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Behind success rate of transplants due to an

Behind the closed doors of the church hall, Jeni Stepien takes a deep breath in her wedding dress, her father, Michael Stepien, had been shot during a robbery years ago and cannot not walk her down the aisle as she married her fiancé Paul Maenner. Preparing herself for what’s to come, Jeni steps through the doors, smiles at Arthur Thomas, and takes his hand. Jeni has asked Mr. Thomas, a man she met the day before, to walk her down the aisle. What makes Mr. Thomas so special? Mr. Thomas received a donated heart just in time to save him from congestive heart failure. The donor heart belonged to Michael Stepien. Jeni feels her father’s heart beating in Mr. Thomas’ chest and is overwhelmed. Years of medical advancements have come to fruition in this beautiful moment: Mr. Stepien, in some form, was able to be there for one of the most important events in his daughter’s life. Stories like this always amaze us because they are so rare; but what if they did not have to be? Organ donation is the process in which Organs and tissues are surgically removed (harvested) from one person and placed into another person. This procedure is one of the greatest advancements of modern medicine as it makes it possible to save the life of someone whose organ has been compromised due to disease or injury. Currently, organ donation is completely optional and a person must give a medical establishment explicit permission to harvest their organs. Unfortunately, this means that the need for Organs far outweighs the supply and stories like that of Jeni Stepien will remain uncommon. To change this, Organ donation should be made mandatory, not a personal choice. Mandatory organ donation would eliminate much of the unnecessarily complex nature of the donation process by simplifying the required steps from finding a match, to completing a successful transplant, save more lives by making rare organs available more readily which would also  raise the success rate of transplants due to an increase in organ matching, and reduce human trafficking.The term Mandatory Organ Donation is a misnomer as it is not a system of coercion but rather a logical replacement for the current system mentioned above. Rather having to ask for explicit permission, this system asks for explicit dissent. This structure would allow medical establishments to presume automatic patient consent to donate their organs after death. Should the patient wish to, he or she can choose to remove themselves from the program and their organs will remained untouched. Additionally, the implementation of this system would not mean that every deceased patient would automatically be harvested as their organs must still be viable for transplants. As explained by the U.S. Department of Health & Human Services, the Organ donation process is as follows: an injured patient is brought to a hospital where a medical team does everything in their power to save the patient’s life; in the unfortunate circumstances where the patients’ health continues to deteriorate, they are placed on artificial or mechanical support in order to keep oxygenated blood flowing to the organs and the medical team continues to try to save the patient. If for whatever reason the patient does not survive despite the best attempts of medical professionals, he or she is then tested for brain death (irreversible brain damage at which point the patient is considered dead). The hospital notifies the local Organ Procurement Organization (OPO), as per federal regulation, that a patient is nearing death. The OPO then tests the now deceased patient to confirm whether he or she has the potential to become an organ donor. If the patient in question has viable Organs, an OPO representative begins the process of confirming the desires of the patient (whether or not they are a registered donor, the desires of the next of kin) this process alone takes a few hours. At this point if the patient can donate organs and the medical establishment has received some form of consent, the Organ Procurement and Transplantation Network (OPTN) evaluates the national database for all patients in the U.S. waiting for a transplant and generates a list of patients who match the donor. A transplant surgeon then determines whether the organ is medically suitable for the chosen recipient. The surgical team removes the organs and tissues from the donor’s body in an operating room. First, organs are recovered, and then additional authorized tissues such as bone, cornea, and skin. Finally after this long tedious process, the hospital and medical staff have just hours to get the organs to their recipients and transplant them into the waiting patient. This process, for obvious reasons, is neither the most effective nor the most efficient way to handle organ donation and mandatory organ donation would significantly simplify the process. Because the hospital would presume consent, from the point at which the patient can no longer be saved, the hospital, OPO and OPTN can begin searching for organ matches almost immediately and rather than spend many hours trying to get consent, they simply have to confirm whether or not the patient has opted-out of the donation. This significantly reduces the legal work, cost, and most importantly, the time taken to complete this process. Successfully recovering the organ of the dead patient and saving the life of its new recipient is a difficult procedure and any time delays could reduce the odds of a successful transplant. In 2017, according to UNOS, there were nearly 34,800 organ transplants. While this is a large number, it is not nearly enough for all the people waiting.There are around 90,000 new people added to the organ waiting list every month (Wickman) with a new person being added every ten minutes( UNOS) and a total of around 116,000 people at any given time waiting for life saving organs (Barone). “Between 1990 and 2003, kidney donations in the United States increased only 33 percent, but people awaiting a kidney for transplant increased by 236 percent (CITE BOOK). This lack of supply means that there are roughly 20 deaths every month (UNOS) which could have otherwise been avoided. The American Transplant Foundation says “one deceased donor can save up to eight lives through organ donation and can save and enhance more than 100 lives through the lifesaving and healing gift of tissue donation.” In light of the fact that one person can save the lives of up to eight people, it is even more disconcerting that there is an organ shortage.  