There is something slightly surreal about sitting in front of a parliamentary committee and explaining something that, for most of your career, felt almost routine. Not routine in the sense of easy or casual, but routine in the sense that it was simply part of the work. Another difficult conversation with a family. Another clinical decision at the edge of life and death. Another moment when tragedy might, very occasionally, allow someone else to live.
Organ and tissue donation occupies a strange space in medicine. It sits at the intersection of hope and loss. For every transplant recipient who receives a second chance, there is a family somewhere whose worst day has just unfolded. That tension is never far away for those of us who have worked in the system.
When I spoke to the Western Australian Parliament’s Standing Committee on Public Administration on the 23rd May 2023 about organ donation, my first instinct was to remind them of something very simple. None of us own this system. Not the clinicians, not the administrators, not the politicians. We are merely custodians of a process that ultimately belongs to the community. That distinction matters because organ donation is built on trust. Without trust, the entire structure collapses.
For the public to support organ donation, they must believe that the healthcare system acts first and always in the interests of the patient. Families must feel confident that doctors are trying to save lives, not looking for opportunities to retrieve organs. If that confidence were ever compromised, even slightly, the willingness of people to donate would disappear overnight.
This is why the clinical separation between patient care and organ donation is so important. In the intensive care unit, the first and only priority is the patient. Treatment decisions are made based on what is best for that individual, not on whether they might become a donor. Only when the medical situation is clear, and when death has been determined according to strict criteria, can the conversation about donation even begin.That sequence is not a bureaucratic technicality. It is the ethical foundation of the entire system.
People often imagine organ donation as a policy problem. Governments discuss legislation, registries, consent systems, and awareness campaigns. These things matter, of course, but the reality of donation happens somewhere much quieter. It happens in intensive care units, often late at night, when a clinician sits down with a family whose world has just been turned upside down.
The family is grieving, exhausted, confused, and trying to understand what has happened to someone they love. In those moments, conversations about organ donation require enormous sensitivity. The decision cannot feel like pressure. It cannot feel like an administrative process. It has to feel like a genuine opportunity for the family to honour the wishes of the person they have lost. Sometimes families say yes. Sometimes they say no. Both responses deserve respect.
One of the misconceptions about organ donation is that increasing donor registrations will automatically increase the number of transplants. In reality, the medical circumstances that allow donation are quite rare. Only a small proportion of deaths occur in conditions compatible with organ donation, usually involving catastrophic brain injury in intensive care. Even then, medical suitability and timing can affect whether donation is possible.
This means that improving donation rates is not simply a matter of public awareness. It also requires strong hospital systems that recognise potential donors and support clinicians through the complex process that follows. Training, communication, and coordination all matter. Yet even the most sophisticated systems depend on something more human: relationships.
Donation programmes rely on cooperation between many different groups. Intensive care clinicians care for the patient. Donation coordinators guide the process with families. Transplant surgeons prepare to receive organs. Administrators and policymakers create the frameworks that support the system. When these groups trust each other and communicate well, donation programmes function smoothly. When relationships break down, opportunities can be missed.
Working in this field also reminds you that healthcare professionals carry emotional burdens that are not always visible. ICU staff regularly confront situations that most people do only once or twice in their lives. Death is not an abstraction in intensive care; it is a daily presence. Supporting families through those moments is part of the job, but it takes a toll. Clinicians learn to balance empathy with professionalism, compassion with the need to continue functioning in a high-pressure environment.
Organ donation conversations occur within that emotional landscape.
What makes donation remarkable is the generosity that families sometimes show despite their grief. Agreeing to donate organs in the hours following a loved one’s death is an extraordinary act of altruism. It is not something that can be demanded or expected. It is something that must be received with humility.
This is why maintaining public trust is so important. Organ donation programmes succeed only when the community believes the system deserves their confidence. Transparency, ethical clarity, and respectful communication are essential.
There is also a tendency in policy discussions to assume that structural reform can dramatically increase donation numbers. While improvements are always possible, we must also recognise the natural limits of the process. The goal should not be unrealistic targets but rather a commitment to ensuring that when donation is possible, it is handled well.
Handled well means respecting patients, supporting families, and ensuring that the clinical process is conducted with integrity.
Looking back on years spent working in intensive care and organ donation, what strikes me most is not the complexity of the medical procedures or the policy frameworks that surround them. It is the quiet dignity of the people involved.
Families who choose generosity in the midst of grief. Clinicians who navigate the hardest conversations with compassion. Recipients who carry the knowledge that their second chance came from someone else’s loss.
Organ donation is sometimes discussed as a healthcare system or a public policy issue. In truth, it is something much more human. It is a moment when a community expresses its values.
Our responsibility, whether as clinicians, administrators, or policymakers, is simply to look after that trust.
If we do that well, the system will continue to work.
And if we forget it, no amount of policy reform will save it.
