(00:00:00) I'm going to stick with the topic I had which is the ethics of organ procurement. I'm going to change the title slightly, but I'd like to call my talk. Today is organ procurement. It's not in the (00:00:12) cards. (00:00:15) What I will be talking about really is. What's going on with the present system? Well, I don't think it's adequate as a matter of either empirical success moral adequacy or public policy talk a little bit with you about some of the alternatives to the present system of donor cards and the philosophy of what I like to term encourage volunteerism. And those Alternatives will include a market presumed consent and something I'll be talking about later on as required request. Then I'm going to talk to you a little bit about something that no one knows about except me. I think butts talked about a lot and that's presumed consent in Europe. I was forced Kicking and Screaming to go to Paris in June. much against my real desires to stay in New York at my desk. And so I did go and I took a the opportunity to talk to a number of nurses and Physicians. There aren't many organ procurement people in France, but I did learn quite a bit about presumed consent and how it works and what goes on with it and I think that might be of interest to you as we think about the question of whether there ought to be a change in American policy about organ procurement and what the most useful policy might be. Well, let me quote to you first from a talk that was recently given at the Hastings Center by Alfred and Blair Sadler. These were two men that happen to be identical twins. As a matter of fact one's a doctor and one's a lawyer. Undoubtedly, making their parents forever grateful and the Sadler's were in Hastings talking about the dark old days of 1968. When the Uniform Anatomical Gift Act was passed they served this team as the Consultants to the commission on uniform state laws, which drafted and passed the Uniform Anatomical Gift Act, which is the legal basis that guides donor cards that you all deal with in your day-to-day practice around the United States and what they had to say in this recent talk was the following. They said in the late 1960s when we became involved in the questions surrounding the procurement of organs for the newly developing technology of transplantation, we and others espouse the principles of informed consent and to quote. Dr. Kaplan encourage volunteerism The Uniform Anatomical Gift Act drafted in 1968 embodied those principles, despite the expansion of transplantation programs and challenges. Those principles today. We believe still quoting them that there is no reason to discard them. Now the law is doing well what it was intended to do providing a clear mechanism for individuals and next of kin to consent to organ and tissue donation for humanitarian purposes. And not so long ago the distinguished senator from Vermont George Aiken proposed a novel solution to the Vietnam War. He observed that the fastest way to stop that war was to Simply declare ourselves the winners and go home. Defenders of the present system of donor cards and voluntary choice on the part of individuals seem to me to have taken George Aikens ironic proposal to Heart the Sadler's declared that they can't see any significant reason for changing or discarding the donor card system as embodied in the Uniform Anatomical Gift Act. I suggest that they Congressman Gore some of the other people who've been defending the present system and saying what we need to do is get that gigantic computer humming get that public education going get those cards out. There are simply not looking carefully at what the reality of the situation is the facts about the supply of organs available and the demand for cadaver organs put aside questions about live donation for the sake of today's talk don't support the decision to solve the crisis in organ procurement by simply declaring the system a success. Our society's decision in the late 1960s to rely on a public policy of donor cards as the primary means for sharing an adequate supply of organs for transplant is no longer in my view tenable. Perhaps such a system was appropriate when organ transplantation was in its infancy, but this is no longer the case or soon will no longer be the case. I don't want to baptize certain forms of transplant is therapy before they deserve it but soon it will no longer be the case. The Centers for Disease Control estimates as you all know that about 20,000 people die each year and I'm taking the conservative numbers here under circumstances that would make them suitable for cadaver organ donation. Let's talk about kidneys. This number should provide a maximum possible pool of 40,000 kidneys. Let's put aside questions of suitability in age and damage and complicating disease. The fact is that in 1982 only 3691 cadaver. Kidney transplants were performed the best estimates are that less than 15% And again that's conservative of potential donors are utilized using a policy of relying on donor cards recent studies estimate that between six and ten thousand people on hemodialysis or waiting for kidney transplants some believe the number of possible recipients. I got this number from dick reading those who know him as really one of the careful experts whose followed the dialysis system. He estimates. In fact that the number could be as high as 20 mm if transplant surgeons were not By the severe inadequacy of the present supply of cadaver kidneys to be conservative in formulating eligibility criteria for transplant similar statistics exist concerning the shortfall of tissues for corneas parts lungs and is the media remind us every day livers and unless something is done to modify the present Reliance on a donor card system the shortage in cadaver organs will continue to worsen rapid progress in the development of surgical techniques tissue matching and immunosuppressive drugs will lead to incessant demands for more cadaver organs in the years ahead transplantation. Maybe he has some critics say a halfway solution to the problem of organ failure. In fact, I'm one of those critics and I say that sometimes but the fact is for those suffering from renal