Resolved: A just society ought to presume consent for organ procurement from the deceased.

AbstractBackgroundThe organ donor shortfall in the UK has prompted calls to introduce legislation to allow for presumed consent: if there is no explicit objection to donation of an organ, consent should be presumed. The current debate has not taken in account accepted meanings of presumption in law and science and the consequences for rights of ownership that would arise should presumed consent become law. In addition, arguments revolve around the rights of the competent autonomous adult but do not always consider the more serious implications for children or the disabled.DiscussionAny action or decision made on a presumption is accepted in law and science as one based on judgement of a provisional situation. It should therefore allow the possibility of reversing the action or decision. Presumed consent to organ donation will not permit such reversal. Placing prime importance on the functionality of body organs and their capacity to sustain life rather than on explicit consent of the individual will lead to further debate about rights of ownership and potentially to questions about financial incentives and to whom benefits should accrue. Factors that influence donor rates are not fully understood and attitudes of the public to presumed consent require further investigation. Presuming consent will also necessitate considering how such a measure would be applied in situations involving children and mentally incompetent adults.SummaryThe presumption of consent to organ donation cannot be understood in the same way as is presumption when applied to science or law. Consideration should be given to the consequences of presuming consent and to the questions of ownership and organ monetary value as these questions are likely to arise should presumed consent be permitted. In addition, the implications of presumed consent on children and adults who are unable to object to organ donation, requires serious contemplation if these most vulnerable members of society are to be protected.BackgroundThe controversy about presumed consent has been recently revived in the UK as a consequence of the organ donor shortfall[1,2]. The debate is far from settled and only altering the law to permit the presumption of consent with respect to donor organs will provide the answer to whether this will indeed remedy the problem of organ shortage. It will not, however, answer the questions about what exactly is being presumed; the ethical and legal implications that could follow will need to be considered carefully. The meaning of presumption, the issues that could be raised about the ownership of and rights over body organs and further implications for gain, are discussed. Applications of presumed consent in different countries are compared and the need for further investigation of factors that influence donation and of attitudes towards presumed consent, is acknowledged. This article also addresses the issue of protection of the most vulnerable members of society who may be unable to dissent.DiscussionThe meaning of 'presumed consent'The understanding of presumption of consent to organ donation may be considered, by some practitioners of law or science, to be an inaccurate and misleading term. This stems from the general understanding of 'presumption' in law and science: as an inference that is made on available fact or evidence with the understanding that vital information that can render the inference invalid may be missing. In law a presumption holds that of innocence, for example until a substantial body of evidence is produced to the contrary. Just like a scientific theory or hypothesis, a legal presumption is maintained for as long as no evidence is provided to disprove it or no valid objection is raised against it. A presumption, in law and science, is therefore a 'provisional estimate of facts'[3] based on some accepted fundamental state or pattern of behaviour.Unlike the presumptions in law or the hypotheses of science, presumption of consent for the use of body organs cannot afford any possibility of abandoning the presumption, reversing the decision or of retracting any action based on the decision (clearly, the deceased donor cannot raise objections). The presumption of consent for organ donation cannot therefore be taken as a presumption of donor willingness, with the specific understanding that there will be a provision for changing the course of action should further evidence emerge, but rather as a presumption of state rights to post-mortem body organs, unless an objection by the 'occupant' of the body is raised whilst the 'occupant' is still in 'residence'. Opponents of presumed consent argue that the absence of donor willingness is morally unacceptable because it can be seen as a violation of their wishes[4]. (It has even been suggested that the term presumed consent be replaced by 'specified refusal' to put the emphasis on the action taken rather than on assumption[5]).It is clear that presumed consent is advocated as a means of meeting organ donor shortages and not because the state wishes to assume ownership of body partsper se. Nevertheless, it places the greater