Organ shortage constitutes an unsolved problem for every country that offers transplantation as a therapeutic option. Besides the largely implemented donation model and the eventually implemented market model, a theorized automatic organ procurement model has raised a rich debate in the legal, medical and bioethical community, since it could show a higher potential to solve organ shortage. In this paper, we study the main arguments for and against this model. We show how, in the light of empirical data extracted from countries with a universal health care system, its implementation could lead to a positive impact on organ procurement rates. Three factors are envisioned as fundamental in the comprehension and a possible regulation of the automatic organ procurement model: the lack of recognition of the conscientious objection, the preservation of the right to choose end of life conditions, and the need to avoid incentives for families or healthcare professionals.
See.MartinD. Trade in kidneys is ethically intolerable. Indian J Med Ethics2016;
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3.
The principles of non-remuneration and voluntariness are emphasized at the WHA 63.22 organized by the WHO in2010and under the title “Human organ and tissue transplantation” in relation to the donation model.
4.
DelgadoJMolina-PérezAShawD, et al.
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103: e112–e118.
5.
See Abadie A and Gay S.
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25: 599–620 and Rithalia A, McDaid C, Suekarran S, et al. A systematic review of presumed consent systems for deceased organ donation. Health Technol Assess 2009; 13: 117.
6.
. These abolished systems are exposed in: James R., India Kidney Trade. TED Case Studies 2001, http://www.american.edu/projects/mandala/TED/KIDNEY.HTM. Nevertheless, in the case of India, for instance, after the passing of the law banning such extreme, the existence of an illegal organ acquisition and supply has been demonstrated. See Muraleedharan VR, Jan S and Prasad R. The trade in human organs in Tamil Nadu: the anatomy of regulatory failure. Health Econ Policy Law 2006; 1: 41–57.
7.
This prediction is based on studies such as the one conducted for the Journal of Economic Perspectives in 2007.
According to the estimates made, a compensation of $15,000 for each living donor would prevent kidney shortage (see Becker GS and Elías JJ. Introducing incentives in the market for live and cadaveric organ donations. J Econ Perspect2007;
21: 3–24).
8.
Laws that legalize human organs trade were derogated in India and Philippines in 1994 and 2008 respectively. On the regulated organ market in Iran, see Ghods AJ. Renal transplantation in Iran. Nephrol Dial Transplant 2002; 1: 222–-228; Hipen BE. Organ sales and moral travails. Lessons from the living kidney vendor program in Iran. Policy Anal 2008; 6: 1 and Larijani B. Ethical and legal aspects of organ transplantation in Iran. Transplant Proc 2004;
36: 1241–1244.
9.
One of the earliest and most thorough defences of the automatic organ procurement model is Silver T. The case for a post-mortem organ draft and a proposed model organ Draft. BUL Rev 1988;
68: 681–728; and, later, Fabre C. Whose Body is it Anyway? Justice and the Integrity of the Person. Oxford, UK: Clarendon Press, 2006, who also argues in favour of the confiscation of kidneys, medulla and hepatic segments from living people. In Spain, this model is supported by De Lora P. El trasplante de órganos y el caso del tranvía: ¿Por qué no confiscamos órganos de cadáver?, Jueces para la Democracia 2012;
74: 11–25. This option is also defended by the same author in Justicia y distribución de recursos. El caso de los trasplantes de órganos y tejidos. In Gascón Abellán M, González Carrasco MC and Cantero Martínez J (coords) Derecho Sanitario y Bioética. Cuestiones actuales. Valencia, Spain: Tirant lo Blanch, 2011, pp.1013–1029; de Lora P and Fajuri AZ. El derecho a la asistencia sanitaria. Un análisis desde las teorías de la justicia distributiva. Madrid, Spain: Iustel, 2009, pp.223–264; and de Lora P. Bioética: Principios, Desafíos, Debates, Madrid, Spain: Alianza Editorial, 2008, pp.188–205.
10.
Rivera LE. Eho argues in favour of the donation model, believes that, in the automatic organ procurement model, posthumous interests are violated. He adds that, by respecting the deceased’s interests, the posthumous interests of the living are also protected. The reason is that it is not only about meeting the deceased’s wishes, but also reassuring the living that their posthumous wishes will be met. (Rivera LE. Ética y trasplante de órganos. México: Fondo de Cultura Económica, 2001, p.69.)
