25 ways to give to charity

HELP A STRANGER
1 Help a stranger and make their day
According to the World Giving Index 2018, 63% of people in the UK helped a stranger last year. Why not carry on the trend and hold a door open, give up your seat on the train or just smile for someone you don’t know?

Share your good deeds on Twitter and Facebook.

2 Teach your kids about giving
Get your children involved by talking to them about the importance of giving. Giving unwanted toys to those less fortunate, smiling at someone on the street, holding doors open for people or visiting a sick relative is still charity because it warms someone's heart.

Start your children's giving

3 Donate blankets, gloves, coats etc.
Spare a thought for those who are homeless or in temporary accommodation. Use our charity search to donate to a homeless charity near you.

4 Be a bobble hat hero
Encourage your children to come to school wearing their favourite bobble hat and raise money to make a difference for other young people.

5 Support a toy box scheme
Not every child has toys or games, so buying an extra toy for a toy box scheme such as KidsOut can go a long way to putting a smile on someone’s face.

Find out more about KidsOut

GIVE YOUR TIME
6 Donate blood
Donating blood regularly - or even as a one-off - is a great way to ensure that you're giving back to those who need it. By giving blood, every donor is contributing to a nationwide challenge to provide life-saving products whenever and wherever they are needed.

Find out more and search for your nearest venue

7 Volunteer your time in a soup kitchen or homeless shelter
Charities really appreciate volunteers and there are likely to be organisations in your community that could use an extra pair of helping hands. It’s a great way to meet new people and develop skills to use at work or university.

Start thinking about volunteering

8 Take part in a charity run
Completing a charity run is a great social event which can make you feel great while helping a cause close to your heart. It also gives you an excuse to tuck into some goodies as a reward.

Find out more about running for charity

9 Get involved with Decembeard
Men – why not ditch your routine and grow a beard for charity? You can spend the time you’d normally spend shaving to do a good deed for someone.

Find out more about Decembeard

10 Sell or donate your unwanted gifts
If you receive unwanted presents, why not spend some time selling them on eBay, Amazon or Gumtree and donate the proceeds to the charity of your choice. Use our charity search for inspiration.

ENCOURAGE OTHERS TO GIVE
11 Shout loud on social media
Share one of our quirky Facebook wall posts to raise awareness for a cause close to your heart. It’s a free and easy way to support a charity at any time of year.

Join us on Facebook

12 Hold a fancy dress day, or a dress down day
Have a dress down day, or a themed fancy dress day, at work and charge your colleagues to get involved.

13 Hold a raffle for charity
If you’ve got chocolates or biscuits leftover from a party, why not raffle them – and other unwanted goodies – for charity? You can pool your money while you decide who to donate to.

Tell your employer about the CAF Staff Charity Fund

14 Organise a charity shop Secret Santa
Rather than buying your annual Secret Santa present from a high street shop, agree to buy your gifts from a charity shop. Your favourite causes will benefit and you’ll receive an unusual and unique present!

Don’t forget to let us know what you got!

15 Encourage your employer to develop a charity partnership for 2018
If your employer isn’t already partnered with a charity, speak to your CSR or HR colleagues about getting involved. Let them know that they can contact one of our expert advisers for help.

GIVE MONEY
16 Support national giving days such as #givingtuesday
Join us again to celebrate all that’s good about giving. Whether you’re an individual, a company or a charity, there are plenty of ways to get involved in national events throughout the year.

Get involved with #givingtuesday

17 Donate money
Give a gift that makes a difference by donating to your favourite cause by credit or debit card, PayPal or CAF Charity Account. UK taxpayers can add an extra 25p for every £1 you donate through Gift Aid.

Donate now

18 Sign up for payroll giving in 2018
If your employer offers a payroll giving scheme, such as CAF Give As You Earn, you can donate from your pre-tax salary and benefit from the full income tax relief.

Get started with payroll giving

19 Think global on International Human Solidarity Day
Every December, the United Nations General Assembly encourages people around the world to think about the value of human solidarity. Why not donate to an overseas charity?

20 Throw an office party for charity
Throw an office party and encourage everyone to contribute. Send round a donation tin to collect donations for your favourite cause and encourage your employer to match your contributions.