emphasis on functionality of body organs and how they can be best utilised to sustain life rather than on the importance of requiring permission of the individual to donate his or her organs. It also takes away the power to 'gift' that donorship confers[6].If functionality of body organs becomes of prevailing importance, it could be argued that the body is predominantly a vessel equipped with all the necessary instrumentation for maintaining life and that is occupied and used by the person to whom the body belongs. Consequently, if presumed consent is advocated, it could be reasoned that since after death the 'occupant' no longer needs the 'vessel', if any of the instrumentation is still functional it should be used to better or save the life of another. The acceptance of this premise and hence of the liberty of the state to assume the rights to decide about further usage (pending no objections) raises further issues about the right of ownership and hence who should benefit from body organs, and how presumed consent will extend to competent minors and mentally incompetent adults.The right to sell body partsThe debate about presumed consent and importance of optimising the functionality of body organs can extend to ownership and the right to sell these organs[7-9]. It has even been argued, in accordance with a rights-based theory of justice, that body organs are akin to goods to which a person can claim rights[10]; the prospect of treating body organs, in future, as 'property' has been raised in a common law case[11]. Whilst alive, the 'occupant' has an acknowledged right of ownership as evidenced in medical and other research practice: autonomy of mentally competent adults is respected and consent to medical treatment and/or study on any part of the body must always be sought. It could be argued that consent is required for research and medical treatment because there may be risks involved and that these risks no longer apply post-mortem, but this does not take into account all the underlying reasons for consent. One of these is the fundamental respect for the right of the individual to make decisions about his or her own body and in certain situations to accept payment for its usage as is evidenced when remuneration is offered for participation in research. It is not a quantum leap to suggest that if functionality of body organs is so valued and remuneration for research on the living body permitted, the worth of body organs (just like land and other acquired assets), should be allowed, after death, to pass to relatives or any other beneficiaries nominated by the deceased in a will. Indeed, this may be considered a natural extension of current practice: that next of kin take care of the deceased body[12]. If the state wishes to presume consent to organ donation (in the absence of any objections) and to treat these as transferable resources, the question of why individuals should not be permitted to organise for the sale of their body organs post-mortem, for the financial benefit of family and loved ones, could very well be raised. The sale of body organs is highly contentious but paradoxically, such a debate may raise awareness of the need for organs and the suggestion of a financial incentive could even encourage organ donation[7,8]. James Stacey Taylor[9] points out that any suggestion of establishing a market in body organs needs to be seen as a means of increasing supply for the benefit of those who are in need and therefore has sound moral grounding[9]. It should be considered alongside other measures and be properly controlled and implemented to avoid exploitation[9]. These arguments in support of the sale of body parts, are made with the assumption that what is considered to be 'morally permissible' does not take into account any objections based on religious beliefs[8]. Religious and cultural views need to be given just consideration because certain beliefs and traditions oppose the sale of body organs and indeed the notion of presumed consent[13]. Conversely, for others such measures are acceptable; surgeons from India have protested against the objections to body organ trade[14].Presumed consent in the case of childrenThe age at which autonomy is granted varies in the UK depending on whether it is with regard to consent to medical treatment or consent to participation in research. In the former case, children are given the status of autonomous adults at the age of sixteen; in the latter the age of consent is eighteen. This distinction has not been properly qualified in the UK and can lead to bizarre situations[15]. Before presumed consent can be permitted, there would need to be a decision made about the age at which autonomy of an individual to object to organ donation is respected. Once such an age is decided, it will inevitably lead, in the UK, to the question of Gillick competency. This term arose from English case law and is applied in relation to consent to medical treatment where there is a question about the rights of a minor to make autonomous decisions about such matters[16]. A Gillick competent child is one who, although chronologically below the determined age of consenting to medical treatment, is deemed to be