Cut the “Gordian Knot”

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We have learned from the article by Nashan et al,1 that Germany has one of the most complex systems of organ donation and transplantation. The authors describe the situation of the organization of both organ donation and transplantation in Germany. They explain the reduction of donors from 16 donors PMP in 2010 to 10 donors PMP in 2014 due to a number of scandals in the allocation of organs in recent years. However, the article does not address whether the complexity of the system is the reason for the low number of donors PMP and does provide any solutions to fixing the situation.
The article consisley reports 3 scandals which have stunned the transplant community. However, the article misses to report the first scandal in the allocation of a liver at a Bavarian University hospital years ago. Everyone involved in the system realized this case was without any kind of consequences for the people involved. The authorities looked at the case and did nothing. Violation of allocation rules was no criminal offence at that time. This was discussed significantly within the community. Knowing that nothing would happen, doctors might have been encouraged to report false laboratory values or manipulate blood samples to get an early access to allocation of organs for patients.
Background is certainly a bit more complex. Lack of validation of laboratory results and probability control the allocation of organs combined with an extremely complicated system of chaired, hidden and intransparent communications and responsibilities. However, this is not an excuse for scandals. There is an ethical and moral obligation for doctors to behave adequate in a situation of extreme scarcity of organs.
Another reason for the decline in donor numbers starting in 2010 in Germany is the change of the German Transplant Act. Tissue donation was included into the law.2 Even legal experts among the doctors on an intensive care unit (ICU) did not know what they were allowed to do and what was forbidden. Tissue, to some extent, was defined as a medical compound allowing the sellers of tissue to make profit. The law states the opposite, however, it is obvious that with the transfer of tissue to another country for tissue preparation and storage doors being wide open, there may be some hidden commercialism. Doctors on ICU did not want that. They were educated that donation is an act of charity without compensation. Now, a contract of each hospital with 1 or more tissue sellers was necessary to make tissue donation happen. Doctors did not know whether the same was true for organ donation.
The article describes quite well the system of contracts and responsibilities of organ donation, however, the system, in reality, is much more complicated when taking into account a background of chaired responsibilities between National and Regional Authorities as well as Universities, Insurance Companies, Hospital Associations, and Board of Medical doctors. Moreover, there are different organizations for Tissue and Organ Donation and for allocation partly on a regional or local level and on a national level.
The authors are happy with the introduction of a mandatory data documentation system. Is not such a system state of the art since more than 20 years in most countries with similar medical standard? And why does the registry not cover the whole process from imminent death on ICU to an actual donor and transplantation? Medical donor data can influence transplant results.
One can assume that nobody is happy with the situation of donation in Germany and the low donor numbers.
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