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Contemporary Issues in Medical Jurisprudence

Honours

“Should Scotland Follow the Lead of Wales and Introduce an Opt-

Out System of Organ Donation?”

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Organ donation has become a topic of widespread debate across the UK. Scotland

has made significant progress in raising awareness of the importance of organ

donation, and from 2007-2013 there has been 74% increase in the number of people

in Scotland who have donated their organs after death1. However, whilst this

achievement has undoubtedly benefited many people, the demand for organs by

those in need across the country still vastly outstrips supply. Several potential

changes to the current opt-in system of organ donation have been suggested. Wales

has led the way in adopting a new donation system, and from 2015 will operate an

opt-out organ donation policy. The question this essay seeks to address is, should

Scotland follow their lead? To establish whether such a decision would be

meritorious, we must first consider the current Scottish position, and why it is in need

of change. Subsequently, we shall investigate the implications of an opt-out organ

donation system, discussing the potential benefits of this scheme, and also

considering the possible objections to this method of organ donation. Finally, having

weighed up the pros and cons of opt-out donation, we shall establish whether

Scotland should indeed follow the lead of Wales in changing the donation system.

Why is Change Necessary?

Organ transplantation, and the subsequent need for organ donation, is not a new

phenomenon. In 1902 Alexis Carrel pioneered the surgical joining of blood vessels,

making the transplantation of organs feasible for the first time2. Surgical

transplantation of organs from deceased as well as living donors began shortly after

WW2, and the UK’s first living kidney transplant took place in 1960 at Edinburgh

Royal Infirmary3. Since then, organ transplantation has grown into a worldwide

practice enhancing the lives of thousands each year. Continued improvement in

medical technology has led to an ever growing demand for organs outstripping the

available donor supply4. According to Organ Donation Scotland, there are currently

616 people waiting for a transplant in Scotland today5, but last year only 341 organ

transplants were carried out6. It can be seen therefore that whilst a great number of

organs are being donated, it is not sufficient to meet the current need. This problem

is exacerbated by the fact that although 65-90% of the population would be willing to

donate, only 30% are registered, and around 40% of families refuse donation even

1 No Author Information, “Number of Organ Donors Rises by Nearly 100% in Six Years”, Organ

Donation Scotland, April 2014, Viewed 3rd

April 2014, https://www.organdonationscotland.org/news-events/number-of-organ-donors-rises-by-nearly-100-in-six-years 2 No Author Information, “NHS History of Organ Donation”, NHS Choices, March 2013, Viewed 3

rd

April 2014, http://www.nhs.uk/Tools/Pages/transplant.aspx 3 Ibid.

4 No Author Information, “WHO Guiding Principles on Human Cell, Tissue and Organ

Transplantation”, World Health Organisation, May 2010, Viewed 3rd

April 2014, http://www.who.int/transplantation/Guiding_PrinciplesTransplantation_WHA63.22en.pdf 5 No Author Information, “Tell Me More”, Organ Donation Scotland”, No Date Information, Viewed 3

rd

April 2014, https://www.organdonationscotland.org/tell-me-more 6 Ibid.

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where the deceased had registered their consent7. The sad reality is that many of

those waiting for an organ in Scotland will die still waiting. Patients on the liver

transplant list have a 20% chance of dying before receiving a transplant, and the

figure is higher for those waiting on a heart8. This chronic shortfall of organs is not

confined to Scotland. There were almost 8000 people awaiting transplants across

the UK in 2012, with 4200 transplants being carried out9. The UK transplant waiting

list is increasing by around 8% per year, and given our ageing population the gap

between demand and supply will only continue to grow10. Despite the continued rise

of UK organ donation rates (with a 34% increase since 2008), the need for organs is

now at a minimum of 50% more than is currently available11.

