Organ donation: facts and fiction

For many of those who live with irreversible organ damage, an organ transplant represents their only alternative for survival or achieving a better standard of living. An organ transplant consists in exchanging a non-functioning organ or tissue for a healthy one removed from a donor.

Unfortunately, there is a severe shortage of organs ready for transplant. Years can pass before a patient receives the organ they so direly need and many die without ever receiving one. 2015 estimates show that approximately only 10% of the global need for organ transplants is currently being met3.

Since many necessary organs and tissues cannot be donated while the donor is alive, the only way to increase organ transplants is for more people to donate their organs after death. Therefore, this article focuses on post-mortem organ donation.

The post-mortem donation rate differs among countries due to religious, cultural, and legal differences as well as health systems. Using official data from 2015, the following map shows where countries stand relative to number of post-mortem donors for every million residents (ppm). As you can see, generally speaking the donation rate is not dependent on each country's economic development or geographic zone. Ever since the 90s, Spain has been the world leader in organ donation, even though it is not the most economically developed country on the list.

Data from the Global Observatory on Donation and Transplantation1. These figures represent the number of donors for every million residents (ppm). In 2015, 119,873 transplants were performed worldwide, a 1.65% increase from the previous year; these transplants were made possible thanks to 27,397 donors3.

How does organ donation work?

In order to declare a person medically deceased, there must be cardiorespiratory arrest or brain death (i.e. the complete and irreversible loss of brain function); the latter allows for the donation of more organs, as shown in the following diagram.

Viable tissues and organs for donation from a person declared brain dead or after cardiorespiratory arrest. Cardiorespiratory arrest can be caused by a heart attack, deep hypothermia, shock, head trauma, electrocution, severe hemorrhage or dehydration while brain death is due to head trauma or stroke. Many more donations are due to brain death than cardiorespiratory arrest. For example, 2015 official data shows that Spain had 6.8 donations per million residents (ppm) due to cardiorespiratory arrest and 33.4 due to brain death; in Malaysia - which is last amongst countries who keep records - there were no donations due to cardiorespiratory arrest and 1 ppm due to brain death that year1.

In both instances, death must occur in a hospital equipped with the necessary equipment to preserve the organs (maintain hypothermia and supply potassium) and perform the necessary assessments so the medical team can rule whether the deceased can be a donor or not. There is a time limit on organ preservation before transplant which varies across organs and tissues (from hours to days).

In Spain, there are three types of criteria which dictate the process of donating and transplanting an organ or tissue: clinical, equity and territory. The main clinical criteria are donor-recipient compatibility and the severity of the recipient's condition. There also exist certain donor contraindications such as the existence of HIV and current or recent risk factors of HIV or neoplasia (cancer). The equity criterion refers to the right of all people to access the same transplant opportunities. Finally, the territory criterion aims to reduce the timeframe between organ extraction and transplant and states that the recipient must be in the same geographical area as the donor2.

Possible organ donors are advised to have a signed donor card to as a testament to their wishes. However, these have no legal standing and when the time comes, the family must authorize the organ extraction via a legal consent. It is important for potential organ donors to discuss their wishes with family members because if the family does not agree with the donor's decision, they can block the donation even with a valid donor card.

Why wouldn't people donate their organs?

Different studies around the world have identified a variety of reasons why people are not willing to become donors. The main reasons reported are found below, although some might be more prevalent in some cultures than in others.

  1. While no religion formally forbids donation, the belief that some religions disapprove of organ donations4, still prevails5. Therefore, some religious people might be reluctant to donate due to a misinterpretation of their particular tenets. On the other hand, some religions are divided and have different schools of thoughts that disagree on organ donation.

  2. The belief that age is a limiting factor in donation6. Despite how widespread this idea is, organ donation is possible and useful regardless of age (although not for all organs). In fact, in Spain more than 50% of donors in 2014 were older adults7.

  3. The idea that donation involves mutilation or disfigurement and the body must remain intact after death8,9. There are certain rituals that require an intact body after death. In fact, recent studies carried out amongst Chinese youth10 and North American natives 11 have found that many desire to donate organs but are held back due to traditional beliefs that highlight the importance of maintaining an intact body. It is worth mentioning that the removal of organs for transplantation is performed with aesthetic surgical incisions and the body is returned to the family in a suitable state for any ritual to be performed.

  4. A lack of trust in the management of the organ donation process 6. This distrust may be due to medical negligence or corruption. There are even people who fear donating because of organ trafficking, which is an extreme occurrence even in a corrupt environment12. The purpose of this article is not to get bogged down in discussing organ trafficking but it is worth mentioning that this is a separate issue than a person deciding whether they want to be a donor or not.

  5. The belief that an extraction takes place before death due to the fact that brain death does not represent a true death13. Generally, people tend to confuse brain death with a vegetative state or coma (a person in a coma has severe brain damage but still shows signs of neurological activity, while a diagnosis of brain death means there is no neurological activity at all).

Illustration by Klifton Kleinmann.