failure today, kidney transplants afford a better quality of life for most people than dialysis and they are much cheaper Medicaid's and Stage disease renal program last year passed the two billion dollar Mark in reimbursing the cost of more than 70,000 dialysis. Patience, how can anyone conclude that? The present approach to procurement is adequate acceptable or working? Well. Nor is it at all evident that donor cards play a significant role in helping to produce even the degree of success that has been attained in the United States today less than 15% of the population carry donor cards transplant coordinators that I've talked to estimate than less than 3% of donors have the cards in their possession at the time of death when data are available. The number of drivers designated as donors and states were organ donation boxes are provided on licenses that compliance rate is not particularly impressive if you take Colorado out of the situation, it stinks. Not only of donor cards failed to produce an adequate Supply not only has a policy of volunteerism on the part of donors fail to produce an adequate Supply to meet the demand I would argue they have not achieved much in the way of moral respect for donors. That is to say if the point of having a system of volunteering to be a donor was to respect individual Choice respect individual autonomy respect individual rights. I don't see them as doing that and let me explain the reasons why a public policy that insists upon informed choice and consent by the donor. Has been considered the only means for protecting personal autonomy, but there are many reasons why this simply is not true consider the psychologically wrenching circumstances that you people have to deal with every day under which family members are asked about the possibility of donation almost always the potential organ donor has died suddenly and unexpectedly relatives. Our friends are in a State of Shock grief and confusion in such situations. And by the way, if he took the parallel to human experimentation and took those characteristics and said can a person give informed consent to a drug trial or any type of experiment absolutely not you'd never let somebody in that state consent to a clinical trial of a drug consent to participation in the test of a new device. In such situations, it's difficult for me to imagine how families can ever have an opportunity to make what we're trying for here and informed or voluntary Choice basic factors held to be absolutely necessary in the human experimentation area or informed consent to therapy area for a choice to be informed and free that is time rationality ability to comprehend information and a suitable decision-making environment are almost always absent in a busy Hospital Corridor or emergency room, the capacity of bereaved family members to comprehend information under such circumstances I would argue is Highly Questionable at best. Moreover it's difficult to know when encouragement by you all to donate becomes pressure or coercion to do. So, I've had the privilege to follow around some of you in this room in doing organ procurement. You Know Who You Are. I'm not going to name you since I'm about to indict you. Those involved in organ procurement are well aware of the strategies that are most likely to produce a donation identify a specific recipient for a particular donation whenever possible even if you don't know who it'll be you could help Jamie Fisk, for example. Painting an overly optimistic picture of the chances of benefiting others downplaying the possibility that the organs that are obtained will not be suitable for transplant and talking in a general way about the overall success rates for organ transplants of various types rather than about the particular rate of success in the program or hospital with the organ will be utilized perhaps given these kinds of biases on the part of those who provide information to potential donors to individuals really choose to have a loved one serve as an organ donor or are they pressured cajoled shamed coerced or even sometimes lied to in order to get them to donate? It's also difficult for me to understand how anyone could think that the present system maximizes individual Choice individual Freedom individual autonomy, when in fact the donor cards one hundred percent of the time or ignored since family consent in my experience is 100% of the time always mandatory before anything happens in one sense. Is it that a donor card system protects individual Choice individual autonomy or individual anything? (00:11:41) So my (00:11:42) argument is pretty miserable scenario, isn't it bad Supply not so good on the ethics front. So again, my point is simply this it does seem to me that the evidence against the present system on empirical grounds right now. It's not doing as well as it should the immediate projections down the road make me worry that the present system of donor cards and voluntary individual donation will not be adequate to meet the demand for organs for proven therapies. And the transplant area just take kidneys and corneas if you like and it seems to be ethically speaking the system is not contrary to the Sadler's view or others doing what it was supposed to do in terms of assuring the absence of coercion and the right of free choice that takes me to the question of what are the Alternatives we have. A market presume consent and required actually, that's a little wrong. It didn't quite get it right required request. Where's that grease pencil to change that bottom one required (00:12:45) request there. (00:12:49) Now the technology is beyond us. Let me talk a little bit about the first (00:12:56) one. (00:12:59) One possible approach as an alternative to get more organs is to allow the creation of a market in cadaver organs there really two variations of this approach the strong Market approach would allow individuals or after death their next of kin to auction organs for sale to the highest bidder. This is the H Barry Jacobs Memorial proposal. So what we have is sort of a business of Oregon Brokers finding donors and kind of putting them in touch with Bitters and the thing would get settled according to