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In order to increase the organ donation rate, Health Minister Lauterbach considers the contradiction solution to be “no alternative”. Statistically, there is no evidence that it actually increases donations.
According to the German Organ Transplantation Foundation (DSO), more than 8,000 people in Germany are currently waiting for a donor organ. The organ donation register will not change this much, said Federal Health Minister Karl Lauterbach when presenting the new portal. “I believe that we cannot solve this problem without the contradictory solution,” said Lauterbach. There is “no alternative” to the contradiction solution.
The North Rhine-Westphalian Health Minister Karl-Josef Laumann is also calling for the introduction of the contradiction solution. He announced that he would submit a legislative proposal to the Federal Council in order to set the parliamentary procedure in motion. The federal states had already called on the federal government in December last year to ensure that the objection solution was included in the Transplantation Act.
What is the Contradiction solution?
The contradiction solution means that people are generally considered organ donors unless they have expressly objected to this. At the moment it is basically the other way around in Germany: an organ can only be removed from a person with their express consent – even after their death. Critics complain that many potential donors were lost as a result of this so-called decision solution and point to Spain, where the contradiction solution applies. With 48.9 donors per million inhabitants, the donation rate there last year was four times as high as in Germany (11.4).
No statistically significant difference
But the fact that the change from the decision-making solution to the objection solution alone causes a sharp increase in actual organ donations is not sustainable from a statistical perspective, says Katharina Schüller, board member of the German Statistical Society. “The contradiction solution increases the number of potential organ donors, but not the number of actual organ donations.”
So has one Study from 2019 compared organ donation and transplantation rates between 17 OECD countries with opt-out rule and 18 OECD countries with consent rule. Accordingly, there was no statistically significant difference in the proportion of actual organ donors. “While there are more donations from deceased people overall in the countries with an objection solution, the proportion of donations from living people is lower,” says Schüller.
This is about living organ donations in most cases around kidneys, 27 percent of donated or transplanted kidneys in Germany in 2022 came from living people. For livers, the proportion was around five percent. “The liver and kidneys together make up more than 80 percent of all transplanted organs, the kidneys alone account for 60 percent,” says Schüller. “This means that if living organ donations drop significantly, many more suitable donors have to be found who can donate kidneys after their death so that this balances out again.”
Other factors are crucial
Also one Study by the Max Planck Institute for Human Development points in a similar direction. The researchers analyzed five countries that had switched from a consent rule to an opt-out solution (Argentina, Chile, Sweden, Uruguay and Wales). The change therefore led to a non-significant increase in the actual organ donation rates.
Other studies attest to the initial positive signs of the contradiction solution with regard to the number of resulting organ donors, for example for Great Britain and the Netherlands. However, there too pointed outthat the differences in organ donation rates cannot be explained by the contradiction solution alone. That’s what it says in one Scottish Department of Health studythat there is encouraging evidence that opt-out as part of a package of measures could lead to an increase in organ donations and transplantation.
And also in Spain According to a study the objection resolution is not the decisive factor for the high donation rate. “A proactive donor identification program carried out by well-trained transplant coordinators, the introduction of systematic death audits in the hospitals, coupled with a positive social atmosphere, appropriate management of relations with the mass media and appropriate economic compensation for the hospitals were responsible for this success” , is the researchers’ conclusion.
In addition, in Spain the objection rule is not strictly interpreted. Even if there is no objection, relatives are usually asked whether they agree to the removal of the organs. However, while in Germany, according to the DSO, relatives decide against it in 74 percent of cases when the wishes of the deceased are unknown, in Spain relatives decide against it in 85 percent of cases.
“Organ donation numbers are always multicausal”
“Countries that have the contradiction solution also have structural and/or social structures that differ from Germany and sometimes have different medical requirements for organ donation,” says a spokeswoman for the Federal Center for Health Education (BZgA). “Organ donation numbers are always multi-causal. How the introduction of an objection solution would affect organ donation numbers in Germany cannot ultimately be predicted.”
Axel Rahmel, medical director at the DSO, also agrees. “To believe that you can introduce the contradiction solution and then the number of donors will explode is certainly not enough,” he says. “But one can hope that the introduction of a contradiction solution will trigger a cultural change.” Because high donation rates are primarily a question of attitude – in Spain there is a completely different mentality when it comes to organ donations.
In Germany we have one BZgA survey According to 84 percent, they have a positive attitude towards organ and tissue donation. 40 percent have an organ donor card, of which more than 80 percent agree to organ donation. In practice, however, the organ donor card is only found in around 15 percent of possible organ donors, says Rahmel.
Even if organ donations were generally viewed positively, many people would keep putting off recording their decision in the organ donor card or in the new organ donation register. The organ donation rate is highest among people whose wishes have been stated in writing.
“Contradiction resolution as a pioneer”
In his opinion, the political framework conditions in Germany have improved greatly in recent years, so that the differences in this respect to Spain are no longer serious. Although there are still considerable differences in implementation between individual clinics in Germany, overall, identified success factors from Spain, such as transplant officers at hospitals, have also been introduced in Germany. In addition, the clinics now receive significantly more money to cover the costs of organ donation.
“It is important to understand that there is no one switch to increase donation rates,” says Rahmel. From his point of view, one building block is that in Germany organs can only be removed if there is an irreversible failure of all brain functions (brain death). In many other European countries, organ donations after cardiovascular death are also permitted. Since significantly more patients in intensive care units are dying of cardiovascular failure, this could increase the donation rate. In some countries, donations after cardiovascular death account for up to 50 percent of all organ donations.
According to Rahmel, another factor could be: Machine perfusion which can reduce damage to the donor organ and thereby lead to better results after transplants.
Overall, however, Rahmel believes that a cultural change when it comes to organ donation is the most important component – and therefore also supports the contradiction solution. “My firm belief is that the contradiction solution, if it is supported by politics and society, can help as a pioneer and supporter of cultural change.”