AMA backs review of presumed consent on organ donations

Chicago -- The AMA decided at its Annual Meeting in June to conduct a review of methods to increase organ donation -- a move that is likely to set the stage for a spirited debate between physicians who find presumed consent unethical and those who say it will save lives.

Although the timing is hard to predict, the board will likely refer the issue to the Association's Council on Ethical and Judicial Affairs, said CEJA member Robert Sade, MD, which will then issue a report for AMA delegates to consider either in December or next June.

The AMA's current opinion on presumed consent (which presumes everyone is willing to be a organ donor unless they have documented an objection to it) is that the concept is not unethical, but there has to be a foolproof opt-out system before the AMA supports it.

Several African-American doctors spoke against endorsing presumed consent, saying it will worsen minority distrust of the health care system. Other physicians argued that -- with 17 people dying each day waiting for an organ -- everything that can be considered should be considered.

"There's nothing intrinsically unethical about presumed consent, so it's definitely something that's worth looking at," said Dr. Sade, a professor of surgery at the Medical University of South Carolina in Charleston. But he added that the current "opt-in" system has been problematic, so he said devising a system in which the choice to opt out is documented and honored will probably prove to be equally as difficult to manage.

AMA prefers mandated choice

With this in mind, Dr. Sade said the AMA supports a "mandated choice" system, in which people are required to declare their choice on organ donation when getting their driver's license or during some other government-mandated task.

Phil Berry, MD, a Dallas-based orthopedic surgeon and previously the AMA's most outspoken supporter of presumed consent, did not attend the Annual Meeting but arrived in Chicago later that week to speak at the Assn. of Organ Procurement Organizations' annual meeting.

"My whole take on this is that what we're doing now is still not working," said Dr. Berry, who received a liver transplant almost 18 years ago and is a member of U.S. Health and Human Services Secretary Tommy Thompson's Advisory Committee on Organ Transplantation. "There's a whole laundry list of things we could do, and presumed consent is one of them."

In Dr. Berry's absence, presumed consent supporters at the AMA meeting invoked his status as an ACOT member to further their cause, but another ACOT member in attendance spoke out against the policy.

Michael A. Williams, MD, a Baltimore neurologist and surgeon, said he opposed presumed consent.

He added that ACOT was working on other measures that may prove more promising -- including studying how other institutions could replicate the programs of hospitals with the top organ-donation rates. He said this approach is working and noted that his institution, The Johns Hopkins Hospital, is nine-for-nine this year in getting the families of organ donor candidates to donate.

Minority patient concerns

Health care finance expert Owen Garrick, MD, a representative of the AMA Minority Affairs Consortium, said minorities often feel their lives are not valued, and this resolution may deepen the feeling of mistrust. He added that presumed consent would violate AMA policy requiring mandatory full disclosure.

Maryland internist Willarda Edwards, MD, said that as director of the NAACP Health Division, she has witnessed firsthand the mistrust minorities have in the health care system and has worked to reverse it.

"[Minority] patients have a concern that their organs would be taken when there's still a possibility that they could be kept alive," Dr. Edwards said in an interview after the meeting.

"I'm all for increasing our donors, but I don't think presumed consent is the best way to do it," she added. "I know that there's a mistrust, because I'm the one going around saying you should sign up."

During a June 15 Joint Commission on Accreditation of Healthcare Organizations news conference, presumed consent, financial incentives and mandated choice were cited as policy initiatives worth studying in demonstration projects.

The news conference was held to announce the release of a new report outlining ways to cut the shortage of available organs. Other strategies included not letting families overrule a dying patient's previously expressed desire to donate; and better treatment of hypertension and diabetes to cut the rate of organ failure and thereby reduce the need for transplants.