Opinion Article :
Organ
shortage transforming death into life, which is what organ transplants symbolize,
needs the end of somebody life, a scientific miracle of our times, but as well a
social problem. Prejudices or ignorance inhibits to offering life to another human
being. The consequence of this conflicting situation is that patients waiting for
transplantation, “unfairly” die every day. States and Social Security should be
involved in this problem. Programming efficient education will be important for
change social conduct towards organ donation. As well, several studies emphasize
the persistence of an insufficient university medical teams training in transplantation.
Organ shortage and waiting lists patients mortality is a failure of social communication
on organ donation and transplantation. Proposals to review social and university
education in current organ shortage crisis might be an ethical duty for states health
and education officials. Solidarity is a positive peoples feeling, nevertheless
faced with death of a loved one; it does not seem to be an enough reason to justify
authorization to donate. For many people, organ donation represents a perverse and
unjustified action of mutilation. Considering the negative reactions that often
can occur in the moment in which the alternative of deciding the donation of organs
of a loved one is presented; we have proposed the inclusion in the social
education plans the following concepts: ·
Organ shortage is a health emergency. ·
Throughout our lives, we might need organ
or tissue
transplantation. ·
Our body after death is a unique source of
health to be shared. ·
Organ donation meant to” share life” more
than “to gift life”. ·
Organ
donation should be a social agreement. ·
People should know the social risks involved
in establishing economic incentives for donation. This
analysis is made to provide a basic knowledge of a vital medical crisis, and to
suggest to decision makers of educational programs useful suggestions for this serious
problem. In addition, and very particularly this work is directed to the Society,
the main protagonist of this problem, requiring to receiving a correct and detailed
information on the dilemma of the lack of organs, in quest that the donation decision
will be an act of full awareness. A french philosopher, Jean Rostand has said "To
dream you have to know". The
main purpose of this work is to make people know the essential details of the extraordinary
possibility, which todays medicine presents to everyone, transforming death into
life, basically with the use of death itself. Organ shortage is a social, psychological,
ethical, moral and political problem. Hundreds of patients on waiting lists are
unjustly dying every day. The cruel reality is that society is denying another human
being a chance to survive. It
is also true, and society knows, that globally thousands of people die every day
due to socioeconomic
inequalities. However, the causes of these deaths are complex, mainly social
injustice and political corruption. Conversely, organ shortage crisis might be much
simpler to solve. The primary objective should be to develop efficient educational
programs, to correctly give to the people a clear knowledge of what organ
transplantation represents for society. The transplantation of organs and tissues,
responsible for the previously symbolising metaphor, has undoubtedly constituted
a millenary, but also mysterious advance of science. Already at 800 B.C. Indian
doctors had likely begun grafting skin-technically the largest organ-from one part
to another part of the body, to repair wounds and burns. Complex
transplants such as “successful” transplantation of an entire leg, performed by
the 13th century by Cosmos and Damien, physicians and saints, were imagined by Fra
Angelico, which was reproduced by several famous paintings. Developing imagination,
and linking art with medical knowledge and organ transplants, we could relate the
fact that Saint Cosmos and San Damian were identical brothers, reminding us that
twin brothers present potential immunity to rejection; of course Cosmos and Damian
were the doctors; but the fact that the painter has imagined a transplant
of limbs, a medical success recently carried out at the end of the 20th century,
leaves without doubt the most creative speculation of every transplant professional,
that will admire this enigmatic painting of the 13th century. Also,
always in the field of creativeness bordering on the fantasy, involving a medicine
that fundamentally uses the end of someones life to start another one; the story
of transplantation leads us to the initiative of Professor Pichlmayr, who makes
the first living liver segmental donor, speculating, according to current knowledge
of medical sciences, on the regeneration of the rest of the organ. This experience
make us to returning to the ancient story of Prometheus, punished by the Gods of
Olympus to be chained on the mountain, offering eternally to eat their liver to
the eagles; the fantasy leads us to question to how the ancient Greeks knew about
liver regeneration, the only justification of the current progress of living donors
liver
transplantation. States
and/or private social security agencies should be actively involved in the solution
of the social problem of organ shortage. Their participation in the development
of elaborated educational programs will be extremely important, searching changes
in social conduct towards organ donation, essential requirement for safety and welfare
for the XXI century society. In addition, should be well pointed out that besides
saving lives, organ transplantation generates economic resources to the social security
of a nation. People should know, to evaluate the benefit for public
health budgets of organ transplantation, that it not only will avoid possible
death of waiting lists patients, but also it will provide substantial economics
