The document discusses the reasons for Spain's success in organ donation rates and some of the ethical issues with its model. Key aspects of the Spanish model include its system of presumed consent, the important role of transplant coordinators in detecting potential donors and approaching families, and educational efforts to increase public awareness and acceptance of donation. Some debates around the model include its reliance on older donors and end-of-life policies that could prematurely declare brain death.

1. Raisons du succès et problèmes éthiques du Modèle Espagnol de don d’organes David Rodríguez-Arias, Linda Wright, David Paredes [email_address]

3. Some international strategies to face organ shortage

4. 1. Don du vivant “ First do not harm” Cohercion? Altruism? The risk of black market of organs

5. 2. Marché régulé d’organes en Iran Larijani B, Zahedi F, Taheri E. Ethical and legal aspects of organ transplantation in Iran. Transplant Proc 2004;36(5):1241-4. 83% of kidneys from living donors Donors: 30/40 year old 84% poor 16% middle class Related morbidity risk: 20% Risk of death: 0.03%. Recipients: 50% poor 36% middle class

6. 3. Don à coeur arrêté contrôlé NEJM ; 2008;359(7):709-14. Hastings Center Report 2010(may-june):24-30

7. 4. Conscription d’organes Spital A. Am J Transplant 2005;5(5):1170-1.

8. 4. Don après euthanasie

9. 5. Xenotransplantation

11. Évolution des chiffres de don en Espagne

12. Chiffres de don en Espagne et dans d’autres pays 2009: 34.4 pmp 2010: 32 pmp

13. 22% of increase of living kidney donation 60 candidates for anonymous donation Exchange programmes

19. Myths and misconceptions

20. “ Succes of Spanish Model is due to a high rate of traffic accidents ”

21. “ Succes of Spanish Model is due to the Spanish culture ”

22. Success of Spanish system is due to its Opt out model? ” Opt-in Opt-out Under discussion Undef./not known

28. Family Refusal Spain 19% (France: 31%)

29. 54% of families initially reluctant, finally accept donation REVERSED REFUSALS GOMEZ MARINERO, P. y SANTIAGO GUERVOS, C. (1995). "La negativa familiar. Causas y estrategias" Revista española de trasplantes 4(5): 334-337. % of total refusals Reason given % Reversed 40.7% Refusal of the donor 23% 24% Refusal of family 55% 7.7% Problems with the hospital’s system 46% 5.8% Problems with brain death 76% 4.8% Image of the donor 73% 3.8% Ignore the wish of the donor 86% 3.8% Social problems 69% 3.8% Religious problems 20% 2.9% “ Assertive” 0% 1.9% Want to have the donor at home 33%

30. Educational factors Specific courses for all types of professionals involved in transplantation on: - donor detection - brain death diagnosis - donor management - family approach (bad news, grief, “relation of help”, management of refusals, cultural issues, communication) - organ allocation - approach to the media - legal issues Source: www.tpm.org

34. Evolution of Spanish donors’ age En 2010, 79% de tous les donneurs sont agés de plus de 45 ans, et 46,6% de plus de 60 ans

35. Spanish Model is not the most efficient one EFFICIENCY Roels L, Cohen B, Gachet C. Am J Transplant . 2007 Cuende et al. Am J Transplant . 2007 PROCURED KIDNEYS from Deceased donors THAT COULD NOT BE TRANSPLANTED (% of total Kidneys procured) NON-USEFUL DONORS

36. End-of-life policies and the “induction” of Brain Death The Dutch protocol : “Starting or continuing mechanical ventilation in patients who are not brain dead, but who are beyond hope of meaningful survival, with the sole intent of awaiting brain death and the possibility of organ donation bears some risk that the patient will not die but remain alive in a persistent vegetative state. ( Erwin J.O. Kompanje, 2006 ) The Spanish Protocol : “In the name of the principle of justice, it is considered that these patients must be hospitalized in the ICU. It is considered ethically acceptable that, even though some of them become in PVS because of an aggressive treatment in the ICU, and even though it violates the non-maleficience principle, the social benefice that organ donation entails is a priority. A clear information to the proxies on these procedures and its probabilities must be given. The State should assume the social costs that follow the perpetuation of those PVS patients (Mercedes Lara ) http://www.uninet.edu/cin2000/conferences/MLara/mlara1/index.htm

38. Donation after uncontrolled cardiac death Manipulation of the place and timing for the determination of death Preserving techniques without patient or family explicit consent  Hardening of the initially “soft” presumed consent Lack of information to the families Unclear if donor brain dead Is this utilitarian policy ethically acceptable?

39. Economic incentives 1. Professionals may be paid by the hospital according to the number of organs procured AND transplanted Compromising patients’ interests? 2. Families receive a compensation if they accept the donation. That includes - Funeral expenses - Repatriation of the corpse for foreign donors “ Unwelcomed irresistible offers”? (R. Veatch) Are these practices compatible with altruism?

41. Diagnostic and procurement teams are really separated? Conflicts of Interest When the coordinator is an intensivist who - treats the patient - participates in the identification and maintenance of potential donors - is likely to receive more income if the procurement is performed

48. Thank you David Rodríguez-Arias Vailhen, PhD [email_address] Merci