munich

The number of organ donors in Germany may soon increase following a decision last week by the Bundestag, the lower house of the federal parliament, to approve a controversial bill regulating organ transplants.

The bill, which has had a five-year struggle, is expected to be approved by the upper house, the Bundesrat, in the next few weeks. It gives legal status to a practice that has in fact been carried out in Germany for many years.

The long debate about the law is due to Germany's extreme sensitivity on any bioethical issue, a reaction to the country's Nazi past. Opponents fear that organs could be removed from people who are still alive.

The German Chamber of Physicians first drew up a protocol for organ transplants in 1982. That, in line with other European countries, defined death as the moment at which the brain ceases to function.

But efforts to formalize this in law, begun in the early 1990s, led to an emotional debate in which critics from all political parties argued that death should be defined as the moment at which the heart also stops beating. As a result of the controversy, the number of organ donors fell by 10 per cent.

The new law does little more than confirm present organ transplantation practice, which is slightly more conservative than elsewhere in Europe. Organs may be removed from a donor at the moment of total brain death, rather than after brain-stem death, which many countries accept as the first irreversible event of death.

Brain death must be confirmed by two independent doctors. Previous ‘informed consent’ from the donor, through a standard donor-card system, or through verbal or written consent in hospital, is required. In its absence, a relative or partner may give consent, but may not contradict any known wishes of the donor. Only close relatives of a patient, or a spouse, may donate kidneys as live donors. The sale of organs is banned.

Organ allocation will still be the task of Eurotransplant, the Netherlands-based office, which uses a single database to allocate organs from its five member countries — Germany, the Netherlands, Austria, Belgium and Luxembourg.

Bernard Cohen, director of Eurotransplant, which allocates 5,000 organs a year but which has a waiting list of 15,000, says the greater public confidence resulting from the new law might increase organ donations slightly, or at least lower the refusal rate.

But he says he would not expect a large increase in the number of donors, because the requirement for informed consent has a restricting effect. The two members of Eurotransplant with the lowest per capita rate of organ donation are the Netherlands and Germany, which both require informed consent, he says.

According to Ludger Honnefelder, director of the Bonn Institute for Science and Ethics, the law has been carefully drafted to avoid directly equating death with brain death to side-step the problem of what ‘alive’ really means.

Reflecting continued memory of Nazi practices, the proposed law states in two separate paragraphs that organs may not be removed until death is observed and that organs may not be removed before total brain death is registered.