intelligent and mature enough to understand the consequences of such a treatment and therefore is considered as able to be treated as an autonomous adult[16]. Whilst the notion of Gillick competency arose from the law, the decision about whether or not to treat a child as Gillick competent (and hence as an autonomous adult) is left to the medical practitioner. The decision about whether or not to allow a minor the autonomous status of an adult with regard to medical treatment is fraught with difficulty and uncertainties. It would become even more complicated if it were applied to presuming consent to organ donation, for the differences between appreciating the consequences of medical treatment, and hence being able to consent to it, and being sufficiently competent to understand what refusal of organ donation may mean, are vast. The former requires the young person to have an understanding of what the treatment will mean to him or her. The latter requires a much more evolved perspective on fundamental issues of life and death and the ability to make a balanced judgment and decision without being pressured by feelings of guilt that refusal will deprive another human being of life. It may be considered safer to reject the notion of Gillick competency for presumed consent altogether and leave the right of refusal for minors in all cases up to parents, guardians and carers. This does not simplify matters. Reliance solely on the decision of parents or guardians, could mean ignoring the wishes of a fourteen year old mother, who is estranged from her own parents and who on her death bed insists that she does not want any of her organs donated. (It is recognised that this situation can only occur where organ recovery is to be made without brain stem death). If Gillick competency to presumed consent cannot be invoked, it would permit taking organs from a minor in cases where no autonomous adult authorised to object to such a measure were available.Presumed consent in the case of mentally incompetent adultsDecisions on behalf of the mentally incompetent need to be made in cases of medical treatment and in such situations, common law in the UK sets the principle that such decisions should always be made in the best interests of the patient[17]. There have been instances in which it has been difficult to ascertain exactly what these best interests are. In one of the more controversial legal cases[18], the decision was made that it would be in best interests of Y, a physically and mentally handicapped woman, to transplant her bone marrow in order to save the life of her (mentally competent) sister even though the procedure was not without risk and provided no benefit to Y. The justification given for why this was in Y's best interests was that the sister had a young child who, without its mother, would be left in the care of its grandmother (Y's mother) who would then not be available to see Y as often as she did. Notwithstanding whether or not this explanation justified the best interests argument, it emphasizes the vulnerability of the mentally incompetent to the decisions that can be made whilst they are alive. The situation is even more uncertain after death. The 'best interests' argument that is used in the case of a living donor cannot be applied post-mortem. A mentally incompetent adult will be unable to raise objections to organ donation because, like a child, the mentally incompetent adult is deemed to be unable to understand the concept. However, unlike the child with parents who are able to make a decision about refusing donation, the mentally incompetent adult may have no living relatives able or permitted to make such a refusal on his/her behalf. The vulnerability of these individuals highlights one of the most potentially dangerous aspects of presumed consent. If presumption of consent is permitted, provision would need to be made to protect such individuals in order to avoid inadvertently exploiting the mentally incompetent as reservoirs of body organs.Applications of presumed consentIntroduction of presumed consent into law can take a number of forms, and variations in the application of presumed consent[19] have been broadly classed as 'strong' ('hard') or 'soft'[7,19] depending essentially on whether or not permission of relatives is required. However, the distinction between the options is blurred. Even in countries in which presumption of consent does not officially require the permission of relatives, this is sought and taken into account[11,19]. There is no conclusive evidence showing which option is the more successful in obtaining donor organs[2]. In France and Spain, where consent of relatives is routinely sought, the donor rates, in 2005, were 22.2 and 35.1 per million population, respectively; in Austria where consent of relatives is not routinely sought, the figure was 24.8 per million population[2]. It is worth noting that in Spain, organs are taken from heart-beating and non heart-beating donors and this has been credited with increasing donation rates[2]. With limitations, in the UK, on organ availability from donors who have suffered brain stem death (heart-beating donors), measures to increase the number of organs retrieved