Numerous barriers to organ donation exist, and the past decade has seen great

efforts to encourage donation to take place. Legal measures include the Human

Tissue Act 200412, and the Human Tissue (Scotland) Act 200613. Alongside these

measures, the UK Organ Donation Taskforce (henceforth Taskforce) was

established in 2006, to identify the barriers to donation and make recommendations

on how we could increase donation within the current legal framework.14Scotland

and the rest of the UK operate an opt-in system for organ donation, whereby persons

have to make their wishes known by joining the NHS Organ donation register,

carrying a donor card or telling members of their family. Where a person dies, the

register is checked, and regardless of whether they have registered or not relatives

are still asked for agreement before donation15. The Taskforce Report made

recommendations to improve donation rates, believing that with these rates would

increase by 50% in five years without changing the donation system16. Despite

donations increasing, the 50% target has not been met, and calls are now being

made for the Taskforce to reconsider its stance on a move away from an opt-in

7 Abadie, A., Gay, S. `The Impact of Presumed Consent Legislation on Cadaveric Organ Donation: A

Cross Country Study`, Journal of Health Economics, Vol. 25, Issue 4, July 2006, Pg 599-620 8 Reilly, H. “BMA Scotland Submission in Support of Petition PE1453”, Scottish Parliament Public

Petitions Committee”, January 2013, Viewed 4th April 2014,

http://www.scottish.parliament.uk/S4_PublicPetitionsCommittee/General%20Documents/PE1453_C_BMA_Scotland_10.01.13.pdf 9 No Author Information, “Statistics – Transplants Save Lives”, NHS Blood and Transplant – Organ

Donation, August 2013, viewed 4th April 2014, http://www.organdonation.nhs.uk/statistics/index.asp

10 Rithalia, A., Mcdaid, C., Suekarran, S., Myers, L. And Sowden, A. `Impact of Presumed Consent for

Organ Donation on Donation Rates: A Systematic Review`, British Medical Journal: Research, January 2009, Viewed 4

th April 2014, http://www.bmj.com/content/338/bmj.a3162

11 Buggins, E, “The Potential Impact of an Opt Out System of Organ Donation in the UK – An

Independent Report from the Organ Donation Taskforce”, NHS Blood and Transplant, November 2008, Viewed 5

th April

2014,http://www.nhsbt.nhs.uk/to2020/resources/ThepotentialimpactofanoptoutsystemfororgandonationintheUK.pdf. 12

Human Tissue Act 2004 13

Human Tissue (Scotland) Act 2006 14

See Footnote 10 15

No Author Information, “Presumed Consent for Organ Donation”, The Patients Association, No Date Information, Viewed 5

th April 2014, http://www.patients-association.com/Default.aspx?tabid=192

16 See Footnote 11

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system17. In response to the ever growing demand for organs, Wales has become

the first country in the UK to change their organ donation system, to opt-out or

“presumed consent”. Should Scotland follow their lead? We must consider what the

method to be adopted by Wales’s entails, both in potential benefits, and objections to

this type of system which have discouraged its implementation until now.

What Does Opt-Out Mean?

In the 1990’s, the British Medical Association (BMA) began looking at ways in which

the organ donation system could be improved to reduce the number of avoidable

deaths and increase the number of lives that could be transformed by a transplant18.

This resulted in a policy campaigning for an opt-out system of organ donation,

alongside new legislation and infrastructure19. The campaign to change to opt-out

garnered support in 2008 from the Chief Medical Officer and the Prime Minister20,

and drew both support and opposition from the public. As a result of the ongoing

debate over the merits of an opt-out system, the Welsh Government published a

white paper outlining proposals to adopt an opt-out consent system for organ

donation in 2011. The results of a consultation on this paper showed strong public

support for the Welsh Government to pursue legislative change and introduce a soft

opt-out system21. After a draft Human Transplantation (Wales) Bill and further

consultation, the Human Transplantation (Wales) Act 201322 (hereafter Human

Transplantation Act) was passed. Therefore from the 1st of December 2015, the Act

will introduce a soft opt-out system for consent to deceased organ and tissue

donation. But what does a “soft opt-out system for consent” involve?

Under an opt-out or presumed consent system, every person living in that country is

deemed to have given consent to organ donation, unless they have specifically

opted out by recording their unwillingness to donate. This type of scheme can then

be sub divided into either “hard” or “soft” opt-out. In a hard opt-out system as in

Austria, organ recovery proceeds unless it is known that the deceased objected

before death, and the views of relatives are not actively sought.23. By contrast, in a

soft opt out system such as in Spain, even where the deceased has not opted out

the views of their relatives are still sought, and any objection they express will be

17

Mercer, L. `Improving the Rates of Organ Donation for Transplantation`, Nursing Standard, Vol. 27, Issue 26, February 2013, Pg 35-40 18

