WORLD ATTITUDES
TOWARD ORGAN DONATIONS
by Miriam Meijer
Since
the early twentieth century, when the first successful transplant surgery
took place, organ donation and transplants have become routine procedures
for many nations worldwide. Uprooting an organ and replanting it in another
human body can be done under three conditions: (1) brain death of a donor;
(2) bone marrow and double organs like kidneys and lungs that can be removed
from a living donor (humans can live with one kidney or one lung); and
(3) corneas, heart and liver harvested only from cadavers. Up to nine
people ("recipients") can benefit from the multiple organ and tissue donations
of a single donor (two kidneys, heart, two lungs, liver, pancreas, small
bowel). Tissues include corneas (eyes), heart valves, skin, and bone marrow.
In many cases, donors unsuitable for organ donation are eligible for tissue
donation. From repairing severe fractures and degenerative conditions
to helping increase the chances of survival for burn victims, tissue grafts
are saving lives. Over one million people worldwide have received an organ
transplant and some have already survived more than 25 years. Five-year
survival rates for most organs are now at least 70%. The number one problem
in organ transplantation is the shortage of organ/tissue donors.
Organ and tissue transplantation is possible only through people generously
deciding that in the event of their death they would like to donate their
organs and tissues to help others. Each day, about 60 people around the
world receive an organ transplant, while another 13 die because of organ
deficiency. Organ shortage —the main limitation to saving the lives
of more patients—is due to individuals and their families not considering
organ donation out of fear, ignorance or misunderstanding.
Some argue for the alternative of xenotransplantation, the use of various
body parts, tissues, organs and cells of healthy animals for implantation
into unhealthy human recipients. However, many oppose xenotransplantation
for medical and humanitarian reasons. The strong international consensus
is that the only acceptable course of action is to make every effort to
maximize the procurement of cadaveric organs for transplantation.
In some countries outside Europe and the United States, adults have voluntarily
sold one of their kidneys in exchange for money or some other kind of
compensation. There have been rumors of kidnapping and coercion to force
the donation of a kidney although these are fortunately mostly unfounded.
Organ trafficking not only poses major ethical problems, but makes it
difficult to guarantee the quality and safety of the organ. Organ donation
and transplantation have to be beyond reproach. The organ donation/transplantation
process is a complex process involving a number of discrete but interconnected
steps: (1) donor identification, (2) donor screening, (3) donor management,
(4) consent/authorization, (5) organ retrieval, and (6) organ allocation.
Transplantation comprises the process of organ donation and the process
of subsequent implantation or grafting. Historically, the latter has received
far more attention than the former, even though the two parts are totally
interdependent.
The future of organ transplantation is dependent upon the availability
of donor organs. Around 1% of all people who die are possible organ donors.
However, organ donation can only take place under very special circumstances.
In practice this means that, for most organs, only relatively young donors
are suitable who are admitted into Intensive Care Units (ICUs) and subsequently
declared brain dead so that organs can be retrieved while the donor's
heart is still beating.
Brain death is the cessation of brain function. There is no blood flow
to the brain and the brain will never recover. In contrast, a coma is
a state of unconsciousness. The patient in a coma is medically and legally
alive and may breathe without mechanical assistance. The brain in a coma
still functions (and may heal) and there is blood flow to the brain. The
clinical criteria for a diagnosis of brain death are well recognized,
explained in specialized publications, and accepted worldwide.
The Partnership for Organ Donation Gallup poll showed that while a majority
of Americans believe that organ donation was a decent idea, less than
half were prepared to sign an organ donor card and discuss their wishes
with family. Some members of minority groups in the United States speak
openly of their distrust of organ procurement and allocation. Yet nearly
half of the more than 70,000 persons on the national transplant waiting
list represent minorities. The National Minority Organ/Tissue Transplant
Education Program (MOTTEP) has been working to solve the shortage of organ/tissue
donors since 1993.
The public attitude toward organ donation is the single most important
determinant of whether someone will be given a chance at receiving a transplant.