Get started with matched giving

MAKE MORE OF YOUR MONEY
21 Shop Fairtrade
Help support artists in developing countries by buying Fairtrade presents. You’re sure to be able to find something unique for those closest to you.

Go Fairtrade this year

22 Give as you shop
If you’re avoiding the busy high streets and doing your shopping online, sign up to a retail website which donates to charity every time you shop with them.

Shop with Give as you Live

23 Send charity Christmas cards
Double your charitable giving by sending a charity Christmas card. Look in your local charity shop or on your favourite charity’s website for their range of cards.

We can help you find a cause that’s close to your heart.

24 Leave a gift to charity in your Will
December 21 may be the shortest day, but your giving can be long-term. A charity legacy is a tax-effective way to give, and allows you peace of mind that your giving will live on.

Find out more about charitable legacies

25 Gift your financial assets
If you have HMRC-qualifying shares, you might want to consider putting these to good use by gifting them to charity.

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Knowledge, attitude, and practice regarding organ donation among adult population of urban Puducherry, South India

Abstract
BACKGROUND:
India is currently having a deceased donation rate of 0.05–0.08 per million population. The National Organ and Tissue Transplant Programme have planned strategies to improve organ donation by creating awareness and capacity building. There is great need to assess the knowledge regarding organ donation among general population.

OBJECTIVE (S):
Among the adult population (≥18 years) residing in urban slum of Puducherry to determine the knowledge, attitude, and practice regarding organ donation.

MATERIALS AND METHODS:
Community-based cross-sectional study was conducted during April to May 2017 among 257 randomly selected participants in selected wards of urban Puducherry. Data regarding knowledge, attitude, and practice were collected through pretested semi-structured questionnaire.

RESULTS:
Mean (standard deviation) age of the study participants was 45 (15) years and majority (57%) were female, 41% of them were educated more than secondary. Almost 90% of the study participants have heard about organ donation. However, only 28% (95% confidence interval [CI]: 22.9–33.8) had adequate knowledge regarding organ donation. 58% (95% CI: 51.5–63.5) had positive attitude toward organ donation. Practice regarding registration for organ donation was only 2.3%. Knowledge regarding organ donation was more among joint family (odds ratio [OR] = 1.86, P = 0.02) and middle socioeconomic status (OR = 2.40, P = 0.01). Positive attitude was more among those who were educated above secondary (OR = 3.47, P = 0.001) and less among Muslim/Christian religion (OR = 0.49, P = 0.03).

CONCLUSION:
Less than one-third of the study population had adequate knowledge regarding organ donation. Even though more than half of them had positive attitude toward organ donation only six individuals registered for organ donation.

Keywords: Awareness, organ transplantation, urban health
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Introduction
“We make a living by what we get, but we make a life by what we give”– Winston Churchill. Organ transplantation is the most preferred treatment for many of the end-stage organ diseases as it increases life expectancy. Besides long-term survival benefits, organ donation also improves quality of life in many circumstances (for instance, in case of cornea, skin, or bone transplantations).[1]

As per data given by the Global Observatory on Donation and Transplantation, globally, there were around 1.2 lakh solid organs reported to be transplanted in 2015. This accounts for about 20.65 donations per million population. It was reported that there was an increase in trend of organ donation of about 5.8% since 2014. Yet, it was <10% of the global needs. Deceased organ donation has an advantage of decreasing this inequity. Globally, deceased organ donation rate, which is around 5.1 donations per million population makeup only one-fourth of the total organ transplantations.[2]

In India, a total of 7715 solid organ transplantations were done in 2015 equalling a rate of 5.9 donations per million population, trailing far behind the global trend. Certaintly, with 1.3 billion population, India is also lagging behind with respect to deceased organ donation with a rate of <1 per million population. The performance of Tamil Nadu, a southern state in India, deceased organ donation rate (1.3 per million population) was relatively better than the national performance (0.05–0.08 per million population). Although, India falls second in the number of live donor transplants, next only to the USA, but stands nowhere in the list of deceased donor transplantation.[3] Recent studies report that India is in need of 260,000 organs every year, which translates to about 180,000 kidneys, 30,000 livers, and 50,000 hearts, whereas only 6000 kidneys, 1200 livers, and 15 hearts are transplanted annually.[4]

Thus, it is clear that the primary hindrance to the organ transplantation program in India is the shortage of donor organs. There is an urgent need to identify the reasons for this wide gap between number of patients who are in need of transplantation and the availability of organs for transplantation in India.