English, V. “Building on Progress: Where Next for Organ Donation Policy in the UK?”, British Medical Association, February 2012, Viewed 6

th April 2014, http://bma.org.uk/working-for-

change/improving-and-protecting-health/organ-donation 19

Ibid. 20

Mercer, L. 2013, Pg 37 21

No Author Information, “Proposals for Legislation on Organ and Tissue Donation: A Welsh Government White Paper”, Welsh Government Consultation Document, November 2011, viewed 6

th

April 2014, http://wales.gov.uk/docs/dhss/consultation/111107orgdonwpen.pdf 22

Human Transplantation (Wales) Act 2013 23

No Author Information, “Opt In or Opt Out”, NHS Blood and Transplant, April 2014, Viewed 6th April

2014, http://www.organdonation.nhs.uk/newsroom/statements_and_stances/statements/opt_in_or_out.asp

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respected24. S3 of the Human Transplantation Act provides that transplantation

activities are lawful if done in Wales either with express consent, or with deemed

consent25. “Deemed consent” tells us that this is an opt-out system, and provisions in

S4 allowing for objections on behalf of the deceased by relatives mean that this is a

soft opt-out system26. This new consent law will apply to those aged over 18 who die

in Wales, if they have lived in Wales for more than twelve months. Organs made

available under this new system will be the same as previously in the opt-in method,

and any organs donated in Wales will be available for transplant patients across the

UK. Soft opt out organ donation systems have gained a great deal of support, and

we shall now consider whether such a system would be valuable for Scotland. .

Do Opt-Out System’s Benefit Countries Operating Them?

Supporters of introducing opt-out organ donation system to the UK believe that

establishing an automatic right to take organs when the donor has not expressed

wishes the contrary would lead to a significant increase in the number of potential

donors27. In passing the Human Transplantation Act, ministers in Cardiff stated that

there is a desperate need to increase transplantation rates in Wales, and that the

opt-out system is hoped to increase donations by around a quarter28. These beliefs

are based on evidence from other European countries that currently operate opt-out

systems as to their organ donation rates, with the Kidney Wales Foundation stating

“deemed consent has a positive and sizeable effect on organ donation rates of some

25% to 35% higher on average in presumed consent countries”29. Several European

countries have opted to change their legislation and introduce a presumed consent

system. The Taskforce commissioned research on the impact of a system of

presumed consent, by comparing countries who had switched to those who stayed

with opt-in, and comparing donation rates in the countries who implemented

presumed consent before and after the change was introduced30.

In the before and after studies, all of the countries reported an increase in organ

donation rates following the systems introduction. In Austria for example, the 4.6

donors per million population per year increased to 10.1 in the four years after the

legislation was introduced31. Similarly, of the comparative studies between opt-in and

opt-out system countries, those of sufficient quality found that opt-out practice was

24

Ibid. 25

S3(1)(a) and(b) respectively, Human Transplantation (Wales) Act 2013 26

S4(4)(a) and (b) Human Transplantation (Wales) Act 2013 27

See Footnote 23 28

Riley-Smith, B. “Opt-Out Organ Donation Will Treat Bodies Like Clapped Out Cars”, The Telegraph, July 2013, Viewed 7

th April 2014, http://www.telegraph.co.uk/health/healthnews/10154686/Opt-out-

organ-donation-will-treat-bodies-like-clapped-out-cars.html 29

Saul, H. “Opt-Out Scheme for Organ Donation Given Go-ahead in Wales”, The Telegraph, July 2013, viewed 7

th April 2014, http://www.independent.co.uk/news/uk/home-news/optout-scheme-for-

organ-donation-given-goahead-in-wales-8684984.html 30

See Footnote 10 31

Ibid, Pg 3.

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associated with increased rates of donation32. Council of Europe data on organ

donation rates show that the UK does not fare well internationally especially in

comparison to Spain, who were one of the first countries to legislate on the matter33.

As of 2008 Spain has the highest donation rate in Europe, with 35 donors per million

of the population, whilst the UK had one of the lowest at only 13 donors per million of

population34. As such the Spanish system is held in high regard as evidence of a

successful presumed consent system, and the benefits an opt-out system can bring.

However, there are several reasons as to why Spain’s high level of organ donation

may not actually be related to their change to an opt-out system.