savings for the states health programs. When patients waiting for a renal transplant,
that represent practically more than 80% of the waiting lists and with a probable
long survival, will be transplanted, the only ones that can practically be transplanted
by a living donor, patient lists will decrease, and dialysis treatments will also
decrease. The
vital fact of transplantation, saving thousands of lives each year, also represents
for the state, eliminating dialysis
treatments, a benefit that would be approximately of $46 billion per year. This
result is even more valuable considering that the 5-year patient survival of a kidney
transplant is twice the survival conferred by dialysis [1-3]. A celebrated researcher
issued these concepts "Physicians are the natural advocates of the poor and
the social problems fall for the most part under their jurisdiction". Regarding
these thoughts, we made add the following words: "If the disease is a social
evil, medicine must be a social good". To-day these notions about medicine
and social security should be evaluated in relation to the innovative practice of
organ transplantation, medical achievement actively developed [4]. The vital requirement
to transform death into life, which is what organ transplants symbolize, fundamentally
needs, as the primary resource to realize this scientific miracle of our times,
the end of somebody life. Due to prejudice, ignorance or misunderstanding, the individual
moral responsibility to offer life to another human being is forgotten. The consequence
of this conflictive situation is that patients waiting for an organ transplant "unfairly"
die every day. A
first notion that society should clearly understand and accept is that everybody
should have the right to receive an organ when necessary, and the duty to donate
at the end of life [5-7]. No matter that several surveys have shown that most people
are willing to donate their organs or those of a family member after death; at the
time of grief, many of them overlook this commitment, and the answer will be negative
[8]. In general, the response to donation is highly positive; as an example, in
US 94.9% of adults responded their intention to donate their organs [9]. However,
showing that people change in face of death, particularly in the case of a loved
one, the 2015 US statistics revealed that only 30973 transplants were performed
from 15064 donors, while more than 121000 candidates were waiting for a transplant.
As a regrettable consequence of this situation, in US in 2018, 43,000 patients per
year die waiting for a transplant, a higher number than due to homicide, Parkinsons
disease or Human
Immunodeficiency Virus (HIV), and roughly comparable to the death toll from
suicide [10,11]. With
respect to peoples information about the ethical-moral aspects and benefits for
health and socio-economy that transplants represent for society, the persistence
of organ shortage and the consequent inadequate social behaviour towards donation,
show that a clear understanding of moral and ethical principles of donation, essentially
necessary at the time of death of a loved one, has not been reached by people. Undoubtedly,
this situation will require an urgent review of social
education plans on transplants and organ donation [12,13]. This current ethical-moral
problem demands constant reflection of decision makers, concerning peoples education
plans on organ donation. Fundamentally, it is necessary to solve the critical dilemma
between the people who require a possibility of life, and the strong inhibitions
to donate that many public feels in face of death. Challenging the serious problem
of continuous and growing deaths on waiting lists, the involvement by health team
protagonists requires an accurate evaluation. Medical teams, and particularly family
doctors, should have a key role in facilitating clear education on donation, to
patients, families and the whole society. Make easy peoples knowledge, should be
an ethical professional concern considering their relevant position to discuss this
difficult subject [14,15]. The
current organ shortage crisis justified, searching for the causes responsible for
this problem, to analyses the characteristics and results that university education,
especially in the area of medical sciences, has achieved in the practice. Different
studies carried out worldwide, emphasize the persistence of an insufficient university
education, with respect to different aspects of the practice of transplantation,
and as well concerning the preponderant role that the medical team should have to
improving peoples knowledge about the organ
shortage crisis. Regarding the statement that specifies the need for a precise
university medical education on the problems of transplantation and donation, different
surveys concerning students and professionals in different branches of medical sciences,
showed that this proposal has not been sufficiently complemented over time [5,16-18]. As
well, globally public health authorities have the responsibility to propose to the
people a clear understanding of the importance of their participation in organ transplant
programs. The states responsibility to achieving higher rates of organ donation
is fundamental. The persistence of organ shortage, and the constant increasing mortality
of patients on waiting lists, consequence of inadequate public education programs,
represents a failure of those responsible of social
communication programs on organ donation and transplantation. In current organ
shortage crisis, a lack of proposals to review social education plans, might be
considered as an ethical responsibility by state health and education officials
[19-22]. Organ transplantation represents a transformation of death into life. Certainly,
the alternative that people will acknowledge this reflexion, should be sustained
by rational strategies of educational programmes on transplantation and donation.