from non heart-beating donors are being advocated[20,21].According to one mathematical model, organ availability is likely to be higher when presumed consent measures are introduced, even when other confounding factors are taken into account, but ambiguities in the model are acknowledged[19]. Results of a study on twenty-two countries show that whilst the highest rates of donation are found in countries like Spain, Austria, Latvia, Portugal and Belgium where presumed consent operates, there is a greater rate of donation (per million population) from Ireland (where informed consent is required) than from France, Slovenia, Czech Republic, Hungary and Italy where presumed consent applies[19]. The factors that influence donation have not been fully identified. It is notable that, with some exceptions, the Catholic countries of Europe, where the legal system is based on Roman law, presume consent[19,22,23] and stress the importance of 'for the greater good'[23]. In Protestant countries, individual rights are considered foremost and informed consent is more likely to be required[23].A recent study[7] that investigated attitudes to presumed consent in Scotland found that, overall, a 'soft' option was favoured although, when it came to opinions from members of donor families, the views were not consistent. Other responses, suggest that a deeper probing of attitudes to presumed consent is needed. For example, while payment for organs was considered, by 70% of respondents, to be a measure that would encourage others to donate, only 21% agreed that a financial incentive should be used[7].Ultimately, whether consent is express or presumed, the donor and/or relatives should be fully informed before any consent is obtained. Special attention needs to be given to those for whom others make decisions concerning their health and welfare. The easiest option would be to apply presumed consent only to specified groups (e.g. autonomous adults) and to disallow any vulnerable individuals from being considered as members of these groups. This would ensure that no situation of abuse of the vulnerable, whether intentional or unintentional, occurs. There is no certainty, however, that such a measure would not invoke cries of discrimination from those who may misinterpret the measure as an indication that the body organs of such individuals are of lesser value. It may also create difficulties and lead to complicated legal arguments with cases brought before the courts should a family situation arise that is similar to that of the case of Y[18], but with a deceased individual, who had been deemed unable to make their own decisions whilst alive, and whose organs could save the life of a relative.The issues for vulnerable individuals require further analysis and, prior to the introduction of any legislation that allows for presumed consent, there needs to be a thorough re-examination of current laws that treat children and mentally incompetent adults as non-autonomous. With regard to children, reviews of the age of consent and the notion of Gillick competency with better guidelines for practitioners are needed. When deciding on mental impairment or incapacity, there should be an assessment of its scope, its nature, its duration and its durability (drugs, medications and alcohol can all have temporary effects that could render a person medically incompetent to make decisions but these effects may not be lasting).ConclusionTo presume consent may or may not alleviate the shortage of donor organs but it will most certainly raise a number of related ethical and legal complexities that will need to be addressed in order to safeguard against unacceptable practices. Fundamentally, what is meant by presumption and how this is applied to the concept of presumed consent to organ donation will have to be determined. It will need to extend beyond the boundaries of current legal and scientific notions and will involve legal and ethical arguments about the sale of body organs, rights of ownership, donation and bequeathing to beneficiaries. More investigation of attitudes towards presumed consent and why and how these may vary is required. Consideration must be given to objections on religious or cultural grounds and whether and how prospective legislation could impinge on beliefs and practices. As always, protection of the most vulnerable, unable to make autonomous decisions, is of paramount importance in any actions taken. Current laws and practices relating to consent and decision-making capacities of children and vulnerable adults need to be reviewed before introducing legislation that permits the presumption of consent.SummaryConsent for body organs cannot be presumed in the same way that presumption is used in law or science. Presuming consent for organ donation places the value of body organ function above the requirement for permission from the donor and raises a number of related ethical and legal questions about ownership and sale of body organs, rights of refusal for children and mentally incompetent adults. The factors that influence donation rates and attitudes to presumed consent have not been clearly identified and require further investigation. Measures for the protection