The President of the Spanish Transplant Organisation has spoken on the issue,

stating that he does not believe that opt-out is the reason for high donation rates. He

believes that it was not the 1979 change in legislation, but rather by the

implementation of a new comprehensive procurement system and changes in

organisational infrastructure ten years later35. The operation of the Spanish system

also casts doubt onto the impact presumed consent has had. There is currently no

register of people who have opted out, and the wishes of individuals are therefore

only known by those with whom they may have discussed them. Thus it has been

argued that this system is fundamentally no different to the UK opt-in system, where

relatives can overrule the deceased’s wishes36. In “Building on Progress”, the BMA

highlighted that there are many factors which can influence donation rates, and

some of these are more easily changed that others. Medical infrastructure, more

intensive care beds, and the number of deaths following road traffic accidents all

play their part in adjusting a countries donor rate37. It is therefore quite possible that

implementing an opt-out system is not the reason behind Spain having the highest

donor rate in Europe. Similarly, the adoption of an opt-out system in Sweden has

had no effect on their organ donation rate, which is currently even lower than that in

the UK38. We must therefore bear these variables in mind when assessing the

potential benefits of changing to an opt-out system for Scotland. Nonetheless,

Taskforce research showed an association in all countries surveyed between

implementing presumed consent legislation and higher organ donation rates. Whilst

estimates of the size of effect varied, with some studies reporting a 20-30% increase

in donation and others only two more donors per million population39, this paper

would suggest that even a small increase in donations would be massively

32

See Footnote 8 33

See Footnote 18 34

Ibid. 35

See Footnote 23 36

Mercer, L. 2013, Pg 37 37

See Footnote 18, Pg 10 38

Weissberg, P. “Organ Donation in Wales: Making Opt-Out a Reality”, British Heart Foundation, April 2013, Viewed 8

th April 2014,

http://www.bhf.org.uk/pdf/Organ%20Donation%20in%20Wales%20Making%20Opt%20Out%20a%20Reality%20April%202013.pdf 39

See Footnote 10

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beneficial, and on this basis perhaps Scotland should follow the lead of Wales in

changing to presumed consent.

This is not a decision to be taken lightly. Recent surveys showed public support of

64% for such a change40, The BMA stated that “overall an opt-out system is better

for recipients as there are more organs available, better for donors as it is more likely

their views will be respected, and better for relatives because it is more likely that the

individuals own wishes will be known41.” But to what extent is this statement correct?

Does an opt-out system make organ donation better for both donors and their

relatives? Many objectors to opt-out would argue the contrary. As such, to decide

whether Scotland should follow the lead of Wales in moving to this system, we must

consider the variety of objections that professionals and the public hold against

implementing a presumed consent system, and whether such objections validate

refraining from change.

Objections to an Opt-Out System for Scotland

Whilst there are a wide range of different objections to a system of opt-out organ

donation, this paper does not have the capacity to discuss all of the issues at hand.

Therefore, it is prudent to focus on the ethical and practical considerations

highlighted by the BMA as crucial to the development of an opt-out system in

Scotland. The first of these is concern over the effect of an opt-out system on the

principles of consent and autonomy.

Consent and Autonomy

The World Health Organisation’s guiding principles for donation state that tissues

and organs may be removed for the purposes of transplantation provided that any

consent required by law is obtained, and there is no reason to believe that the

deceased objected42. One fear with a presumed consent system is that people may

not get around to registering an objection, and therefore a person who has not

wished to consent has had their wishes overruled after death43. Others argue that

rather than the presumed consent model relieving relatives of the burden of having

to decide about donation, this system makes the process worse by taking the

decision from their hands44. Whilst these objections would be very persuasive

against a hard opt-out system, they can be easily countered by the soft opt-out

system which Wales will be implementing. Where an individual passed away, the

register would be checked as to whether they had opted out of donation. Where they

40

Mercer, L. 2013, Pg 37 41

Reilly, H. “Scottish Parliament Briefing: Where Next for Organ Donation?”, Scottish Parliament Public Petitions Committee, December 2012, Viewed 8

th April 2014,

https://www.scottish.parliament.uk/S4_PublicPetitionsCommittee/General%20Documents/PE1453_J_BMA_Scotland_10.10.12.pdf 42