the laws of Commerce the weak Market approach. Would discourage direct compensation of donors by recipients, but would allow for the creation of various tax incentives or perhaps in kind reimbursements to encourage donation, those who donate for example could guarantee their loved ones our friends priority for future transplants or as I was shocked to hear at a recent Hearing in New York state one of the Physicians who is involved in transplant in that area said people who don't or are unwilling to serve as donors should not get organs when they need them and that would be an example of a weak Market approach. It's the equivalent of replacement in the blood banking industry. That's a system where you don't pay but you're paying in Kang. So those are the two versions of a market a strong system where you just let people buy it and those who have money get it and those who don't don't and the weak one way you create incentives by either tax break or an in-kind payment the second approach that of Presumed consent. Would Grant medical personnel the authority to remove organs from cadavers for transplantation. And whenever usable organs were available at the time of death again, there are two versions of this in strong presumed consent the state simply grants positions complete authority to remove usable tissues regardless of the wishes of the deceased or family members that is dr. Simply have the right to take tissues that they can use and they don't have to ask any permissions to do it. The presumption is that the public good to come from having the organs available is so strong that it doesn't matter if individual objections rights or values or overridden they simply get ignored in the organs get taken in week presumed consent. The law would presume that organ procurement organization element can be undertaken in the absence of some form of objection from the deceased or family members. We consent places the burden of opting out of organ donation on those who have objections to the procedure rather than is the as is the case under the present system of volunteerism upon those who want to opt in to organ donation. See what the donor card system does is it tells you if you want to be a donor You got to find the card you sign it you carry it. You keep it with you you join the system by opting into it. We presumed consent says we presume everybody wants to be an organ donor. We recognize that there are people who may not it's your problem to figure out how to get your objection registered you carry a card. You tell your family members that you don't want it or what have you but the burden is on you to stay out of the system rather than the burden being on those who want to come into the system. So those are the two variants of Presumed consent there around a third approach which has not been widely discussed in the current debate is what I'm going to talk about as required request. In the strong version of this policy every citizen would be asked to indicate his or her willingness to participate in organ donation, perhaps by means of a mandatory check off on applications for a driver's license a social security card or on a tax return see what required request if you don't like my phrase think up another one of your own but what that would basically do is it says sure you have the right to say yes or no, but you must answer the question. So required request strong policy puts the burden on everybody to at least be asked in the weak version current legislation pertaining to the definition of death might be modified. I mean if we had definition of death standards in all 50 states that might be nice but in those places where we have them and perhaps as part of the current national bill that's coming up soon. I guess it's in January for a national death statute. This could be modified to state that the time of death. When death is declared a person who has no connection to the process of determining death is required to ask family members about the possibility of donation. So the required request burden here falls upon those who are involved in the determination of death to say as part of what it means to be dead. Your relatives get asked. Is there an objection to organ donation that becomes a rider or a modification of the present process for death, by the way those of you who are interested in the parallel to Oregon for human procurement, which I've been thinking about a lot here in been talking to an entirely different group about the Pathologists and autopsy. I would extend this policy out to the autopsy requirement as well and try to handle disposition of body questions under required request weak form across the board and I can say more about that in the discussion, but that's just a little aside for those of you who care about your brethren in other parts of (00:18:08) Medicine. all (00:18:10) two of you now the so let's talk about these policies for a little bit and you give me a kick if I start to get close to running out of time. I'm might stop what the what the public thinks about all this. There's been a good deal of public debate as we all know about the moral acceptability of the strong Market approach to procuring organs near unanimity of public opinion is emerged about the unacceptability of an open market in cadaver organs at least one State Virginia. The home of dr. Jacobs has banned the sale of organs for transplant already other states are considering such bands New York is one as is the United States Congress transplant surgeons have repeatedly stated. They're adamant opposition to Market Solutions, the moral revulsion that has characterized discussions in the popular press and in professional journals about the spectacle of the desperately ill furiously bidding against one another for kidney or liver has at least for the present rendered both versions of this policy academic, so I don't think right now politically Politically the market approaches are viable both seem to be have been beaten up pretty well in the press and I don't think they're going anywhere right now. It's interesting though that the ethical arguments against them have not been as strong as the psychological arguments. The image of