Invited commentary – Sanctity and organ donation’s societal value in an opt-out country: The Austrian experience

Nonbeating heart organ donation was reintroduced in most developed nations in the early 1990s to expand the potential donor pool to include futile care withdrawals for patients with irreversible brain injury but persisting brain stem function and unsuccessful in- and out-of-hospital cardiac arrest resuscitations. The favored form of donation after cardiac death (DCD) is controlled withdrawal of intensive care until the onset of circulatory arrest. In this situation, the transplant team’s awareness of organ warm ischemia vulnerability and their obligation not to deliberately transplant a severely damaged organ are pitted against the shortest ethically sustainable “no-touch” time between circulatory arrest and the start of organ perfusion.
This discomforting dilemma is a poor exit strategy for the imbalance of organ supply and demand. The Belgian experience with DCD kidney retrieval showed that it did not substantially increase the total donor pool and, rather, resulted in a proportional shift from brain-dead to DCD donors by not allowing a potential donor to progress to brain-death determining criteria.1

Different European approaches

Opt-in and opt-out are diametric ethically valid concepts within the Eurotransplant region, which encompasses Belgium, the Netherlands, Luxembourg, Germany, Austria, Slovenia, and Croatia. Austria and Belgium have implemented an opt-out approach as national endorsements of transplantation’s societal value which still allow individuals to decline becoming a donor. This system is sometimes portrayed as encouraging the transplant community to prey unethically upon severely brain-damaged trauma victims; however, the reality is far different. When a patient is declared brain-dead, the decision whether organ donation will be considered is left to the patient’s relatives, and their choice is always respected. Although Austrian law would allow organ retrieval without involvement of the donor’s relatives, the negative publicity of even a single case where the family’s wishes were ignored would far outweigh the benefit of the retrieved organs. Organ procurement organizations in opt-in countries probe a potential donor’s thoughts about donation by asking the relatives: this method is more similar than different from the Austrian opt-out system.

The Eurotransplant report for 2010 lists 22.6 donors per million inhabitants in Austria compared with only 15.4 donors per million in Germany, where the culture and health care system are similar to ours.2 It is important to recognize that this huge difference in organ availability also affects the quality of the available organs. Our public perception of organ donation as a natural part of Austrian citizenship, rather than as private gifts to anonymous persons, has a positive influence on family members’ decisions and has a substantial effect on our higher donation rates. In an opt-in system, healthy persons harbor a concept of their bodily integrity being violated, without its balancing societal value, and simply turn their minds away from this unsavory issue.

Organs from brain-dead patients

In almost all societies, the moment of death and the treatment of the earthly remains are handled with dignity and silence. The loss of central physiologic regulation as brain stem function ceases goes unnoticed and does not break the outward silence. In reality, however, a violent cytokine storm is being unleashed that causes profound hemodynamic instability and, if untreated, eventual cardiac arrest. Fortunately, this is amenable to pharmacologic intervention. Many centers treat this expectantly with a preset cocktail of steroids, insulin, and thyroid hormone, as experimental studies have demonstrated tremendous upregulation of pro-inflammatory cytokines in deceased donors in comparison with living donors. These cytokines aggravate the organ’s subsequent ischemia-reperfusion injury, which can be successfully mitigated by administering steroids.3,4 We have routinely administered 1g of methylprednisolone prior to cold organ perfusion during the retrieval procedure, and have now changed donor preconditioning to repeated steroid pulses from the time death is declared until organ retrieval.

Hypothermic machine perfusion rather than static cold storage was once empiric, but now has a firm scientific basis for kidneys.5 In Austria, our compact geography usually equates to brief cold ischemia times, so static cold storage has been the standard. We now use hypothermic machine perfusion for anticipated longer cold ischemia times when the donor hospital and transplant center are unusually far apart and for grafts that were subjected to prolonged warm ischemia, typically in DCD situations, improving both early organ function and prolonged survival.

Our transplant professionals deal every day with the tension between preserving the dignity and sanctity of the deceased donor and the life-extending value of each successfully transplanted organ. In that process, we are always mindful of our obligation to use maximum diligence and every available tool to obtain the best possible organ quality and function in the recipient.


  1. Van Gelder F, Delbouille MH, Vandervennet M, Van Beeumen G, Van Deynse D, Angenon E, Amerijkx B, Donckier V. An 11-year overview of the Belgian donor and transplant statistics based on a consecutive yearly data follow-up and comparing two periods: 1997 to 2005 versus 2006 to 2007. Transplant Proc. 2009;41:569-571.
  2. Eurotransplant 2010 Annual report. Available at: Accessed September 7, 2011.
  3. Weiss S, Kotsch K, Francuski M, Reutzel-Selke A, Mantouvalou L, Klemz R, Kuecuek O, Jonas S, Wesslau C, Ulrich F, Pascher A, Volk HD, Tullius SG, Neuhaus P, Pratschke J. Brain death activates donor organs and is associated with a worse I/R injury after liver transplantation. Am J Transplant. 2007;7:1584-1593.
  4. Kotsch K, Ulrich F, Reutzel-Selke A, Pascher A, Faber W, Warnick P, Hoffman S, Francuski M, Kunert C, Kuecuek O, Schumacher G, Wesslau C, Lun A, Kohler S, Weiss S, Tullius SG, Neuhaus P, Pratschke J. Methylprednisolone therapy in deceased donors reduces inflammation in the donor liver and improves outcome after liver transplantation: A prospective randomized controlled trial. Ann Surg. 2008;248(6):1042-1050.
  5. Moers C, Smits JM, Maathuis MH, Treckmann J, van Gelder F, Napieralski BP, van Kasterop-Kutz M, van der Heide JJ, Squifflet JP, van Heurn E, Kirste GR, Rahmel A, Leuvenink HG, Paul A, Pirenne J, Ploeg RJ. Machine perfusion or cold storage in deceased-donor kidney transplantation. N Engl J Med. 2009;360(1):7-19.

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