of the most vulnerable need to be addressed before legislation to allow for presumed consent can be permitted.Attitudes toward Financial Incentives, Donor Authorization, and Presumed Consent among Next-of-Kin Who Consented vs. Refused Organ DonationJames R. Rodrigue,1,4Danielle L. Cornell,2andRichard J. Howard3Author informationCopyright and License informationThe publisher's final edited version of this article is available atTransplantationSee other articles in PMC thatcitethe published article.Go to:AbstractBackgroundFinancial incentives, donor authorization, and presumed consent are strategies designed to increase organ donation rates. Surveys designed to assess attitudes toward these initiatives have been conducted with the general public, transplant patients, and transplant professionals.MethodsTo assess attitudes toward financial incentives, donor authorization, and presumed consent and to identify multivariate predictors of such attitudes, we conducted telephone interviews with 561 family members who had recently been asked for consent to donate the organs of a deceased family member (348 donors, 213 nondonors).ResultsFinancial incentives would have made a difference in the donation decision for 54% of nondonors (vs. 46% of donors,P= 0.02), and a higher percentage of nondonors would themselves become donors if financial incentives were available (P= 0.03). Donors had significantly more favorable attitudes toward donor authorization (P< 0.0001) and presumed consent (P< 0.0001) policies. Overall, 54% of participants thought that family permission for donation was unnecessary when the deceased documented their donation intention, and 24% favored a presumed consent law with an opting out provision.ConclusionsOf the three initiatives, donor authorization is likely supported by more donor and nondonor families than either financial incentives or presumed consent. Public education efforts should aim to better inform the public regarding existing and proposed donor authorization legislation and its benefits for registered organ donors and their families.Keywords:Organ donation, Financial incentives, Presumed consentThe shortage of donor organs is without question the major impediment to extending the lives of more patients awaiting solid organ transplantation. The gap between the number of patients awaiting transplantation and the number of donor organs procured continues to widen (1,2). Although most individuals report favorable attitudes toward organ donation (3), next-of-kin consent rates at time of death are approximately 54% (1). This low consent rate has been cited by the Association of Organ Procurement Organizations as the primary reason for the gap between the number of potential organ donors and the number of actual donors (4).Some strategies designed to close the gap between potential and actual donors have been implemented with little controversy or debate. These include extensive public education campaigns, required request policies, an in-house organ procurement organization (OPO) program, donor authorization or first-person consent legislation, the establishment of statewide donor registries, and the Organ Donation Breakthrough Collaborative initiated by the US Secretary of Health and Human Services Tommy G. Thompson in 2003, among others. Despite the apparent success of some of these efforts (5,6), deceased donation rates have not yet been maximized.Other proposed strategies appear to be more controversial. For instance, both direct (actual monetary value, e.g., cash payment) and indirect (organs traded for goods or services of cash value, e.g., funeral expense voucher, contribution to charity) financial incentives have been proposed and debated in the literature (712) and were the topic of several presentations at the 2005 American Transplant Congress in Seattle, Washington (13). Proponents of financial incentives argue that they are cost-effective and would increase donation rates; whereas opponents counter that such incentives would intrude on altruism by promoting dehumanization and reduce consent rates. Another controversial strategy is the presumption of consent, unless an individual has opted out of donation prior to death (14,15). In such instances, OPOs could proceed with organ removal when the donors intentions are not known or not documented, even in the absence of family consent. Proponents of presumed consent argue that it is a moral and ethical imperative for the benefit of society and that it has increased donation rates in other countries, whereas opponents counter that it will undermine respect for autonomy and self-determination, which are basic tenets of informed consent.Several surveys have been conducted to examine the perceptions of the general public (16,17), transplant patients (18), and the transplant community (1921) regarding these controversial proposals to increase deceased organ donation. Findings have been mixed, with no clear public imperative to prevent or promote such initiatives. While these cross-sectional opinion surveys have included various segments of the transplant community, they have largely ignored the perspective of those families that have faced the organ donation decision. This