While lack of awareness and negative attitude toward organ donation could be possible reasons for the gap between the need and availability of organs. Lack of awareness about the concept of brain death, religious attitudes, superstition related to rebirth, fear of misuse of organs, health risks due to organ donation, and lack of consensus among family members have been identified as potential barriers for successful implementation of organ donation program in India.[5]

There is a paucity of studies assessing the community's awareness, attitude, and practices with respect to organ donation in India. Hence, this study has been undertaken to assess the knowledge, attitude, and practice regarding organ donation among adult population in the selected wards of urban Puducherry.

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Materials and Methods
A community-based cross-sectional study was conducted from April to May 2017 among the adult population residing in JIPMER Urban Health Centre (JIUHC) service area. JIUHC provides general outpatient services from 9.00 am to 4.30 pm for 6 days in a week. JIUHC caters to a population of about 9423 spread over four wards (Kurusukuppam, Vazhaikulam, Vaithikuppam, and Chinnayapuram). All the four wards were located along the coastal areas of Puducherry where fishing was the major occupation.

The sample size was calculated using OpenEpi (v 3.01 updated on 2013, USA).[6] Based on a previous study, assuming awareness regarding organ donation as 53%,[7] absolute precision of 6%, and 5% alpha error, the minimum sample size was calculated to be 266.

All adults aged 18 years and above and their address details were obtained from the line list. The line list of adults was maintained at JIUHC, by regular yearly household survey by field staff, public health nurse, and nursing sister in-charge. Two hundred and ninety-two adults were randomly selected (keeping nonresponse rate as 10%) using this line list through simple random sampling. All the adults aged 18 years and above and residing in JIUHC service area for >6 months were included in the study. Individuals who were not able to understand and answer questionnaire were excluded from the study.

All the selected individuals were contacted through household visit and questionnaire was administered by data collectors after obtaining informed written consent. The purpose and motive of the study were explained to the participants. Six training doctors posted in urban health center were chosen as data collectors. They were sensitized regarding the objectives of the study, confidentiality of information, participant's right and informed consent, and were also trained to administer the questionnaire to the participants. Postgraduates posted in the same urban health centre supervised the data collection procedure by reviewing all questionnaires at the end of each day. If the house was locked or individual was found missing even after two consecutive visits, then that particular individual was considered as nonrespondent and subsequently excluded from the study.

Semi-structured questionnaire was used after pilot testing for about 10 individuals attending outpatient service in urban health centre. Questionnaire contained sociodemographic details of individuals such as age, gender, occupation, education, marital status, religion, type of family, and socioeconomic class. Details regarding their awareness about organ donation, source of information regarding organ donation, their attitude and willingness to donate organ in future, awareness regarding procedure and place of registration, as well as current registration status for organ donation was also captured.

Knowledge regarding organ donation was assessed based on three domains. It included whether they have heard about organ donation or not, knowledge regarding eligibility status for organ donation, and knowledge regarding the place of registration for organ donation. Participants who were able to answer correctly for all the three domains were considered to have adequate knowledge regarding organ donation.

Attitude toward organ donation was assessed based on two domains. It included their willingness to donate organ in future and persons to whom they are willing to donate organs. Participants who answered as willing to donate organ in future as well as willing to donate to unknown members were considered to have good attitude toward organ donation. Practice of organ donation was assessed based on their current registration status for organ donation.

Statistical analysis
Data were entered using Epidata Entry 3.1 and analyzed using STATA version 12.0. Continuous variables such as age of the participants and age at which the participant registered for organ donation were summarized as mean (standard deviation [SD]) or median (interquartile range) based on their normality in distribution. Categorical variables such as gender, occupation, religion, socioeconomic class, awareness regarding organ donation, source of information and knowledge, and attitude and practice regarding registration of organ donation were summarized as frequency (percentages). Binary logistic regression (Chi-square test/Fisher exact test) was used to find the association between sociodemographic characteristics and knowledge and attitude regarding organ donation which were summarized as odds ratio (OR). P < 0.05 was considered statistically significant.