the bidding has a lot more power and some of these debates than the question of who ought not be allowed to sell body tissues. And I remind you for those of you who don't think we have markets in the tissue procurement area. Remember that you still can sell plasma in the United States sperm donors in the United States are routinely reimbursed and surrogate mothers routinely are paid to rent their wombs. So there is at least three there are at least three versions out there of Markets in human tissues and it's not clear to me if it's acceptable there. What is worse about the sale of bone marrow or the sale of a kidney and so forth. I think the ethics there in fact is still open to some more debate and I would suggest you by the way that if the if something doesn't happen to get the present system off the dime that we're going to hear about both strong and weak Market proposals as Solutions in the near (00:20:19) future. (00:20:22) Similarly little public enthusiasm seems to have emerged for system of strong presumed consent in a recent survey done by Roger Evans of the Patel National heart transplant study. He found he tells me that less than 8% of those interviewed felt and I'm quoting him. That doctor should have the power to remove organs from people who died recently but have not signed an organ donor card without consulting next of kin. So basically what Roger found although he fails to distinguish between strong and weak presumed consent is that people don't like the idea of strong presumed consent Americans don't seem comfortable with the idea of not allowing individuals to raise objections to organ transplant and just giving the authority to the state by the way. It's interesting that this is not a pie in the sky proposal since I made it. I'm the one who gets all the pies but although it's not original to me. There was actually a nice early version of a presumed consent discussion in the New England Journal of Medicine back in 68 by do come in here and Sanders those of you want to go see the historical antecedents to this earth the argument I'm presenting you today, but the fact is that some localities as some of you know have instituted a version of strong presumed consent and Coroner's offices where they're taking kidneys from unclaimed bodies, Florida and San Francisco. Those are strong presumed consent policies because they're simply saying no no, no objection by the deceased. No family members come we presume the consent and take the corneas. It's not a system that's necessarily hypothetical by any means, although I would tend to agree despite sneering at Rogers study that most Americans aren't ready for a strong presumed consent policy. The big argument though against presumed consent is come out of people who are looking at the European (00:22:05) experience (00:22:08) Defenders of the present system. Keep coming back to the fact that it's not clear what has happened in those European countries who have versions of Presumed consent. It seems evident that some European countries that have presumed consent laws still have waiting lists of people on hemodialysis for transplants if that's true critics of Presumed consent say why should we Institute a policy? That doesn't get more organs. That is the reason that I went over to France recently and that's what I'd like to talk about next because in fact that is one of the countries that has a strong presumed consent law. Here is European countries. In fact, including Austria, Denmark Poland Switzerland and France have legislation mandating a policy of what I'm terming strong presumed consent other nations such as Finland Greece Italy Norway Spain and Sweden have adopted versions of week presume consent on the books in those countries. You can take organs if there's no objection and you have to make what's called a reasonably prudent search to find family members. However, as critics have observed many many times the empirical data is ambiguous about what the story is and those countries that have strong presumed consent laws relative to the increase in Supply. It is interesting to note that the swedes according to their own published data have gotten to the point now where they transplant nearly as many patients suffering from kidney failure as they maintain on hemodialysis about 121 that compares pretty well with a ratio of 921 dialysis to transplant that prevails in the United States. However, statistics on the actual rates of organ procurement and Sweden and these other European countries are not readily available and that's too bad. It's hard to compare the systems is the data isn't collected. It is true. However that in all these countries there are still waiting list for people who want kidney transplants and every one of them. In June, I did go to Paris reluctantly to discuss organ procurement with a number of transplant surgeons and nurses organ transplant in France has been confined as I learned almost exclusively to corneas and kidneys French positions in government officials told me that about 800 kidney transplants were performed in 1982. This suggested a rate that was only slightly higher than the rate of kidney transplant in the United States relative to the population size there. There are indeed waiting list for people on hemodialysis who hope for a transplant now why should this be so given the fact that France has a policy of strong presumed consent. I mean, that's the real question if the doctors they are can take kidneys without asking anybody. Why is anybody on a waiting list, or why isn't there nothing more than a small percentage? French positions gave me two explanations first though. The law has resulted in an increase in the number of cadaver organs available for transplant. The increase is not readily reflected in the overall rates of transplant because the additional organs have been utilized to decrease the numbers of live donors. Whereas live donations had provided about a third of the kidneys available for transplant in France in the late 1970s today live donors make up less than 10% of the donor pool. Those of you from here know that we have about a third live donation from kidney still here. So one answer to the great