Perspectives on Opt-Out Versus Opt-In Legislation for Deceased Organ Donation: An Opinion Piece

Does implementing opt-out solve the organ shortage problem? Evidence from a synthetic control approach

In light of the persistent shortage of organ donations needed to save precious human lives, several countries have modified their organ donation laws by introducing an opt-out system, making every deceased a potential organ donor unless the person has objected. This study examines the impact of adopting opt-out on organ donation rates. Using a panel dataset covering a 21-year period, I apply a synthetic control approach to focus on countries that changed their prevailing organ donation legislation from opt-in to opt-out. I compare them to a synthetic counterfactual from countries that have kept their legislation the same since 1999. Synthetic control estimates show that Argentina and Wales achieved substantially higher organ donation rates with the shift from an opt-in to an opt-out system than without the reform taking place. My findings suggest that as one strategy among others, implementing opt-out cannot solve the organ shortage problem entirely but effectively contributes to reducing it considerably.

A Test of Autonomy Restoration Postscripts to Mitigate Psychological Reactance to an Opt-Out Organ Donor Registry in the United States

The organ shortage continues to present problems around the world including the United States. In response, some countries have switched from an opt-in organ donor registry to an opt-out registry. The United States currently utilizes an opt-in registry where an individual is not considered an organ donor until they register their intentions. In the current study, U.S. adults were randomly assigned to a 2 (message valence: promotional, refutational) x 2 (autonomy restoration postscript: present, not present) x 2 (social proof: high likes, low likes) posttest only control group design evaluating social media message regarding an opt-out organ donor registry for implementation in the U.S. Results revealed an interaction between message valence and autonomy on freedom threat perceptions toward the message. Consistent with psychological reactance theory, freedom threat perceptions were positively associated with reactance, which in turn was positively associated with an intention to sign a petition and call a representative to voice disapproval of the opt-out organ donor registry. The discussion is focused on pragmatic recommendations for organ donor practitioners and advocates as well as the theoretical contributions to reactance theory.

Early experiences of deemed consent legislation for organ donation in Nova Scotia: a qualitative study

PURPOSE

In 2021, Nova Scotia, Canada, became the first jurisdiction in North America to adopt a deemed consent organ donation system under its revised Human Organ and Tissue Donation Act. This study sought to understand the early experiences of program staff and clinicians involved in implementing this legislation.

METHODS

We conducted semistructured interviews with members of the provincial organ donation program and intensive care unit and emergency department clinicians (n = 14). Two investigators coded transcripts of interviews, then categorized the coded data into themes.

RESULTS

We identified four key themes: 1) legislation has limited impact on daily practice; 2) legislation does not address existing barriers; 3) legislation aids conversations with donor families; and 4) legislation should provide more autonomy to patients and families, not less.

CONCLUSION

Deemed consent legislation had limited impact on clinician's day-to-day practices, because of lack of infrastructure changes and infrequent donation opportunities. Nevertheless, participants felt the introduction of deemed consent in Nova Scotia eased conversations between families of potential donors and clinicians. These findings should be used to inform ongoing implementation of deemed consent and be considered by those contemplating similar legislative changes.

The right to know from the opt-out effectiveness system perspective in organ transplantation cases

OBJECTIVE

Aim: This article examines the legal challenges associated with opt-out and opt-in systems in transplantation cases. It focuses on the low public knowledge and awareness of the national transplantation system, assessing its compliance with international prerequisites for an opt-out system. The analysis centres on the "right to know" perspective and the effectiveness of opt-out in organ transplantation. .

PATIENTS AND METHODS

Materials and Methods: The research methodology includes scientific principles, public surveys, relevant regulations from the Republic of Latvia and EU, and grey literature on the health system and organ donation in the EU. Scientific articles from databases such as Scopus and WOS were selected based on criteria such as language (English and Latvian) and focus on living wills and comparisons of organ donation systems. Previous EU and national studies, reports, and court judgments were used to analyse data on opt-in and opt-out transplantation systems and policy efficiency in organ transplantation.