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Results
Totally 292 individuals were contacted, out of which 257 individuals were included in the study. Out of the 35 individuals who were not included in the study, we could not contact 15 individuals as the house was locked even after two consecutive visits or change of address. Rest 20 individuals were not able to understand and respond to the questionnaire. Response rate was 88%.

The mean (SD) age in years of the study population was 44.6 (15.4). Table 1 depicts sociodemographic characteristics of the study participants. Majority 147 (57.2%) were females; 127 (49.4%) were unemployed which includes homemaker, ex-serviceman, pensioner, and retired personals; 195 (75.9%) were married; and 213 (82.9%) belonged to Hindu religion. Almost one-third of the study participants, 78 (29.9%) were graduates; more than half, 137 (53.3%) belonged to nuclear family and nearly one-fourth, 62 (24.1%) belonged lower middle socioeconomic class according to modified BG Prasad classification May 2016.

Table 1
Sociodemographic characteristics of the study participants belonging to selected wards of urban Puducherry, N=257

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Table 2 shows the knowledge regarding organ donation determined based on three domains among the study participants. Nearly nine out of ten, 229 (89.1%) have heard about organ donation in their lifetime, but only half of them had adequate knowledge regarding eligibility status for organ donation and place of registration for organ donation, 115 (44.8%) and 152 (59.1%), respectively. Overall, 72 (28%) had adequate knowledge regarding organ donation. (95% confidence interval [CI]: 22.9–33.8)

Table 2
Knowledge regarding organ donation determined based on three domains among the study participants belonging to selected wards of urban Puducherry, N=257

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Media was the only source of information in more than half, 130 (56.9%) of the study participants. Among those who have heard about organ donation (n = 229), more than half of them (130 [56.9%]) reported that media was the only source of information regarding organ donation. Majority (75 [32.3%]) believed that the eye, heart, and kidney are the organs that can be donated.

Table 3 represents attitude toward organ donation determined based on two domains among the study participants. More than half of the study participants, 151 (59%) thought about organ donation at any time in the past during their lifetime and 169 (66%) were willing to donate organ in the future. Among those who were willing for organ donation, more than three-fourth (186 [77.5%]) of them were willing to donate organ to unknown member.

Table 3
Attitude toward organ donation determined based on two domains among the study participants belonging to selected wards of urban Puducherry, N=257

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Overall 60% (148) had positive attitude toward organ donation if they were willing to donate organ in future and willing to donate organs either to unknown members or to a medical college (95% CI: 51.5–63.5).

Only 6 (2.3%) were registered for organ donation. All six were registered for eye donation. The median (interquartile range) age of registration for organ donation was 23 (18–39).

Table 4 represents the association of sociodemographic characteristics with knowledge regarding organ donation. Chi-square test/Fisher exact test was used to find the association between sociodemographic characteristics and knowledge regarding organ donation. The study participants belonged to joint or three generation family (OR = 1.86) and middle socioeconomic status (OR = 2.40) were found to have more adequate knowledge regarding organ donation when compared to those belonged to nuclear family and lower socioeconomic status and also found to be statistically significant (P < 0.05).

Table 4
Association of sociodemographic characteristics with knowledge regarding organ donation determined based on three domains among the study participants belonging to selected wards of urban Puducherry, N=257

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The study participants of age >30 years, female gender, educated from Class 1 to Class 10, employed, and single were found to have less adequate knowledge regarding organ donation. However, these variables are not statistically significant.

Table 5 represents the association of sociodemographic characteristics with attitude toward organ donation. The study participants educated 11th standard and above were found to have more positive attitude for organ donation (OR = 3.47) when compared to those who did not have any formal education. The study participants belonged to Muslim/Christian religion were found to have less positive attitude for organ donation (OR = 0.49) when compared to those who belonged Hindu religion and also found to be statistically significant (P < 0.05).

