Organ transplant

.	ORGAN TRANSPLANT
	A NEW CULTURE OF DONATION
.	AN INTERVIEW WITH PROF. CORRADO MANNI

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After the important intervention of Ruth Faden - former President of an American Government Committee charged to investigate on radiations experiments during the “cold war” - the debate on bioethics continues ion our journal.
The following article is dedicated to the serious question of organ donation. In fact the Parliamentary Committee on Social Affairs has recently presented (May 12, ‘98) a bill containing new provisions on transplants. To have exhaustive information about this matter we have interviewed Corrado Manni, Director of the Dept. of Anaesthesiology and Reanimation of the Università Cattolica of Rome and member of the National Committee on Bioetichs.
L. M. - Professor, if the bill would be approved, the organ drawing could be prevented only by an explicit and opposite will declaration, expressed by the deceased during life. It means that silence-consent would prevail. What is your opinion?
Manni - Before saying my opinion, I wish to underline that the ethic value of donation is beyond doubt. It is enough to think about the fact that 50.000 people is still alive thanks to transplant and that the multiorgan transplant is opening new perspective also concerning therapy of pathologies deemed untreatable till now, specially the oncology ones.
L. M. - Do you agree, Professor, that, in many cases, transplant is not considered the best therapeuthical method?
Manni - It must be clear for all that the transplant is nowadays the sole possible therapy for many pathologies featured by unsuccessful prognosis; myocardium dilating diseases, cirrhosis of the liver, striking down, toxic or virus hepatitis. In these cases, carrying out transplants means saving a life; and life protection is for us, the physicians, a deontology imperative. Unfortunately, comparing our country with the European ones, the transplants number carried out in Italy is significantly lower to the expected and foreseen. It is suffice to think that Spain, France, Scandinavian Countries and England the transplant rate is within 24 e 32 per million habitants; on the opposite, in our country is only 11 per million habitants.
L. M. - Could you explain the reasons of a so low incidence of transplants in Italy?
Manni - The reasons of the insufficient transplant realisation are surely several: lacking of notice of in brain dead patient; difficulties in maintaining the donor, lacking of consent. Really the opposition of the relatives prevent the organ donation in the 15-20 % of cases. This data brings us to suppose that the main reason of the insufficient organ finding is to be detected in the lacking of notice.
L. M. - Is it possible to know exactly the number of the unnoticed donors?
Manni - Several Reanimation Centres which operate in our country do not have ever notice brain death suspected patients. The matter would deserve a more careful analysis; anyhow it is well known that the main reason of the lack in notice is to be searched in the inexcusable organisation lacks (concerning personnel and equipment) featuring the mentioned units and in an insufficient donation culture also among wealth operators. Some Reanimation Centres of the roman hospitals, for example, find it difficult to carry out a electroencephalograph test and find great difficulties to designate the committee charged to state death using neurological criteria, committee, as you know, must be formed by an anaesthetist-reanimation operator, a medico-legal and a electro<d>encephalograph skilled neurologist.

L. M. - Professor, is the lacking of notice due to the difficult situation, on a structural point of wiev, of centres?
Manni - If the Reanimation Centres would be settled in the better working conditions I am sure that, by the means of the in force law, it would be possible to eliminate the gap between the other European countries and us. Honestly, I’ve also underlined that unfortunately it still exists an insufficient culture about donation, even among wealth operators. I wonder, for example, if the sense of the Art. 3 Law 578 which forces upon the physician to notice immediately Sanitary Direction the existence of conditions to state death by the means of neurological criteria, has been receipt or we have already understood that the death assessment, independently from the employed criteria, is a juridical duty and a deontology imperative, even not regarding the transplant perspective.
L. M. - It does not seem that there is, among you colleagues, a unanimous consent for a positive answer to the mentioned questions. And overall we think that neurological criteria death assessment has not yet become praxis in all the Reanimation Centres and Intensive Therapy, indepen<d>dently from the eventual transplant.
Manni - In my opinion, even among the greater difficulties, professional skilled men, if motivated by an aim they believe to, can obtain positive results. On the contrary, none organisation, even the a perfect one, can give good results if it isn’t supported by a positive participation of whom works inside.
L. M. - We cannot deny that, among the reasons at the basis of the insufficient finding of organs, we must count the lack of consent to donation. If the bill should pass, silence-consent would prevail. Isn’t that a forced solution of the problem?
Manni - Yes, it is. The ‘missed consent’ cannot be overtaken by the means of imposed acts, but, as we believe, must be searched and reached by special health education.
In fact the transplant ethic value - as therapy act aimed to save life, or, anyhow, to better its quality - does not justify, by itself, a consent to donation anyhow reached.
L. M. - Within this field, Professor, are to be located current problems about the clearly expressed consent (opting-in) and the tacit consent (o silence/consent or presumed consent)?
Manni - The expressed consent, as well known, supposes the citizen has clearly expressed during his live the will to donate his organs after his death for transplant.To allow that it has been appointed Donor Cards in some States of North America, the consent to donate is recorded on the driving licence.

