Public knowledge and attitudes towards consent policies for organ donation in Europe. A systematic review

Do ethical views of end-of-life patients' family members impact organ donation decisions?

Background: The relatives of patients who decide to donate their loved one's organs experience dilemmas about organ donation and are affected by culture, religion, and individual views.Aim: The aim of this study was to determine the relationship between the ethical position and personal characteristics of the family members of the patients receiving end-of-life care and their thoughts about organ donation in Turkey.Research design and participants: The study was completed with 158 family members. For data collection, a personal information form and the Ethics Position Questionnaire were used.Ethical considerations: This study was obtained from the ethics committee of the faculty of medicine in Turkey. It was based on voluntary participation, informed consent, confidentiality, and anonymity.Results: All participants in the study shared the same faith and were Muslims. The idealism and relativism tendencies of the participants tended to be high. The number of children, the participants have, participants' status of waiting for an organ transplant, the view that the clergy and health personnel will increase interest in organ donation were identified as factors associated with idealism tendencies. Participants' status of having children, the number of children participants have, participants' status of organ transplant waiting, the view that the health personnel will increase interest in organ donation were identified as factors associated with relativism tendencies (p < 0.0.5).Conclusion: The results of this study demonstrated a relationship between participants' idealism and relativism tendencies, among those with a large number of children, waiting for organ donation, advocating for clergy guidance to increase organ donations, and believing healthcare professionals need not guide to increase organ donations. In light of this finding, it may be recommended to establish a multidisciplinary team, including healthcare professionals and clergy, and to inform the society with accurate information to increase the number of organ donations.

The right to know from the opt-out effectiveness system perspective in organ transplantation cases

OBJECTIVE

Aim: This article examines the legal challenges associated with opt-out and opt-in systems in transplantation cases. It focuses on the low public knowledge and awareness of the national transplantation system, assessing its compliance with international prerequisites for an opt-out system. The analysis centres on the "right to know" perspective and the effectiveness of opt-out in organ transplantation. .

PATIENTS AND METHODS

Materials and Methods: The research methodology includes scientific principles, public surveys, relevant regulations from the Republic of Latvia and EU, and grey literature on the health system and organ donation in the EU. Scientific articles from databases such as Scopus and WOS were selected based on criteria such as language (English and Latvian) and focus on living wills and comparisons of organ donation systems. Previous EU and national studies, reports, and court judgments were used to analyse data on opt-in and opt-out transplantation systems and policy efficiency in organ transplantation.

CONCLUSION

Conclusions: Individuals' right to autonomy over their bodies extends even after death, encompassing the right to integrity. Organ donation, being a deeply personal choice reflecting one's values and beliefs, plays a crucial role in saving lives through transplantation. To enhance cooperation and donation rates, international regulations stress the significance of public awareness regarding organ and tissue transplantation. Unfortunately, inadequate compliance by authorities and low awareness pose ethical and legal dilemmas, potentially violating constitutional rights. Reports highlight limited public understanding of transplantation systems, raising concerns, particularly in opt-out systems. National governments bear the responsibility of safeguarding these rights and addressing challenges beyond legal means, thus establishing a more ethical organ donation system that upholds voluntariness, generosity, and individual autonomy.

Mapping trust relationships in organ donation and transplantation: a conceptual model

The organ donation and transplantation (ODT) system heavily relies on the willingness of individuals to donate their organs. While it is widely believed that public trust plays a crucial role in shaping donation rates, the empirical support for this assumption remains limited. In order to bridge this knowledge gap, this article takes a foundational approach by elucidating the concept of trust within the context of ODT. By examining the stakeholders involved, identifying influential factors, and mapping the intricate trust relationships among trustors, trustees, and objects of trust, we aim to provide a comprehensive understanding of trust dynamics in ODT. We employ maps and graphs to illustrate the functioning of these trust relationships, enabling a visual representation of the complex interactions within the ODT system. Through this conceptual groundwork, we pave the way for future empirical research to investigate the link between trust and organ donation rates, informed by a clarified understanding of trust in ODT. This study can also provide valuable insights to inform interventions and policies aimed at enhancing organ donation rates.