See Footnote 4, Principle 1 43

See Footnote 23 44

Fabre, J. `Organ Donation and Presumed Consent`, The Lancet, Vol. 352, Issue 9122, July 1998, Pg 150

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had not objected, family members would still be consulted as to whether the

deceased had any unregistered objection. Donation would also not proceed if doing

so would cause severe distress to relatives45. Therefore the system does not remove

consent, it presumes consent, and this presumption can be readily overturned by

either opting out, or by the relatives of the deceased. The argument that such a

system is an affront to patient autonomy because it removes choice from donors

therefore does not stand. Under an opt-out system individuals have exactly the same

choice as in an opt-in system, to donate or not to donate, this decision clearly still

rests with the individual46. To protect those underage or those without capacity, they

would automatically be excluded from donation, to alleviate concerns that these

groups may be vulnerable under an opt-out system47. Therefore, this paper would

suggest that concerns over consent and autonomy in presumed consent have been

met by the safeguards implemented alongside Wale’s opt-out system, and such

safeguards could easily be replicated in Scotland. The principle of the opt-out system

is that the default position of a country should be to save lives, and that unless an

individual objects to donation then their organs should be used after death to benefit

others48. It is crucial that everyone has the right to refuse to donate their organs after

death, and that this right is respected. This is therefore another major concern in

relation to opt-out systems, that the deceased’s wishes will not be respected.

Respecting the Deceased’s Wishes

Although the current system of organ donation is referred to as opt-in, the majority of

people who donate organs have not given prior consent. In 2010/11, 33% of donors

in the UK were registered to donate their organs, and the remaining donations came

from persons who were not registered but the donation was authorised by family

members49. Whilst some family members will have known the deceased’s wishes,

the majority of these decisions will have been made based on their best guess of

what the deceased would have wanted. Therefore in some cases where the relatives

refused donation, the individual would have been happy to donate, and thus the

organs were lost, and vice versa50. While there are concerns that an opt-out system

would not respect the deceased wishes, it is more likely that they in fact would be

respected. In presumed consent there is a formal mechanism for those who oppose

donation to record their wishes, which ensures they will be respected should they

pass away. The programme of publicity that would precede an opt-out system being

implemented would encourage people to share their wishes with family, and would

45

No Author Information, “FAQ – Organ Donation from December 2015”, Organ Donation Wales, No Date Information, Viewed 8

th April 2014, http://organdonationwales.org/FAQs/Organ-donation-from-

december-2015/?skip=1&lang=en 46

See Footnote 41 47

See Footnote 23 48

See Footnote 41 49

See Footnote 9 50

See Footnote 8

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perhaps force people off of the fence about the issue51. Whilst it has been argued

that absence of an objection cannot be taken as informed consent, this publicity,

combined with the continued role of the family, ensure that everything possible is

done to both ascertain and respect the wishes of the deceased52. On the basis of

these protections, having an opt-out system would more accurately reflect the

wishes of the majority, and would allow donation to become the default position.

Whilst this is of course the aim of implementing an opt-in system, a moral

consideration of doing so is the risk that by making donation the norm, we are

removing the value of the act.

The Value of Donation

As mentioned above, the central principle behind the opt-out system is that it will

save lives and that if persons do not object, then it is right that their organs should be

used for the benefit of others. This system does not oblige people to donate nor

remove their right to object, it simply assumes that if they have expressed no

objection they would wish to act altruistically53. The current organ donation system is

based on altruism, and the notion of a gift relationship. The Taskforce heard

evidence that this gift element was important to both the families who consent, and

those who receive the organs54. Many felt that if donation became the “default”

position, rather than a positive action by the deceased or their family, then the organ

is no longer a gift. The BMA would argue however that in an opt-out system,

individuals go through the same though process in deciding not to object as they

would deciding to opt in. Not objecting to donation is no less of a gift than opting to

do so.55 Ultimately, people are not dying through a lack of altruism, but through a

lack of donor organs. Whilst it may be preferable to require donors to take active

steps to donate, what matters in the end is that donor organs are not attained by

violating the rights of others. So long as the system is morally sound, then organ

donation will always be a valuable gift to others56. As such, it cannot be argued that

organs have a different moral value dependent upon the system they were received

under. The final concern in following the lead of Wales is the potential for a negative

public response to a presumed consent system.