L. M. - In Italy, instead, In the case of death, lacking any declaration of the fellow, the consent is required to relatives, who are invested with the terrible responsibility of deciding for their own relative in a full of anguish moment.
Manni - As it was said by the philosopher of medicine Carl Cohen ‘we ask wrong persons, in a moment presumable the worst, what maybe we must never ask anyhow.’.Just for this observation that may be shared it is justified the requirement, ‘during life’ of the consent to donation.
L. M. - The problem now to establish is that if, to avoid the relatives’ opinion, it would be convenient the silence/consent or the ‘explicit consent’.
Manni - The most important blame concerning ‘the explicit consent’ is that it supposes a lack of involvement, that is that the citizen does not wish to donate his own organs after death. Statistical surveys, carried out in the United States, have pointed out however that the majority of the interviewed citizens are really favourable to after death organs transplant and drawing. . In Italy, a survey carried out in the North, Italian Transplant has documented that only the 7% of citizens are against organ donation. The percentage increases up to 30% in the real situation, if consent is demanded for an own relative. The silence-consent, on the contrary, starts in over the premises that citizen wish to done their own organs after death. If a citizen does not agree, he must explicit his dislike.
L. M. - The principle of the silence/consent must however grant that all citizens are well informed about the organ donation and asked to know their will . Do you agree with that?
Manni - According to our proposal, the sole silence/consent must turn into an informed silence/consent. It must be underlined that in some countries (for example France) where law foresees the tacit consent, relatives are demanded anyhow for the authorisation to drawing in order to not disregard the will of relatives. On the contrary, in the bill of law introduced by the Social Affairs Committee, deceased’s relatives are deprived of any possibility of objection in all that cases the opinion was expressed during life. Else I deem the problem of consent to donation must be faced, more than over the juridical plan, on the cultural one, improving health education programs ad<d>dressed to the whole population and aimed to favour that solidarity feeling, which is at the basis of donation. .
L. M. - So the ‘lack of consent’ is a problem to be resolved by involving the people responsible moral sense.
Manni - The donation of an organ is an act of love toward a suffering person. The drawing carried out against the relatives’ will, when the deceased’s will is unknown features behaviour models which we are not prepared to assume; that’s the reason because we prefer the explicit consent or, at least, the informed silence/consent. It must evidently concern a clear information, given by the means of a completion form, addressed to all citizens and that must report evidently that the lack of answer means a consent. A silence/consent not enough informed, on the contrary, must not set aside the relatives’ will
L. M. - About the debate concerning silence/consent, we will attend a strong contra<d>position of your eminent colleagues’ conviction and part of the public opinion, and it will not avail, probably, the cause of donation.
Manni - It is my opinion, too. But there are other aspects I want you to pay attention to and that can widely involve physicians if it were approved the bill concerning silence/consent:
- Are we sure we could limit the relatives’ claims in the case they contrast anyhow the donation ?
- Does who propose the silence/consent law take into account some cultural situations existing in our country?
- If a parent would ask us - even if with motivations we do not share - to ‘leave alone’ his own son, at least after death, are we sure we will be available not to listen to him?
L. M. - These obstacles are difficult to remove.
Manni - And the first one is exactly the cultural one.
- We must reassume the ethic values that pretend the respect for the corpse.
- We must learn to give back its meaning to the moment of death.
- We must learn to assume a correct relationship with the relatives, recovering the Christian pity sense or the human understanding avoiding a distant professional behaviour that, most times, hides inaptitude to manager the death moment
In other words, we must promote and obtain the consent to donation and not overcome the obstacle imposing the drawing out of the feeling of donation.
L. M. - Logistic problems related to adhesion to transplant are probably due to excessive shattering of data which should be computerised.
Manni - I think that organisation of such an information system will find great difficulties and surely it must not be thought to employ the silence/consent until the citizen is not allowed to express or not express a clearly conscious opinion and until physicians are allowed to access this information in a simple and immediate way.
In this article we have analysed only some aspects of organs transplants and we will treat again the subject in order to pull down - by means of moral, cultural and philosophic weapons - the obstacles opposing to a quick increase, in Italy, of organs donation. Congresses report that Italy is the country with the lowest rate of transplants. Are Italians bad? Are they insensible? Are they egoist? We do not think so. We think that this situation is mainly due to a lacking information. Every day the public opinion is bombed with bad news on Italian health care, how can a family authorise an organ donation? These unexpressed doubts are, in our opinion, the real enemy to fight.

Leadership Medica^®

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