Required Request for Organ Donation: Moral, Clinical and Legal Problems Recent proposals for uniform procedures have received widespread acceptance as a means of increasing the supply of organs and tissues available for transplant. [1] Adoption of such procedures, which mandate a request for organ and tissue donation from families of donors, is required by state and federal legislation, as well as by new hospital accreditation standards. [2] While increased availability of organs and tissues may be beneficial in the short term, difficult moral, clinical, and legal issues must be addressed before we can be assured that this benefit is not significantly offset by adverse consequences. [3] In particular, a policy of required request creates conflicts of interest at the clinical, psychological, and social/economic levels that produce considerable disvalue. An analysis of these three areas of conflict leads us to conclude that current required request laws are inherently mistaken and must be substantially amended or repealed. Clinical Conflicts of Interest Required request laws typically mandate that hospitals utilize accepted medical standards in articulating policies for the identification of potential organ donors. [4] Potential donors are usually victims of accident caused trauma, sudden acute illness, or self-inflicted injury. In all such cases, a diagnosis of brain death establishes that the body's internal controls can no longer be maintained and that recovery is not possible. [5] However, once a person is identified as a organ donor the attending physician is placed in a very difficult position, for if recovery of viable organs is to be accomplished, the physician must begin to consider preservation of organs over preservation of the brain. This process requires the attending physician to begin switching loyalties from the patient to the organ recipient. As a result, required request procedures produce clinical conflicts of interest in both the identification and medical management of the patient/potential donor, as well as in caring for the donor's family. These conflicts arise in relation to physical care, professional responsibility, and legal accountability. Medical treatment of severely brain-injured persons, a major group of donorss, is difficult under the best of circumstances. For example, patients with extensive brain injury usually die from the effects of cerebral edema, which prevents circulation to the brain. Maintaining a slightly dehydrated fluid balance benefits the brain by lessening the edema, while overhydration tends to increase edema and reduce circulation to the brain, thus increasing the possibility of brain damage. Unfortunately, fluid management that is beneficial to the brain can be harmful to other organs. For example, limiting fluid intake in order to reduce cerebral pressure may injure the kidneys through reduction of urine output, especially when the brain injury causes concomitant release of antidiuretic hormones. Conversely, increasing fluids will counter antidiuresis and enhance kidney function, but may precipitate or hasten brain death through increased cerebral edema. [6] More graphic and potentially costly conflicts arise with gunshot wounds to the head. In cases where the bullet had damaged the thalamus and hypothalamus, producing blood and air in the ventricles, the untreated lesion is inevitably fatal. However, treatment intended to preserve physiological equilibrium suitable for organ donation may result in preservation of the brain stem and persistent vegetative state for the patient. While such conflicts of patient management are as old as medicine itself, introducing organ procurement into the decision process puts the conflicts in a different light, for the physician now experience pressures that have no relation to patient care. Institutionalizing the identification of organ donors appears to assume a shift in the physician's clinical attitude so that willingness to diagnose or even hasten the diagnosis of brain death supersedes the incentive to fight for life. …