline in the rate of organ donation.

While world-leading countries such as Spain and Croatia have 'opt-out' models, the practice is still to seek family approval before proceeding with donation. DonateLife points to Greece, which also has an 'opt-out' model and is one of the lowest ranking donation countries in the world. But this could be due to the fact that just three percent of Greeks are atheists, whereas, in the 2016 census, 29.6 percent of Australians reported ‘no religion.’ It’s not comparing apples with apples.

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Opt-out systems led to 25 percent higher donation rates in Austria and Singapore. (Image: Getty)

In 2017, France introduced a law that requires doctors to only inform a deceased person's relatives about which organs are to be procured, and not ask their permission. This is called a “hard opt-out” system.

Austria and Singapore both have "hard opt-out" systems, which has increased the organ donor rate by up to 25 percent.

So what should the current Australian review recommend?

If we trust our medical professionals not to prematurely declare someone dead, and our politicians to roll out a program giving everyone a clear choice, a hard opt-out system could be the way forward. It could save lives.

But we’d need to get over the taboos we create around death first.

Twitter: @garynunn1

To join the donor register visit https://donatelife.gov.au/register-donor-today