When wishes and facts do not match

Different studies carried out in various parts of the world have asked people if they are willing to become organ donors upon their death and the majority answer yes, they are willing9,14. However, just because someone agrees to become an organ donor doesn't necessarily imply that the donation will take place, as there are circumstances that can impede it, such as:

a) a person may not die in a hospital with the requisite personnel or infrastructure to carry out the donation process; b) the donor may have medical reasons that prevent donating, as described above; and c) the family does not authorize the donation which might be due to a lack of communication from the patient to their family. The family might not be ready for this type of decision so soon after death, the ideal moment for organ viability, or the family might not agree with organ donation even if the deceased wished to donate.

Another factor that might explain the apparent contradiction in the high percentage of people willing to donate versus the lack of organs donated is the nature of a formal survey where it is common for the respondent to give socially "accepted" responses. In this case, organ donation is seen as a charitable act and a positive response is considered the right thing to answer.

Final thoughts

Prejudice, lack of knowledge, and distrust are all barriers that hinder organ donation. It may take years to tackle these problems but it is time to begin. There are successful cases such as Spain, where the government has carried out efforts to increase the rate of organ donation and transplants with encouraging results. From 1989 to 2015 the rate of donation in this country increased from 14.3 to 40.2 ppm.

Many countries, such as Portugal, Croatia, Belgium, Italy, France and some Latin American countries, have been inspired by Spain's success and managed to increase their donation rates7.

Part of the success of the Spanish model lies in making the State a part of the solution and having them manage organ donation and transplants. These were previously managed by private or volunteer organizations but now the Ministry of Health has taken over administering a system that benefits the population as a whole. It is worth pointing out that the work of multidisciplinary teams is indispensable since all parts of the donation and transplant process have medical, social, psychological, ethical and legal implications.

The National Transplant Organization in Spain (ONT) has set out various recommendations for hospital coordination teams in regards to the ideal profile of a hospital Transplant Coordinator, how to improve the effectiveness of patient referrals and patient care in intensive care units, and how to improve the process of obtaining donation consent15. These include training the Transplant Coordinator in identifying donors, contacting and providing adequate guidance for the family, and making sure that the donation is carried out. It is clear that the Coordinator is key to the strength and success of the Spanish system.


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  2. Organización Nacional de Trasplantes. Trasplantes. s/f. In Accessed 28 Feb 2017. 

  3. El mundo. España, líder mundial en trasplantes por 24° año consecutivo. 2016. In Accessed 28 Feb 2017. 

  4. Breitkopf, CR. Attitudes, beliefs and behaviors surrounding organ donation among Hispanic women. Curr Opin Organ Tran. 2009;14:191-195. 

  5. Randhawa G, Neuberger J. Role of religion in organ donation- development of the United Kingdom faith and organ donation action plan. Transplant P. 2016;48:689-694. 

  6. Gómez-Rázuri K, Ballena-López J, León-Jiménez F. Mitos sobre la donación de órganos en personal de salud, potenciales receptores y familiares de potenciales donantes de un hospital peruano: estudio cualitativo. Rev Per Med Exp Salud Publica. 2016;33:83-91. 

  7. Sánchez, N. Por qué España es líder mundial de trasplantes. BBC Mundo. 2015. In world Accessed 12 Oct 2016 

  8. Bustamante UM, Villareal NP. Motivación a la donación de órganos en Chile. Panorama Socioeconómico. 2008;26:86-97. 

  9. Wong LP. Knowledge, attitudes, practices and behaviors regarding deceased organ donation and transplantation in Malaysia’s multi- ethnic society: a baseline study. Clin Transplant. 2011;25:E22-E31. 

  10. Chen JX, Zhang TM, Lim FL, Wu HC, Lei TF, Yeong PK, Xia SJ. Current knowledge and attitudes about organ donation and transplantation among Chinese university students. Transplant P. 2006;38:2761-2765. 

  11. Jernigan M, Fahrenwald N, Harris R, Tsosie U, Baker LO, Buchwald D. Knowledge, beliefs, and behaviors regarding organ and tissue donation in selected tribal college communities. J Commun Health. 2013;38:734-740. 

  12. Wilczek-Rużyczka E, Milaniak I, Przybyłowski P, Wierzbicki K, Sadowski J. Influence of empathy, beliefs, attitudes, and demographic variables on willingness to donate organs. Transplant P. 2014;46:2505-2508. 

  13. Güden E, Çetinkaya F, Naçar M. Attitudes and behaviors regarding organ donation: a study on officials of religion in Turkey. J Relig Health. 2013;52:439-449. 

  14. Lozano RG, Liberman SS, Ito RM, Andrade PP. Conocimientos y creencias acerca de la donación de órganos y tejidos en la Ciudad de México. Psicología y Salud. 2005;1:77-83. 

  15. Organización Nacional de Trasplantes. Guía de Buenas prácticas en el proceso de la Donación de Órganos. 2012. In Accessed 5 Mar 2017. 

  16. Image Design: Omar Efrén Espinosa Morett
    bone, cornea, ligament, blood vessel, cartilage, heart, liver, lung, kidneys