Ethical, Socio-Cultural and Religious Issues in Organ Donation

Abstract

Brain death and cadaveric organ donation for transplantation present many challenges to society and even to the medical community; therefore, an ethical and legal framework is mandatory. Social values, death taboo, ignorance and procrastination are often issues that can influence the act of organ donation. This article sets out the close link between modern bioethics principles, legal framework, social and cultural value and cadaveric organ donation in the Romanian society. Organ donation, brain death and transplantation will continue to present challening questions for laws and bioethics and it is crucial that medical comunity and society members understand the involved principles, so that they can contibute to increasing the rate of organ donation and maintaining public confidence.

Keywords:ethics, organ donation, transplantation.

INTRODUCTION

The study of medical ethics has developed for several centuries, while the practice of organ donation and transplantation from brain death donors is a relatively new phenomenon, bringing along a range of ethical dilemmas which society has struggled to deal with.

Extending the definition of death, advances in immunosuppression, surgical tehniques, medical and pharmacological progress have made transplantation possible from cadaveric organ donors starting in 1967, when Christiaan Barnard had undertaken the world’s first cardiac transplant. In Romania, the first successful transplant from a deceased donor was a kidney transplant, performed in 1980, in Timisoara. There are currently five accredited centers for renal transplantation: four for liver transplantation, two for cardiac and one for lung transplantation.

Transplantation undoubtedly saves lives or improves the quality of life for patients with end-stage organ failure. It is already scientifically proven that there is a substantial long-term survival advantage for renal transplantation compared with dialysis (1). Guiding principles on human cell, tissue and organ transplantation are regulated by national and international laws with considerations of ethical issues. Consent to organ donation differs and is in line with national laws in force. There are two types of legislation: presumed consent and informed consent. The legal framework in organ donation and transplantation in Romania is ensured by the law No. 95/2006. Despite all this, ethical and moral dillemas continue to pervade the practice of organ donation and transplantation.

Principles of biomedical ethics

Beneficence: act in the best interest of the pacient. Non-maleficence: first, do not harm „primum non cere”. Autonomy: respect for a person’s choice. Justice: fairness and equality (2, 3). General guiding principles in organ and tissues donation: should be voluntary and altruistic, free and consented; respect for donor’s and recipient’s autonomy; confidentiality and protection of donor’s and recipient’s data; equitable opportunities and fairness in allocation; prohibition on making the human body and its parts a source of financial gain; physicians who determine brain death occurrence should not be directly involved in organ removal from the donor. „The declaration of Istanbul on organ trafficking and transplant tourism”, published in 2008, established definitions of practices such as transplant tourism and organ trafficking, and principles to guide policy makers and health professionals working in organ donation and transplantation. Since 2008, more than 135 professional societies have formally endorsed the Declaration.

Rules and law regulation in organ donation

In Romania, the republished version of law No. 95/2006 on Health Reform, with subsequent amendments and completions, establishes the legal framework for the development of the national transplant program. Informed consent is the fundamental governing principle with different requirements applying for tissue or organs from the dead and living donor.

The National Transplantation Agency is a public institution with legal personality, specialized body subordinated to the Ministry of Health, and represents the authority that implements national policies and programs for transplantation of human organs, tissues and cells. It has the role of coordinating the activity of sampling, preparation, preservation, validation, allocation, storage and transport for the transplantation of human tissues and cells for therapeutic use in the territory of Romania (4).

In case of deceased donors, Romania adopted informed consent, an „opt-in” system, where individuals register their willingness to donate organs in the event of their death and the record of this is the organ donor register. For the deceased who did not sign anything while alive, their family has to make a decision, and actually the final decision is the family’s. As enhanced education and better knowledge of the system correlates with increased willingness to donate, greater efforts in education among general public seems an important policy initiative (5).

Cultural, social and religious values

In Romania, a multiethnic and multicultural country, religion plays an important role, influencing the choices people make in certain areas of life. The last census in 2011 showed that only 0.2% of the total population of the country declared themselves to be without religion or atheists, the majority (86.5%) being Orthodox. Of the Romanian population, 56% lives in urban areas and 46% in rural areas (6). The official position of a religion towards organ donation and transplantation plays an important role in convincing the community in accepting organ donation for transplantation. Most religions support and encourage organ donation and transplantantation, Pope John Paul II had repeatedly advocated organ donation and organ transplant as a „service of life”. Understanding the ethical, cultural, social and religious values of a multiethnic population is important and can change the final decission in organ donation without violating these values. Some of the issues are the lack of awarenes regarding organ procurement, religious acceptance, brain death, and misconceptions that need to be corrected (7). Examples of misconceptions include the belief that the body of the donor would be mutilated and treated badly, or that even if a person wanted to donate one organ, other organs would be also taken (8). This is completely false, because organs are surgically removed in a routine operation and only those specified for donation will be taken from the body, which does not disfigure the body or change its appearance. A collaborative work with religious leaders regarding organ donation among religious communities and debates to ensure an active committment with organ donation must be considered at national and local levels.

Death taboo and procrastination

The lack of registrations in the organ donation registry can be interpreted as procrastination and death taboo (9), as people do not like to think about their death and to what will happen to their body once deceased. As a result of not choosing, the decision is delegated to to family members, but given the death taboo, they often have no idea what was the will of their deceased relative (10). The family, contrary to the individual, has no other choice but to evaluate the situation and make a difficult decision after the death of their relative. Public comunication campaigns should include strategies to provoke interpersonal communication about brain death, organ doantion, as a means of creating social representations able to promote behaviors that support organ donation and transplantation (11).

Illusion of lingering life, protection of the individual’s value, distrust, anxiety and alienation are some other examples of attitudes towards dying and organ donation and transplantation (12).

It is important to remember that somebody who does not accept the state of brain death will not be willing to donate one’s organs (13). Concerns about the erroneous diagnosis of death have been expressed many times among the general public or even medical staff. Historically death was defined by the presence of putrefaction or decapitation, failure to respond to painful stimuli, or loss of observable cardiorespiratory action. In 1968, an ad hoc committee at Harvard Medical School reexamined the definition of brain death and defined irreversible coma, or brain death, as unresponsiveness and lack of receptivity, the absence of movement and breathing, the absence of brain-stem reflexes, and coma whose cause has been identified (14, 15). Brain death is defined as the irreversible loss of all brain functions, including the brainstem. In Romania, brain death is considered death as in most countries of the world; Order of the Ministry of Health No. 1170/2014, Annex 3 about diagnostic criteria for confirmation of brain death, sets out very clearly the conditions under which the diagnosis of brain death is established.

DISCUSSIONS AND CONCLUSIONS

Organ donation and transplantation still presents many ethical challenges and dilemmas, both at personal and community level, even within the medical community. The various aspects of ethical, cultural and religious nature should not be a barrier to the act of organ donation and transplantation – all of these are issues to be solved. Applying ethical principles, transparency, identifying and fighting the main concerns with the utmost professionalism can bring changes in the attitude towards organ donation.

Involvement of medical staff with specific professional training, promoting interpersonal communication among community members, campaigns aiming to create a more accurate perception of the entire medical act, the legal and ethical framework are essential elements for a good development of the whole process of organ donation and transplantation.

Conflict of interests: none declared

Financial support: none declared.