Everyone Should Be a Donor

The Old Switcheroo

Over 10,000 people in Germany are waiting for a new organ. However, organ donor figures are lower than ever before. That’s why Dr. Christian Hugo is fighting to establish a new culture of organ donation.

Dr. Hugo, with 46.9 donors per million inhabitants, Spain was the world leader in organ donations in 2017. In Germany, there were only 9.7 donors per million inhabitants. Why is that the case?

Unfortunately, our society is not conducive to organ donation. German law treats organ donation as a major exception instead of as a standard. Patients and their relatives are merely encouraged to be donors. However, despite the statutory ‘decision-based’ approach to organ donation, people don’t actually need to make a decision as far as this is concerned. What often ends up happening, then, is that a recently deceased individual’s next of kin must decide during their darkest hour as to whether their loved one would have wanted to donate their organs or not. Many countries, including Spain, have long had a presumed consent (‘opt-out’) system in place to prevent this issue. Spanish citizens need to bindingly declare whether they would like to be organ donors or not. That increases the number of possible donors. Brain death, during which the other organs continue to function, is only a prerequisite for a donation in extremely seldom cases. Moreover, hospitals often fail to consider or clarify whether a donation can be made. Other factors that play a role include a pressure for efficiency, advance directives that don’t contain any information about organ donations, and, occasionally, a lack of awareness on the part of hospital staff. That’s why there are only around 800 donations per year in Germany, even though over 900,000 people die every year.

How can people be motivated to become organ donors?

We need to facilitate a public discourse to promote organ donation. Of course, virtually nobody wants to confront the matter of their own mortality. But it’s precisely for this reason that a statutory presumed consent system is the best option. Everyone should consider the topic of organ donation at least once. That way, it can become part of society’s value system. In countries with a presumed consent system in place, organ donation is no longer considered to be an unusual, altruistic act done by a small handful of people; it becomes more of the norm.

What downsides are there to a presumed consent system?

None. One counterargument is that it’s patronizing for the government to be involved in what happens with your body. However, the presumed consent system grants everyone total freedom of choice at all times. The only thing required is for people to make a decision. I think that’s a legitimate approach. Even the liberal Netherlands recently introduced this regulation, and nearly twice as many organ transplants are carried out there as in Germany. You could argue that a new law alone won’t solve the problems that clinics have with recognizing brain-dead patients and implementing organ donations. While that is true, in my opinion, a new system will help everyone involved with ­precisely these processes, since there will be a different general approach taken to organ donation. The presumed consent system helps take into account the true will of the deceased concerning the handling of their body.

30 percent of organ donations come from living donors. How can this figure be increased?

So-called ‘cross-over donation’ is an idea worth considering. If partners or relatives can’t donate to one another, they can carry out this kind of donation with another pair of donors and recipients. In the U.S., there’s already an official pool system in place that brings together suitable pairs of donors and recipients. The bigger the pool, the better the system functions. In Germany, however, we, unfortunately, don’t have a clear judicial ruling as far as this is concerned. That’s why some patients go abroad, such as to Spain, to take part in a cross-over donation.

Over 10,000 people in Germany are waiting for a new organ. However, organ donor figures are lower than ever before. That’s why Dr. Christian Hugo is fighting to establish a new culture of organ donation.

Dr. Hugo, with 46.9 donors per million inhabitants, Spain was the world leader in organ donations in 2017. In Germany, there were only 9.7 donors per million inhabitants. Why is that the case?

Unfortunately, our society is not conducive to organ donation. German law treats organ donation as a major exception instead of as a standard. Patients and their relatives are merely encouraged to be donors. However, despite the statutory ‘decision-based’ approach to organ donation, people don’t actually need to make a decision as far as this is concerned. What often ends up happening, then, is that a recently deceased individual’s next of kin must decide during their darkest hour as to whether their loved one would have wanted to donate their organs or not. Many countries, including Spain, have long had a presumed consent (‘opt-out’) system in place to prevent this issue. Spanish citizens need to bindingly declare whether they would like to be organ donors or not. That increases the number of possible donors. Brain death, during which the other organs continue to function, is only a prerequisite for a donation in extremely seldom cases. Moreover, hospitals often fail to consider or clarify whether a donation can be made. Other factors that play a role include a pressure for efficiency, advance directives that don’t contain any information about organ donations, and, occasionally, a lack of awareness on the part of hospital staff. That’s why there are only around 800 donations per year in Germany, even though over 900,000 people die every year.

How can people be motivated to become organ donors?

We need to facilitate a public discourse to promote organ donation. Of course, virtually nobody wants to confront the matter of their own mortality. But it’s precisely for this reason that a statutory presumed consent system is the best option. Everyone should consider the topic of organ donation at least once. That way, it can become part of society’s value system. In countries with a presumed consent system in place, organ donation is no longer considered to be an unusual, altruistic act done by a small handful of people; it becomes more of the norm.

What downsides are there to a presumed consent system?

None. One counterargument is that it’s patronizing for the government to be involved in what happens with your body. However, the presumed consent system grants everyone total freedom of choice at all times. The only thing required is for people to make a decision. I think that’s a legitimate approach. Even the liberal Netherlands recently introduced this regulation, and nearly twice as many organ transplants are carried out there as in Germany. You could argue that a new law alone won’t solve the problems that clinics have with recognizing brain-dead patients and implementing organ donations. While that is true, in my opinion, a new system will help everyone involved with ­precisely these processes, since there will be a different general approach taken to organ donation. The presumed consent system helps take into account the true will of the deceased concerning the handling of their body.

30 percent of organ donations come from living donors. How can this figure be increased?

So-called ‘cross-over donation’ is an idea worth considering. If partners or relatives can’t donate to one another, they can carry out this kind of donation with another pair of donors and recipients. In the U.S., there’s already an official pool system in place that brings together suitable pairs of donors and recipients. The bigger the pool, the better the system functions. In Germany, however, we, unfortunately, don’t have a clear judicial ruling as far as this is concerned. That’s why some patients go abroad, such as to Spain, to take part in a cross-over donation.

Transplantable organs are hard to come by. How can ethical distribution be ensured? By law, the urgency and chances of success are the decisive criteria for organ donation allocation. However, it’s often difficult to reconcile these two factors. A rare, young donated kidney can serve a young, relatively healthy patient for 30 years, while an older, seriously ill patient might be able to use it for far less than ten years. So, who should receive the valuable organ? Doctors often have to ask themselves difficult ethical questions, ones which we as a society need to answer. In the U.S., for example, there has been a long public discourse on this topic. A point system introduced over the past few years ensures that better-quality or younger organs are often given to younger patients. Organ donation allocation systems in Anglo-American countries traditionally place more weight on the chances of success than we do in Germany.

Transplantable organs are hard to come by. How can ethical distribution be ensured? By law, the urgency and chances of success are the decisive criteria for organ donation allocation. However, it’s often difficult to reconcile these two factors. A rare, young donated kidney can serve a young, relatively healthy patient for 30 years, while an older, seriously ill patient might be able to use it for far less than ten years. So, who should receive the valuable organ? Doctors often have to ask themselves difficult ethical questions, ones which we as a society need to answer. In the U.S., for example, there has been a long public discourse on this topic. A point system introduced over the past few years ensures that better-quality or younger organs are often given to younger patients. Organ donation allocation systems in Anglo-American countries traditionally place more weight on the chances of success than we do in Germany.

Picture credit: TÜV Rheinland/Franziska Pilz