Sean Cheng Yishao, 19

Topic: Should organ donation after death be mandatory?

Award: High Distinction, Open Category, 2021

A discussion on the opt-out system

The Human Organ Transplant Act (HOTA) is a mandatory organ donation scheme in Singapore. All Singaporeans and permanent residents aged 21 years old will receive a letter informing them about HOTA. It must be noted that while HOTA is considered to be a mandatory organ donation scheme that presumes consent, organ donation is not completely compulsory. Any individual who voices their displeasure at this scheme can choose to opt out from HOTA. This has led to HOTA being dubbed as an “opt-out system”. In the world today, there is no organ donation scheme that is entirely mandatory; the closest system to a “mandatory” one would be opt-out systems such as HOTA. To allow for meaningful analysis of an existing policy in the status quo, this essay will be scoped to focus on whether the opt-out system should be implemented in society.

Globally, the opt-out organ donation scheme is considered to be a successful policy as it has helped increase the number of organ donations, giving more people a 2nd chance to live. However, some have criticised the opt-out system as they feel that it tarnishes the will of their deceased relatives who may be unaware of this scheme and that it violates the individual’s bodily autonomy. Instead of an opt-out scheme, some have suggested alternative measures like the mandated consent scheme. Ultimately, I argue that the opt-out system is still the best organ donation system. Nonetheless, there are some ways to improve the existing system and the opt-out system should not be done in isolation.

Indeed, the opt-out system is the best organ donation scheme as it allows for a substantial increase in organ donations. After HOTA was enacted in 1987, there was a 300% increase in the number of annual organ donations in Singapore ^[1]. Elsewhere, in Spain, their opt-out system has led to them having the highest number of organ donations in the world; in 2019, they had a whopping 49 dead organ donors out of every million citizens.

One main reason for the efficacy of this policy is that it overcomes administrative barriers. In countries with an opt-in organ donation scheme such as the US, there are significant administrative barriers that slow down the rate of organ donations. A 2005 Gallup poll attributes this to inefficiencies in the system. Consequently, this leads to a smaller proportion of organ donations. For instance, while there are around 90,000 individuals in the US seeking kidney transplants, there are a mere 14,000 donors. The opt-out system is advantageous as it helps overcome such barriers. By having a mandatory organ donation system, it presumes consent and does not require a citizen to go through complex administrative procedures to become a registered donor. This allows for increased organ donations.

Another reason for the efficacy of this policy is that it overcomes the status quo bias of citizens and aligns their altruistic interests with action. Most citizens are actually supportive of organ donations. For instance, in the UK, about 90% of citizens support organ donations. In practice, however, only 40% registered as donors. This has been attributed to the status quo bias popularised by behavioural economists. The status quo bias indicates that a citizen will be more inclined to follow a decision according to their current norms (in this case, not actively registering to donate their organs). The opt-out system overcomes this as it helps to bridge the gap between such altruistic intentions and concrete action of becoming organ donors. This helps to overcome the status quo bias of citizens and increases organ donations.

Moreover, there is a utilitarian argument for the opt-out system. Should an opt-out system be in place, there will be a significant increase in organ donations in a country. This benefits recipients of organs as they can receive a 2nd chance to live or have reduced financial costs; for instance, the British Columbia Renal Agency found that an individual can save between $35,000 to $45,000 through reduced dialysis treatment ^[2]. This leads to greater societal happiness or as Pradeep Prabhu puts it “the dead cannot be harmed” while “the living stand to benefit”.

Despite the immense benefits of this mandatory organ donation scheme, some have criticised this scheme as they feel that it violates their individual autonomy. They might feel that without an individual’s explicit consent, the opt-out system can be characterised as empowering the state with more authoritarian power and can be considered as even “theft”. This has even led to cases of severe family distress in countries like Singapore as they felt that the post-mortem dignity of their relatives was being undermined. Critics have also claimed that “presumed consent” is really more of “presumed lack of objection”. An underlying cause behind this lack of objection is ignorance about HOTA. Families might be uncomfortable with HOTA as they feel that without explicit consent by their deceased relatives, this opt-out system may violate the deceased’s bodily autonomy or potential wishes.

I argue, however, that this concept of individual bodily autonomy might be problematic. For instance, in cases of criminal investigations when the cause of death of an individual is unknown, an autopsy is conducted. An autopsy can be considered to violate the bodily autonomy of the deceased as forensic investigations have to be conducted on the cadaver. The main reason why nobody is against autopsies is that it benefits society as a whole as the information derived from the autopsy can be used to arrest criminals or ease the concerns of the relatives of the deceased. Similarly, I argue that organ donations also help society as a whole due to this similar utilitarian principle. Another parallel that can be made is how when mandatory seatbelt laws were initially implemented, they have also been criticised for violating individual bodily autonomy. However, the overall utilitarian benefit of such laws have caused such laws to be normalised.

Furthermore, the opt-out policy is still more reliable than alternative policies. In response to the cases of family distress due to the opt-out policy, some in the Singapore parliament have proposed a mandated consent policy. A mandated consent policy involves tying up the implementation of this compulsory law with routine, state-regulated tasks such as the registering of driving licences. The benefits of this policy are that it enhances an individual’s autonomy and reduces family distress due to the explicit consent given. However, mandated consent might not be a reliable policy as there are few state-regulated tasks that have such a sizable reach of the population. Common tasks such as registering driving licenses only reach about 55% of the population; significantly lower than the population outreach of HOTA. Hence, an opt-out system is still preferable due to the greater scope of outreach.

