A serious proposal on organ donation

The issue of presumed consent (see earlier posts in Jan '08: 1 2 3 4) has been raised once more, as the BMA is saying that the number of organs is not sufficient to meet the demand (BBC). The BMA wants the issue of presumed consent to be raised as a way to increase the supply of organs. As my previous posts indicate, I am sceptical of presumed consent. I don't think the state owns my body, or ought to presume to tell people what to do with it, even once they are dead.

The real thing we ought to be debating, and which no-one is willing to do, is the question of paying for organs. We pay for medicines. We pay for medical tools. We pay for surgeons' skills. We pay for hospitals. We pay for practically everything in the health service, but we don't pay for organs.

There are reasons why we don't: the weakest, I think, is an aesthetic distaste for paying for organs; the strongest is the observation that there will be pressures on the poorest to put themselves in permanent difficulty by selling their organs for hard-needed cash. I certainly accept that that is a difficulty, and so I would propose something a bit different. After all, there does come a point when we don't need our organs any more, a time when they could be used (if they are in a usable condition) to help someone else. Rather than presuming the consent of the deceased, why don't we compensate the estate of someone whose organs are transplanted on death?

Before I anticipate a couple of objections, let me point out that this would affect small estates the most. The payment would be flat rate, and so the proportionate effect would be greatest at the lowest end, and also the entire compensation would accrue to the estate, rather than attracting death duty. Given that inheritance is one of the major wealth transfers, boosting the estates of poorer people by a large proportion would be socially beneficial as well.

And now, let me approach the aesthetic distaste I think people may feel at even this small proposal to change the structure towards payment. My belief is that our gut reaction arises because we have an idea that organs used in transplantation should be an altruistic gift. I don't know what the ethical reasoning is which makes us so certain of this conclusion, but I do know that people find it hard to be altruistic when they don't know the recipients personally: witness the fact that many transplanted kidneys, the most highly-demanded organs, come from a relative or close friend of the recipient. So let's move the altruism closer to home, and let people see more clearly the benefit to people they know and love.

There is then a further sticking-point, which is that bereaved relatives often refuse permission for the organs to be removed, even when the deceased wished that to be the case. I don't think most grieving relatives would be crassly counting the inheritance when the doctors come to ask for permission to take any usable organs, and I don't think that dangling a payment to the estate in front of them should be used to change their minds. That would be as exploitative as presumed consent, and more insidious. But the issue of compensation will place the organ issue in a different frame, which is that the relatives are being asked to administer a part of the estate while it can still be used.

Apart from an emotional reaction, what's the problem? We need more organs, and treating organs as part of the estate provides an opportunity to calibrate people's interests without using the cudgel of law to do it.