Bad publicity about matters like brain death or fairness of access to
transplantation can have an adverse effect on the public's predisposition
to agree to organ donation. Rumors about organ trafficking (mainly false)
have caused significant damage to altruistic attitudes to organ donation
all over the world. While local and national organizations speak to people
in schools and meetings, most people get their information about donation
and transplantation from television and movies. All kinds of drama, adventure,
and soap opera shows base their plots on the worst myths and urban legends
that have been spread around the world in the last two decades. TV programs
like "Law and Order," "Chicago Hope," "Strange Luck," "The X-Files," "ER,"
and "Voyager" leave the impression that organ donation is potentially
harmful.
The power of the press can also be demonstrated in the so-called "Nicholas
Green effect." Nicholas was a 7-year-old American child, shot dead by
a bandit in Italy in 1994. His parents agreed to donate his organs and
the Italian reporters added to the positive impact of the parents' decision
on organ donation rates.
Gallup surveys demonstrate that fewer than 10% of those persons polled
were aware that their religion has doctrines that favor organ and tissue
donation. At the 1987 First International Congress of the Society for
Organ Sharing, an international group of medical experts established to
facilitate and set up guidelines for organ transplants around the world,
Pope John Paul II stated: "With the advent of organ transplantation, which
began with blood transfusion, man has found a way to give of himself,
of his blood and of his body, so that others may continue to live."
Protestants favor organ donation. Methodists are encouraged to receive
or to donate their organs and tissues that will restore any of the senses
or that will enhance health. The use of a signed donor card is part of
the recommended arrangements to be done by Lutherans, as long as organs
are not sold. The Presbyterian religion respects individual conscience
and the right to make decisions regarding one's own body. Organ donation
is a matter of individual conscience for Mormons. The Jehovah Witness
faith bans blood transfusion but does not oppose donating or receiving
organs as long as the organs and tissues are first completely drained
of blood.
While the human body is sanctified in Judaism, saving a human life is
considered to be superior to maintaining the sanctity of the human body.
The donor must be brain dead, and a direct transplantation is preferred.
The Rabbinical Council of America (RCA) approved organ donation as permissible,
even required from brain dead patients. The endorsement put the world's
largest body of Orthodox rabbis at odds with other Orthodox authorities
who argue that the cessation of brain function does not indicate death
according to Jewish law.
No religious law prohibits Hindus from donating their organs and tissues.
Hindu mythology even contains traditions of use of body parts to benefit
others. In the story of Dadhichi, the earth was terrorized by a demon,
Vrtra. Only the bones of a great sage, (Dadhichi), could be used to make
a weapon that could be later used as an antidote to Vrtra. The Sage donated
them unhesitantly. In the tale of Lord Ganesh, Lord Shiva, out of rage,
cut off the head of his son Ganesh. Later, upon remorse, the lord fixed
the head of a elephant on Ganesh's trunk.
Based on several sayings from the Quran (Allah's words) and the Hadith
(the Prophet Muhammad's sayings and examples from his life), the Islamic
Code of Medical Ethics approved organ donation in 1981. Organs of Muslin
donors must not be stored in organ banks but must be transplanted immediately.
In Jordan, for example, the first successful kidney transplant occurred
in 1972 and the first corneal transplant in 1977. In 1997 the Jordan Society
for Organ Donation (JSOD) was established under the auspices of Her Majesty
Queen Rania. Usually the recipient's relatives donated the kidney and
bone marrow transplants.
Since there is no specific law or doctrine that governs organ donation
in Buddhism, it is a matter of individual conscience. In Singapore, a
small, highly developed parliamentary democracy where the main religions
are Buddhism, Christianity, Hinduism, Islam and Taoism, Dr. Khoo Oon Teik,
a nephrologist [kidney specialist] whose own brother died from kidney
failure, established The National Kidney Foundation of Singapore (NKFS)
in the early 1960s. From its humble beginnings as a fledging dialysis
unit at Singapore General Hospital, the NKF has grown to become the world's
single largest not-for-profit provider of dialysis care. In 1983 NKF created
history with the first overseas transplant in Singapore. The NKF supported
the Human Organ Transplant Act, an act passed in 1986 that allows the
kidneys of accident victims to be used for transplants. In 1991 the nation-wide
Muslim Organ Donation Campaign was launched and in 1992 the Singapore
Buddhist Welfare Services (SBWS)-NKF Dialysis Centre was set up. By 1992
the NKF organized the First International Congress on Transplantation
in Developing Countries with delegates from 70 countries.