CONCLUSION

Conclusions: Individuals' right to autonomy over their bodies extends even after death, encompassing the right to integrity. Organ donation, being a deeply personal choice reflecting one's values and beliefs, plays a crucial role in saving lives through transplantation. To enhance cooperation and donation rates, international regulations stress the significance of public awareness regarding organ and tissue transplantation. Unfortunately, inadequate compliance by authorities and low awareness pose ethical and legal dilemmas, potentially violating constitutional rights. Reports highlight limited public understanding of transplantation systems, raising concerns, particularly in opt-out systems. National governments bear the responsibility of safeguarding these rights and addressing challenges beyond legal means, thus establishing a more ethical organ donation system that upholds voluntariness, generosity, and individual autonomy.

Updates in Kidney Transplantation From the 2022 Banff-Canadian Society of Transplantation Joint Meeting: Conference Report

Purpose of the Conference

The 2022 Banff-Canadian Society of Transplantation Meeting in Banff, Alberta, brought together transplant professionals to review new developments across various aspects of solid organ transplantation (SOT) in Canada.

Sources of Information

Presentations included consensus recommendations from expert-led forums; experiences with new procedures and legislation; reports from public health data repositories; original clinical and laboratory research; and industry updates regarding novel technologies. Speakers referenced articles and reports published in peer-reviewed journals and online, and unpublished data and preliminary findings.

Methods

All authors attended presentations in-person or virtually. Recordings of select presentations were available for later review. Summaries emphasize concepts indicated by speakers as new and clinically relevant.

Key Findings

The COVID-19 pandemic disproportionately affected solid organ transplant recipients (SOTRs), who experience worse outcomes of COVID-19 infection than the general population. Vaccinations demonstrate an attenuated immunological response in SOTRs yet provide meaningful protection. Monoclonal antibodies are effective for both passive immunization and treatment of COVID-19 in SOTRs. Infection control protocols have driven the development of virtual methods for clinical research, such as using home blood draws and virtual follow-up to evaluate vaccine efficacy in SOTRs; and patient care delivery, such as employing telerehabilitation post transplant. Access to living kidney donation is limited by various disincentives experienced by potential donors, which may be overcome by more efficient evaluations including a One-Day Living Kidney Donor Assessment Clinic. The International Donation and Transplantation Legislative and Policy Forum provided a means of establishing consensus guidance for organ donation and transplantation (ODT) program policy to standardize delivery across jurisdictions. The implementation of a deemed consent model for organ and tissue donation in Nova Scotia may provide insight as to whether this model indeed improves access to organs. Canada's Indigenous population experiences unique barriers to transplantation, prompting efforts for more inclusive ODT policy-making. The Pan-Canadian ODT Data and Performance Reporting System Project has defined performance quality indicators, of which iTransplant and other point-of-care software solutions may facilitate collection; however, these endeavors ultimately require information technology infrastructure that exceeds the capabilities of the existing Canadian Organ Replacement Register and Canadian Transplant Registry. Pig-to-human xenotransplantation requires genetic modification of pigs and xenoantibody testing in recipients but may yet prove viable. Serum cell-free DNA, urine biomarkers, and genetic markers offer an alternative to routine biopsy for identifying subclinical rejection. Modified perfusion temperatures and perfusion solutions with hydrogen sulfide donor compounds may improve organ preservation. Molecular compatibility tools provide another means of improving SOTR outcomes, and the Genome Canada Transplant Consortium has been examining important considerations of their implementation.

Limitations

We were unable to capture all presentations and topics at the meeting due to the sizable quantity and variety. Topics ultimately excluded from this summary include those in pathology including Banff Classification updates; those unique to extra-renal SOT; as well as numerous abstract and poster presentations, allied health provider forums, and business meetings. A portion of the material was presented by speakers prior to peer-review or publication.

Implications

The various conference presentations summarized in this report identify methods by which individual clinicians and provincial ODT programs may improve access, delivery, and quality of SOT care in Canada, while additionally identifying gaps in the literature that investigators are encouraged to pursue.