Table 5
Association of sociodemographic characteristics with attitude toward organ donation determined based on two domains among the study participants belonging to selected wards of urban Puducherry, N=257

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The study participants of age >30 years and female gender were found to have less positive attitude toward organ donation. However, these variables are not statistically significant.

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Discussion
This cross-sectional study on organ donation which was done among the adult population of urban Puducherry reported that 28% (95% CI: 22.9–33.8) had adequate knowledge and 57.6% (95% CI: 51.5–63.5) had positive attitude toward organ donation. Practice of organ donation was also assessed among the study participants based on their registration status for organ donation. It was found that 2.3% were registered for organ donation. Adequate knowledge regarding organ donation was observed to be more among those who belonged to the age group of ≤30 years, male gender, educated up to higher secondary and above, Hindu religion, joint family type, and middle socioeconomic status. However, only family type and socioeconomic status were found to have statistically significant association. Similar findings were found regarding the attitude toward organ donation; participants belonging to the educational status up to higher secondary and above and joint family type were found to have significant positive attitude toward organ donation.

Studies from different parts of the country have assessed knowledge and attitude toward organ donation using various domains.[7,8,9,10] However, we could not find any community-based study reporting adequacy of the knowledge regarding organ donation among general population. However, there were studies which reported adequacy of knowledge among health-care professionals such as doctors, nurses, undergraduate, and postgraduate medical students.[11,12,13,14,15,16,17]

In our study, we found that 89% have heard about the term organ donation. Similar results were found in studies done in Kanchipuram (86%), Ahmedabad (86%), and Maharashtra (78%).[5,18,19] Studies done in Kerala showed that almost all the participants have heard about organ donation. Higher awareness regarding the term organ donation among our study population can be attributed to the higher educational status of the participants.

Regarding the domain eligibility status for organ donation, we have found that almost half of the study participants were aware that both living donor and deceased can donate organs. Similar results were reported in studies done in Ahmedabad, where more than half were aware about eligibility status regarding organ donation.[18] However, contrast findings were found in studies done in West Bengal were only 15.6% had knowledge about eligibility criteria.[10] These contrast findings can be attributed to the socioeconomic and cultural differences between the study populations.

The current study found that more than half of the study participants had positive attitude toward organ donation. In contrast, studies done in Kerala (26%) and West Bengal (42%) reported lesser proportion had positive attitude toward organ donation.[7,10] This difference in attitude can be attributed to the religious beliefs among Muslim population which has been reported in the previous studies.[20,21] Since most of our study population belonged to Hindu religion, attitude toward organ donation was better.

Practice of registration for organ donation was found to be poor among the study population. The findings were even worse in studies done in Kanchipuram and Ahmedabad where none of the participants were registered for organ donation.[5,18] Lack of knowledge regarding the necessity of registration for organ donation was the main contributor for poor registration status.

Limitations of the study were cross-sectional nature of the study which makes precludes the association between awareness regarding organ donation and sociodemographic factors. Reasons for lower practice of registration for organ donation could have been explored more.

In spite of these limitations, the current study has certain strengths also. Reporting the adequacy of knowledge and nature of attitude toward organ donation was one of the important strengths of the study. This being a community-based study makes the generalizability to general population. Good response rate was also an added strength to the study.

Organ donation is emerging as a topic of public health importance as a result of ever-increasing gap between the need and actual status of donation. This inequity is prevailing not only in India but also among the developed countries. Major reason for the existing inequity can be attributed to lack of awareness regarding organ donation among the general population. In the current study, we have found that even among those who were aware about the organ donation, practice of registration was poor. This might be because the health professionals acted as a source of information for less the 10% of the study population. Involvement of health professionals plays a vital role in developing the trust and motivating the community to register for organ donation.

There might be certain misconceptions and sociocultural beliefs regarding organ donation which needs to be addressed through “awareness campaigns.” Involvement of primary health-care workers in such campaigns is important as Primary Health Centre is the first point of care and closer to the community. As the procedure for registration of organ donation is cumbersome, simplification of the process and availability of registration facility at lowest possible level of health care need to be done. Further study to explore the reasons or hindering factors in registration of organ donation is required.