How clinicians discuss patients' donor registrations of consent and presumed consent in donor conversations in an opt-out system: a qualitative embedded multiple-case study

BACKGROUND

The Netherlands introduced an opt-out donor system in 2020. While the default in (presumed) consent cases is donation, family involvement adds a crucial layer of influence when applying this default in clinical practice. We explored how clinicians discuss patients' donor registrations of (presumed) consent in donor conversations in the first years of the opt-out system.

METHODS

A qualitative embedded multiple-case study in eight Dutch hospitals. We performed a thematic analysis based on audio recordings and direct observations of donor conversations (n = 15, 7 consent and 8 presumed consent) and interviews with the clinicians involved (n = 16).

RESULTS

Clinicians' personal considerations, their prior experiences with the family and contextual factors in the clinicians' profession defined their points of departure for the conversations. Four routes to discuss patients' donor registrations were constructed. In the Consent route (A), clinicians followed patients' explicit donation wishes. With presumed consent, increased uncertainty in interpreting the donation wish appeared and prompted clinicians to refer to "the law" as a conversation starter and verify patients' wishes multiple times with the family. In the Presumed consent route (B), clinicians followed the law intending to effectuate donation, which was more easily achieved when families recognised and agreed with the registration. In the Consensus route (C), clinicians provided families some participation in decision-making, while in the Family consent route (D), families were given full decisional capacity to pursue optimal grief processing.

CONCLUSION

Donor conversations in an opt-out system are a complex interplay between seemingly straightforward donor registrations and clinician-family interactions. When clinicians are left with concerns regarding patients' consent or families' coping, families are given a larger role in the decision. A strict uniform application of the opt-out system is unfeasible. We suggest incorporating the four previously described routes in clinical training, stimulating discussions across cases, and encouraging public conversations about donation.

Do the Compassion and Spirituality Levels of Turkish Nursing Students Influence their Attitudes Toward Organ Donation?

This study was a descriptive-correlational design which evaluated the relationship between compassion and spirituality levels and attitudes toward organ donation among Turkish nursing students. A sample of 296 participants studying in the nursing department of a foundation university in the spring semester of the 2021-2022 academic year was formed. A descriptive information form, Spirituality Scale, Compassion Scale, and Organ Donation Attitude Scale were used for data collection. Pearson correlation and multivariate regression analysis were used to evaluate scale scores. The compassion levels of students were high, their attitudes toward organ donation were positive and strong, and their level of spirituality ([Formula: see text]= 18.71 ± 6.10) was slightly above average. Higher levels of spirituality and compassion were positively correlated with positive attitudes toward organ donation (p < 0.05). The compassion and spirituality of nurses should be high for raising public awareness of organ donation.

Prevalence and Predictors of Knowledge and Attitudes Toward Eye Donation Among the General Population: A Systematic Review

PURPOSE

The purpose of this systematic review was to investigate knowledge and attitudes toward eye donation and sources of eye donation information among the general population.

METHODS

A search was conducted using MEDLINE through Ovid and Scopus; CINAHL through EBSCOhost and ProQuest; and Embase through Ovid database entries from January 2010 to March 2021. Quantitative studies were selected if they included participants aged 16 years or older from the general population (nonhealthcare) and had a sample size of >200. Studies were included if they measured knowledge and attitudes toward eye donation and sources of eye donation information. Methodological quality was assessed using JBI criteria, and the data were analyzed using SUMARI software.

RESULTS

A total of 25 studies were included in this review. Pooled data from 6 studies demonstrated that 30.8% of participants [95% confidence interval (CI) = 11.0-55.4] had some knowledge of eye donation. Seventeen studies reported that 40.6% (95% CI = 39.8-41.3) were willing to donate their eyes, and 5 of these studies found that 7.3% (95% CI = 6.5-8.3) had already pledged their eyes. Eleven studies reported on the source of eye donation information, indicating 50.9% of participants (95% CI = 49.8-52.1) received information from mass media.

