Elective Ventilation and Opting-In or Opting-Out

The biggest UK bioethics story of this past week (apart from the on going attempt to ruin the NHS by the Tory led coalition) has been the BMA's report 'Building on Progress: Where Next for Organ Donation Policy in the UK' which proposes and considers a number of ways in which the supply of organs suitable for transplantation might be increased. Public discussion has been particularly focused on the idea of 'elective ventilation' which involves extending life support to patients who will derive no benefit from the treatment (although since they will derive no benefit it is questionable if it can be called treatment). Dominic Wilkinson, an Australian Consultant Neonatologist and Assistant Professor of Medical Ethics at the University of Adelaide, discusses the ethics of elective ventilation here, on Oxford's Practical Ethics blog and here, cross posted on the JME blog. Broadly speaking elective ventilation is where the sole reason for commencing or extending 'life support,' i.e. artificial ventilation, is to allow for the harvesting of organs in the best possible condition for transplantation. 

In a subsequent post Wilkinson also argues that elective ventilation should not be elective but should, in fact, be obligatory (the post is here on the practical Ethics blog and here on the JME blog). In brief his view is that because the process elective ventilation is designed to facilitate involves, in the first instance, the determination of the individual's wishes regarding organ donation then it should be done as a matter of course as not doing so would risk denying a potential donor the chance to become a donor. Since being ventilated would be of only minor inconvenience to those who do not wish to donate their organs then it would seem that, in cases of uncertainty, ventilating dying patients is the right thing to do. 

As it is the case that all patients determined to be brain stem dead are ventilated prior to this being ascertained elective ventilation has once again become a question as Donation after Circulatory Death (DCD) has become a more common occurrence over the past decade. Although there may be practical problems engendered by putting people on life support when you otherwise would not do so (it may create problems down the road when you wish to withdraw it) and although there will be a need to significantly increase the resources required I am inclined to agree that elective ventilation should become standard practice. However I think this question of whether elective ventilation should be standard practice is interestingly related to another very common aspect of the organ donation debate and once again raised by the BMA report. This is whether appearing on the organ donation register should be a matter of opting-in or opting-out.

It has always seemed to me that whether we should have an opt-in or opt-out system is, in the final analysis, a democratic question and should, therefore, be related to the predominant view regarding donation in any particular culture, society or polity. If the view of most people is that they do not wish to donate their organs then appearing on the organ donation register should be something one has to actively seek out. One should have to opt-in. If, on the other hand, the majority feel donating their organs is something they would like to do then the right approach would be to have an opt-out system. In effect, a register of all those who do not wish to donate their organs. This same approach can, I think, be mapped onto the idea of elective ventilation. If the majority wish to donate then it seems right to, essentially, begin the process of donation by ventilating the individual whilst the necessary checks are made. If, on the other hand, the majority do not wish to donate then it seems that electively ventilating individuals as standard practice is not the right thing to do. It would be an unwarranted interference in the dying process of most individuals in this situation. If this is the case, that most people do not wish to donate and there is an opt-in system, it seems to me that the onus should be on those who wish to donate to make their views clear and on the donation system charged with recording those views to be more responsive.

Of course, in the UK, the facts of the matter are that the majority of people are willing to donate but that we still have an opt-in register for organ donation. Furthermore far fewer people appear on the register than would apparently be willing to donate according to surveys. Furthermore, perhaps out of caution or simply grief, families often refuse organ donation even when the indications are that the individual would have wished to donate their organs. This is unfortunate and moving to an opt-out system would, I think, appropriately reflect the wider consensus and help to prevent these sorts of eventualities. Once we have this system in place, and as part of the process of it becoming fully embedded in medical culture and wider social norms, then elective ventilation should become standard practice.

However, I think for the time being the focus should be on instituting an opt-out system as elective ventilation should be seen as consistent with that kind of system and not with the current opt-in register. As an opt-out system would more accurately reflect the wider views of society and the views of most individuals instituting a policy of elective ventilation without moving to such a system is something of a distraction. We should focus on the strategy most likely to be successful i.e. to produce the larger number of organs. This has to be an organ donation register that we opt out of. Only then should elective ventilation become non-elective and standard practice.