Recently, France’s national assembly gained attention for enacting legislation on national organ donation. This law was enacted because the number of people who need organs is increasing every year, while the number of organ donors has remained relatively low. In spite of the shortage of organ donors, there has been much opposition to the law because it is viewed by some as infringing on people’s rights.

What is organ donation?

             Organ donation is giving an organ to help someone who needs a transplant. There are three ways to donate. Firstly, brain stem death, which is donating to a patient who has suffered from a brain injury. Secondly there is post donation, which involves donating one’s eyes after death. The last one is living donation, which is donating part of one’s liver or a whole kidney while the donor is still alive. Generally, kidneys, livers, hearts, and corneas are in the highest demand.

             As of March 2017, approximately 120,000 people in the United States were still waiting for organ donations, though only 3,948 people had donated organs in the year prior to that. In 2014, the number of people who want donation in different countries, including EU members, Norway, and Turkey, reached 86,000 and 16 people died everyday waiting for organs. The number of organ donors is decreasing globally. From 2008 to 2015, donors decreased by 30.4% in Iceland, 9.2% in Hungary, and 7.2% in South Korea.

             The reasons for these decreases are various; however, there some particular reasons that can be cited in certain countries. In Switzerland, for example, the organ donation process is very complicated, so a lot of people can’t even afford their organ because they feel it's so complicated and hard to apply as a donor. In Germany, because the number of organs is insufficient, some doctors change the waiting list of orders of patients, so people perceive organ transplantation negatively. Similarly, in South Korea, interest in organ donation is not as big as in other countries.

Different policies on organ donations

             Currently, the most common type of organ donation is that which occurs upon death, which is called post-donation or brain stem death donation. There are two different ways in which organs are acquired for transplants; the donor either decides to donate before death, or mandatory national policies may be implemented if applicable.

Countries implementing organ donation by choices

             The most popular system for organ donation is opt-in policies. Opt-in policies require prior consent from people to perform organ donations. In other words, if people want to be organ donors, they have to apply. Most countries subscribe to such a system, such as the US, Germany, Japan, South Korea, Canada, the Netherlands, and Denmark.

             The United States, the most representative country to operate an opt-in policy, makes it clear that organ donations can only take place if the potential donor has indicated an intention to donate before they die. In 2015, the annual number of transplants in the US exceeded 30,000 for the first time. Also, the number of donors per 1 million people is one third, though the organ transplant rate in the US is just 15% of the population and this is less than Europe which is 90% on average. In addition, it is marked on US driving licenses whether a person is a donor or not, which means that every time when people renew their license, they have the opportunity to reapply. On average, 48% of people who have been issued a license said they would like to be an organ donor.

             In the US, there are 116 transplant hospitals, which is very few in relation to the population. In addition, transplant costs range from $50,000 to $250,000, and so due to these reasons the number of patients successfully receiving organ transplants is low. Richard Kinton, who is 43 years old and lives in the US, had successful liver transplant surgery in the past, but it is unaffordable for ordinary working-class people due to their inability to afford the massive medical bills. Thus, the number of patients who are still waiting for organ transplants is more than 121,700, which is far higher than the number of organ donors. 22 people die a day because of this organ shortage. According to data from the US Department of Health and Human Services, the average waiting time for transplants is 2 years, though for kidneys it is 3 years. Due to the organ shortage, 10% of US organ transplants involve the illegal buying and selling of organs.

An organ donor's card (Organspendeausweis) in Germany

             In Germany, like in the United States, an opt-in policy has been implemented since 1997, and the number of organ donors is always over 1000 per year. The German government tries to increase the organ donation rate by asking the public to opt-in to organ donation every two years so that people can debate the issue with their families. Also, those aged 16 years old or older are asked regularly by the health insurers whether they want to donate their organs or not. However, since 2013 the number of donors has dropped to 876 people, which is a decrease of 16 percent, and since 2015 only 12 people per 1 million are registered organ donors. Also, 70% of people in Germany said that they are willing to donate their organs, but less than 20% of people are actually donating because of  an increase in incidences of waiting lists being changed for bribes.

Second life toy in Japan

             In Japan, the “Donna Card” system has been implemented. “Donna Card” is a system created by the Japan Organ Transplant Network Association, which makes it easy to to register for through convenience stores such as Seven-Eleven. It even allows citizens to confirm organ donation procedures such as granting permission for euthanasia in the event of an unexpected accident. To improve organ transplant culture, awareness campaigns to educate people, especially children, have become important. “Second life toys”, for example, is a programme in which the concept of organ donation is mirrored. Both transplant applications send an image of ‘injured’ dolls by email or letter and waiting for approval. If the doll gains approval, the doll is sent to the company and get transplants from other dolls. The special part of this campaign is if the recipient receives a second life toy, they have to write a thank you letter to another doll’s host. 

