In their recent study, Siminoff and colleagues [1] found that despite widespread public support for organ and tissue donation, family refusal was "the major impediment to procurement." This important observation confirms previous suggestions that the need to obtain family approval represents a major barrier to the donation process [2, 3]. It is therefore unfortunate that, in contrast to the authors' assertion, our approach to organ and tissue procurement has emphasized the family, rather than the individual person. Although the Uniform Anatomical Gift Act does give adults legal authority to make binding decisions for themselves regarding donation, public policy ignores this law and requires family consent even when advance directives exist [3].

Mandated choice has been proposed as an alternative system for obtaining consent that is designed to eliminate the family barrier [2, 3]. Under this plan, all competent adults would be required to prospectively decide and record whether they wish to become organ donors at the time of their deaths, and their decisions would be controlling. Siminoff and colleagues [1] suggest that this approach might actually decrease the consent rate "[g]iven the common fear ... that persons who are willing to donate may be declared dead too soon." To support their concern, they allege that Texas has had a negative experience with mandated choice. However, their discussion of this issue is incorrect.

The study cited as showing a widespread fear that prospective donors will be declared dead prematurely (authors' reference 45) actually showed the opposite: This fear affected only 26 of the 143 university students surveyed [4]. Furthermore, despite the authors' statement, Texas has had no actual experience with mandated choice (nor, to my knowledge, has anywhere else). Although all adults applying for drivers' licenses in Texas are apparently asked about donation, an answer to this question is not required [5]. Those who say "I don't know" or refuse to answer default to "no," accounting for the spuriously high refusal rate reported by the authors.

Whether or not mandated choice would help alleviate the organ shortage remains to be determined. Public opinion polls are encouraging enough to recommend a pilot study of this plan [2, 3]; however, while an actual trial is being contemplated, dissemination of damaging misinformation must be avoided by refraining from making and publishing statements that have not been carefully corroborated.