The revised UAGA (2006) challenges the Patient Self-Determination Act (PSDA), which is enshrined in living wills and individual declarations on the use of end-of-life support systems. The challenges arise from the UAGA`s review of the standard choice on presumption of intent to donate and the use of life support systems to ensure medical suitability of organs for transplantation. The default choice takes precedence over the intention expressed in a person`s will to live to refuse and/or remove life support systems at the end of life. The revised UAGA (2006) overrides living wills for utilitarian reasons, posing a serious ethical challenge to society. The subtle evolution of the revised UAGA (2006) towards the presumption of disposal of organs in the event of death may pave the way for an affirmative « obligation to donate ». At least two steps are needed to solve these challenges. First, physicians and hospitals must fulfill their responsibility to educate patients about new laws and document their preferences for using life-sustaining systems for end-of-life organ donation. Second, a broad societal debate must be launched to decide whether the revised UAGA (2006) violates the PSDA and the individual`s right to autonomy. The discussion should also address other ethical concerns raised by the revised UAGA (2006), including the moral position on 1) interpreting the rejection of life-sustaining systems as inapplicable to organ donation and 2) disregarding the diversity of cultural beliefs about end-of-life in a pluralistic society. The revised UAGA (2006) states that if a donor has a gift document, there is no reason to seek consent from the donor`s family, as they do not have the right to give it legally . If a person has not drafted an act of donation during his or her lifetime, the Revised UAGA (2006) assumes the intention to donate organs and has therefore expanded the list of persons (in Article 9a) who may consent to organ donation on behalf of that person. The revised UAGA (2006) assumes that every person has the right to donate their organs at or shortly before death. If a person prefers not to donate, this must be documented in an explicit and signed refusal.
If it is determined to be a potential donor, the revised UAGA Article 21 (2006) creates a standard rule requiring that measures necessary to ensure the medical fitness of an organ for transplantation cannot be withheld or withdrawn. The initiation and/or continuation of life support systems is the standard rule and takes precedence over a potential donor`s expression in a living will not to prolong life through life support systems. To resolve the tension between the presumed intention to donate organs and the express intention not to administer life-sustaining systems solely to prolong life, section 21 assumes that, for a potential donor, the desire to save lives through anatomical donation outweighs the desire to refuse life support systems. The revised UAGA (2006) requires a potential donor to explicitly indicate contrary intentions in order to prevent the use of life support systems for organ donation purposes, whether in a declaration or living will. It is an open access article distributed under the terms of the Creative Commons Attribution (creativecommons.org/licenses/by/2.0) license, which allows unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The use of life support systems for organ donation without explicit consent is contraindicated at the end of life and contradicts recommended practice guidelines for quality palliative care [19,22]. Life support systems have no palliative benefit and inflict unwarranted traumatic and distressing experiences on dying patients and their families [23,24]. While Article 21(b) (2007) recognizes the apparent conflict between life-sustaining systems for organ donation and adequate end-of-life care for dying patients, the amendment is not sufficient to protect patients and families from possible violations of their rights to quality palliative care.
Section 21(b)(2007) requires the treating physician to assess contraindications to end-of-life care and the need to preserve organs, which can only be done after completion of the medical examination by the OPO to determine whether a patient qualifies as a potential donor. Paragraph 21(b) (2007) also includes the OPO as an agent to assist in the resolution of conflicts related to end-of-life care, but the same agent has other undisclosed incentives, i.e., to maximize opportunities to obtain organs . There are no real safeguards in place to prevent the OPO from prolonging or manipulating end-of-life decision-making for potential donors in order to obtain consent to donation. The revised UAGA Section 14 (2006) was drafted in accordance with the Federal Control Act requiring hospitals to notify an organ procurement authority (OPO) of any person whose death is imminent or who has died in hospital, in order to increase the possibilities of obtaining organs for transplants . In the case of potential organ donation, a patient who is deceased or close to death is given the necessary steps to ensure the medical fitness of an organ for transplantation in order to determine if the patient could be a potential donor. This provision applies to sudden cardiac death or death outside the hospital when resuscitation fails . Organ preservation requires the administration of life support systems until the BOO determines whether a patient can be a potential donor. Revised paragraph 14(c) of the UAGA (2006) requires that life support systems already administered to a patient referred to the AOO for assessment continue until it is determined that the patient has organs medically fit for transplantation. This section applies to a patient who is already on a life support system in the emergency room or intensive care unit at the end of life.
Lax medical fitness criteria for donation is of particular concern for patients who become potential donors without donation documentation and who have clear living wills expressing the intention to refuse and/or withdraw end-of-life support systems (Figure 1).1). In these circumstances, the revised UAGA (2006) requires the treating physician to address and resolve the conflict between the use of end-of-life systems and adequate end-of-life care with families and/or surrogate decision-makers while the patient continues to follow life support systems.