Given the possible strong reaction to peoples sensitivity, that this concept may
produce, a suggested slogan such as "After death, the body is a unique source
of health" might be a useful alternative for its acceptance by society [23]. Solidarity
is a positive feeling in most people; however, given the death of a loved one, it
does not seem to be an enough reason to justify the authorization to donate. For
many people organ donation represents a perverse and unjustified act of mutilation,
significant inhibition cause for rejection of the donation consent. This difficult
situation in the requesting donation interview with the family can often be complicated
by the lack of medical
education on aspects of donation methodology, and with their possibility of
having useful arguments to help people understanding their potential responsibility
in the current organ shortage crisis [24-26]. Potential
reasons of current social behaviour towards organ donation have been suggested: ·
There
is only partial awareness of how common and indispensable organ transplantation
is. ·
The
knowledge that a transplant may be needed during their life, is not well-thought-out
by people. ·
Suspicion
that chances for transplantation is dependent upon a patients socioeconomic status.
·
Lack
of awareness that deceased organs and tissue transplants should be accepted as a
health
insurance benefit for everybody. ·
Universities,
mainly in the field of medicine, have not developed relevant programs on transplantation. ·
Persistent
rejection consent to donation is a consequence of peoples ignorance or fear about
brain death diagnosis [5,27,28]. With
regard to the possibility of insufficient knowledge or doubts about the diagnosis
of death, and mainly to the controversial ethical-moral reactions that can occur
in the public, and even in the area of medical practice concerning to the confirmed
equivalence between brain death diagnosis and death due to cardio
circulatory arrest; an explicit concept has been suggested: "A sustained
increase in the number of organs available for transplantation could never be achieved
until the concept of brain
death, debated clearly at all popular and scientific levels, reaches a definitive
consensus on the part of the whole society" [29,30]. Moreover, religious misunderstandings
are another factor that repeatedly comes up in the research of donation barriers.