CONCLUSIONS

The results of this review indicate that understanding eye donation knowledge and attitudes is crucial for developing interventions or tools to increase eye donation rates. Further studies in different populations are required.

Attitudes of European students towards family decision-making and the harmonisation of consent systems in deceased organ donation: a cross-national survey

Background

European countries are increasingly harmonising their organ donation and transplantation policies. Although a growing number of nations are moving to presumed consent to deceased organ donation, no attempts have been made to harmonise policies on individual consent and the role of the family in the decision-making process. Little is known about public awareness of and attitudes towards the role of the family in their own country and European harmonisation on these health policy dimensions. To improve understanding of these issues, we examined what university students think about the role of the family in decision-making in deceased organ donation and about harmonising consent policies within Europe.

Methods

Using LimeSurvey© software, we conducted a comparative cross-sectional international survey of 2193 university students of health sciences and humanities/social sciences from Austria (339), Belgium (439), Denmark (230), Germany (424), Greece (159), Romania (190), Slovenia (190), and Spain (222).

Results

Participants from opt-in countries may have a better awareness of the family’s legal role than those from opt-out countries. Most respondents opposed the family veto, but they were more ambivalent towards the role of the family as a surrogate decision-maker. The majority of participants were satisfied with the family’s legal role. However, those who were unsatisfied preferred to limit family involvement. Overall, participants were opposed to the idea of national sovereignty over consent policies. They favoured an opt-out policy harmonisation and were divided over opt-in. Their views on harmonisation of family involvement were consistent with their personal preferences.

Conclusions

There is overall division on whether families should have a surrogate role, and substantial opposition to granting them sole authority over decision-making. If European countries were to harmonise their policies on consent for organ donation, an opt-out system that grants families a surrogate decision-making role may enjoy the widest public support.

Differential impact of opt-in, opt-out policies on deceased organ donation rates: a mixed conceptual and empirical study

OBJECTIVES

To increase postmortem organ donation rates, several countries are adopting an opt-out (presumed consent) policy, meaning that individuals are deemed donors unless they expressly refused so. Although opt-out countries tend to have higher donation rates, there is no conclusive evidence that this is caused by the policy itself. The main objective of this study is to better assess the direct impact of consent policy defaults per se on deceased organ recovery rates when considering the role of the family in the decision-making process. This study does not take into account any indirect effects of defaults, such as potential psychological and behavioural effects on individuals and their relatives.

DESIGN

Based on previous work regarding consent policies, we created a conceptual model of the decision-making process for deceased organ recovery that included any scenario that could be directly influenced by opt-in or opt-out policies. We then applied this model to internationally published data of the consent process to determine how frequently policy defaults could apply.

MAIN OUTCOME MEASURES

We measure the direct impact that opt-in and opt-out policies have per se on deceased organ recovery.

RESULTS

Our analysis shows that opt-in and opt-out have strictly identical outcomes in eight out of nine situations. They only differ when neither the deceased nor the family have expressed a preference and defaults therefore apply. The direct impact of consent policy defaults is typically circumscribed to a range of 0%-5% of all opportunities for organ recovery. Our study also shows that the intervention of the family improves organ retrieval under opt-in but hinders it under opt-out.

CONCLUSIONS

This study may warn policy makers that, by emphasising the need to introduce presumed consent to increase organ recovery rates, they might be overestimating the influence of the default and underestimating the power granted to families.

The Effect of Islamic Belief and Spiritual Well-being on Organ Donation in Turkey: A Descriptive-Relational Study

The aim of the study is to determine how Islamic belief and spiritual well-being affect the attitudes of individuals towards organ donation. The study was designed as a descriptive-relational study and included the participation of 402 adults in the eastern Mediterranean region of Turkey. For data collection, a personal information form, the Organ Donation Attitude Scale, and the Spiritual Well-being Scale were used. A statistically significant relationship was observed between the acceptance of organ donation according to Islamic beliefs and organ donation attitude. A negative relationship was found between organ donation attitude and the scores on the anomie sub-dimension of the Spiritual Well-being Scale, while a positive relationship was found between organ donation attitude and the scores on the transcendence and harmony with nature sub-dimensions. It was concluded from the results that Islamic belief and spiritual well-being have an effect on the organ donation attitudes of individuals.