Cadaver donation is undeveloped in Japan because the Japanese find it
hard to believe doctors' declarations of a relative's brain death when
the patient is still breathing with the help of respirators and the person's
body remains warm. In 1968 Juro Wada performed Japan's first heart transplant,
which triggered controversy when the 18-year-old recipient died 83 days
after the operation. Wada faced allegations of manslaughter but prosecutors
did not indict him. In 1997 the Japanese Diet (parliament) opened the
way for Japan's first organ transplant in 30 years by approving an amended
version of a bill that authorized organ transplants from brain-dead donors
under strict conditions. The original bill raised controversy because
it plainly defined brain death as human death. The legal definition of
death as adhered to by the police in Japan currently requires confirmation
that the heart and lungs have stopped and that the pupils of the eyes
have dilated. The revised law sidesteps the issue of legal definition
of brain death and instead provides that brain death signifies human death
only when a donor is tested and confirmed to be brain dead by two or more
doctors before the removal of organs and their transplant. Japanese doctors
can only remove organs from a brain-dead donor when the donor gives written
consent in advance to brain-dead testing and the removal of organs, and
when the donor's relatives do not object to the procedures. In February
2000, a 44-year-old woman who was declared brain dead following a brain
hemorrhage and stroke donated all four of the organs used in recent transplants.
The woman's heart went to a man in his 40s. Three other patients later
received the donor's liver and kidneys, and all of the operations reportedly
went smoothly. The donor carried a donor card and her family consented
to the procedure. Only about 2.5% of the Japanese carry donor cards, but
more than 13,000 Japanese are waiting for transplants.
There is a serious organ shortage in the United Kingdom. In 1998, 7% fewer
transplants were carried out than in 1997, while waiting lists increased
by 3%. There are fewer fatal car accidents thanks to seat belt legislation,
but efforts to increase the donor pool by advertisements urging people
to carry donor cards have not been successful. Patients and their doctors
are frustrated by long waiting lists, which for many means a steady deterioration
in their condition. From 1995-1999, about 1,000 patients died while waiting
for a heart, heart and lung, lung or liver transplant. The current regime
in America, the United Kingdom, and Australia are described as "encouraged
voluntaristic" or "opting-in" systems that require the direct, expressed
consent of the donor and, almost always, the donor's family. The English
situation contrasts with some of Europe's success stories, notably that
of Spain.
The Organizacíon Nacional de Trasplantes (ONT), established in
1989, transformed Spain's transplant service from having a shortage to
exporting surplus organs to neighboring countries. Spain rose from one
of the lowest donation rates in the world to become one of the highest,
going from 14 to 25 donors per million population (pmp). This increase
followed nationwide implementation of a standard donation process, focusing
responsibility for handling the donation process with hospital-based donation
teams. Hospitals are held responsible for their performance in donation.
The first transplants were performed in Madrid and Barcelona in 1965.
In 1986, a law was passed that allowed obligatory donation unless a refusal
was registered in the national computer. The ONT was formed to address
the problem of declining donation rates and instituted a formal but flexible
management structure. Their integrated approach, with the appointment
of national and regional people in charge of ensuring that the Transplant
Coordinators (TCs) working at the "grass roots" have a sense of involvement
and accountability for performance, led to a steady increase of organ
donor rate from 14.3 pmp in 1989 to 22.6 by 1993. Spain's 43.8 kidney
transplants in 1996 was achieved despite the fact that Spain also reached
the largest reduction in traffic road accidents of the European Union
during the last 3 years.
Nations debate about the relative merits of laws that "presume consent"
(unless the individual has "opted out") and those that require either
the positive consent of the donor (via donor card or register) or the
consent of relatives. Belgium, Austria, Finland, France, Norway, Spain,
and Singapore implement "presumed consent" (sometimes referred to as "implied"
consent) public policies. Since 1976, France's presumed consent (PC) law
has produced increases in organ donation approaching 5,000%. Austria passed
its PC law in 1982. By the end of 1990, the number of patients receiving
kidneys was nearly the same as the number on the waiting list. Belgium
passed its version of PC in 1986, and organ donation climbed by 183%,
with multi-organ retrieval significantly increased to 119% for kidneys.