The ignorance of the concern of monotheist churches on this topic might be a reason
for a familys rejection to donation. On the other hand, medical teams frequently
might wish to avoid this sensitive subject, because of their own lack of knowledge
about religious issues related to transplantation. While
the lack of public knowledge of the economy that organ transplants representing
for the states health budgets, is not an inhibitory factor at the time of donation,
might be useful that the educational programs make clear to the people, the importance
that this savings represents for the solutions to other problems, related to society
well-being. A study from Kalo, et al. concerning economic aspects, with respect
to dialysis
treatments, showed that on average, the costs per patient over three years were
significantly higher (P<0.001) in the hemodialysis
group than in the group that received transplants. Also, the cost of one year
gained by transplantation was significantly less (P<0.001) than the cost associated
with hemodialysis. The
understanding of the potential economic benefits associated with increasing organ
transplantation, might be another motivating factor in the moments of peoples decision-making
regarding donation [2,31]. The educational efforts trying to overcome peoples barriers
towards donation should offer clear information on the risks of inadequate conduct
toward donation. People should understand that anyone, at any time in life, might
require an organ transplant. Also, it should be acknowledged that during life everybody
should have the right to receive an organ if necessary, and the duty to be a donor
when life ends. In addition, people should be assured, by those responsible for
the daily practices of different religious creeds, that all monotheistic religions
accept and support organ donation. Considering the importance of these factors in
social conduct, we proposed the discussion of the following concepts to be considered
in the revision of public education programs: ·
The
shortage of organs is a health emergency. ·
Organ
donation is meant to share life. ·
Throughout
our lives, we are all potential organ and tissue
receptors ·
Our
body after death is a unique source of health to be shared. ·
Organ
donation after death should be a tacit social agreement for the welfare of society. Many
of these concepts related to psychological aspects, are often based on ancestral
background and should be studied by social, psychological and religious experts,
to find a clear understanding and acceptance by the public [4,32]. Should be of
interest to evaluate the transcendental importance in this crisis of the Media,
as they constitute the largest source of public information. Not only because of
its potential beneficial aspects, but mainly for the serious consequences that misinformation,
based on rumors or unconfirmed facts, might produce in the populations behaviour.
It has been evaluated that the most important educational information on transplants
and organ donation reaches the people through the Media [33]. The Media often covers
sensational news highlighting myths that have been linked to transplantation. In
this way, the public has been subjected to reports about confusing episodes of untruths
and misinformation such as declaration of premature deaths, transfer of donor personality
to the receptor, criminal
organs market, corruption in the medical communities and celebritys privileges
in transplant requirements. Essentially, this untruthful information has undoubtedly
generated negative reactions in social behaviour towards donation. A well-designed
Media campaign can undoubtedly influence the knowledge of the problem and create
a consequent improvement of the current partial attitude of society towards donation
[34,35]. Although
until the present-day, public
education towards organ donation have been managed to stress the importance
of this medico-social
resource, the persistence of organ shortage and the progressive increasing mortality
on waiting lists, evidences the need to analyse their results, and to consider alternatives
that will encouraging the public to understanding the urgent vital relevance of
organ donation. An essential objective of education on transplantation and organ
donation should be to motivate individuals to acknowledge that during their existence
they have the right to receive an organ if needed, and the duty to be a donor at
the end of their life. In the quest of this achievement, we have proposed changes
from the classical slogan: "donation is the gift of life" to "to
donate is to share life" and "during life we are all potential transplant
recipients". Every single action, in any intend to change individuals conduct
toward donation improving educational programs, would be extremely important. Government
and private health and social service organizations should be involved in the solution
of this public problem. It should be essential that information regarding donation
and transplantation should be not susceptible to produce confusing interpretations
by Society [5]. Efficient
public education, looking forward to developing peoples knowledge and understanding
of this crisis, now and in the future; will guarantee the necessary qualities for
mental, emotional, and physical well-being required to complement current social
obligation for people behaviour. The
following positive motivation concerning all aspects of this health social crisis
should be necessary to be acknowledged by the people: ·
To
improve their mental
emotional well-being for making informed decisions. ·
To
experience the potential enjoyment that this accomplishment will signify for them.