The main advantage with mandatory organ donation in this respect would be that in a short period of time, it would eliminate the issue of a lack of organs for people who need them. Contrary to the popular belief that the main reason for low donor rates is because people have set preferences which they follow no matter the circumstance, a study conducted at Stanford university found that “people’s preferences can be dramatically influenced by minor variations in the phrasing of a question or by the method by which they are elicited. Such findings, in turn, suggest that preferences often are constructed on the spot and in light of the surrounding context.” To put this finding into perspective we need only look at the differnce between the donor rates of countries with opt-in systems versus the countries with opt-out systems. The study found that in the countries with opt-in systems the donor rate was around 15%. With nothing to compare it to, that number may seem like a good number. When compared to the 90% donation rate in opt-out countries however, we see that it really holds no water (Ross). This huge difference can be explained by the difference in effort and initiative required for participation. “defaults impose physical, cognitive, and in the case of donation, emotional costs on those who must change their status.”(Johnson). In other words, it simply is easier for a willing participant to be registered as a potential organ donor in an opt-out country than in an opt-in country. This means that even if a person is against donating their organs at the moment, it may not be because of their fundamental beliefs and they may not be against it if the question were presented to them differently. To further corroborate the results found in the study mentioned above, we can look at the results of another study conducted comparing the effects of defaults in organ donation systems. By surveying the responses of multiple different demographics who had not yet registered for donation, on whether or not they would donate their organs based on the different donation systems ranging from “explicit Consent” to “No choice given” the researchers reached the following conclusion: “based on donation rates in an explicit consent system (50 percent) a reform in the direction of a presumed consent system would be an improvement as the number of registered donors increases by approximately 12 percentage points, reaching a donation rate of 62 percent” (CITE comparing default systems pdf). In 2015, Wales, a european country, introduced the opt-out system and found that the number of transplants in their country rose by a third. If this trend were to be replicated in the US, then the number of transplants would jump from 34,800 to 46,284 potentially saving the lives of 11,484 more people. In an interview with The Week UK the National Health Service said “Family refusal is the biggest obstacle to donation.” After a patient’s death, if no information can be found regarding their donation status the decision falls to the family. This process is flawed as the family may not always know the wishes of the deceased patient. Additionally, as mentioned above, to be able to use the organs of the dead patient, they must be harvested within hours of the death which means that the family must make a decision fairly quickly. According to Herbert G. Lingren, following the death of a loved one,  Some of the family members’ words and actions may seem foolish and out of character to others. It is wise not to make major decisions, such as selling one’s house or moving, during this period.” Lingren also says “Anger and resentment are common emotions of bereaved individuals. It is often expressed as a protest against what seems to be a cruel, unfair and incomprehensible fate… when this happens, the individual may project this anger onto more accessible targets (e.g. spouse, family member, hospital, physician, the government) or others involved in the loss chain. Overt expressions of anger, such as verbal outbursts, sarcasm, and unreasonable or persistent demands can be expected.” If the family should not make any major decisions and are understandably traumatized, then it does not make sense to ask them to donate the organs of their loved one so soon after their death and expect a logical and comprehensive decision. Mandatory Organ Donation would provide a far more logic based system in which the family can easily decide whether or not they want to opt-out of donation long before any crisis situation arrives and compromises their decision making abilities. It is important to understand that not every person can get a donated organ simply because it is available. There are many different aspects that are taken into consideration when deciding the recipient of the donated organ. To receive an organ, the recipient must have the same blood type as the donor, they must be in a state of greater need than