Search

Background: The important shortage of organ donors is still a fundamental public health problem in France. Improving the knowledge and attitudes of health care professionals could help to promote organ donation. The aim of this survey was to evaluate the level of knowledge of medical students and their gaps about organ donation prior to any medical course., Materials and Methods: A survey was conducted among 571 first-year medical students at a medical faculty in Lyon. Their knowledge, attitudes, personal views, and perceptions toward organ donation and transplantation were investigated prior to any medical course. A 31-item anonymous questionnaire including queries about personal views of organ donation, factual knowledge, and awareness of French law was distributed to the students., Results: To "willingness to donate a kidney to a relative," 97.7% of respondents consented, 0.9% objected, and 1.4% did not answer. Their attitudes toward cadaveric organ donation were different: 81.1% agreed, 13.5% refused, and 5.4% did not answer. Regarding their knowledge about which organs could be transplanted, 95% of the respondents were aware of the possibility to transplant a face and 14% thought that xenotransplantation was performed nowadays., Conclusions: First-year medical students have a good knowledge level regarding the organ donation and transplantation system prior to their medical course. Some gaps remain which could be improved. The results of this study supported a greater emphasis on providing information regarding transplantation in medical schools to improve the knowledge of future health care professionals. A follow-up survey of the participants at the end of their medical course will be interesting to assess the progress of their attitudes.

Despite considerable efforts to promote organ donation and increase the amount of organ retrieval, demand for grafts is increasing and remains much higher then availability. This short supply is noticeable for all organ transplantation whether for heart, lungs, liver or pancreas but mainly for kidneys. The objective of graft allocation and attribution rules is to insure an allocation as fair as possible, to find the best recipient, to take into account the emergency of the need for grafting or the access difficulty for certain patients, and to seek optimal graft usage. These rules are based on the setting up of priority categories for patients whose lives are threatened on a very short-term basis or for those having difficult access to transplantation. This implies the issue of seeking the balance between an allocation as fair as possible and technical constraints associated with organ retrieval, transportation and graft quality preservation.

Organ transplantation, the gold standard therapy for end-stage organ failures, has become a victim of its success. Indeed, the number of patients listed for transplantation has been increasing faster than that of available grafts. The number of brain-dead donors, the primary source of organ donation in France, is limited, but this figure is becoming more and more comprehensive, thanks to the work carried out by hospital transplant coordination units. The room for manoeuvre is limited: to increase the transplantation rate in this respect, the only possibility would be to reduce the rate of donation refusals, which still accounts for more than 30 percent of all identified brain deaths. It is thus more and more critical to resort to other donor sources: living donors and non-heart-beating donors. Each donor source is associated with different constraints and limitations in terms of available resources, removal organization and ethics. For cadaver donors, the key ethical issues are the acceptance of presumed consent, the difficulty in diagnosing the exact time of death and the notion of body integrity. For living donors, the ethical issues are related to the quality of the consent and the assessment of the risk undertaken by the donor, when no personal benefit is expected.

Objectives: Renewed interest in living donor transplantation in France led us to survey French transplanters to determine their opinion concerning this technique and the ethical issues involved. Their concerns and suggestions about current legislation were examined., Methods: An anonymous questionnaire was sent to physicians working in the different kidney, liver and lung transplantation units operating in France., Results: French transplanters expressed a wide range of opinions concerning living donor transplantation and possible broadening of the current regulations. Sixty-two percent of the transplanters had a positive opinion on living donor transplantation compared with 22% who expressed a negative opinion. For 23% of the transplanters, it is preferable to transplant with a living donor graft compared with 64% who preferred cadaveric grafts. A living donor transplantation program is under study in 65% of the units. There is some debate concerning the legitimate nature of the emergency donation situation for spouses. About one-half of the transplanters were in favor of controlled extension of potential donors to second degree relatives and to the recipient's spouse or living partner., Conclusion: There is no real consensus among French transplanters concerning living donor transplantation due to the complexity of the ethical issues involved. Their opinions reflect medical tradition with background marked by autonomy and paternalism. This leads to a wide range of opinions concerning current bioethics legislation and the usefulness of more flexible laws.

