Large segments of the U.S. public have serious reservations about organ donation. Dr. Spital questions our interpretation of Hessing and colleagues' study [1], which found that 18.2% of respondents reported a fear of being declared dead too soon and a significant association with willingness to donate. A fear reported by 18.2% of the population would be considered "common" by most social scientists.

Seltzer, Siminoff, and Arnold presented data at the Third Biennial Conference on Psychiatric, Psychosocial and Ethical Issues in Organ Transplantation showing that 28.0% (n = 414) of respondents reported agreeing with the statement "I worry that if the doctors know I am willing to donate organs they won't do as much to save my life" [2]. An earlier survey reported that 48% of the general population responded affirmatively to this question (Lieberman Research, Inc., 1991). These findings represent an obvious impediment to mandated choice.

Concerning the issue of mandated choice in Texas, we have had extensive communications with LifeGift, one of the State's three regional Organ Procurement Organizations, about the implementation of Texas House Bill 271. Whereas the original intent of the law may not have been to pass a mandated choice bill, the wording of the bill can certainly be construed as such. Section 11B(b) states, "A statement of gift must [emphasis added] be executed each time a driver's license or personal identification card is renewed, reinstated or replaced." More importantly, the Texas Department of Public Safety has chosen to implement this law as if it were mandated choice and requires that the public choose a donor status when obtaining their drivers' licenses because it forces a choice to be made: "yes" or "no" (Shafer T, LifeGift. Personnel communication). Those who say "don't know" are defaulted to "no"; in essence, however, when someone says that he or she is not willing to make a commitment at that time to be a donor, the response is negative. The experience in Texas casts serious doubts on the utility of mandated choice. Indeed, it seems that mandated choice has already been put to the test and has failed.

Mr. Nathan's letter raises an important issue. We hope that further data analysis and our current study of how families decide whether or not to donate will enable us to evaluate more precisely the issues of who should speak with the family and when.