Knowledge and Attitude of Society Concerning Organ Donation in Turkey

This study aims to identify the knowledge and attitude of society in Turkey concerning organ donation, as well as to learn the recommendations proposed by members of society to promote organ donation. The study employs a mixed-methods research design (quantitative and qualitative). The study sample consisted of 1385 people between the ages of 18 and 90 who had sociodemographic and cultural characteristics, lived in various regions/districts within Istanbul province, had varying levels of education, worked/did not work in various institutions and organizations, and agreed to participate voluntarily in the study. The data were collected using an Information Form and a Semi-Structured Individual Opinion Form. Most of the participants had not donated organs but were willing to do so, and the majority of those who had donated or wished to donate their organs desired to do so in order to save a life, serve humanity, or help someone else. Among those who did not wish to donate their organs, their reasons included a desire to preserve the integrity of their bodies and a desire for nothing to be detached from their bodies. Moreover, those unwilling believed that it was not religiously permissible. The participants indicated that society needed to be educated, primarily through visual and print media, to promote organ donation. Organizing seminars, conferences, panels, as well educational activities related to organ donation can be recommended to raise awareness and improve attitudes toward organ donation.

Public Perception of Organ Donation and Transplantation Policies in Southern Spain

BACKGROUND

This research explores how public awareness and attitudes toward donation and transplantation policies may contribute to Spain's success in cadaveric organ donation.

MATERIALS AND METHODS

A representative sample of 813 people residing in Andalusia (Southern Spain) were surveyed by telephone or via Internet between October and December 2018.

RESULTS

Most participants trust Spain's donation and transplantation system (93%) and wish to donate their organs after death (76%). Among donors, a majority have expressed their consent (59%), and few nondonors have expressed their refusal (14%). Only a minority are aware of the presumed consent system in force (28%) and feel sufficiently informed regarding the requirements needed to be an organ donor (16%). Participants mainly consider that relatives should represent the deceased's preferences and be consulted when the deceased's wishes are unknown, as is the case in Spain.

CONCLUSION

Public trust in the transplant system may contribute to Spain's high performance in organ donation. High levels of societal support toward organ donation and transplantation do not correspond with similar levels of public awareness of donation and transplantation policies in Spain.

Should the family have a role in deceased organ donation decision-making? A systematic review of public knowledge and attitudes towards organ procurement policies in Europe

GOAL

To assess public knowledge and attitudes towards the family's role in deceased organ donation in Europe.

METHODS

A systematic search was conducted in CINHAL, MEDLINE, PAIS Index, Scopus, PsycINFO, and Web of Science on December 15th, 2017. Eligibility criteria were socio-empirical studies conducted in Europe from 2008 to 2017 addressing either knowledge or attitudes by the public towards the consent system, including the involvement of the family in the decision-making process, for post-mortem organ retrieval. Screening and data collection were performed by two or more independent reviewers for each record.

RESULTS

Of the 1482 results, 467 studies were assessed in full-text form, and 33 were included in this synthesis. When the deceased has not expressed any preference, a majority of the public support the family's role as a surrogate decision-maker. When the deceased expressly consented, the respondents' answers depend on whether they see themselves as potential donors or as a deceased's next-of-kin. Answers also depend on the relationship between the deceased and the decision-maker(s) within the family, and on their ethnic or cultural background.

CONCLUSIONS

Public views on the authority of the family in organ donation decision-making requiere further research. A common conceptual framework and validated well-designed questionnaires are needed for future studies. The findings should be considered in the development of Government policy and guidance regarding the role of families in deceased organ donation.

