In the media and in educational material promoting organ donation we are constantly told that “organs are in short supply”, and that there is an urgent need to address the shortfall. From a medical perspective, the lack of availability of organs for transplantation is a problem, as the shortage of solid organs and body tissue is regarded as a threat to our healthcare system. In New Zealand, various strategies have been adopted aside from publicity campaigns to increase the supply of transplantable organs. These include paired kidney exchange schemes, policy implementation around donor compensation and the removal of disincentives to ease the financial burden for living donors. More radical suggestions include ideas about presumed consent and opt-out systems, directed “altruistic” donation and the use of expanded criteria and marginal donors. A recent initiative is the reintroduction of donation after circulatory determination of death, or donation after cardiac death (DCD). DCD was recently endorsed by the Ministry of Health in the 2016 Review of deceased organ donation and transplantation rates, which states that “increasing the number of DCD donors could be an avenue for increasing New Zealand’s overall donation rates”.
Many New Zealanders agree with organ donation as an abstract good, but most people who register their assent to donate organs on their driving licence application will have only a vague understanding of what deceased donation entails. This is not simply a reflection of public ignorance; it is also a consequence of information disclosure. When New Zealanders tick “yes” to donating their organs on their driver’s licence, it is nowhere clarified in the application process that deceased donation can occur through two main pathways: donation after brain stem death (DBD) and DCD. Nor is it explained to the prospective donor that these pathways entail different experiences for them and for the donors’ family. Additionally, unlike the UK system, which asks prospective donors which organs they would be prepared to donate after death, the New Zealand driver’s licence application asks no such questions. When I recently renewed my driver’s licence for a 10-year period in February 2017 at an inner-city Transport Agency, there were no organ donor information brochures on display or available upon request (I was sent a brochure in the mail with my renewal notice).
While all proposals to increase the supply of transplantable organs raise ethical issues, DCD raises questions around the determination of death and the difficulty of establishing an irreversible loss of consciousness as part of the DCD pathway. It thus has implications for the way we think about dignified death, and, depending on the circumstances of a person’s death, issues around the consent process. Admittedly, public information disclosure that speaks plainly about the timing of death and what donation and transplantation operations entail may be too much information for many people. Nevertheless, failure to distinguish DBD and DCD does not adequately meet informed consent criteria. If the New Zealand healthcare system does value autonomy, then the public should be entitled to information about what DCD involves. Such information is not only important in jurisdictions that already have or seek to move to opt-out systems (eg, France in January 2017), it is necessary given the time-critical manner required to facilitate DCD processes surrounding the withdrawal of cardiorespiratory support. Being required to make quick decisions about DCD, in an emergency or with little time to consider the pros and cons of the process, may make families vulnerable. It does not help, as Marck and colleagues indicate in a survey of 648 Australian healthcare providers, that many medical professionals working in this domain are also unfamiliar with processes involving DCD.1
People outside the medical profession are largely unaware of these issues, yet they raise concerns that prospective donors and their families are entitled to consider prior to checking the box on the driver’s licence application form to indicate consent to deceased donation. I do not oppose organ donation; my concern regarding DCD rests with the informed consent process. There are documents available in Australia and New Zealand for members of the public to find out about DCD; for example, The DCD Plain Language Statement published in 2010 by Australian Organ and Tissue Authority and the 2010 ODNZ Annual Report. The new-look ODNZ website also includes information about what organs people can donate. However, unless people know that the DCD pathway exists, they are unlikely to search for and read these documents. Now DCD is once again an option, we risk ‘suboptimal consent’ as bioethicists such as Kirby contend,2 if members of the public are not sufficiently informed when they check the box on their driver’s licence application saying ‘yes’ to organ donation. At the very least, in addition to stating what organs they are prepared to donate, prospective donors should be able to indicate which organ donation procedure they consent to, from a range of available options, at the time of signing their driver’s licence or joining an organ donation registry.