US Organ Donation Policy

Abstract

To the Editor The Viewpoint on organ donation policy maintained that the US opt-in organ donation system performs among the best in the world. 1 Donors per potential eligible donor were used as evidence despite this metric being criticized for potentially overestimating organ procurement organization (OPO) performance. 2 Organ procurement organizations self-regulate and may be incentivized to modify eligibility of missed cases to meet performance requirements. Also, countries with optout programs consider cases when death occurs unexpectedly, often termed uncontrolled donation after circulatory determination of death. Implementing uncontrolled donation after circulatory determination of death increases organ supply but with more attrition. Countries that consider higher-risk candidates have fewer donors per potential eligible donor compared with the United States, which has stricter criteria.To maintain trust, a key component for organ donation, opt-out systems initiate preservation only after judicial approval is obtained, allowing time for families to consider donation. If a family refuses, preservation is discontinued. Families rarely refuse, yielding opt-out rates exceeding 90%. 3 Much of the success of opt-out donation is attributable to functioning within universal health care systems and having physician specialists manage preservation. Unfortunately, empirical data suggest that the US public does not support opt-out donation, given cultural emphasis on autonomy and pervasive mistrust of an inequitable health care system. 4 Unless improvements in trust of the US health care system are achieved, it is unrealistic to expect increases in organ donor registration rates under either the opt-in or the opt-out strategies.We believe it is more important to establish the means for increasing organ donation opportunities through innovative policy, particularly through uncontrolled donation after circulatory determination of death. Current US policy, formulated by ethics panels sponsored by the Health Resources and Services Administration, promotes a rigid interpretation of the dead-donor rule (permanence or irreversibility), deeming it ethical to conduct controlled and live donation over uncontrolled donation after circulatory determination of death. 5 The premise is that any attempt to preserve organ function with oxygenated fluids after death invalidates prior death determination based on circulatory and respiratory criteria. This policy is not universally accepted. 3 In the United States, uncontrolled donors are not eligible, while in Europe they are. Working through this ethical conflict would likely show, using the same metric of donors per potential eligible donor, that the United States underperforms Spain, the best-performing country in the world. We believe mitigating the organ donation crisis in the United States requires modifications of policy to increase organ donation opportunities for those already willing to donate, improving OPO efficiency and accountability, and providing access to health care f...