Organ donation and ethics: lessons from four European countries
Sometimes a single care team fulfills multiple roles: determining that further treatment is no longer useful, confirming impending death, and discussing organ donation with the family. Can this lead to a conflict of interest?
An international study in four countries shows that transparency, clarity of roles, and empathetic communication are crucial everywhere to maintain the trust of families.
Publication
Mapping and Handling Conflicts of Interest in Deceased Organ Donation: How to Handle Ethical Issues and Build Trust in the Healthcare Team
Authors: David Shaw, Nichon Esther Jansen, Alicia Pérez-Blanco, Anne Floden, Rutger Jan Ploeg, Jessie Cooper, Tineke Jentina Wind, Dale Gardiner – on behalf of the ELPAT Deceased Donation Working Group.
Transplant International, October 2025
Ethical dilemmas
In the case of a hopeless prognosis in the ICU or ED, two sensitive topics converge: the care for a dying patient and raising the topic of organ donation with the family. Healthcare professionals must constantly balance optimal patient care, clear communication with the family, and carefully facilitating donation.
Important ethical questions:
- Who conducts the donation conversation with the family?
- May this be the same doctor, or should another professional do this?
- How do you prevent families from doubting the doctor's intentions?
European research
Research in Sweden, the Netherlands, the United Kingdom, and Spain shows that there is no universal approach. Each country makes its own considerations based on culture, legislation, and organization. Central to this is the choice between continuity of care or a clear separation of roles. In practice, many hybrid forms exist.
How is this arranged in the four European countries?
Sweden
- The donation conversation is usually conducted by the intensivist and ICU nurse. Sometimes a specialized donation nurse is involved.
- The perception of intensivists is that it would be 'betrayal' to transfer this conversation to someone else because of the existing bond of trust between the intensivist and the family.
Netherlands
- Intensivist or attending physician usually conducts the bad news and donation conversation together with an ICU nurse, after consulting the Donor Register.
- There could be a potential conflict of interest, because the attending physician is also the one who informs the family about the patient's impending death and conducts the conversation prior to donation. Nevertheless, physicians see it as their duty to discuss donation with the family.
United Kingdom
- Stopping treatment requires the consent of two senior physicians.
- Donation conversations are conducted by a multidisciplinary team.
- A Specialist Nurse Organ Donation (SNOD) is involved. Physicians experience this as a relief: they can focus on decision-making and care. Families appreciate the specialized expertise and the carefulness of the conversation.
Spain
- Multidisciplinary team decides on termination of treatment. The donor coordinator is not involved in this decision.
- The Spanish model revolves around proactive, well-trained coordinators who conduct ALL donation conversations.
- The separation of roles is clear and embedded in both legislation and culture.
- Donation is only discussed after the family agrees to palliative care.
5 tips: What can we learn from each other?
International research shows that there is no universal working method: each country chooses its own balance between continuity of care and separation of roles. The most important lessons are:
- Be transparent about roles and timing
Clarity on who is involved and when strengthens the trust of families and professionals. - Evaluate the distribution of roles in the procedure
Clarify who makes decisions, who conducts the conversation, and who coordinates the donation. - Consider a hybrid approach
Have the physician and donation coordinator conduct the conversation together to combine continuity and objectivity. - Take cultural and contextual differences into account
What is taken for granted in one country may pose an ethical dilemma elsewhere. - Guide families carefully
Empathetic communication helps with emotionally charged decisions and strengthens trust.
Nichon Jansen, a researcher at the Dutch Transplantation Foundation, emphasizes: 'It is not about potential conflicts of interest, but primarily about how families experience this. Clinging to a separation of roles can lead to discontinuity in the care of families who prefer the same trusted healthcare provider to remain involved.'
Interesting interview
In the United Kingdom, major strides have been made regarding organ donation in recent years. What can we learn from this in the Netherlands? Dr. Dale Gardiner discusses this in an interview.
Read the interview