"When you talk to representatives from Spain, they will tell you it has little to do with presumed consent legislation," she tells DOTmed News. "There are several countries in Europe that have presumed consent in place that have the lowest donor rate in Europe," she says, such as Bulgaria, with only 1.1 donations per million residents.

In fact, Schlessinger says even with presumed consent enshrined as law, Spanish doctors routinely approach families for consent.


What the Spanish model is about instead, Schlessinger argues, is better management and coordination among hospitals, better training of staff, and more aggressive outreach to the media.

Plus, in Spain, hospitals have organ donor specialists who manage potential donors to ensure optimal preservation of organs. Schlessinger notes that these specialists are often better able to preserve organ function so that organs remain viable enough for transplant.

Recently, a group from Spain wrote out the seven principles of the Spanish model, which include closely watching media coverage of transplants, ensuring coordination among transplant groups at regional, national and local levels, and continuous audits on brain death and donation across the country so doctors can get an up-to-the-minute summary of the "potential" in each hospital.

"There's nothing about presumed consent legislation there," notes Schlessinger.

Possible distortions?

For all the touted benefits of the Spanish model, it's possible that the way numbers are reported could somewhat distort the program's success.

Usually, the donation rate is calculated as the number of donations per million population. But the problem is, as Schlessinger puts it, "When you report purely organs per million population you don't know what that million population is all about."

The catch is that many patients who consent to donate are ruled ineligible for donation for medical reasons. So a population that's, on average, unhealthier, would have lower donation rates even if there were a strong willingness to donate and a well-functioning system to carry out donations.

For instance, Shclessinger notes that Alabama has a low donation rate, though it's not because Alabamans oppose donation, but because they have one of the nation's highest rates of diabetes, making many unable to give their organs at death.

"In the U.S...we've moved away from donor per million population calculation, and they now look at actual death audit reviews from each organ recovery agency from a donor service area, to determine actual potential after medical rule-outs, so we're comparing apples to apples, not 'apples to organs,'" Schlessinger says.

But even looked at with other metrics, Spain comes out ahead. Its conversion rate, the number of potential donors who actually donate, is around 80 or 85 percent, slightly higher than the rate in the U.S., at around 75 percent.

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