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Conclusion
Less than one-third of the study population had adequate knowledge regarding organ donation. Individuals belonging to middle socioeconomic status and joint family type had higher chance to have adequate knowledge. Even though more than half of them had positive attitude toward organ donation, only six individuals registered for organ donation. Awareness campaigns with registration facility can be conducted in community and primary health-care facility on regular basis to promote organ donation.

Financial support and sponsorship
Nil.

Conflicts of interest
There are no conflicts of interest.

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Acknowledgment
I would like to acknowledge the staff of JIUHC and the Interns of 2012 batch for their contribution and support in conducting this study.

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References
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Opt-out organ donation 'in place by 2020' for England

 new opt-out system for organ donation will be in place by 2020 in England, if Parliament approves "Max's Law".

Under the plans detailed by ministers, adults will be presumed to be organ donors unless they have specifically recorded their decision not to be.

The government said it would save up to 700 lives each year.

In the UK in 2017, 411 people died before the right donor was found, and more than 5,000 people are currently on the waiting list in England.

A similar opt-out system has been in place in Wales since 2015. Scotland plans to introduce a similar scheme and Northern Ireland has also expressed an interest.

"Max's Law" is named after Max Johnson, from Cheshire, who was saved by a heart transplant.

His search for a suitable heart was followed in a series of front-page stories in the Daily Mirror, as the newspaper campaigned for the change in the law.

Last year, Theresa May wrote to the 10-year-old, saying she chose the name after she heard his "inspirational story".

The legislation was subsequently introduced last year, and will return to the House of Commons in the autumn to be voted on.

If passed, it is expected to come into effect in England in spring 2020 - because the timetable for its introduction will allow for a year of "transition" to the new law.

The government said it would also encourage people to discuss, with their families, the issue of whether they would want to be a donor in the event of their death.

'It really is the gift of life'
Mark Smith had diabetes for 25 years, which caused his kidneys to fail. He was on the waiting list for seven months before he was able to have a kidney and pancreas transplant.

Mr Smith told BBC Breakfast that he had got in touch with the family of his donor, a 24-year-old manslaughter victim, to express his gratitude.

"Having lost a younger brother myself, I wanted them to know that I could empathise," he said. "Although I hadn't lost a child, I knew what it was like to lose someone young in very tragic circumstances."

Image caption
Mark Smith received a double transplant in 2009
Since then, he said they have been in touch several times and had become "really good friends".

"I've always been a supporter of organ donation, it's such a noble thing to do for people to give that gift - it really is the gift of life," he added.

The new system presumes that over-18s in England are in favour of donating their organs when they die, instead of the current system where people opt in by signing the NHS Organ Donor Register.

Under the new law, those who do not wish to donate their organs will still be able to opt out via the register and by using an NHS app that launches at the end of the year.

The register will also include an option for people to state their faith, if it is important to their decision.

Currently, fewer than half of families give consent for their loved one's organs to be donated if they are unaware of their wishes, and ministers hope that the new system will encourage people to make their wishes known before their death.

Research shows 82% of people support organ donation, yet only 37% have recorded their wishes on the NHS Organ Donor Register.

Under the new plans, specialist nurses will be on hand to discuss donation with families after a loved one dies.

'My Hayley saved six lives'
Hayley Louise Jordan died from a brain haemorrhage when she was 32, and her organs were donated to six people, including two children.

She had signed the organ donor register before her death, and her mum Carol says she was glad her daughter's wishes could be granted.

Image caption
Hayley Louise's mum Carol Jordan feels comfort after her daughter's organs were donated
"My Hayley had gone, she wasn't there any more," she said. "Now I've got comfort knowing she's saved six recipients.

"I just want them to have a healthy and happy life - that's the comfort I get now. "I just wanted some good to come from it.

"They were sitting waiting for a call and it's a miracle for those recipients."

Carol says she agrees with the new system of presumed consent.

"It's a good thing because you're taking the decision off the parents."

Jackie Doyle-Price, Secretary of State for Mental Health and Inequalities, said the changes could save up to 700 lives every year, but she said organ donation remained a gift.