another recipient, they must  be available and have no current infection or other temporary reason which could affect the surgery success chance, they must be relatively close to the place where the organ is located (this varies with different organs based on their ability to live outside the body), and perhaps most importantly, their body must be of a similar size in order to accommodate organ: a newborn baby could not get the heart of a fully grown adult because the heart would not fit, similarly an adult could not get the heart of an infant because the heart would be unable to support the body. These qualifications make it difficult to find recipients even when organs are available because the recipient who is nearby may not be a match and a person who is a match may not be nearby. With the mandatory organ donation system, we have already established that the number of organs available would increase significantly and in a few years, there would be enough organs available to treat all of the patients who need them. The large increase in the number of Organs available would mean that there would be enough of every type and every size at every location. This means that with this system, in the future, medical professionals would be deciding between which organ to give a person and not which person to give an organ: a much better decision to have to consider.  Not all donors consent to sell their organs however, many people are coerced through physical and mental threats, others can be kidnapped, killed, deceived, or sold. The United Nations reported that ”as regards trafficking in children for the purpose of organ removal, although there is no conclusive evidence, a number of reports indicate that many abducted or missing children have subsequently been found dead, their bodies mutilated and certain organs removed” (CITE UN PDF). The Red Market, a subsection of The Black Market, is the illegal organization which facilitates the acquisition and sale of human body parts. The Red market is widespread and encompassed not only the underworld crime syndicates, but also well established hospitals and governments. There have many reports of people who were admitted into hospitals in Argentina, Brazil, and India for accidents or other unrelated illness that have reportedly awoken with missing kidneys (CITE BOOK). Alexis A. Aronowitz reports in his book Human Trafficking, Human Misery the case of Laudiceia da Silva. She had admitted herself in a Brazilian hospital in June 1997 to have an ovarian cyst removed but during a routine follow-up examination, it was discovered that she was missing a kidney. Unfortunately, Stories like this are not uncommon, in fact it is estimated that around 10% of all organ transplanted globally are illegal (CITE TRAFFICKING PDF). And while not all sales on the Red market are obtained illegally, those who voluntarily sell their organs usually do so because they have no other option to make money and this sees like the only option left. In his book The Red Market: On the Trail of the World’s Organ Brokers, Bone Thieves, Blood Farmers, and Child Traffickers Scott Carney says “I weigh just a little under two hundred pounds have brown hair blue eyes and a full set of teeth … At six feet and two inches I have long femurs and tibias with solid connective tissue. Both my kidneys function properly and my heart runs at a steady clip of eighty-seven beats per minute. All in I figure I’m worth about $250 000.” While this is a large sum of money, the unfortunate truth is that the organ seller often times receives a very small amount of the money acquired by the sale of his or her organ. In a study of 305 Indians, 96 percent of the organ sellers did so to escape debt. While The Organ itself sold for an average of a few hundred thousand dollars, the sellers received, on average, $1070 which was spent repaying debts, on food, and on clothing. The average family income declined after the operation, the families were still in debt, and the population living under the poverty line increased (Goyal). While there have been attempts to regulate and reduce the Red Market, they have been largely unsuccessful and it is still unknown exactly how large the criminal organization is. Mandatory organ donation could help regulate and reduce this Red Market. There are two main driving forces behind the Red Market, the buyer and the seller, the seller sells their organs because they are in need of money and the buyer buys the organ because they have been unable to get an Organ the legal way (through the waiting list). For the purposes of this paper we will focus on the buyer as the goal of this paper is not to suggest a way to solve a financial crisis but rather the problem of Organ donation. If Mandatory organ donation was implemented, then we have already established that in a few short years there would be an abundance of organs available and every person in need of one could get one in a much more timely manner than what is currently the norm. Because every person would have the ability to receive an organ the legal way in a timely manner that wouldn’t put them in danger of dying, the incentive to illegally buy an organ would no longer exist. People would much rather receive an organ from an official legalized source because even though buying the organ would mean a faster delivery, the condition of the organ itself, along with the manner of retrieval and the cost plus the fact that it is in fact against the law would mean that a slightly longer wait is worth it. Currently however, the wait time to legally obtain an organ is too long to rule out being an organ illegally. If the incentive to buy organs decreases, then naturally the sale of illegal organs will follow making organ trafficking significantly less profitable for all those involved and in a matter of years it would actually cost more to run the trafficking organization than the return it was bringing. This drop in profitability would lead to a decrease in organ trafficking all together as the main reason, the money, would no longer be there. There have been many arguments against Organ donation. The most popular of these being religion. The argument simply states  that there are many people whose religion would not allow them to donate their organs and that presumed consent would go against their religious beliefs. This argument however is based on a misconception. In a study conducted on the religious aspects of organ transplantation, it was found that “no religion formally forbids one to donate or receive organs or is against transplantation from living or deceased donors.”  