To Be (a Donor) or Not to Be? A Question Older than Shakespeare

By Johain Ounadjela

Peer Reviewed

I still remember filling out the application form for my driver’s license at the Redwood City, California Department of Motor Vehicles. I was 16 years old and ready to zoom around the city without the watchful, critical eyes of my parents in the passenger seat. At the bottom of the page, I noticed a box asking me whether I would be willing to register as an organ donor; without a second thought, I checked the box and felt a sense of pride that I might one day save someone’s life. When I returned home and relayed this excitement to my family, to my surprise I faced the disappointment of my mother; she fiercely disagreed with my choice and could not bear the thought of her body being desecrated after her death.

The history of organ transplantation dates back to the Ebers Papyrus, an Egyptian medical papyrus from 1550 B.C.E. that mentioned skin grafting for the treatment of burns. The Indian surgeon Sushruta was credited with the first full-thickness skin grafts in 600 B.C.E.1 As humanity advanced, so too did its fascination with transplantation, culminating in the first successful non-skin organ transplant by Joseph Murray in 1954: a kidney transplant between identical twins.2 As progress in transplantation accelerated over the next 70 years, we now live in a time when pig-to-human xenotransplantation may one day become common practice.3

However, this progress has not come without challenges. Ethical dilemmas abound. These include but are not limited to deciding on who receives a transplant, the objectification of humans, whether recipients’ needs should be prioritized over donors’ needs, and whether social factors should influence a recipient’s place on the candidate waiting list.4 Public attitudes have grown increasingly positive towards organ donation but may not reflect actual practice; for instance, a 2019 survey of 10,000 US adults found that 90% of adults support organ donation but only 60% are actually signed up as donors.5 This discrepancy may be due to a variety of personal factors, including a lack of medical knowledge, mistrust in the healthcare system, and cultural beliefs.6,7 In the case of my mother, a radiologist with substantial knowledge of medicine, her beliefs were strongly influenced by our Islamic religion and the sanctity of the human body. I was interested to learn that she is not alone; studies have shown that Muslims in western countries have more negative attitudes toward organ donation than individuals from other religious backgrounds.8

Although this is a microcosm of a vast array of beliefs towards a complex subject, one thing is certain: there are not enough organs. In 2023, over 46,000 transplants (the majority of them kidneys) were performed, yet over 103,000 people remain on the waiting list.9 There are two methods broadly used for organ donation post-mortem: the opt-in and opt-out systems.10 The former necessitates explicit consent from potential donors, such as when I checked the organ donor box on my driver’s license application. The latter constitutes presumed consent; if this system were practiced in the US, my mother would have to check a box on her application stating that she did not want to be a donor. Otherwise, it would be presumed that she had consented to donating her organs. One could expect conflicts with this system, as someone might forget to opt out and have their organs extracted after their death against their wishes. Mandating citizens to report a choice could solve this issue but would force individuals to make a choice when they might not be comfortable making one.10 Ideally, an opt-out system would lead to more available donors, as the default is to donate and activation energy is required to remove oneself from consideration. Indeed, in the most recent International Registry in Organ Donation and Transplantation 2022 report, there were only two opt-in countries in the top 15 of deceased donors per million people: the US (2nd) and Canada (15th).11,12

When looking under the surface, however, it is not as straightforward as it might seem. Studies have shown that increased donor rates in opt-out countries may not be clearly attributed to the opt-out system alone, and may be confounded by varying implementations of the system.10,13 One study found no significant difference between deceased donor rates in opt-out and opt-in countries, even finding that living donor rates declined in opt-out countries.14 The country most often cited as evidence of the opt-out system’s superiority, Spain (1st in deceased donor rates, with >40 deceased organ donors per million population ), has a practically defunct opt-out system with no official register and always seeks family approval.14 It has instead concentrated its efforts on education and infrastructure, improving its ability to effectively recognize donation opportunities, ease the transition to donation, and bolster public support for donation after death.15 Regardless of the system used, common attitudes suggest it may be most important to prioritize the individual’s recorded wishes after death, involve appropriate surrogate decision makers if there is no recorded preference, maintain a functional register, and maximize ease of registering.16