·
To
evaluate the possibilities regarding the mental, emotional and social capacity and
physical abilities that a healthy lifestyle would offer the organ required to leave
the waiting list if that alternative could be presented in life. ·
To
establish a pattern of health and wellbeing that will be maintained during life,
and that will help to promote the health and well-being of the next generations
[21,36]. A
societys contemporary incongruities are that the success of organ transplantation
is increasing whilst waiting list mortality is also increasing. Almost inexplicably,
peoples educational approach to improve the supply of organ donation has remained
largely unchanged. The
importance of a real efficiency of university and social education programs trying
to improve current social behaviour towards organ donation is undoubtedly an essential
need in the search for solutions for this crisis of health worldwide. Although
different authors have highlighted the relative inefficiency achieved by the different
conceptual schemes used in the dissemination of these programs, the methodology
of the same has never been modified in this regard. Changing current peoples educated
methodology about organ donation might be a possible way of dealing with the critical
lack of donors. Efforts to change social education programs will require the support
of the main international medical societies, and as well of the World
Health Organization (WHO), The
United Nations, Educational Scientific and Cultural Organization (UNESCO) and
representatives of all monotheistic religions. The
evaluations of the social strategies in search of solving the dilemma of the organ
shortage, leads us to the analysis of the tactics and results of societys education
in transplants and organ donation. The efforts of social education worldwide, has
also seek to curb the progress of living donors, generated by the persistent stability
of deceased donors, compared to the constantly increasing waiting lists. Nevertheless,
although several authors have suggested that an effective educational strategy could
change attitudes and social behaviours regarding organ donation and that new measure
in educational methodology would be necessary to reduce the massive gap between
supply and demand for organs; these initiatives so far have never been attempted.
Well-organized public education campaigns, based on a detailed analysis by social
communicators, psychologists
and religious experts of essential barriers to donation, might be useful in overcoming
the strong no-cognitive donation fears, and offer a way to challenge this persistent
global
health crisis [5,37]. For
decades the message to the public has basically be relied on concepts of altruism;
the “gift that will save someones life”. Solidarity and altruism have been the fundamental
bases preponderantly used searching for a better peoples response towards organ
donation. Several surveys have shown that individuals are open to donating their
organs or those of family member after death; however, at the time of grief, a high
percentage fails to remember this commitment, and the gift of life does not come
to fruition. On
the other hand, studies currently in force regarding the importance of no-cognitive
inhibitory factors towards donation, have never been considered by those responsible
for the methodology of public social education programs in this regard [38]. The
possible amendments to the current concept of altruistic
donation, by means of legal modifications accepting the option of to stimulate
a change in the inappropriate behaviour of society towards organ donation using
the economic resources of the States, is currently the subject of controversy ethical
discussions. The main justification for this option is the present dilemma of dying
waiting for the organ that probably will never come. Current
literature shows the tendency to generate an agreement, to change the philosophy
of altruistic and essential solidarity of transplant ethics, for the utilitarian
option of buying life through economic incentives for donation, legally backed by
the States; justifying this decision because of the dramatic need to avoid the death
of patients on the waiting list. Certainly, this option goes against the ethical
and moral concepts proclaimed as essential with respect to transplantation. This
conceptual change of the organ and tissue transplant practice that modifies the
philosophy, of the act of donating, generating a materialistic reasoning of it,
could be responsible for possible critical consequences at the social level. This
philosophical-materialist discussion currently in force in the media cannot help
mentioning a critical question: who will receive and who will give those organs
in exchange for a payment. Is this a new opening towards social inequality? [39-41].
An educational program considering rational and subconscious barriers toward donation
will help to save the lives that are currently lost daily. Concerning the importance
of this change of peoples feelings when facing the reality of death, I suggest based
on my experience of several decades in transplantation and organ
procurement as a nephrologist
and as well as educator, the evaluation for new educational programs of the following
catchphrases: ·
Organ
shortage is a health
emergency. ·
The
body after death is a unique source of health for everyone. ·
Sharing
the body after death should be a tacit social agreement for the common welfare of
society. ·
Organ
donation is not giving life; it is sharing life. ·
Throughout
our lives we are all potential organ and tissue recipients [42,43]. Changing
the message and focusing particularly on the young, could be a way toward a solution
to this serious social dilemma. Shoenberg, and educator not a medical doctor interested
on organ transplantation, pointed out in 1991, to a vast number of important professionals
actively engaged in the practice of organ transplants, that teaching
young people about organ transplantation would not be particularly difficult.
