Organ donation and dual advocacy.

To the Editor: In a Perspective article in this issue of the Journal, Truog provides his views on organ donation, suggesting that the pendulum between the need for transplantable organs and the rights of potential donors’ families “has swung too far in the direction of procuring organs.”1 Truog asserts that consent for organ donation is obtained “at the expense of commitments that are fundamental to the patient–physician relationship.” We disagree with this description because it does not reflect current consent practices. In practice, there is a confluence between the ethical commitments that Truog outlines: “that the desires of people who want to donate organs are respected” and “that the consent process is informed and voluntary.” The New England Organ Bank (NEOB) and most other organ-procurement organizations (OPOs) have supplanted the “presumptive” consent approach criticized by Truog with a consent process of “dual advocacy.” This approach considers the interests of both the donor family and persons awaiting a transplant.2 It is based on the fact that most people, given the opportunity, will choose to help others. By supporting the family’s right to make a choice that is based on complete information, including the positive impact that the gift will have on others and the solace derived from organ donation, dual advocacy recognizes that those requesting donation must also consider the needs of the donor family. This approach relies on observations and data indicating that the involvement of an OPO professional is critical to success, that health care practitioners cannot reliably predict which families will want to donate, and that apologetic approaches to seeking consent are more likely to result in refusals.3 In addition, Truog implies that the consent process for medical research should be used as a model for obtaining consent to organ donation. The research consent process is designed to protect human subjects, not their families, from the risk of participating in research; there is no risk of harm to the donor after death. Moreover, Truog’s portrayal of donation after cardiac death is inconsistent with current practices, which have been refined through accumulated experience. In the NEOB service area, the donor’s family usually is given a choice for the location of the withdrawal of treatment, catheters are seldom placed before death, and no vasodilators are administered. A recent Gallup survey showed that almost 95% of the U.S. public supports organ donation, yet the current consent rate for donation hovers around 65 to 70%.4 This gap suggests that families are not in fact being browbeaten but rather that the goal of the Department of Health and Human Services of achieving 75% donation rates is anchored in a realistic reflection of public attitudes. As an organization that has coordinated more than 5500 organ donations, we are grateful for the opportunity to work with organ donors and their