Increasing the rate of organ donation in our small country is a complex challenge, not only because of the emotional aspects of the decision that individuals and their families face but also because of the organisational and clinical demands of recovery, allocation and transplantation. At the same time, it is important to keep in mind the recipients of transplants and those awaiting transplantation. They are the beneficiaries and potential beneficiaries of organ donation, and their health and well-being are the reasons it is so important to increase the rate of organ donation.

Although the first transplantation in 1954 involved a kidney from a living donor, most organ transplants are the result of donations from deceased donors. Deceased donors provide multiple organs, whereas most living donors provide only one partial or complete organ. As things currently stand in Malta, the law regulating organ donations is the Human Organs, Tissues and Cell Donation Act, Chapter 558. Many organs are now harvested for donation, including the kidney, cornea, heart, liver, lung, pancreas, intestine, bone, skin, heart valves, tendons, ligaments, and saphenous veins. However, in Malta, only kidney, cornea and heart transplants are carried out. These, and other organs, may be sent abroad through the arrangement in place with Italy.

Currently, in Malta, the majority of donations are cadaver donations. Anyone can be a donor, provided they are healthy. However, even those who have or have had some form of cancer can be eye donors. They could be organ and tissue donors if they have been cancer-free for at least five years. Organ removal from a living donor may be carried out for the benefit of a recipient with whom the donor has a close personal relationship as defined by law, or, in the absence of such a relationship, only under the conditions defined by law and with the approval of an appropriate independent body.

Whereas many countries now have an opt-out system, in Malta we still retain the opt-in system, whereby organs can be retrieved from the dead body only if permission from the family of the deceased is given. Even the presence of a donor card, signed by the deceased, does not give the doctors the right to remove organs from the body. With an opt-in system, donors are often asked to register with the appropriate authority and obtain an organ donor card after providing adequate information, enabling informed consent.

On the other hand, with the opt-out system, which is practised in countries like Spain, Austria and Belgium, the law allows, indeed requires doctors to take organs from the dead body if they can be used for transplantation purposes without the permission of the family. In other words, there is “presumed consent”. The only restriction is that, in cases where the deceased indicated, when alive, his or her wish not to donate organs, doctors must respect these wishes.

Organ donations have always been considered gifts. The principle of voluntary, unpaid donation of tissues and cells was recognised for the first time in Spain in 1979 and in Luxembourg, Belgium and Finland in the early 1980s. Whereas donors abroad cannot be remunerated but may receive compensation strictly limited to making up the expenses and inconvenience related to the donation, Malta law does not allow compensation. Yet we have no specific regulation restricting or prohibiting the advertising of the need for or availability of human tissues and cells with a view to offering or seeking financial gain or comparable advantages. The only prohibition we have is Article 248 of the Criminal Code, which makes it illegal to indulge in traffic involving persons for exploitation in the removal of organs, for instance, for transplantation.

In all probability, in such circumstances, the immediacy for those on a waiting list might lead recipients to seek to obtain organs through payment. Once various studies conducted have shown that the clear majority of Maltese would be willing to donate one of their organs compared with those who are against the idea, perhaps it is time to review the situation here. Malta is one of the few European countries that does not have a Transplant Authority and this should be a priority if we are to have an organisational structure and produce an efficient system suited to our needs. Those who oppose an opt-out system principally do so because of their strong belief that a donation should be altruistic without any pressure and after having reached a conscious decision following adequate information. The latter information may be lacking if the state has a “presumed consent” policy.

Altruistic beliefs and values are one of the mainstays of the voluntary organ donation system. Altruism is the unselfish concern for the welfare of others, and in deceased organ donation, this particularly applies to the goal of improving the lives of (usually unknown) patients who are the potential recipients of the donated organs. Individuals and families often want to see something positive come out of tragedy and the "gift of life" and "donate life" themes of organ donation efforts highlight the values of altruism.

Whatever system is adopted, efforts to improve the organ donation process and encourage individuals and family members to consent to donation will need to take into account the many variables involved in the decision-making process.

The measure of life is not its duration but its donation. We are a piece of someone else’s puzzle. We may never know where we fit, but others will fill the holes in their lives with pieces of us.

Dr Mark Said is a lawyer