             In Japan, unlike other countries, strong individualism has caused the rate of organ donation to decrease. Because of this reason, about 14,000 patients are waiting for transplantation every year, but only 300 of them actually receive organ transplants. The special policies of Japan are that having organ transplants and donating by relative first. On April 21 2017, a 50-year-old man who died of gastric cancer pledged to donate his corneas. However, he pledged having donation to relative so the hospital decided to take a pair of corneas and transplanted to his invisible wife. And the other organ will be transplanted to the general waiting list.

Countries with mandatory organ donation policies

             An opt-out policy establishes that all citizens are organ donors unless they have directly expressed otherwise. This is currently implemented in France, Austria, Spain, Belgium, Hungary and Sweden.

             In France, from January 1st 2017, the policy treats all people as organ donors if they have not registered on the list of refusal to donate. In 2016, the organ donation status in France was measured at 22 people per million. This law allows individuals to apply for organ donation even if the deceased does not register in advance for avoidance of organ donation both online and by mail. As of February 2017, 150,000 people had registered for avoidance of organ donation. The biggest obstacle in countries with few donors, such as France, is that contrary of the closest family and relatives. So the French government expects disputes between families, doctors, and the deceased to be alleviated by the law. 

             Based on 2015 data, the neighboring country German’s organ donation rate was 12%; however, in Austria it was 99.98%, which is close to 100%. This is because Austria is a country that has successfully implemented the opt-out system. The government said that 90% of people are willing to donate their organs, but the process of being a donor is complicated and difficult and can lead to low organ donor rates, which is why the government decided to implement an opt-out policy.

             Spain is the most successful organ transplant country, and the donation rate of organ donors is 35 people per 1 million people in the world. Spain was the first country to implement an opt-out system. Family opposition to organ donation is around 15%, which is much lower than the European average of 40%. Also, the average waiting time for an organ transplant is 40 days, which is the fastest time in the world. One of the main reasons for this is Spain’s ability to identify patients with a high likelihood of brain death early, and to move to the stage of persuasion of organ donation at a faster pace. Also, at each hospital there are physicians and nurses who identify potential organ donors and persuade their bereaved.

Organ donation in Korea

             According to the Korea Organ Donation Association, as of December 31 2016, the total number of brain stem death donated organs was 573, an increase of 14.3% over the previous year. However, in 2016, 30286 people were on a waiting list, but the actual number of transplants was 4,658, making up 15.4% of the total. Also the average waiting time for organ transplant is 3 years and 9 months. In Korea, like Japan, applicants who want to donate organs should be 16 years old or older to donate to relatives, and 19 years old or older for donating to others. In addition, like the United States, when people apply for a first or reissued driving license, if they check “Yes” to donate organs, they will be registered as an organ donor.

             In Korea, the rate of brain-dead donation is the lowest, while the survival rate is the highest, and this is because of the influence of Confucian culture. The reason for this is 80% of organ transplantations and donation procedures are received from family members so that it is more safe and suitable for the patients. Public awareness of organ donation is very high at 97-98%. However, when it is time to decide to donate organs, many hesitate due to the reason that they don’t want to ‘damage’ the body of their family member. This seems to be a cultural influence that emphasizes filial duty and family. On the contrary, the donation to others is only 1%. Also the brain death judging committee is required to judge whether brain death has occurred or not. However, the process time is too long so that a lot of patients miss the right time.

             To solve these problems, two main solutions exist. Firstly, to encourage organ donation, improvements in policy are needed. The Korean government has designated 400 places, including private institutions, hospitals, and public health centers, as organ transplant registration agencies. However, according to Korean law, if a potential donor dies or becomes brain dead, the final decision should be made by family members. So, the law has to be changed in line with other countries whereby the decision made by the person wishing to be an organ donor is upheld after his or her death. Although the Act on Transplantation of Organs has been implemented since 2009, which has guided most of the regulations on organ transplantation ethics committees and  management of organ transplant institutions, relatively few long-term beneficiaries and donors have been been found to date. Secondly, awareness of organ donation is insufficient compared to other countries. Since the development of awareness of organ transplantation is still necessary, we should educate young people to have positive attitudes towards organ donation. In the case of France, 90% of the people are in favor of organ donation because of widespread a belief in the obligation to donate and the right to receive organs if in need. Therefore, the creation of a suitable social atmosphere for donors and the careful preparation of policies are needed.

김지윤  jeeyoon0817@hanmail.net

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