Australian Perspectives on Opt-In and Opt-Out Consent Systems for Deceased Organ Donation

Introduction: As many countries change to opt-out systems to address organ shortages, calls for similar reform in Australia persist. Community perspectives on consent systems for donation remain under-researched, therefore Australian perspectives on consent systems and their effectiveness in increasing donation rates were explored. Design: In this descriptive cross-sectional study, participants completed a survey presenting opt-in, soft opt-out, and hard opt-out systems, with corresponding descriptions. Participants chose the system they perceived as most effective and described their reasoning. Results: Participants (N = 509) designated soft opt-out as the most effective system (52.3%; hard opt-out 33.7%; opt-in 13.7%). Those who identified with an ethnic/cultural group or were not registered had greater odds of choosing opt-out. Six themes identified in thematic analysis reflected their reasoning: (1) who decides (individual, shared decision with family); (2) right to choose; (3) acceptability (ethics, fairness); and utility in overcoming barriers for (4) individuals (apathy, awareness, ease of donating, fear/avoidance of death); (5) family (easier family experience, family veto); (6) society (normalizing donation, donation as default, expanding donor pool). Choice and overcoming individual barriers were more frequently endorsed themes for opt-in and opt-out, respectively. Discussion: Results suggested the following insights regarding system effectiveness: uphold/prioritize individual's recorded donation decision above family wishes; involve family in decision making if no donation preference is recorded; retain a register enabling opt-in and opt-out for unequivocal decisions and promoting individual control; and maximize ease of registering. Future research should establish whether systems considered effective are also acceptable to the community to address organ shortages.

A Multiethnic Asian Perspective of Presumed Consent for Organ Donation: A Population-Based Perception Study

Background: Organ shortage is still a world-wide problem, resulting in long waiting lists for kidney, liver, and heart transplant candidates across many transplant centers globally. This has resulted in the move toward presumed consent to increase deceased organ donation rates. However, there remains a paucity of literature on public attitude and barriers regarding the opt-out system, with existing studies limited to Western nations. Therefore, this study aimed to understand public sentiment and different barriers toward organ donation from the perspective of Singapore, a highly diverse and multiethnic Asian society.

Methods: A cross-sectional community semi-structured interview was conducted in a public housing estate in Singapore. Pilot test was undertaken before participants were interviewed face-to-face by trained personnel. All statistical evaluations were conducted using Stata. The χ²-test compared subgroups based on patient characteristics while multivariable logistic regression identified predictors of willingness to donate/ assent. Effect estimates were quantified using odds ratio (OR).

Findings: Out of 799 individuals, 85% were agreeable to organ donation after death and 81% were willing to assent to donations of family members' organs, which declined by 16% (p < 0.001) after a clinical scenario was presented. Demographic factors including ethnicity, education, marital, and employment status affected willingness to donate and assent. Knowledge correlated significantly with willingness to donate and assent. In particular, knowledge regarding brain death irreversibility had the strongest correlation (AOR 2.15; 95% CI 1.60–2.89).

Conclusions: Organ donation rates remain low albeit presumed consent legislation, due to patient-level barriers, including but not limited to knowledge gaps, cultural values, religious backgrounds, and emotional impact at relatives' death. To effectively boost donor rates, it is crucial for policy makers to invest in public education and improve transplant provisions and family protocols.

Presumed post-mortem donors: the degree of information among university students

BACKGROUND

Organ transplantation represents the most effective and acceptable therapy for end-stage organ failure. However, its frequent practice often leads to a shortage of organs worldwide. To solve this dilemma, some countries, such as Portugal, have switched from an opt-in to an opt-out system, which has raised concerns about respect for individual autonomy. We aimed to evaluate whether young university students are aware of this opt-out system so that they can make informed, autonomous and conscious decisions, as well as to identify the factors that determine a positive attitude toward post-mortem organ donation.

METHODS

An observational, cross-sectional study was developed and a questionnaire was administered to first-year students from six faculties of the University of Porto.

RESULTS

Of the 841 participants, 60% were unaware that Portugal had adopted an opt-out system. Among the informed individuals, their main sources of information included social media, internet, and family. Furthermore, only 48% of all participants agreed with the current opt-out system. Female sex (p = 0.049; OR 1.393), knowledge of the law (p < 0.001; OR 4.749) and family being the primary source of information (p < 0.001; OR 2.855) were independent factors associated with a positive attitude toward post-mortem organ donation law.