11.
Regarding kidneys, the most frequentlyreplaced organ, transplantation is considered as the best treatment for chronic renal insufficiency as for survival, quality of life, lower number of complications and better cost-profit ratio in comparison to dialysis. This is supported, among others, by Matesanz Acedos R and Domínguez-Gil González B. Strategies to optimize deceased organ donation. Transplantat Rev2007;
21: 177.
12.
On this issue, see De Lora P and Zúñiga Fajuri A. El Derecho a la Asistencia Sanitaria. Un Análisis Desde Las Teorías de la Justicia Distributiva.
Madrid, Spain:
Iustel, 2009, p.239.
13.
SeeSAErinCA. Conscription of cadaveric organs form transplantation: let’s at least talk about it. AJKD 2002;
39: 611–615. There is a tendency here to generate a certain percentage of negative answers from subjects who, in principle, are in favour of mortis causa donation. This tendency is explained by Urruela MA. Trasplante de órganos y tejidos: aspectos jurídicos y sociológicos ligados al consentimiento familiar. In Romeo CM (coord) El nuevo régimen jurídico de los trasplantes de órganos y tejidos. Granada, Spain: Comares, 2005, p.340.
14.
SpitalA.Conscription of cadaveric organ for transplantation: a stimulating idea whose time has not yet come. Camb Q Healthc Ethics2005;
14: 107–112.
15.
MoyaGC.La Protección Jurídica Frente al Tráfico de Órganos Humanos. Especial Referencia a la Tutela Penal en España.
Madrid, Spain:
Marcial Pons, 2018, pp.25–71.
16.
As an example, in Spain the ONT has detected 10 losses in 2018 due to problems in the organization, which may be included within the first cause. See, in this sense, Organización Nacional de Trasplantes. Memoria de Resultados de la Autoevaluación. Programa de Garantía de Calidad del Proceso de Donación, 2018.
17.
According to the Memoria de Resultados de la Autoevaluación, 2018, in Spain there were 30 losses in 2018 for this reason.
18.
For the case of Spain, such judicial authorization will be requested only if there is no explicit opposition to donation by the deceased (art. 5.3, Law 30/1979), and upon the prior record of will about donation for transplantation signed by the family. See, Caballero F and Matesanz R. Capítulo 15. Autorización Judicial para la Extracción de órganos para trasplante. Casos judiciales. Manual de donación y Trasplante de Órganos Humanos, www.coordinaciontrasplantes.org/index.php/bloque-09/capitulo-15 (accessed 5 November 2019).
19.
The sustained impossibility of contacting the family may result in the loss of the organs that are at risk of ischemia or in an interruption in the measures for organ preservation within four hours after their application. The Memoria de Resultados de la Autoevaluación, 2018, has reported five losses due to this cause in Spain in 2018.
20.
This may occur for example if the will of the deceased recorded while alive in the advanced directives registry is known. As an example only 56, % of all the registered documents in the Valencian community up to 2008 were in favour of organ donation for transplantation. On this subject Nebot C, Ortega B, Mira JJ, et al. Morir con dignidad. Estudio sobre voluntades anticipadas. Gaceta Sanitaria 2010;
24: 437–445. According to the data provided by the ONT, out of the 2124 cases of donors with brain death in 2018 in Spain, 314 organs were lost due to refusal to donation. Out of those 314, 124 were refusals by donors while alive.
Gobierno de EspañaEDQM, Council of Europe. International figures on donation and transplantation. Newsl Transpl 2017; 23: 2018.
23.
These data refer to the following organs:
kidney, liver, lung, heart and pancreas. This information is the result of the sum of the disaggregated data provided by: Gobierno de españa, EDQM, council of Europe. Newsl Transpl2018;
24: 2019.
Gobierno de España, EDQM, Council of Europe, 2018.
26.
Zúñiga FA.El consentimiento presunto y la reciprocidad como mecanismos Para aumentar la donación. Rev Méd Chile2015;
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27.