mystery of where did those French kidneys go under strong presumed consent is that they have shifted more toward cadaver donation and away from dependence on live donors. Second French Physicians told me and some nurses that despite a public policy allowing strong presumed consent doctors are never willing to remove organs from cadavers without the consent of family members strong presumed consent. In fact exists only on paper and France in practice French positions find it psychologically intolerable to remove tissue from a body without obtaining the permission of next of kin. So while we keep seeing in the literature of transplant and journals like transplantation and so on the list of countries that have strong presumed consent I can now tell you that at least in one country that's a paper law in practice. It is only done as a version of week presumed consent. In the view of both Physicians and nurses. However, the French public strongly supports organ transplantation the Physicians. I spoke with reported consent rates or that is objection rates between 5 and 10% when permission was sought to remove solid organs in practice French Physicians believed strongly in allowing family members to retain the right to object to object to organ removal few family members actually do object-- indicating that a public policy of week presumed consent is quite compatible with a moral values of both health professionals and the public in France. Even if French positions are only willing to participate in a system whose governing philosophy is one of week presumed consent. Why given the low rate of refusal are not still a larger number of organs made available for transplant? The answer I think is Illuminating for our discussion today France. Unlike the United States does not have a Cadre of highly trained Personnel to handle the process of organ procurement. What a stroke that's you I'm talking about you don't exist in France contrary to your belief, but your equivalents don't exist in France. There really isn't a group of people who does organ procurement. I think someone told me they were somewhere between five and ten people who had as a full-time job organ procurement for a hospital. Although they're trying to increase that number but they're not there right now health professionals usually nurses must bear the burden of inquiring about objections to Oregon removal locating a suitable recipient and arranging the removal of organs French hospital administrators Physicians and nurses all said that this process with was both time. Assuming and costly given the growing concern in France to about Rising costs of Health Care. There is a reluctance as expressed by some of the hospital administrators. I talk to in Paris to devote scarce medical resources the time of nurses in particular to organ procurement. French transplant surgeons also noted that at present there were severe limits both in terms of personnel and Hospital space on the number of transplants of all types that can now be performed one surgeon told me that quote if we had your resources and facilities for transplantation. We would be much more aggressive in pursuing organ donors and quote limits on the availability of transplant services in France seem to dampen the yarder with which organ procurement is undertaken. So even though they have a law that says strong presumed consent and even though the practice is week presumed consent. There are plenty of disincentives there for people not to get involved with organ procurement in any way particularly the lack of personnel to do it. They're always taking away from somebody else's time. That's really why we don't see the big difference in rates between at (00:28:53) least France and the United States (00:28:57) moreover the French like their American counterparts find it psychologically difficult to approach grieving family members about the prospect of organ procurement, even if only to a certain And whether the family objects to what is usually described in their consent process as routine customary and legally sanctioned busy emergency room Personnel or loathe to take the time necessary to fully discuss the subject of transplantation with distraught family members. The French experience with strong presumed consent holds I think important lessons for those like me who believe that our system of organ procurement must be overhauled the French positions unwillingness to act upon the authority granted them by the state through Federal legislation in their country to remove organs regardless of the wishes of the deceased or family members parallels 100% the unwillingness of American Physicians to remove organs solely on the basis of the legal Authority granted by donor cards, they don't follow their law here. We don't follow our law. as organ procurement Specialists, like you know only too well donor cards are almost never viewed by Hospital administrators risk management consultants and Physicians as adequate authorization for allowing organ retrieval or the DA's of a lot of counties in New York state these days the permission of family members is always sought prior to Oregon removal whether or not a donor card or other legal document can be found on the other hand the Practical experience obtained by the French with a version of week presumed consent does not support the kinds of concerns that are raised by some critics of Presumed consent French positions are impressed with the fact that objections have been raised by less than 10 percent of families who have given who have been given the opportunity to refuse consent The French Press is not reported once any dissatisfaction on the part of the public with presumed consent and French positions were uniformly relieved to be able to decrease their earlier dependence on live donors a policy of week presumed consent appears to me to have produced a significant amount of social good well allowing for Emily choice and autonomy in an atmosphere of mutual respect and understanding the organizational financial and psychological factors at work in the French system of organ procurement are also present here unlike the French. However, we have a highly trained and skilled system