How Large is the Potential of Brain Dead Donors and what Prevents Utilization? A Multicenter Retrospective Analysis at Seven University Hospitals in North Rhine-Westphalia

Organ donation after brain death is constantly lower in Germany compared to other countries. Instead, representative surveys show a positive attitude towards donation. Why this does not translate into more donations remains questionable. We retrospectively analyzed all potential brain dead donors treated in the university hospitals of Aachen, Bielefeld, Bonn, Essen, Düsseldorf, Cologne and Münster between June 2020 and July 2021. 300 potential brain dead donors were identified. Donation was utilized in 69 cases (23%). Refused consent (n = 190), and failed utilization despite consent (n = 41) were reasons for a donation not realized. Consent was significantly higher in potential donors with a known attitude towards donation (n = 94) compared to a decision by family members (n = 195) (49% vs. 33%, p = 0.012). The potential donor´s age, status of interviewer, and the timing of the interview with decision-makers had no influence on consent rates, and it was comparable between hospitals. Refused consent was the predominant reason for a donation not utilized. Consent rate was lower than in surveys, only a known attitude towards donation had a significant positive influence. This indicates that survey results do not translate well into everyday clinical practice and promoting a previously documented decision on organ donation is important.

The rights and interests of First Nations, Métis, and Inuit in debates over deemed consent legislation for deceased organ donation in Canada: calls to action

Nova Scotia, Canada is the first jurisdiction in North America to pass deemed consent legislation for organ donation. Individuals medically suitable to be deceased organ donors are considered to have authorised post-mortem organ removal for transplantation unless they opt out of the system. While governments do not have a legal duty to consult Indigenous nations before passing health legislation, this does not diminish Indigenous interests and rights in relation to the legislation. This analysis discusses impacts of the legislation, specifically intersectionality with Indigenous rights, trust in the healthcare system, transplant inequities, and distinctions-based health legislation. How governments engage Indigenous groups about the legislation is yet to unfold. Consultation with Indigenous leaders and engagement and education of Indigenous peoples is, however, key to moving forward legislation that respects Indigenous rights and interests. What happens in Canada is being watched globally, as deemed consent is debated as a solution to organ transplant shortages.

VA, A. KB, S. B, K. K, J. D, J. WM, Tennankore KK. Estimated Impact of Deemed Consent Legislation for Organ Donation on Individuals With Kidney Failure: A Dynamic Decision Analytic Model

BACKGROUND

There is little data modeling the impact of deemed consent legislation (eligible individuals who do not register their decision to decline to be a donor are presumed to consent after death) on outcomes for individuals with kidney failure.

OBJECTIVE

To estimate the change in life-years (LYs) and quality-adjusted life-years (QALYs) resulting from different changes in the rate of deceased donor kidney transplantation associated with deemed consent legislation and health system transformation.

DESIGN

Dynamic Decision Analytic Model.

SETTING

This modeling study included kidney failure patients in Atlantic Canada (all of whom receive their kidney transplants in Halifax, Nova Scotia). The adoption of deemed consent legislation was the intervention, and opt-in (the status quo) was the reference comparator.

PATIENTS

Prevalent kidney failure patients at the end of 2019 in all of Atlantic Canada (N = 3615) served as the starting population.

METHODS

We compared expected outcomes between the intervention and comparator. Changes in QALYs and total LYs were modeled under different changes to the proportion of patients receiving a deceased donor kidney transplant (from -10% to 20%) resulting from deemed consent relative to the status quo. Changes in QALYs and LYs were reported for 3 different time horizons (5, 10, and 30 years). Uncertainty around QALYs and total LYs was reported using 95% confidence intervals (CIs) constructed from a probabilistic sensitivity analysis using 1000 Monte Carlo Simulations.

RESULTS

The increase in QALYs ranged from 7 QALYs (95% CI: 5-10) with a 5% increase using a 5-year time frame to 882 QALYs (95% CI: 619-1144) with a 20% increase over a 30-year time frame. Parallel changes in total LYs were also observed. In contrast, decreases in deceased donor kidney transplantation resulted in a loss of QALYs (for example, -463 QALYs; 95% CI: -633 to -306 for a 10% decrease over a 30-year time frame). Using the most optimistic scenario (a 20% increase), there was an 18% increase in the cumulative number of deceased donor kidney transplant recipients over a 30-year observation period.

LIMITATIONS

The results are subject to uncertainty depending on changes to the dialysis or transplant population that were not modeled and that may not be fully captured with probabilistic sensitivity analysis.

CONCLUSIONS

Deemed consent legislation will lead to variable changes in QALYs and total LYs for the kidney failure population, depending on the degree to which deceased donor transplantation rates change and the time horizon of observation. This modeling study may serve as a baseline to monitor the future impact of deemed consent legislation.

