Andy Tookey: Give donors first priority

Opinion

New Zealand has one of the lowest organ-donor rates in the Western world. Despite three years of lobbying and parliamentary select committee hearings last year, the number of donors was just 40 people.

The three years have not been wasted, though. After a lot of red tape, wrangling and arguing, changes are in the pipeline, even though some are unenthusiastic token efforts on behalf of the Government and the Health Ministry.

In some countries, health ministers are enthusiastic about organ donation reform. Here, Annette King sits on the fence and won't commit to anything until advised by bureaucrats.

Though the coming changes in practice will no doubt see a small rise in the number of organ donors, it will never be enough to meet demand. This means thousands will die unnecessarily, buried next to people who had the power to save lives but chose not to donate.

These people may have been willing to be organ donors but did not realise that it is not their choice. It is their family's choice - whatever the definition of "family" is these days. It may be they were one of the 40 per cent of potential donors whose relatives vetoed a request for the gift of life. In New Zealand, autonomy dies with the patient.

However, during my research, I came across an innovative solution that could not only improve the donor rate but wipe out the waiting list for organ transplants.

A non-profit group in the United States, called Lifesharers, aims to do just that by circumventing the red tape of government and running its own organ donor club. It's simple, it's fair, anyone can join for free, and it's effective.

Its premise is that if you are not prepared to be a donor, your place on the waiting list should be below those who are registered donors. This causes more people to sign up as donors, and even benefits those who refuse to donate but are happy to receive.

I am in touch with my American counterparts to consider implementing such a system here.

About 70 per cent of today's transplanted organs go to recipients who are not prepared to be donors, and many of those willing to be donors go without. Justice would connect the business of organ procurement with the matter of organ distribution.

Access to organs for transplantation should be linked to the willingness to be an organ donor. The right to receive a donated organ should be tied to the duty to offer to donate organs.

In transplantation, the criterion is need, not contribution, thereby wiping out incentives to contribute. Many of those who would not donate organs would still accept an organ if they needed one. These people are willing to benefit from a common resource without investing anything to create it.

A problem with the system by which donor organs are rationed is that it takes no account of, indeed it encourages, the free rider - the person who hopes to benefit from the co-operation of others even though he does not himself contribute to the socially desired end. Although it is in each individual's interest that donor organs are available, it is in no one's interests to make his or her own organs available.

On Monday, Jack can express his religious or aesthetic opposition to organ donation, and on Tuesday, perhaps after being diagnosed with life-threatening liver failure, immediately enter a waiting list for a new liver. Julie, who may have expressed a lifelong willingness to donate, may have encouraged her family and friends to declare their intentions to donate, will enter the waiting list under the same terms and with the same waiting time as Jack.

If we are skittish about giving Julie preference over Jack, we must remember that the system of organ donation depends on the goodwill of organ donors. In a world of Jacks, there would be no organ donation.

Our system relies solely on altruism to motivate donation. Altruism is a fine thing but it is in short supply. Relying purely on altruism for organ donations would certainly be ideal, but it is not worth the loss of many lives annually.

We may hope for love but should plan on self-interest for the sake of ourselves and our children. This new system would replace a system based on handouts with one based on individual responsibility.

People are motivated more by self-interest than by altruism. To increase organ donation, the incentive needs to be aligned with self-interest. Agreeing to give the gift of life would no longer be an act of pure altruism; it would be an insurance policy. Even the most selfish individuals would be willing to become a donor if it gave them greater access to the hearts or livers that might save their lives.

Those who want to give priority to those who were, and still are, willing to donate need not want to exclude other people from organs. All that is needed is an interest in furthering and rewarding morally fair contributions to practices that lie in the interest of all.

People may feel compassion for those who do not contribute as well as with those who do contribute, but still may feel the need to give priority to those who are contributors if a choice must be made because of scarcity. And this is an ethically respectable motive.

The benefits of registering under a priority incentive programme clearly exceed the costs. Even after registering, it is extremely unlikely that a registrant will donate organs because it is rare to die with organs medically eligible for transplantation. Potential donors can make the trade-off between the remote possibility of becoming an organ donor and the not-quite-so remote possibility of needing an organ.

Opponents of the scheme may say it's not fair. In fact, it makes the organ allocation system fairer. What isn't fair is giving an organ to someone who won't donate their own when there is a registered organ donor who needs it. It's like awarding the Lotto jackpot to someone who didn't buy a ticket.

When you die, you can bury your organs, cremate them, or donate them and save lives. When those are your only choices, deciding not to donate is a spectacularly selfish thing. People who make that decision have no moral claim to an organ transplant.

Without donors there can be no organ transplants.

Opponents may also claim that it is a slippery slope. They are wrong. Giving organs first to women doesn't produce more women, and giving organs first to Christians doesn't produce more Christians. But giving organs first to organ donors produces more organ donors, and that saves lives. The goal of our organ donation system should be to save lives, not to spread deaths equally among groups.

As long as people who refuse to be a donor can jump to the front of the waiting list if they need a transplant we'll always have an organ shortage.

The solution to the shortage is simple - if you don't agree to donate your organs when you die, you go to the back of the waiting list if you ever need an organ to live.

* Andy Tookey is the promoter of GiveLife NZ, an organ-donation reform lobby group.