John is on his family practice rotation and working at an outpatient clinic. One day he sees Ms Smith for a routine medical exam. She has been a patient of the clinic for 7 years, has always been compliant with recommendations, and has no significant past medical history. While reviewing Ms Smith's history with her, John asks if she has any specific questions or concerns. Ms Smith states that she recently saw an ad about organ donation and wanted to know more about becoming a donor. John becomes excited about this question because he knows that there is a shortage of organ donors, and he sees this as an opportunity to educate Ms Smith about this altruistic act. At 30 years old and in good health, Ms Smith is probably an eligible donor, John thinks.
As the conversation progresses, Ms Smith asks John if he has "ever seen organs being removed for donation" and John states that he, personally, has not seen this, but knows that the utmost care is taken to procure the organs. Ms Smith then discloses that she is worried that if she becomes a donor her organs may be taken before she is dead. John assures Ms Smith that this would not happen and that many tests are performed to make sure the patient is dead before organs are recovered. After answering all her questions, John informs Ms Smith that she can fill out the necessary paper work for organ donation in the office. Just as he is about to excuse himself to get her the necessary documentation, Ms Smith states that she is not entirely convinced about being an organ donor. "I'm still unsure—I still need some time to think about it." John is clearly disappointed because he knows how important organ donation is but does not want to pressure Ms Smith into making a decision.
There are currently more than 60 000 people on the waiting list for kidney transplants in the US, and in many parts of the country average waiting time for a kidney is more than 5 years. More than 7 percent of wait-listed patients die annually before receiving transplants. As a consequence, there is ongoing discussion about how to increase the number of available organs.
Ethical issues are of primary importance in discussions about enrolling new donors. In the case presented here, a third-year medical student is enthusiastic about trying to persuade a patient to sign organ donor forms. The patient, Ms Smith, has many questions and is unsure about whether or not she wants to become a donor. I was asked how I would address this as a clinician and how I would navigate between giving the patient information and coercing her into becoming a donor.
Simply stated, there is no room for coercion in medicine. This is both a legal and a moral point. Coercion is defined as "persuasion (of an unwilling person) to do something by use of force or threats."1 The courts have ruled that a competent person can refuse a life-saving procedure (ie, cannot be coerced into having it). This has been demonstrated by Jehovah's Witnesses' refusing life-saving blood transfusions. Another concern in this case is that the student (or any other enthusiastic believer) might exploit or manipulate Ms Smith's vulnerability as a patient by suggesting, for example, that she might get better medical care if she were a potential donor.
What do I believe the third-year medical student should do under these circumstances? There are numerous possibilities; here are some of them:
- He could offer to spend more time with Ms Smith, either at this or a follow-up visit, to discuss her concerns;
- He could ask Ms Smith if she would like to discuss her reservations with the attending physician;
- He could give her the telephone number for the local Organ Procurement Organization (OPO) so she could get more information about the organ donation process.
What if, after numerous discussions and a review of available literature, Ms Smith is still unsure if she wants to donate? Organ donation is a wonderful act which has been termed "the gift of life." An organ donor (or donor family) has the opportunity to prolong and improve the quality of many lives. But no one should be "talked into" signing organ donor forms (or any other informed consent document). If Ms Smith is still unsatisfied after discussing her concerns with the people who can answer her questions, the medical student should curb his enthusiasm.
The New Oxford American Dictionary. New York: Oxford University Press; 2001.