He considered that helping young people understand problems related to donation
and organ transplantation will increase their understanding of its importance. The
goal of children education in basic concepts of organ donation and transplantation
will be useful to multiply the educational effect, by discussing the donation with
their families and partners. Currently, intense and persistent educational efforts
focused specifically on young people are relatively rare, and a specific educational
structure in this regard is seldom in force globally. It is essential that this
topic will be organized by education authorities, initiating as a first face a basic
preparation of the teachers, and structuring permanent curricular schemes, to be
included in the educational training of young people at all levels of corresponding
educational levels. Shoenberg
considered that teaching young people about organ transplantation is not particularly
difficult. He noted that helping young people to understand the problems surrounding
organ donation and transplantation will increase their understanding of its importance.
Consequently, organ donation education for young people, beginning in primary school
and continuing at college and university, has been suggested as a promising method
of changing social attitudes and behaviour with respect to organ donation [44].
Improving education at all levels of society may offer a possibility to change critical
organ shortage. We have considered that a methodology change based on modification
of the message to society may be a way to challenge this stagnant dilemma. As we
have previously discussed, it should be of importance to consider within new educational
plans the complex mentioned barriers to donation. It is evident that the time has
come for an essential educational change, to try a professional and public response
to the achievement of a solution to a health
crisis that implies a new epidemiology of the XXI century: Dying due to ignorance,
fears or prejudices by society as a whole. Research
conducted in the US has demonstrated that rational factors have less influence on
individuals behaviour than no-rational variables such as a fear of mutilation or
death and a lack of confidence in physicians. Within the accountable reasons of
the shortage organ, we have commented that the request for donation can generate
a representation of perverse and unjustified action of mutilation towards the loved
one. This situation makes it difficult and even cancels the request interview with
the family of the potential donor [38]. We certainly consider that the total lack
of evaluation of the importance of no-rational or no-cognitive inhibitions in current
education programs might be a cause of this people attitude. On the other hand,
the lack of university training of medical teams about medical, legal, social and
religious aspects of organ
donation methodology, previously described, are also causes of failure of this
crucial interview in face of the potential donor
death [24-26]. Through the last decades we have appreciated attempts trying
to find a solution of organ shortage at political, medical and legal proposals. An
analysis of them would show that some can generate controversies, sometime crossing
the limits established from the ethical-legal point of view, and even from the classic
medical criteria in donor and recipient acceptances. With respect to the proposed
legal modifications, and already implemented in several countries, the presumed
consent that requires citizens to establish in an official registry their desire
not to be a donor, otherwise it will be in case of death; The results of this law
are still uncertain. Anyway, my thinking is that there are no laws that modify the
behaviour or feeling of people, this possibility can only be achieved with education.
Medical challenges to save lives of patients dying in waiting lists, with the acceptance
of the so called expanding criteria donors, donors in cardio-circulatory arrest,
or family exchanged transplantation, because extremely difficult immunologic
incompatibility, are at some point ethically controversial; but nevertheless,
morally understanding, when doctors are impotent to avoid a patient death [45-47]. Finally,
after this evaluation of the important efforts that have been made at legal and
medical levels and even controversial economic proposals to stimulate peoples behaviour
toward donation, generating an alternative to change the solidarity and altruistic
fundamental basis of the philosophy of organ donation, should be important to emphasize
again that, unfortunately, a possible basic resource for change that has not yet
been tested is the review and implementation of new public education programs that
can achieve a different response from society. This summary analysis of the dilemma
of organ shortage search to make available to the people a basic knowledge of organ
transplantation, a vital chance for its subsistence, and as well to suggest to decision
makers possible options, that might be useful to improve this serious problem. In
addition, and very particularly, this work is directed to society that is requiring
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of Medical Science, Catholic University, Argentine, Tel: +00 54 11 4801 6757, Email:felix.cantarovich@orange.fr Cantarovich F. Organ shortage, will peoples knowledge be a path to the solution? (2019) Nursing and Health Care 4: 46-51. Organ Shortage, Altruism, Donation, People’s behaviour, Share life, Social education.Organ Shortage, Will Peoples Knowledge be a Path to the Solution?
Félix Cantarovich
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