Some think that countries condoning "presumed consent" approximate "routine
salvaging of organs." William Person describes the French "Caillavet Law"
as based on the "Good Samaritan" principle but that it gives "greater
weight to the needs of the transplant recipient than to the possibility
that the individual will of the donor has been violated." The origin of
divergence between the advocates and opponents of presumed consent lies
in the ethical assessment of tolerable risk. Advocates of presumed consent
find cases of false positives permissible. Opponents perceive a "statist,"
non-individualistic intent behind presumed consent. "Statism" is the principle
of concentrating extensive economic and political controls in the state.
Liberal societies assume that the individual, not the state, should control
his or her physical disposition. Exceptions to liberal individualism must
meet a severe test, as in wartime when the coercive military draft is
premised on the need to serve vital national interests.
Currently the policy status quo in the United States is a state-centered
approach relying on the use of the back of driver's licenses, applications
for driver's licenses, or the distribution of donor cards to be carried
with or attached to the driver's license. Fifteen states require Department
of Motor Vehicles employees to ask applicants for driver's licenses if
they would like to be a donor. Twenty states include the donor question
on the driver's license application itself. However, the approach is uncoordinated
across the states. Not only is there no centralized collection of donation
preferences but not even the same data points are collected. The United
Network for Organ Sharing (UNOS) Ethics Committee recommends a national
policy of "required response" to replace wasteful uncoordinated state-level
programs with a uniform method of collecting and disseminating donation
preferences to procurement organizations. They believe that it would accelerate
the historical increase in the number of Americans who have indicated
a willingness to be organ donors. As adults increasingly "opt-in" to the
donation system by expressing "yes" via required response, the practical
necessity of checking the database recording preferences would diminish
over time.
"Mandated choice" laws require citizens to declare whether they want to
donate their organs or not. In 1996, Sweden instituted a mandated choice
law, in which all adults were required to choose between donating or not
donating their organs. There was an immediate increase of 600,000 potential
donors. A similar 1990 law in Denmark increased their donor registry by
150,000.
Several economists and lawyers in America have proposed providing financial
incentives or rewards to promote organ donation. In such a system the
donor's beneficiaries would receive some type of benefit (e.g., monetary
or hospital care credits) as part of the donor's estate. Such payments
would be made if the organs were retrieved and used. J. Blumstein of the
School of Law Vanderbilt University argues that this solution would eliminate
"the exclusive reliance on altruism" as well as adhere "to principles
of autonomy and individual choice of donors and their families." Lloyd
Cohen, Professor of law at George Mason University, claims that financial
incentives or rewards for donors and/or their beneficiaries would alleviate
America's organ shortage. Congressman James Greenwood of Pennsylvania
introduced legislation to use federally-financed life insurance programs
as an incentive for people to donate their organs. They conclude that
financial incentives would produce enough organ donations each year to
meet current clinical demands. Evidence from Egypt and India suggests
that such inducement works, involving a contract for sale of organs upon
the donor's death. This policy is not to be confused with the sale of
organs from living donors, which ethicists maintain should remain unsupported.
There is an organ shortage crisis but it is a crisis with a cure. Encouraging
people to speak about organ donation and transplantation and to make their
wishes known to their relatives could change the picture resulting in
93-94% of people allowing donation. When the wishes of the deceased are
not known, only 50% of people will agree to organ retrieval from their
relatives. The approach to the relatives of a potential donor is most
sensitive, given that it coincides with the distress surrounding death,
particularly if that death is sudden or unexpected as is so often the
case when the patient is young. There is evidence that relatives will
rarely refuse to allow organ donation if the donor has previously made
clear his/her willingness to donate. Many donor relatives have stated
that donating their loved one's organs does not make the pain of their
death disappear but that it gives their death meaning: that something
so positive comes from tragedy. Bereaved families can experience comfort
that their loved one's gift gave another person a second chance at life.
It is hard to discuss your own death; that stops many people from talking
about organ donation. Some people may discuss it when making their prepaid
funeral arrangements. Mentioning organ and tissue donation in a will is
too late for transplantation by the time the will is read.
Remember that the most important thing that you can do is to tell your
family about your decision. Remember also that any one of us could one
day require an organ or tissue transplant. It's a two-way street.
The author would
like to thank Christine Wilson, a kidney transplant recipient, for assisting
her with the initial research.
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