Thousands of patients receive human tissue grafts every year. Developments in cell and tissue engineering have also increased considerably the number of available products of human origin. France has very strict regulations, in part stimulated by problems of public health and ethics that have emerged in recent years and also in part as a result of a report by the 'Inspection Générale des Affaires Sociales' on the removal and grafting of human tissues in May 1993. These have resulted in two laws on bio-ethics being passed, in July 1994, that are the basis of current legislation and represent the first steps in differentiating between organs and tissues or cells. Henceforth, the French legal framework covering tissues and cells of human origin has been increased to include a large number of legislative texts and regulations. The fundamental ethical principles that are consent, free donation, anonymity, no publicity and respect for public health have become a major ethical imperative that applies to all products originating from the human body including tissue and cells. In addition, specific provisions have been made covering: removal (conditions for removal and system for authorization); conservation, transformation, distribution, packaging, import and export of tissues and cells; and tissue and cell grafts. Finally, penal and administrative sanctions have been foreseen where there is non-compliance with these regulations.

Organ transplantation more than a scientific fact is now a social fact. Since the first organ transplantations in France, forty years ago, medicine demonstrated its ability to perform the operation and to obtain (what was more difficult) the tolerance of the graft but medicine so far remains unable to give the material: organs. These organs are given by the donor's relatives when the kidney is concerned and when it is a donation from a living person. But such donation remain strictly limited in our country (less than 5 p. cent of the kidney transplantations) due to the risk of moral pressure and commercialization. More often and for the other organs (liver, heart, lung) the donation is obtained after death, a special and dramatic death: the brain death. The nowadays spectacular results of organ transplantation 70 to 80 p. cent survival rate at 10 years with a complete rehabilitation gave a considerable increase on the demand. Unfortunately organ transplantation is the victim of its success, the number of donor's organ being insufficient to satisfy the needs. So in December 1990, 6,055 patients were on the waiting list and only 3,772 (56 p. cent) were transplanted. In December 1991, 6,334 patients were on the waiting list and may be only 4,000 could be transplanted. So the difference between the needs and the possibilities is increasing each year with for consequences, the death of 10 p. cent of the waiting patients and, for those who could be transplanted, a considerable increase in the waiting period responsible for slow deterioration of their status and less chances of success.(ABSTRACT TRUNCATED AT 250 WORDS)

With regard to medicolegal problems, semantics are of considerable importance: indeed, depending on whether we call grafting or transplantation of an organ the operation that takes a living organ to reimplant it in the same person or the operation that takes a living organ from a donor to reimplant it in a recipient, the issues raised are completely different. The transposition of a dental organ does not raise any particular problems apart from the technical requirements to be met; there is no special problem of prevention or ethics to be taken into consideration. The problem is a completely different one when it means taking a living organ from a living or dead subject and reimplanting it in another subject. All measures decreed from the point of view of law and regulations that are dictated by considerations of prevention and ethics must then be strictly applied.

France was in tenth position in the field of kidney transplant in Europe in 1982, and is currently at the top of western countries for all transplant activities (per million inhabitants). Cyclosporin A was certainly a favourable factor for liver, heart and lung transplantations. Nevertheless the transplantation activity in France is twice than of Great Britain or Germany for those transplant specialties and the percentage of renal transplantations from living related donors is very low in France: 2.7% versus 30% in others. These data depend on a specific French organization which involves: a presume consent law; an emergency policy with mobile medical rescue teams and polyvalent intensive care units; a three level France Transplant organization: national, regional and local; hospital physicians as regional transplant coordinators who are independent from transplant teams; waiting list telematic computer system which promotes priorities: high emergencies, high-sensitized and pediatric recipients.