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Can presumed consent overcome organ shortage in India? Lessons from the Belgian experience.

© The National Medical Journal of India 2012 INTRODUCTION The past quarter century has witnessed rapid advancement in the field of transplantation medicine. Various methods have been used which facilitate organ preservation, decrease organ rejection, improve organ matching, and, in general, augment the success rates of transplantation. Using the best of transplantation techniques, physicians and surgeons are trying both to overcome organ shortage and improve graft outcomes. To this end, many organ recipients are put on more effective immunosuppressant medication. Steroids, which have long been responsible for complications, are used less frequently today. This makes transplant surgery relatively safe. Minimally invasive techniques, such as laparoscopic donor nephrectomy, are used, swap transplants are encouraged and extended donor criteria are used more often now than ever before. Counselling is now an essential part of any successful transplantation programme and it is hoped that this will increase not only the quality, but also the quantity of organs available for transplantation. Despite all these efforts, waiting lists keep growing. Futuristic solutions that are looked forward to include the availability of hybrid organs that would diminish the risk of post-transplant organ rejection, as well as 3D organ printing. The large-scale application of such technologies, however, is still in the realm of science fiction. Many patients die waiting for a transplant because of organ shortage. Behind these shortages lie stories of loss of life that cause immense grief to families and friends. Some countries have introduced a system of presumed consent (opt out) in an attempt to decrease the shortage of organs. They assume that every citizen who does not opt out agrees to deceased donor organ donation. Belgium introduced the system of presumed consent in 1986. In India, the introduction of a deceased organ donation programme was initiated with the Transplantation of Human Organs Act (THOA) in 1994. Yet, 18 years after the law was passed, deceased organ transplantation is still in its infancy. Meanwhile, only a minuscule number of patients who have endstage renal or liver disease have been able to get a transplant. The rising incidence of diabetes and hypertension in India is likely to further increase the organ failure rate and the demand for organs. Given this situation, the country needs to promote the deceased organ donation programme, as well as to consider other means of increasing the donor pool. An option that has been discussed among policy-makers and the medical community is the system of presumed consent. Our close association with counsellors of the Mohan Foundation in Chennai and Hyderabad, which works towards deceased organ donation, and our knowledge of the implementation of presumed consent in Belgium allow us to reflect on whether such a model could be feasible in India. In response to those who advocate the implementation of a policy of presumed consent, we ask whether ‘transplanting’ the policy from one cultural context to another would work. Indeed, this year Belgium witnessed a major turnaround in public opinion regarding organ transplantation regulations and has reconsidered the option of presumed consent, looking at it more critically. Examining another country’s experience with presumed consent would be a good starting point to understand the pros and cons of the policy and discuss its potential impact on healthcare in India. We also highlight areas of concern that are likely to play a role in the implementation of such a policy, given the socioeconomic and political context of the country.