CONCLUSIONS

There is a significant lack of knowledge among young university students regarding the presumed post-mortem organ donation law and how it works. Female sex, having family as a primary source of information and being aware of the presumed post-mortem organ donation law are the strongest independent factors that determine a positive attitude toward the opt-out system.

Nudging to donate organs: do what you like or like what we do?

An effective method to increase the number of potential cadaveric organ donors is to make people donors by default with the option to opt out. This non-coercive public policy tool to influence people's choices is often justified on the basis of the as-judged-by-themselves principle: people are nudged into choosing what they themselves truly want. We review three often hypothesized reasons for why defaults work and argue that the as-judged-by-themselves principle may hold only in two of these cases. We specify further conditions for when the principle can hold in these cases and show that whether those conditions are met is often unclear. We recommend ways to expand nationwide surveys to identify the actual reasons for why defaults work and discuss mandated choice policy as a viable solution to many arising conundrums.

Governance quality indicators for organ procurement policies

Background

Consent policies for post-mortem organ procurement (OP) vary throughout Europe, and yet no studies have empirically evaluated the ethical implications of contrasting consent models. To fill this gap, we introduce a novel indicator of governance quality based on the ideal of informed support, and examine national differences on this measure through a quantitative survey of OP policy informedness and preferences in seven European countries.

Methods

Between 2017–2019, we conducted a convenience sample survey of students (n = 2006) in Austria (AT), Belgium (BE), Denmark (DK), Germany (DE), Greece (GR), Slovenia (SI) and Spain (ES), asking participants about their donation preferences, as well as their beliefs and views about the policy in place. From these measures, we computed indices of informedness, policy support, and fulfilment of unexpressed preferences, which we compared across countries and consent systems.

Results

Our study introduces a tool for analyzing policy governance in the context of OP. Wide variation in policy awareness was observed: Most respondents in DK, DE, AT and BE correctly identified the policy in place, while those in SI, GR and ES did not. Respondents in opt-out countries (AT, BE, ES and GR) tended to support the policy in place (with one exception, i.e., SI), whereas those in opt-in countries (DE and DK) overwhelmingly opposed it. These results reveal stark differences in governance quality across countries and consent policies: We found a preponderance of informed opposition in opt-in countries and a general tendency towards support–either informed or uninformed–in opt-out countries. We also found informed divergence in opt-in countries and a tendency for convergence–either informed or uninformed–among opt-out countries.

Conclusion

Our study offers a novel tool for analyzing governance quality and illustrates, in the context of OP, how the strengths and weaknesses of different policy implementations can be estimated and compared using quantitative survey data.

Opt-out policy and the organ shortage problem: Critical insights and practical considerations

The legal shift to an opt-out system of consent for deceased organ donation is now official in England, Wales and Scotland. While it is commendable that national governments across the United Kingdom have publicly signalled their serious engagement with organ donation, it remains questionable that opt-out policy can in and of itself solve the public health issue of organ shortage. Opt-out policy risks becoming a futile solution if it fails to attend to key factors in clinical practice. Thus, this article provides critical insights and practical considerations in order to work towards increasing the availability of organs for transplantation: 1) organ donation specialists on their own are not enough, a collaborative hospital culture of donation is also needed; 2) investment in innovative perfusion technologies is fundamental to increase both the quantity and quality of organs utilised for transplants; and 3) opt-out does not solve the enduring problem of consent or authorization for donation, rather than hoping that opt-out will shift the societal culture of donation and make donation the default choice, it is necessary to acknowledge that families' authorization remains essential and their emotional experience can neither be minimized nor excluded altogether. Importantly, consent rates are not the only factor to account for overall deceased donation rates. The organ shortage cannot be solely attributed to a matter of negative public attitudes reversible by law. Doing that does a disservice to the public and diverts strategic attention and resources from fostering the organizational and technological enablers of organ donation in clinical practice.