of Specialists available to do organ procurement, but constant pressures to reduce costs of the sort we heard about in the previous speaker from the previous speaker in combination with an increasingly litigants atmosphere in medicine make it unlikely that the modest reforms of the present donor card system of bigging of building bigger computers of doing better tissue matching is going to lead to any significant Improvement in the supply of cadaver organs. So that leads me to the wrap up of this talk and the policy that I think I would compromise on (00:31:44) which is required request and got (00:31:47) me take a little more time explain that to you. One key factor emerges from both the French and the American Experience. The major obstacle to organ procurement is the failure to ask the failure to ask family members about organ donation French positions are entitled by law to take tissues without asking anyone but they never do American Physicians are entitled by The Uniform Anatomical Gift Act to take tissues from those who signed donor cards, but they never do whether or not one believes that the wishes of the family should supersede either the wishes of the public as is the case in France or the wishes of the individual as is the case here. In fact, both countries always treat the family as the final Authority insofar as the disposition of the Dead is concerned. The respect accorded family members and their wishes and these two large and medically sophisticated countries seems to me to dictate the kind of public policy answer that has the greatest chance to alleviate the present and likely future shortage in cadaver organs. The French experience indicates that the only practical policy options are those that recognize and respect the role of family members in participating in decisions about cadaver donation. The weak version of required request acknowledges the role of family members while at the same time ensuring that an optimal environment exists for eliciting organ donation Physicians nurses or other Hospital Personnel, I believe should be required to inquire whether available family members will give their consent to organ donation. This could be accomplished by modifying the current legal process for declaring deaf in all states to include a provision requiring that a request be made concerning organ donation to available family members by a Not connected with the determination of death when family members are not available organs could only be removed only if a donor card or other legal document were present. Or for those of you who didn't make it to Dallas, but would like to indulge certain Republican and libertarian approach has another way to get required request and the reform through is to Simply make it part of Hospital accreditation requirements. If you don't like government meddling and you can Embrace this kind of an approach through professional society and professional self regulation hospitals could simply decide to include a provision mandating that at death in hospitals accredited hospitals family members of potential donors must be approached about the willingness to consent to donation. So there's really two routes open to have a week required request policy. Come about one is to put it in law. The other is to put it into accreditation or some other Hospital regulatory process. What you're asking for is that people be mandated to ask about donation you put the burden on the providers to say whenever there's a possible donor. We will make a reasonable search for family members and we will ask them if they have. Of any objection if we find a card we're still going to do that if we find a card and there's no family members. We will remove the organs if we can't find family members, then nothing will happen. That way you will guarantee the rights of individuals to not participate in donation if they don't want to for whatever reason but at the same time you'll be able to take advantage of what a lot of the public opinion survey show altruism and a willingness to give a public policy. I think of week required request could be merged with a further change in our current procurement policy. We could modify the consent process from the present system of opting in to one of opting out along the lines of the week present system week presumed consent system that I described to you that prevails in practice in France. But week required request doesn't have to be linked to any version of Presumed consent. Let's go to the other slide get that one that drilled into your minds now up there for four (00:35:46) hours. (00:35:51) There's really four possible combinations of Presumed consent and required request. You can make requests optional or required right now. It's optional for us and you can have consent when someone presents it if you are getting informed consent from someone there are two ways to do it. You can say would you like to volunteer to come into organ donation or opt out? Do you have any objections to what is routinely done that is to take organs for transplantation. So it's all in the matter of style as to how the consent is presented. Now, I obviously believe that the strongest policy and the one most likely did produce a maximum number of organs is the combination of required request and opt-out consent, but what I'm here to say today and to basically conclude this presentation with is that I'd like to compromise or offer a compromise position that we think all of us think about moving toward at least a policy of required request. Holding the consent part constant that is if people are still worried about the notion of Presumed consent and raising objections as somehow being coercive or pressuring in and of itself the idea of the burden being on you to say no rather than the burden being on you to volunteer to say, yes, fine. Let's see what would happen if we could get some version of a required request system in so that despite drgs despite malpractice fears despite laziness despite psychological unwillingness emergency room Personnel doctors and Hospital administrators would know that whenever a potential donor appeared. They're supposed to call you (00:37:28) guys. Thank you.