"I want to encourage people who wish to give life in the event of their death to take the time to record their wishes and discuss it with their family," she said.

"However, we know this new system alone is not a magic bullet.

"We need to address myths and misconceptions around donation, and we will only do this by having informed debate and dialogue, which I hope will be fostered by these proposals."

'Soft opt-out'
Fiona Loud, policy director of Kidney Care UK, told BBC Breakfast the experience in Wales, where donations did not initially increase, showed the new system depended on widespread public support.

"We must have a full, consistent public education system with faith groups, schools, colleges, universities, and with the public as well," she said.

She added the new system would involve a "soft opt-out", where families could override the presumption in favour of donation if they strongly believed their dead relative would not have wanted it.

Simon Gillespie, chief executive of the British Heart Foundation, said introducing an opt-out system in England would reflect the views of the general public better.

He said: "This will also ease the agonising pain felt by many families who risk losing a loved one while they wait for an organ.

"It's still really important for all of us to have conversations with our loved ones about organ donation so our wishes can be met if the worst should happen."

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Organ Donation and the Principles of Gift Law

The legal framework governing organ donation in the United States is built on principles uniquely designed to support the system of transplantation. Understanding how the laws are designed and operate in practice provides insight into organ donation practices and performance and illuminates how the law is utilized to drive change in the field.

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The primary law governing organ donation in the United States is the Uniform Anatomical Gift Act (UAGA) (1). The UAGA is a model legislation drafted by the Uniform Commissioners that is then passed into law state by state. The Uniform Commissioners are a body of law and policy experts appointed by the governors of each state to identify areas that would benefit from uniformity nationwide but which cannot be federally regulated because they fall under the reserved powers of the state (2). Organ donation is one of those areas. The experience and policy of deceased organ donation should be consistent throughout the country regardless of what state you live or die in. Because matters of public health, contracts/gifting, and estate are reserved powers for the state to regulate, so too is organ donation, which involves components of each of those areas. Recognizing the need for a single approach to organ donation policy, the UAGA has been enacted in every state in the United States, providing national consistency through state law.

The UAGA establishes gift law as the central legal principle in the United States opt-in system of organ donation (1). The choice of gift law is significant. Because medical providers are trained in the central health law doctrine of informed consent, they are often surprised to learn that organ donation laws do not follow the same legal principle. Informed consent is the concept of permission granted by a patient for a particular treatment after a facilitated understanding of risks and benefits including available alternatives. Deceased donation, however, presents neither risks nor benefits to the donor because the donation occurs after death. Moreover, individuals provide permission for donation in advance of death (often years or decades), making it unknowable what organs or tissue will be suitable to actually donate at the time of death. For these reasons, informed consent as a legal structure is ill-suited for the regulation of organ donation. Alternatively, gift law provides the legal framework under the UAGA (3).

A gift—in legal terms—is the legally binding voluntary transfer of something from the donor to the donee without payment (4). The lack of monetary exchange is important in this context because federal law prohibits the purchase or sale of organs (5). Consequently, ordinary contract law would be an inappropriate legal framework for organ donation because for a contract to be legally binding, there must be “consideration” (payment for the promise to transfer something from one individual to another). Note that donation and transplantation professionals are paid for their services as this is excluded from the federal prohibition, and because under the UAGA the donee of the anatomic gift is the transplant recipient, such payments do not abrogate the legal construct of organ donation as a gift. Clarity that transfer of organs from donors to recipients is legally binding is required as a matter of policy; the entire system depends on it. Gift law provides the legal certainty required and fits with the reality of deceased organ donation as a decision distinguished from typical health care decisions.

Gift law requires three basic elements: donative intent, transfer, and acceptance (4). Fulfillment of these elements results in a legally binding transfer of a gift from the donor to the recipient. Donative intent under the UAGA can be fulfilled either by an adult before death or a surrogate (next of kin) at the time of the donor’s death.

Because the UAGA does not incorporate an informed consent standard, donation professionals utilize the term “authorization” versus “consent.” Although both terms mean legal permission, this distinction aligns the terminology with the underlying legal principles. An individual authorizes an anatomic gift whereas a patient provides informed consent for a medical treatment.

