Issues Concerning Consent

Gloria Taylor, M..A., Professional Services Coordinator and Staff Ethicist and James Wolf, M.D., Director of Medical Affairs, United Network for Organ Sharing.

The UAGA also outlines a consent process for donation. It describes who can complete this process and provides a vehicle, the donor card, for the process. The donor card by virtue of the UAGA is a legal document. Nonetheless, organ and tissue recovery agencies in the United States rarely act solely on the presence of a donor card. The majority of organ and tissue recovery agencies will seek permission from the next of kin for donation even in the presence of a signed donor card. In a recent survey performed by the UNOS Council for Organ Availability in which 65% of all organ recovery agencies responded, only three (7%) of the recovery agencies responded that they would act on a signed donor card in all situations. Typically, in the absence of any family member, and after a diligent search, the recovery agencies will act on a donor card.

Another vehicle for stating one's donation wishes is an advance directive. These legal documents were created by the 1990 Patient Self-Determination Act and do vary somewhat from state to state. Some states do not honor an advance directive unless the patient is terminally ill. The ability to express one's wishes regarding organ and tissue donation is founded in the ethical principle of autonomy. Autonomy renders respect to the decision-making capabilities of individuals and opens the door to issues of informed consent, privacy and confidentiality.

The concept of consent for organ and tissue donation in turn opens the door to a variety of opinions all with enormous possible ethical repercussions. In response to the organ shortage, ideas for alternate methods of gaining consent for donation have been proposed. Suggestions of the adoption of presumed or implied consent, mandated choice, and routine salvaging to the idea of preferred status have been presented. Many of the recommendations allow for some type of opting "in" or opting "out" mechanism. The UNOS Ethics Committee evaluated the notion of presumed consent and proposed an alternative reform called "required response." In a required response plan, all adults would be required by public authorities to express their preferences regarding organ donation. They would have the option of indicating a willingness or objection to donation. Additionally the individual would have an option of delegating the donation decision to their legal next of kin or designated surrogate. Many doubts concerning various alternative mechanisms for consent are founded in ethical concerns. Fear, distrust, coercion, and the devaluation of the individual are some of the generalized concerns.