Public Responses

During the Taskforce’s review of opt-out systems, concerns were raised that where it

was known that a person had not opted out, doctors may make less of an effort to

save their lives as they are a source for organs57. This concern is not exclusive to

51

Seminar Handout, `Organ Shortfall Crisis`, Contemporary Issues in Medical Jurisprudence, 23rd

February 2014. 52

Fabre, 1998, Pg 150. 53

See Footnote 18 54

Ibid. 55

See Footnote 8 56

Saunders, B. `Opt Out Organ Donation Without Presumptions`, Journal of Medical Ethics, Vol. 38, Issue 2, 2012, Pg 69-72 57

See Footnote 11

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opt-out, and has already been raised in relation to our current opt-in system as a

factor which could affect the trust between the public and the medical profession.

Whilst a valid concern, it must be remembered that first and foremost doctors focus

on saving your life. When you enter a hospital, you are seen by a doctor whose

specialty relates to your condition, and they have a duty of care to give you the best

treatment possible58. A clear separation exists between your treatment team and the

hospitals transplant team, and as such your donor status plays no role in the level of

care you receive. It is crucial that the public are educated in the working of any new

donation system so that myths such as this do not dissuade people from donating59.

If as much information is given as possible, there is no reason why an opt-out

system should damage the doctor-patient relationship.

The final concern highlighted by the BMA is that if an opt-out system is implemented

without enough public support, then as a show of objection people will opt-out of

donating. This fear is not without precedent. Brazil introduced a presumed consent

system in 1998 without public support and in an era of public mistrust, which

ultimately had to be abandoned due to the volume of people opting out60. However,

as discussed previously, surveys conducted in the UK have found majority support

for a move to presumed consent61. If efforts are made to ensure widespread support

of the system, through comprehensive debates and information on the topic, then the

threat of such action is greatly reduced62. Whilst a reasonable concern, if as in Wales

great care is taken to ensure public support, there is no reason why this possibility

should prevent Scotland from implementing an opt-out system. Having considered

the potential benefits of the system Wales will shortly be implementing, and

evaluated the merits of the most prevalent objections, is it possible to answer the

question of whether Scotland should follow Wale’s lead?

Scotland’s Future – Presumed Consent?

Scotland has worked hard to tackle the organ donation shortfall, and as discussed

previously has seen great increases in the number of donations per year. 2012-2013

saw a record (94) deceased organ donors, and over 41% of the Scottish population

are on the organ donor register63. Despite this progress, every day organs are lost

that could have saved lives. Whilst many suggest that Scotland should focus on

improving the current system, we have already seen from the implementation of

58

See Footnote 45 59

No Author Information, “Pros and Cons of Automatic Organ Donation”, The Week, July 2008, Viewed 19

th April 2014, http://www.theweek.co.uk/health-science/35635/pros-and-cons-automatic-

organ-donation 60

Bramhall, S. `Presumed Consent for Organ Donation: A Case Against`, Annals of the Royal College of Surgeons of England, Vol. 93, Issue 4, May 2011, Pg 270-272 61

Mercer, L. 2013, Pg 37 62

Bird, S. `Time to Move to Presumed Consent for Organ Donation`, British Medical Journal, May 2010, viewed 21

st April 2014, http://www.bmj.com/content/340/bmj.c2188

63 No Author Information, “A Donation and Transplantation Plan for Scotland”, Scottish Government

Publication, July 2013, Viewed 23rd

April 2014, http://www.scotland.gov.uk/Resource/0042/00427357.pdf

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Taskforce recommendations that this is not enough. There will of course be

obstacles to overcome in implementing an opt-out system, but this paper has shown

that with sufficient education and information many of the suggested objections can

be alleviated. From the studies considered, we have seen that the implementation of

an opt-out system has a positive effect on organ donation rates64, and increasing

donation rates is more important than ever for Scotland. BMA Scotland have stated

that action must be taken now, and that presumed consent is the way forward65. This

paper would agree. Whilst academics have made more radical propositions that all

organs should be automatically available66, we would suggest that such a system

infringes too far upon both autonomy and consent, and does not respect individual’s

wishes after death67. We must consider the interests of both donors and recipients,

and the system to be implemented in Wales achieves this. Continuing to respect

donors whilst increasing the number of life saving organs can only be a good thing

for Scotland. Where so much is at stake, we must consider a change in the system

to prevent the needless loss of life that occurs under an opt-in system68.