Authorizing Donation: Two Bites of the Apple

Under the UAGA, an individual can make a gift before death or a surrogate can authorize a gift at the time of the donor’s death. In this manner, the UAGA provides “two bites of the apple.” This is an important legal component of the system because it provides two different legal avenues to arrive at a “yes” to donation.

First-person authorization is the term used when an individual authorizes their own anatomic gift before death, usually through a donor registry. Donor registries are registries of anatomic gifts. From a legal perspective, the donor registration process is not an informed consent process because it is not designed to be one and it is not required to be one under the law. The donor registration process meets the gift law standard under the UAGA. An adult individual can make a gift by registering as a donor or can decide not to make a gift.

Donor registries have been successful, with annual growth for the past 10 years and over 142 million registered donors as of January 2018, representing over 54% of the adult population (6,7). If an individual is registered, there is legally binding permission for donation at the time of the donor’s death under the UAGA, and family members do not have the right to override this decision (1). This is not only the law, as in current practice most donations proceed even over family objection (3). The ability to move forward in these circumstances is supported by a measure of confidence that making an anatomic gift was the individual donor’s affirmative decision—a voluntary exercise of autonomy under constructs of law and medical ethics. In the rare case where a donation from a registered donor does not proceed over family objection, it is usually because of marginal transplant potential or unusual circumstances regarding the registration. In such cases, from a legal perspective, the gift is not revoked, rather there is no transfer or acceptance (the second and third element under gift law).

The number of registered donors is only half the story. The donation rate is not 54%, rather the donor registration rate is 54%. The UAGA also permits surrogates to authorize donation at the time of an individual’s death, providing a second opportunity to obtain a “yes”. Because only a small percentage of deaths are eligible for donation for transplant, it is a very small number of surrogates that are ever approached for donation permission. Of that group, over half authorize donation. As a result, the donation rate (actual donors over eligible donors, defined by federal policy) is over 75% (8). The definition of eligible in the denominator of the donation rate as a proxy for medical suitability is currently the subject of national conversation. This should change over time, as medical advances and critical need result in transplantation of organs from increasingly complex donors (e.g., HCV-positive donors) given the risk-to-benefit ratio of waitlist mortality versus transplant outcomes. The numerator of the donation rate is a composite: about half of donors previously authorized their own donation through a registry and surrogates authorize slightly more than 50% of the remaining half.

The UAGA establishes three legally recognized positions: (1) authorized gift, (2) no decision, and (3) refusal to make a gift. Before death, an individual can move between these three positions. A registered donor is in the positive position, i.e., an anatomic gift has been authorized. If registration is then revoked, the individual moves back to the neutral position. Revocation is legally equivalent to having never made a gift. The UAGA does not provide for inference of intent from a revocation. A previous revocation does not bar a surrogate from authorizing an anatomic gift at the time of the individual’s death (1). If an individual does not want to be a donor, the UAGA recognizes that only through a refusal (1). A refusal can be made through a signed document (e.g., advanced directive) and is legally binding.

The opportunity to approach surrogates for permission when the donor has neither made a gift nor registered a refusal is an important component of the system. This is particularly true for some segments of the population where registration rates are lower because of a preference for the family to make the donation decision at the time of death.

The UAGA Works for the United States

United States culture is deeply steeped in individual rights, starting with the Constitution and mirrored through the many laws, regulations, and cultural norms that prioritize individual autonomy. A rights-based culture is well matched with the UAGA legal framework requiring an affirmative, voluntary decision to make a gift. Under this opt-in policy, the United States experienced over 27% growth in deceased organ donors and transplants in the past 10 years (9) and measures favorably worldwide. Some areas of the United States significantly exceed the donation rate in Spain, which is widely regarded as the world leader (10). Although there is more that can and must be done to continue to increase the number of donors and available organs in the United States, the UAGA provides a good framework, on the basis of sound legal principles, to support that goal.

Disclosures

None.

Acknowledgments

The content of this article does not reflect the views or opinions of the American Society of Nephrology (ASN) or the Clinical Journal of the American Society of Nephrology (CJASN). Responsibility for the information and views expressed therein lies entirely with the author(s)