Despite the great demand, very few Americans donate their organs when they die. But the reason for that may not be what you’d think -- it’s your relatives.

That’s what David Shaw, honorary lecturer at the University of Aberdeen in Scotland, thinks the real problem is. In an article published Tuesday in the British Medical Journal, he writes that one of the biggest reasons more people don’t wind up donating is veto by their family.

Even when you have signed a donor card or checked off your driver’s license a family member can still object to your being an organ donor.  And some do -- at least 10 percent of the time or more, says Shaw. (That number may be even higher, according to other U.S. researchers.) Shaw says doctors ought to forget cousin Fred’s second-guessing or your sister’s distaste for donation  and ought to honor your written wishes and use you as a donor.

Interestingly enough, that’s actually the law in the U.S. In nearly every state, a signed driver’s license or organ donor card is fully adequate for allowing donation no matter what your brother-in-law or other family member thinks. But despite that, doctors are still swayed by the family’s wishes.

Shaw is up against some tough problems when he urges doctors to ignore family protests. Is it really realistic for organ and tissue procurement to proceed no matter how upset family members might be about it?

And even if doctors are willing to plow ahead no matter what kind of emotional chaos is occurring in the next room, which hospital wants to risk a headline that says, “Liver removed while widow wails; Doc says ‘But I had a signed driver’s license’”?

Shaw is right to urge doctors not to give up at the first sign of family discomfort. When you sign a card or your driver’s license, you should expect that you will be able to be a donor.

I would argue, however, that the problem with family objections is not fearful doctors backing down in the face of distressed or divided families. The problem is what you and I often fail to do when we sign those cards and licenses — tell others!

If you sign your driver’s license at motor vehicles it is not likely that the friendly employee you waited an hour to see is going to be there when you die. Your family and friends will be. You need to tell them while you are alive that you want to be an organ and tissue donor. That is the antidote for avoiding an outbreak of objections when your number is up and being a donor is the last way you can help those in need. If you make it clear while alive what your wishes are that is the most important step you can take to having them honored when you are not.

Arthur Caplan is the head of the Division of Medical Ethics at NYU Langone Medical Center.

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The decision by the Supreme Court to uphold the constitutionality of nearly all of President Barack Obama’s health reform plan is ethically very good news. Excluding tens of millions of Americans who had no access to health insurance because they could not afford it or because no one would insure them because they were too sick has long been the single greatest ethical failure of American health care.

The Supreme Court has now affirmed, admittedly on purely legal grounds, that imposing a mandate on each of us to pay for health insurance for all of us can happen. But Obama and the administration cannot become complacent. They still have a huge challenge before them — selling the American people on the morality of insuring access to every American to health care by mandating that we all pay.

Critics of the Affordable Care Act have convinced America that the Obama plan stinks. The government mandate was their best bogeyman in stirring distrust of health reform. They had placed all their chips on a "shock and awe" strategy of having the Supreme Court blow away Obamacare’s mandate in one gigantic negative decision. That did not happen. 

The critics will now shift gears and start to fight a guerilla war to chip away at the plan. They will complain about cost, government meddling in the doctor-patient relationship and reopen talk of death panels. The only way to meet these criticisms is for the administration and its allies to do what they still have not done — convince the American people, not of the legality of health reform as happened today but of its morality.

Poll: Do you agree with the Supreme Court ruling on health care law?

The moral case involves three key arguments. First every American deserves equality of opportunity.  The only way to ensure that is to ensure access to basic health care. Just as is true of food and education, you need access to basic health care to compete and flourish in a free market.

Second, no one should go without health care just because they are sick. Excluding people because of pre-existing medical problems is simply immoral.

And lastly if we are a truly a nation, then we have to act like one and bring everyone into access to basic health care by all being willing to pay something for it. Individual rights dominate our political rhetoric. What we need to hear from the President is more about our duties and obligations as citizens to one another.

The Supreme Court has now deemed health reform legal. It is now up to the president to make sure that Americans buy into the argument that it is moral.

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