Thursday, 29 March 2018

Presumed Consent

Recent movements on presumed consent have spurred me to action on this long-planned post. There’s a lot of waffle about the private members bill that recently passed its second reading being a historic event, it’s not, it’s symbolic rather than a practical step change.  
Few private members bills become law, this one is stronger than most in that it has cross-party support and is welcomed by the Prime Minister and the much-maligned Health Secretary, but there are still powerful religious lobbies who oppose its passage.
All this will actually do is bring England into line with Wales, by adopting a soft-opt out system that has yet to demonstrate a major uplift in donations from the deceased. One problem is that a key blocker for recovering organs remains in place; the donor’s next of kin can still overrule the presumption of consent, in fact this can happen now even where a donor has explicitly given their consent.
I’ve seen arguments that increasing life spans are part of the problem, that as people die at an older age there are less healthy organs available. I’m not entirely convinced. Because a donor was old donor doesn’t mean the organ isn’t viable, in some cases it will be true, but it depends on the donor and the organ. Kidneys tend to lose function naturally over time, but some organs like the liver are remarkably resilient. Besides a kidney that gives ten years free of dialysis is better than nothing, especially as medical science moves forward to longer term solutions.
A more fundamental problem this bill will not address is the required investment in the transplant system needed to drive up utilisation of donated organs. The Spanish system is considered a golden standard in this respect; time, money and energy have been spent on the systems and processes needed to drive up donation rates.
One intriguing argument is to allow people to sell their organs, though there’s an undoubted taboo about this which causes an instinctive recoil in some people. No doubt it goes on around the world, where it is associated with economic coercion and the exploitation of the poorest and most vulnerable. But there remains a utilitarian case around its efficacy in saving lives, the economic rationale is sound, and the ethics of free will are a counterbalance to allegations of exploitation. Still, breaking through such strong moral objections is a challenge.
My own personal views on presumed consent are conflicted. Once upon a time I believed it to be an oxymoron, accept this and you could presume consent for anything you like regardless of whether you were likely to get it or not. There’s a whole slippery slope of consequentialism for brighter thinkers than me to mull over. These days I’m not so sure.
I don’t like special pleading and given I’m likely to need a transplant in the next ten years or so, I could very quickly descend to that. So, I need a good argument.
There are obvious benefits of taking organs from dead people who don’t need them anymore and giving them to sick people who do need them, but expropriating stuff from people because they don’t need it isn’t usually associated with responsible authority. There is a crucial distinction, the organs have no intrinsic value to anyone other than the suitable candidate for transplant.
Whilst watching the first series of The Frankenstein Chronicles I was struck by an argument used by a Resurrection Man, you cannot steal a dead person’s body from them. This makes sense, they don’t own it any longer and it’s not part of an estate to be passed to an heir in the manner of a house or jewellery. You don’t keep Granddad’s vital organs on the mantelpiece. I’m sure some people will disagree with this, but outside of a few Indonesian communities I’m pretty sure they won’t keep the decomposing body around for very long.

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