Often times religious doctrines have no direct mention as to the protocols surrounding organ donation and therefore the decision lies with the individual.An often cited example of a religion that prohibits organ donation is the Jehovah’s Witness however according to UNOS “Jehovah’s Witnesses are often assumed to be opposed to donation because of their belief against blood transfusion. However, this merely means that all blood must be removed from the organs and tissues before being transplanted. Similar misconception ie around other religions and UNOS has, their website, listed the major world religions and their stances on organ donation. It can be seen that there are no major world religions that oppose organ donation. The question then arises as to the beliefs of the minor, lesser known religions who may not support organ donation. It would be quite difficult to attempt to follow every desire of all the world religions without running into ethical and legislative conflict. For example in the Sikh religion, one is required to carry a religiously symbolic dagger with them at all times. One can imagine the conflicts this religious requirement would create in a great many countries. If there was a religion which strongly opposed organ donation, then it would be in the believers power to opt-out of the system therefore not breaking the desires of this religion. In the United States another major point of discussion is the constitutionality of  mandatory organ donation, the conflict states that to presume consent and take the organs of a deceased person without their consent is a violation of their rights and freedom of choice and therefore unconstitutional. While in the US, the laws dealing with organ donation support this argument, there are other aspects of medicine in which presumed consent is already practiced. For example, according to the U.S. Department of Health & Human Services “medical examiner laws authorize the autopsy of deceased persons for unexplained deaths without requiring consent or permission by the deceased person’s family.” This law is justified by saying that the health and safety of the public overrides the interests of a deceased individual.  If this justification is enough to justify the examination of a body through surgical means, then why not for organ donation in which the surgery is actually saving the lives of up to 8 other people? If one person can save eight other people, is it not health and safety?why would this not merit the overruling of  the interests of a deceased individual? Another major point of disagreement for mandatory organ donation is that if it were set into place then many doctors may not try to the best of their ability to help the patient and may hasten the death of said patient in order to obtain the organs for another patient. In reality, the U.S. Department of Health and Human Services says that “The medical team trying to save the patient’s life and the transplant team are never the same team.” Even with a system of mandatory organ donation, this rule would not be altered and the team of medical professionals providing the patient with care would know whether or not the patient had chosen to opt-out of the system. As stated by the Cleveland Clinic: “Only after brain death has been confirmed and the time of death noted, can organ donation become a possibility.” This means that until the patient is beyond medical help, the medical professionals will still try to the best of their ability to help the patient survive. Other common arguments against mandatory organ donation include: The proposed change implying that the deceased patient’s body belongs to the State as soon as they are dead, an offensive assumption, the reduced significance of the act of donating an organ, organ removal could be distressing for the living family, and a terminally ill patient or his/her relatives would be made to feel selfish if permission was withheld. While all of these arguments are true, they are based on sentiment and not laws or facts. The real question here would be whether it is more important to preserve the sentiments of a few families who are already in traumatic shock, or  to save the lives of those who are still alive. The US government,as we have seen above, has chosen the latter with regards to autopsy, so why not for organ donation? Finally as to the point regarding patients and families being made to feel selfish, this is more of a problem with the current system than with the proposed revision. Currently, the doctor must ask in person whether or not the patient and family would like to donate and if the family would like to say no they are still made to feel selfish. In the revised system however, the family can decide ahead of time to say no and opt-out without having to feel selfish in front of a stranger who has asked them this difficult question.

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