Bill Barrable was chief executive officer of BC Transplant from 1994 to 2009
A new campaign is being organized in Canada to make organ donation automatic unless you specifically decide to opt out.
During my 15-year tenure as chief executive of BC Transplant we researched the efficacy and agonized over the ethics of presumed consent as a means to improve the deceased organ donor rate in British Columbia, and indeed across Canada. This is what we found.
In countries that had passed presumed consent laws, only three had donor rates higher than Canada's: Austria, Belgium and Spain. When we looked closer we discovered that in none of these jurisdictions was presumed consent the reason for the higher donors per million rate of donation. The reasons for differences had more to do with how people were dying and the definition of organ donor in that individual country. For example, Spain has a mortality rate from motor vehicle accidents that is more than 50 per cent higher than Canada's. (Spain doesn't require helmets to drive two-wheeled vehicles.) It simply has a lot more medically suitable candidates who meet the criteria of brain death for donation. Canada is a healthier and safer place to live than Spain, which is great unless you are waiting for an organ for transplant. Spain should be aspiring to Canada's accident mortality profile.
Further research showed that Canadians are at least as generous, if not moreso, in giving their consent to organ donation when their wishes are recorded. Confounding comparisons is that the definition of an organ donor is more conservative in Canada than Spain. In Spain, only consent must be given for a person to be counted as a donor whereas in Canada at least one organ from a donor must be transplanted successfully into a recipient to meet this definition. It is not uncommon for organs to be found medically unsuitable for transplantation following recovery. We are comparing apples to oranges.
Spain and Austria also have a surplus of physicians who are employed to identify and refer potential organ donor candidates in their hospitals. The ethical acceptability of this role in a critical care setting in Canada, where a potential conflict of interest emerges, is open for debate.
Presumed consent is not a panacea for the problems faced in organ donation, as these are complex issues.
The United States follows first-person consent, whereby the recorded wishes of the donor are not allowed to be overridden by anyone, including health care providers. Meanwhile each province in Canada has an anatomical gift Act which gives the recorded wishes of the potential donor the same legal protection as an advance directive or living will. Morever, a national public opinion survey by Marktrend revealed that 80 per cent of Canadians did not want their wishes overturned by next of kin.
Not surprisingly, The Globe's current online poll shows a clear distaste for the adoption of presumed consent among its readers. Presumed consent elicits similar reactions to negative option billing adopted by members of the telco industry in years gone by.
It's disheartening to read that Canada's rate of deceased donation per living Canadians is the same as it was a generation ago, but even more concerning is that the exact same issues are still being debated. It's time to move ahead. Perhaps it would be best for Canadian organ recovery agencies and hospitals to first start by honoring the rights of donors by following their recorded wishes, unfettered by others, and then start comparing apples to apples before drawing conclusions on what strategy will work best in a Canadian environment.