When Sushruta was performing the first skin graft in India and Joseph Murray was transplanting the first kidney in Boston, I wonder if they ever thought that in 2014, a 16-year-old would be debating with his mother over whether to join the hundreds of millions of people worldwide who were signed up as organ donors. Countless lives have been saved because of their work, for which we are grateful. However, there remain countless lives to save and much work to be done in optimizing the organ supply that is not as simple as opt-in vs opt-out. Next time your mother scolds you for wanting to sign up as an organ donor, consider engaging her in a deeper conversation. I know I will.

Johain Ounadjela is a Class of 2026 medical student at NYU Grossman School of Medicine

Reviewed by Michael Tanner, MD, Executive Editor, Clinical Correlations

Image courtesy of Wikimedia Commons, source: https://commons.wikimedia.org/wiki/File:Shakespeare_Droeshout_1623_From_the_First_Folio_Edition.jpg

References

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2. Deivasigamani S, Phillips B, Yeo CJ, Tholey RM. Joseph Murray: Pioneering plastic surgeon and father of the first organ transplant. Am Surg. 2023;89(4):871-874. doi:10.1177/00031348211048843

3. Montgomery RA, Stern JM, Lonze BE, et al. Results of two cases of pig-to-human kidney xenotransplantation. N Engl J Med. 2022;386(20):1889-1898. doi:10.1056/nejmoa2120238

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5. U.S. Department of Health and Human Services, Health Resources and Services Administration, Healthcare Systems Bureau. 2019 national survey of organ donation attitudes and practices: report of findings. https://www.organdonor.gov/sites/default/files/organ-donor/professional/grants-research/nsodap-organ-donation-survey-2019.pdf. Published February 2020. Accessed February 13, 2024

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8. Ali A, Ahmed T, Ayub A, et al. Organ donation and transplant: The Islamic perspective. Clin Transplant. 2020;34(4):e13832. doi:10.1111/ctr.13832

9. U.S. Department of Health and Human Services Health Resources & Services Administration. Organ donation statistics. https://www.organdonor.gov/learn/organ-donation-statistics. Published February 2024. Accessed February 13, 2024

10. Lewis A, Koukoura A, Tsianos G-I, Gargavanis AA, Nielsen AA, Vassiliadis E. Organ donation in the US and Europe: The supply vs demand imbalance. Transplant Rev. 2021;35(2):100585. doi:10.1016/j.trre.2020.100585

11. International Registry in Organ Donation and Transplantation. Final numbers 2022. https://www.irodat.org/img/database/pdf/IRODaT_Newsletter_2022.pdf. Published December 2023. Accessed February 13, 2024

12. Spuentrup SS. Does implementing opt-out solve the organ shortage problem? Evidence from a synthetic control approach. ifo Working Papers. 2023;(403).

13. Ezaz G, Lai M. How the “opt-in” option optimizes organ donation rates. Dig Dis Sci. 2019;64(5):1067-1069. doi:10.1007/s10620-019-05483-z

14. Arshad A, Anderson B, Sharif A. Comparison of organ donation and transplantation rates between opt-out and opt-in systems. Kidney Int. 2019;95(6):1453-1460. doi:10.1016/j.kint.2019.01.036  https://pubmed.ncbi.nlm.nih.gov/31010718/

15. Matesanz R, Domínguez-Gil B, Coll E, Mahíllo B, Marazuela R. How Spain reached 40 deceased organ donors per million population. Am J Transplant. 2017;17(6):1447-1454. doi:10.1111/ajt.14104

16. Hyde MK, Masser BM, Edwards AR, Ferguson E. Australian perspectives on opt-in and opt-out consent systems for deceased organ donation. Prog Transplant. 2021;31(4):357-367. doi:10.1177/15269248211046023

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