This argument is also used, among other, by De Lora and Zúñiga, 2009, p. 239; Rivera López, 2001, pp.105–106; and Gordillo Cañas A. Trasplantes de órganos: ‘pietas’ familiar y solidaridad humana. Madrid, Spain: Civitas, 1987, p.102.
28.
On the legislation in these three countries, see Zúñiga, 2015, pp.1332–1333.
29.
SchwarkD.Organ conscription: how the dead can save the living. J.L. & Health2011;
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30.
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3: 153–156 and HammerCLRivlinMM. A stronger policy for organ retrieval from cadaveric donors: some ethical considerations. J Med Ethics2003; 196–200.
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Delaney DB and Hershenov J. Mandatory autopsies and organ conscription. Kennedy Inst Ethics J 2009;
19: 367–391. Organ confiscation is compared to autopsies also by Rivera López, 2001, pp.80–81 among others. The inheritance tax is also compared to organ confiscation by Schmidt-Petri, based on the following arguments: (a) they both occur after the death of the person, (b) they are not undertaken to benefit the deceased but in order to benefit somebody else and (c) they involve the transfer of resources (why not confiscate? In Jox R, Assadi G and Marckmann G (eds) Organ Transplantation in Times of Donor Shortage. Challenges and Solutions. Springer, 2016, pp.71–81).
34.
S. Delaney Hershenov2009, p.378.
35.
Figures indicate rather the opposite. For example, 700 autopsies are conducted on average in one Spanish region alone, Murcia (see Instituto de Medicina Legal y Ciencias Forenses de Murcia. Memoria de Actividad 2018: 69). These figures are significantly higher than those for organ donation, which have never exceeded 100, according to the ONT. See, on this point, the historical data on organ donation, available at: https://reports.ont.es/datoshistoricos.aspx. (accessed 15 July 2020).
36.
CroninAJHarrisJ.Authorisation, altruism and compulsion in the organ donation debate. J Med Ethics2010;
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RichardsA.Don’t take your organs to heaven … heaven knows we need them here: another look at the required response system. N. Ill. U. L. Rev2006;
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DorffEN. Choosing life: aspects of Judaism affecting organ transplantation. In: Younger S, Fox R and O’Connell L (eds) Organ Transplantation: Meanings and Realities. Madison, WI: University of Wisconsin Press, 1996, p.179, cited by: Delaney DB and and Hershenov JJ, 2009.
39.
See Glannon 2003.
40.
See Schwark 2011.
41.
De LoraP. Transplantation and the trolley case: why not confiscate cadaveric organs? https://ssrn.com/abstract=2030011 (27 March 2012, accessed 20 July 2020).
42.
BertolinoR. L’obiezione di coscienza negli ordinamenti giuridici contemporanei. Torino 1967, pp.8–9; Navarro-Valls R and Martínez-Torrón J. Las objeciones de conciencia en el derecho español y comparado. Madrid, Spain: McGRAW-HILL, 1997, pp.17–35; Llamazares Fernández D. Conciencia y Derecho. Libertad de conciencia y libertad de comportamiento. Objeciones de conciencia. Navarra, Spain: Civitas, 2007, pp.341–486.
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See Banyubala2016.
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49.
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50.
See SpitalA.2005. The questions wording was: ‘in view of the tremendous shortage of life-saving organs, would you be willing to accept a policy that allows trustworthy medical teams to remove organs from people who have died without asking for permission, unless they had objected on religious grounds?’. Furthermore, the question was preceded by an explanatory paragraph on organ shortage.
51.
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17: 251–255. The exact wording of the question is not detailed.
53.
The survey was conducted by Rodríguez-Arias D and Molina Pérez A, in cooperation with the IESA-CSIC, in Autumn-Winter2018. The results have not been published yet. Personal communication.
54.
The survey was commissioned to IMOP Insights by the Institute for Advanced Social Studies and CSIC. On the technical details of this study, see Viciana H. Encuesta: El apoyo social a la eutanasia en España es muy alto y sigue creciendo. The Conversation, 5 May 2019.
55.
However, this would not endanger the efficiency of the transplantation system insofar as altruism and solidarity would be no longer necessary. Nevertheless, the deterioration of the values that contribute to social cohesion may have costs that are more intangible and symbolic in nature.
56.
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