Nonetheless, this mandatory organ donation scheme of the opt-out system is not a panacea to the organ shortage situation globally. Although the opt-out system has generally been correlated with increased organ donations worldwide, it is also important to note that this might not necessarily be the sole cause for the increased organ donations. For instance, according to a study by the BMC Public Health, it might be hard to “disentangle” the importance of other causal factors such as improvements in “transplantation infrastructure” and public attitudes. In Singapore, while this mandatory organ donation policy has been instrumental in increasing organ donation rates, the fact remains that the median waiting time to get an organ is still long. For instance, for the donation of kidneys, the median waiting time is about 9 to 10 years; in contrast, countries like Spain and Croatia have a significantly shorter waiting time of about 1 to 2 years. This highlights the need for additional steps to be taken to combat the organ shortage situation.

Ultimately, in order to better deal with this organ shortage, the opt-out system must not be the sole system used. Additional measures such as better public education efforts and investments in transplantation infrastructure must be taken. The instances of family distress due to the opt-out system in countries such as Singapore are due to insufficient communication and knowledge about such policies. Currently, in Singapore, it seems that measures to educate the public about HOTA are restricted to a text format like a letter or an information booklet by LIVEON. A more effective medium of public education could be videos to the public. Apart from publicising about the opt-out system of HOTA, there should be more campaigns to increase public awareness about the opt-in system of MTERA and encourage more living donors to donate their organs.

In the final analysis, the mandatory organ donation scheme of the opt-in system should be the main policy adopted as it has been generally successful in increasing organ donations, allowing for utilitarian benefits. However, this opt-in system is not a silver bullet solution to the organ shortage situation and it is important to complement these efforts with a rigorous public education campaign and investments in transplantation infrastructure. Together, these policies can give more individuals a 2nd chance to live.

^[1] According to this document, the kidney donation rate was about 3 donations annually, but this number jumped over 300% to about 13 donations annually. Amendments to HOTA have also led to increases in organ donations to about 46 donations annually. Understanding HOTA (Singapore: LIVE ON, 2013), p.7. https://www.liveon.gov.sg/docs/info_booklets/SO20870_Hota_english2013.pdf

^[2] According to this article, the yearly amount needed to pay for dialysis treatment is about $50,000. However, the cost associated with one time treatment is between $5,000 to $15,000 making the estimated cost saved between $35,000 and $45,000. Ajnesh Prasad Professor & Canada Research Chair and Karly Nygaard-Petersen Doctoral student, “An Opt-out Organ Donor System Could Address Canada’s Shortage of Organs for Transplant,” The Conversation, September 13, 2020, https://theconversation.com/an-opt-out-organ-donor-system-could-address-canadas-shortage-of-organs-for-transplant-145088

References

1. Ajnesh Prasad Professor & Canada Research Chair, and Karly Nygaard-Petersen Doctoral student. “An Opt-out Organ Donor System Could Address Canada’s Shortage of Organs for Transplant.” The Conversation, September 13, 2020. https://theconversation.com/an-opt-out-organ-donor-system-could-address-canadas-shortage-of-organs-for-transplant-145088

2. Carney, Scott. “The Case for Mandatory Organ Donation.” Wired. Conde Nast, August 5, 2007. https://www.wired.com/2007/05/india-transplants-donorpolicy/

3. Essay. In Understanding HOTA, 7. Singapore: LIVE ON, 2013.

4. Jing, Jih Chin. “Mandated Consent – Not a Viable Solution for Organ Transplant in Singapore .” Annals Academy of Medicine Singapore 47, no. 2: 71–73. Accessed July 3, 2021. https://www.annals.edu.sg/pdf/47VolNo2Feb2018/V47N2p71.pdf

5. Liu, Jean. “Commentary: Timely to Review Our Opt-out Organ Donation Policy.” CNA, February 9, 2021. https://www.channelnewsasia.com/news/singapore/commentary-timely-to-review-our-opt-out-organ-donation-policy-9317580

6. Low, Donald. “Organ Donation: Consider Mandated Consent.” The Straits Times, May 24, 2016. https://www.straitstimes.com/opinion/organ-donation-consider-mandated-consent

7. Miller, Jordan, Sinéad Currie, and Ronan E. O’Carroll. “‘If I Donate My Organs It’s a Gift, If You Take Them It’s Theft’: a Qualitative Study of Planned Donor Decisions under Opt-out Legislation.” BMC Public Health. BioMed Central, November 6, 2019. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-019-7774-1

8. Prabhu, Pradeep Kumar. “Is Presumed Consent an Ethically Acceptable Way of Obtaining Organs for Transplant?” Journal of the Intensive Care Society. SAGE Publications, May 2019. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6475984/

9. Tai, Janice. “Organ Donations Remain Low despite Changes to Law.” The Straits Times, May 22, 2016. https://www.straitstimes.com/singapore/organ-donations-remain-low-despite-changes-to-law

10. “What Is HOTA All about?” MCI - Gov.SG. Gov.sg, August 21, 2013. https://www.gov.sg/article/what-is-hota-all-about

Disclaimer: Please note that the views and opinions expressed in the essays for the Live On Festival 2021 are those of the participants and are not endorsed by the National Organ Transplant Unit (Ministry of Health).

To learn more about organ donation and organ transplantation in Singapore, please visit www.liveon.gov.sg