study seeks to examine the attitudes and opinions of donor and nondonor families regarding financial incentives, donor authorization, and presumed consent.Go to:MATERIALS AND METHODSWe conducted a nonrandom, cross-sectional survey of adults who had recently been approached about donating a deceased family members organs. Participants were recruited between July 2001 and December 2004 using three different strategies. First, each next-of-kin or legal surrogate who was approached by coordinators from one Southeastern US organ procurement organization (OPO) were given a laminated card describing the studys purpose, the inclusion criteria and likely time commitment, and how to indicate interest in the study. Second, a message describing the study and inviting participation was posted on three separate occasions on the National Donor Family Council (NDFC) web-site. Third, a study advertisement was placed in three regional newspapers (Jacksonville Florida Times-Union, Boston Herald, Omaha World-Herald) for three non-consecutive days. Inclusion criteria included: at least 18 years old, primary (preferred) or secondary decision-maker when approached about organ donation, residential telephone service, and ability to complete a telephone interview in English. Monetary reimbursement ($25 to $75 US) was provided.Survey Administration and ContentIn all instances, prospective participants who called the research centers toll-free number spoke to a trained research assistant, who ascertained whether the individual met eligibility criteria and provided more information about the study, answered questions, requested study participation, and, for those desiring to participate, scheduled an interview time. Prospective participants were then called at the scheduled time, oral consent was obtained and documented, and the semi-structured interview was conducted. If the individual was not available, we either left a message or called back at another time to reschedule the interview. If a second scheduled appointment was missed, we considered this a passive refusal and made no further attempt to contact the individual. All interviewers were research assistants with specialized education and training in the organ donation request process, grief and bereavement, crisis management, and the protection of human research participants.The development of the semi-structured interview was guided by theoretical considerations (3), our own pilot studies, prior research with next-of-kin donors and nondonors (2224), and recommendations of an advisory panel that included OPO and transplant professionals, donor families, and behavioral scientists. The interview comprised 115 questions that gathered information about the sociodemographic characteristics of the deceased and next-of-kin participant, the circumstances surrounding the death and hospitalization of the family member, the donation request and decision-making processes of the next-of-kin, understanding of brain death, current attitudes toward transplantation and organ donation, and organ donation beliefs at the time of the donation request. The University of Florida Institutional Review Board approved all study procedures.Attitudes about Organ Donation InitiativesIn addition to the content noted above, participants responded to seven questions related to financial incentives, donor authorization, and presumed consent. To measure attitudes about financial incentives, two questions were asked: (1) Would a cash payment to you or your loved ones estate, paying for your loved ones funeral expenses, or a charitable contribution in your loved ones name have made a difference in deciding whether to donate his/her organs? Answers were yes, would have made a difference; no, would not have made a difference. (2) Would a cash payment to your estate, paying for your funeral expenses, or a charitable contribution in your name make a difference in deciding whether to donate your own organs at time of death? Answers were yes, would make a difference; no, would have no effect at all on my decision. For those who indicated that financial incentives would make a difference, we asked whether such incentives would make themmoreorlesslikely to donate their organs.To assess attitudes toward donor authorization, three statements were read and respondents indicated their level of agreement (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree): (1) If a person dies and has documented that they wanted to be an organ donor, then it is not necessary to get the familys permission for organ donation. (2) If a person dies and has documented that they wanted to be an organ donor, then the organs should be removed even if the family objects to donation. (3) The family should have the right to overrule a persons documented organ donation decision, at the time of their death. To assess attitudes toward presumed consent, respondents indicated their level of agreement (1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree) to the following two statements: (1) If a person dies and has not documented that they wanted to be an organ donor, the organs should be removed without getting the familys permission. (2) There should be a law that assumes that