To conclude therefore, Scotland should follow the lead of Wales in changing to an

opt-out system, so long as majority public support for this change continues, and a

comprehensive programme of education and awareness is implemented alongside

this change. This system must also contain the same safeguards for autonomy and

respect as the proposed Welsh system, to uphold the integrity of organ donation as

the most altruistic of gifts.

64

See Footnote 39 65

No Author Information, “Organ Donation: Scotland Should Consider Opt Out”, The Scotsman, July 2013, Viewed 24

th April 2014, http://www.scotsman.com/news/health/organ-donation-scotland-should-

consider-opt-out-1-2999279 66

Harris, J. `Organ Procurement: Dead Interests, Living Needs`, Journal of Medical Ethics, Vol. 29, Issue 3, June 2003, Pg 130-134 67

McGuiness, S., Brazier, M. `Respecting the Living Means Respecting the Dead Too`, Oxford Journal of Legal Studies, Vol. 28, Issue 2, 2008, Pg 297-316 68

Hamer, C., Rivlin, M. `A Stronger Policy of Organ Retrieval from Cadaveric Donors: Some Ethical Considerations`, Journal of Medical Ethics, Vol. 29, Issue 3, 2003, Pg 196-200

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Bibliography

Electronic Resources Cited

No Author Information, “Number of Organ Donors Rises by Nearly 100% in Six Years”, Organ Donation Scotland, April 2014, Viewed 3rd April 2014, https://www.organdonationscotland.org/news-events/number-of-organ-donors-rises-by-nearly-100-in-six-years No Author Information, “NHS History of Organ Donation”, NHS Choices, March 2013, Viewed 3rd April 2014, http://www.nhs.uk/Tools/Pages/transplant.aspx No Author Information, “WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation”, World Health Organisation, May 2010, Viewed 3rd April 2014, http://www.who.int/transplantation/Guiding_PrinciplesTransplantation_WHA63.22en.pdf No Author Information, “Tell Me More”, Organ Donation Scotland”, No Date Information, Viewed 3rd April 2014, https://www.organdonationscotland.org/tell-me-more Reilly, H. “BMA Scotland Submission in Support of Petition PE1453”, Scottish Parliament Public Petitions Committee”, January 2013, Viewed 4th April 2014, http://www.scottish.parliament.uk/S4_PublicPetitionsCommittee/General%20Documents/PE1453_C_BMA_Scotland_10.01.13.pdf No Author Information, “Statistics – Transplants Save Lives”, NHS Blood and Transplant – Organ Donation, August 2013, viewed 4th April 2014, http://www.organdonation.nhs.uk/statistics/index.asp Rithalia, A., Mcdaid, C., Suekarran, S., Myers, L. And Sowden, A. `Impact of Presumed Consent for Organ Donation on Donation Rates: A Systematic Review`, British Medical Journal: Research, January 2009, Viewed 4th April 2014, http://www.bmj.com/content/338/bmj.a3162 Buggins, E, “The Potential Impact of an Opt Out System of Organ Donation in the UK – An Independent Report from the Organ Donation Taskforce”, NHS Blood and Transplant, November 2008, Viewed 5th April 2014, http://www.nhsbt.nhs.uk/to2020/resources/ThepotentialimpactofanoptoutsystemfororgandonationintheUK.pdf No Author Information, “Presumed Consent for Organ Donation”, The Patients Association, No Date Information, Viewed 5th April 2014, http://www.patients-association.com/Default.aspx?tabid=192 English, V. “Building on Progress: Where Next for Organ Donation Policy in the UK?”, British Medical Association, February 2012, Viewed 6th April 2014, http://bma.org.uk/working-for-change/improving-and-protecting-health/organ-donation