A Qualitative Content Analysis of Comments on Press Articles on Deemed Consent for Organ Donation in Canada

BACKGROUND AND OBJECTIVES

In 2019, two Canadian provinces became the first jurisdictions in North America to pass deemed consent legislation to increase deceased organ donation and transplantation rates. We sought to explore the perspectives of the deemed consent legislation for organ donation in Canada from the viewpoint of individuals commenting on press articles.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In this qualitative descriptive study, we extracted public comments regarding deemed consent from online articles published by four major Canadian news outlets between January 2019 and July 2020. A total of 4357 comments were extracted from 35 eligible news articles. Comments were independently analyzed by two research team members using a conventional content analysis approach.

RESULTS

Commenters' perceptions of the deemed consent legislation for organ donation in Canada predominantly fit within three organizational groups: perceived positive implications of the bills, perceived negative implications of the bills, and key considerations. Three themes emerged within each group that summarized perspectives of the proposed legislation. Themes regarding the perceived positive implications of the bills included majority rules, societal effect, and prioritizing donation. Themes regarding the perceived negative implications of the bills were a right to choose, the potential for abuse and errors, and a possible slippery slope. Improving government transparency and communication, clarifying questions and addressing concerns, and providing evidence for the bills were identified as key considerations.

CONCLUSIONS

If deemed consent legislation is meant to increase organ donation and transplantation, addressing public concerns will be important to ensure successful implementation.

Web-Based Perspectives of Deemed Consent Organ Donation Legislation in Nova Scotia: Thematic Analysis of Commentary in Facebook Groups

Background

The Canadian province of Nova Scotia recently became the first jurisdiction in North America to implement deemed consent organ donation legislation. Changing the consent models constituted one aspect of a larger provincial program to increase organ and tissue donation and transplantation rates. Deemed consent legislation can be controversial among the public, and public participation is integral to the successful implementation of the program.

Objective

Social media constitutes key spaces where people express opinions and discuss topics, and social media discourse can influence public perceptions. This project aimed to examine how the public in Nova Scotia responded to legislative changes in Facebook groups.

Methods

Using Facebook's search engine, we searched for posts in public Facebook groups using the terms "deemed consent," "presumed consent," "opt out," or "organ donation" and "Nova Scotia," appearing from January 1, 2020, to May 1, 2021. The finalized data set included 2337 comments on 26 relevant posts in 12 different public Nova Scotia-based Facebook groups. We conducted thematic and content analyses of the comments to determine how the public responded to the legislative changes and how the participants interacted with one another in the discussions.

Results

Our thematic analysis revealed principal themes that supported and critiqued the legislation, raised specific issues, and reflected on the topic from a neutral perspective. Subthemes showed individuals presenting perspectives through a variety of themes, including compassion, anger, frustration, mistrust, and a range of argumentative tactics. The comments included personal narratives, beliefs about the government, altruism, autonomy, misinformation, and reflections on religion and death. Content analysis revealed that Facebook users reacted to popular comments with "likes" more than other reactions. Comments with the most reactions included both negative and positive perspectives about the legislation. Personal donation and transplantation success stories, as well as attempts to correct misinformation, were some of the most "liked" positive comments.

Conclusions

The findings provide key insights into perspectives of individuals from Nova Scotia on deemed consent legislation, as well as organ donation and transplantation broadly. The insights derived from this analysis can contribute to public understanding, policy creation, and public outreach efforts that might occur in other jurisdictions considering the enactment of similar legislation.

An Ethical Defense of a Mandated Choice Consent Procedure for Deceased Organ Donation

Organ transplant shortages are ubiquitous in healthcare systems around the world. In response, several commentators have argued for the adoption of an opt-out policy for organ transplantation, whereby individuals would by default be registered as organ donors unless they informed authorities of their desire to opt-out. This may potentially lead to an increase in donation rates. An opt-out system, however, presumes consent even when it is evident that a significant minority are resistant to organ donation. In this article, we defend a mandated choice framework for consent to deceased organ donation. A mandated choice framework, coupled with good public education, would likely increase donation rates. More importantly, however, a mandated choice framework would respect the autonomous preferences of people who do not wish to donate. We focus in particular on the Australian healthcare context, and consider how a mandated choice system could function as an ethical means to increase the organ donation rate in Australia. We make the novel proposal that all individuals who vote at an Australian federal election be required to state their organ donation preferences when voting.