everyone who dies is a potential organ donor, unless they have documented that they didnt want to be a donor.We were primarily interested in examining whether donor and nondonor next-of-kin differed in their attitudes toward financial incentives, donor authorization, and presumed consent. However, we also assessed whether other factors were associated with attitudes, including sociodemographic characteristics (sex, age, race, marital status, education, employment status), donor registration status (documented intention or not), attitudes toward transplantation, and organ donation attitudes. General attitudes toward organ transplantation were measured by responses to four questions (4-point Likert scale), with higher scores (range = 4 to 16) reflecting more positive attitudes. Organ donation attitudes were assessed with six questions (4-point Likert scale), with higher scores (range = 6 to 24) indicative of more positive attitudes.Statistical AnalysisUnivariate relationships between the financial incentive attitudes and next-of-kin donation decision were examined using the Fisher exact test. For donor authorization attitudes, ratings on the last question were reverse-scored and then the ratings for the three questions were aggregated. This yielded one attitude score that ranged from 3 to 12, with higher scores indicating more favorable attitudes toward donor authorization. Similarly, the individual ratings on the two presumed consent questions were aggregated, yielding one score that ranged from 2 to 8. Higher scores reflected more favorable attitudes toward presumed consent. T-tests were then used to examine whether donor authorization and presumed consent attitude scores varied as a function of next-of-kin donation decision. Chi-square analyses were then conducted for each of the donor authorization and presumed consent questions. Multivariate analyses (logistic regression for financial incentives, multiple regression for donor authorization and presumed consent) were then conducted to examine the predictive value of sociodemographic characteristics, donor registration status, attitudes toward transplantation, and organ donation attitudes. All data were analyzed using the Statistical Package for the Social Sciences database (SPSS, Version 11, Chicago IL).Go to:RESULTSSample CharacteristicsRegarding the OPO recruitment strategy, 456 (67%) of those next-of-kin who were approached about donation during the study period received a study information card, 312 (68%) next-of-kin made inquiries about the study, and 285 (147 donors, 138 nondonors) completed telephone interviews. Also, 137 individuals responded to the study advertisement on the NDFC website, and 121 (99 donors, 22 nondonors) completed the interview. Finally, 207 individuals responded to the newspaper advertisements, although 43 of them did not meet eligibility criteria and 9 met eligibility criteria but did not complete the interview. Thus, 155 next-of-kin (102 donors, 53 nondonors) of those recruited via newspaper advertisement completed the interview. Preliminary analyses indicated that participants across the three recruitment groups did not differ significantly on any of the socio-demographic variables (P>0.05). Therefore, all subsequent data are based on the total sample of 561 next-of-kin who completed the interview.Mean age of participants was 47.6 yrs ( 13.9; range1885 yrs). The majority of participants was female, white, married, employed, had at least some college education, and had a donor designation on their drivers license. Relationship to the deceased was as follows: parent (34%), adult child (27%), spouse (21%), sibling (9%), and other (9%). Sixty-seven percent of participants lived in United Network for Organ Sharings (UNOS) Region 3 (Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, Puerto Rico). Mean interview length was 43.1 min ( 11.6; range 3180 min) (Table 1).

TABLE 1Sociodemographic characteristics, next-of-kin donation decision, and donor registration status (n = 561)Regarding the demographic characteristics of the prospective donors (i.e., deceased relative of study participant), mean age was 42.4 yrs ( 20.6; range, 279 yrs), 61% male, 76% white, 39% married, 33% college educated, and 63% employed at time of death. In general, these data mirror those of the regional OPO population during the study (mean age = 42 yrs; 59% male; 80% white) as well as national donor-specific data (mean age = 41 yrs; 58% male; 77% white).Attitudes toward Financial Incentives, Donor Authorization, and Presumed ConsentOverall, 91.4% of participants reported that financial incentives would not have influenced their decision to consent or not consent to donation at the time of their family members death. Nondonors were more likely than donors to state that financial incentives would have made a difference in their final decision (P=0.02). Specifically, 12% of nondonors would have consented to donation had financial incentives been offered; however, 6% of donors would not have consented to donation if approached about financial incentives. Similarly, nondonors were twice as likely to say that financial incentives would influence their donation decision about their own organs (P