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No Author Information, “Proposals for Legislation on Organ and Tissue Donation: A Welsh Government White Paper”, Welsh Government Consultation Document, November 2011, viewed 6th April 2014, http://wales.gov.uk/docs/dhss/consultation/111107orgdonwpen.pdf No Author Information, “Opt In or Opt Out”, NHS Blood and Transplant, April 2014, Viewed 6th April 2014, http://www.organdonation.nhs.uk/newsroom/statements_and_stances/statements/opt_in_or_out.asp Riley-Smith, B. “Opt-Out Organ Donation Will Treat Bodies Like Clapped Out Cars”, The Telegraph, July 2013, Viewed 7th April 2014, http://www.telegraph.co.uk/health/healthnews/10154686/Opt-out-organ-donation-will-treat-bodies-like-clapped-out-cars.html Saul, H. “Opt-Out Scheme for Organ Donation Given Go-ahead in Wales”, The Telegraph, July 2013, viewed 7th April 2014, http://www.independent.co.uk/news/uk/home-news/optout-scheme-for-organ-donation-given-goahead-in-wales-8684984.html Weissberg, P. “Organ Donation in Wales: Making Opt-Out a Reality”, British Heart Foundation, April 2013, Viewed 8th April 2014, http://www.bhf.org.uk/pdf/Organ%20Donation%20in%20Wales%20Making%20Opt%20Out%20a%20Reality%20April%202013.pdf Reilly, H. “Scottish Parliament Briefing: Where Next for Organ Donation?”, Scottish Parliament Public Petitions Committee, December 2012, Viewed 8th April 2014, https://www.scottish.parliament.uk/S4_PublicPetitionsCommittee/General%20Documents/PE1453_J_BMA_Scotland_10.10.12.pdf No Author Information, “FAQ – Organ Donation from December 2015”, Organ Donation Wales, No Date Information, Viewed 8th April 2014, http://organdonationwales.org/FAQs/Organ-donation-from-december-2015/?skip=1&lang=en No Author Information, “Pros and Cons of Automatic Organ Donation”, The Week, July 2008, Viewed 19th April 2014, http://www.theweek.co.uk/health-science/35635/pros-and-cons-automatic-organ-donation Bird, S. `Time to Move to Presumed Consent for Organ Donation`, British Medical Journal, May 2010, viewed 21st April 2014, http://www.bmj.com/content/340/bmj.c2188 No Author Information, “A Donation and Transplantation Plan for Scotland”, Scottish Government Publication, July 2013, Viewed 23rd April 2014, http://www.scotland.gov.uk/Resource/0042/00427357.pdf

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No Author Information, “Organ Donation: Scotland Should Consider Opt Out”, The Scotsman, July 2013, Viewed 24th April 2014, http://www.scotsman.com/news/health/organ-donation-scotland-should-consider-opt-out-1-2999279

Journal Articles Cited

Abadie, A., Gay, S. `The Impact of Presumed Consent Legislation on Cadaveric Organ Donation: A Cross Country Study`, Journal of Health Economics, Vol. 25, Issue 4, July 2006, Pg 599-620

Mercer, L. `Improving the Rates of Organ Donation for Transplantation`, Nursing

Standard, Vol. 27, Issue 26, February 2013, Pg 35-40

Fabre, J. `Organ Donation and Presumed Consent`, The Lancet, Vol. 352, Issue

9122, July 1998, Pg 150

Saunders, B. `Opt Out Organ Donation Without Presumptions`, Journal of Medical Ethics, Vol. 38, Issue 2, 2012, Pg 69-72

Bramhall, S. `Presumed Consent for Organ Donation: A Case Against`, Annals of the

Royal College of Surgeons of England, Vol. 93, Issue 4, May 2011, Pg 270-272

Harris, J. `Organ Procurement: Dead Interests, Living Needs`, Journal of Medical Ethics, Vol. 29, Issue 3, June 2003, Pg 130-134 McGuiness, S., Brazier, M. `Respecting the Living Means Respecting the Dead Too`, Oxford Journal of Legal Studies, Vol. 28, Issue 2, 2008, Pg 297-316 Hamer, C., Rivlin, M. `A Stronger Policy of Organ Retrieval from Cadaveric Donors: Some Ethical Considerations`, Journal of Medical Ethics, Vol. 29, Issue 3, 2003, Pg 196-200

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Legislation Cited

Human Tissue Act 2004 Human Tissue (Scotland) Act 2006

Human Transplantation (Wales) Act 2013

Other Sources Cited

Seminar Handout, `Organ Shortfall Crisis`, Contemporary Issues in Medical

Jurisprudence, 23rd February 2014

Sources Considered But Not Cited

Mason, J. And Laurie, G. Mason & McCall Smith’s Law and Medical Ethics 9th

Edition, Oxford University Press, Oxford, 2013, Chapter 17.