When a person experiences brain death - a state in which brain functions are irreversibly shut down - the team of doctors in charge of organ transplantation informs the family and presents them with the possibility of organ donation. On the one hand, it is necessary to find a potential recipient who meets all the necessary overlapping factors, while on the other hand, it is necessary to obtain the consent of the family. Often it is this second part that is much more difficult. Decision-making is influenced by many psychological and social aspects. In the process of deciding on organ donation, a key role can be played by emotions, beliefs, but also by the wider social environment from which the deceased person's family comes. Also, the moment of announcing the death of a loved one can be decisive for whether the family will agree to the donation. Lack of trust in the system, tabooing of death, insufficient information, lack of systematic education and campaigns, social stigmas, prejudices, pressure from the local environment, as well as the strong emotional reaction of the family after the loss, are factors that greatly influence the final decision whether organs will be donated or not.
DECISION-MAKING ASSISTANCE
In some countries, the practice involves the involvement of trained psychologists and social workers in the process of communication with the family of the deceased. In Serbia, such practice is not institutionalized. Doctors working in intensive care or neurosurgery units, where potential donors are most often identified, are generally responsible for breaking the news of death and initiating donation discussions.
A psychiatrist who worked at the University Clinical Center of Serbia tells "Vreme" that even during his time at the Clinical Center, as well as now, psychiatrists and psychologists did not participate in this process, and that this was never a practice. However, he adds that such a thing would be significant if it were institutionalized. Saša Knežević, an anesthesiologist, clinical assistant at the faculty and one of the transplant coordinators of the University Clinical Center of Serbia, explains to "Vreme" that when a family loses a loved one, they are not, of course, ready for a tragedy, it is a big unpleasant surprise, but, he says, the family must gather strength and decide in those moments whether they want to donate the deceased's organs, because doctors do not have much time to wait. This is one of the problems in the transplantation process, the interlocutor believes, because people cannot be allowed to think for days whether it would be good for them and for the deceased or not.
Psychologists and psychiatrists, in countries where their involvement in the transplant process is practiced, have the task of helping the family to process the information about the death of a loved one in the most humane way possible, as well as to create a space in which the decision to donate can be made without feeling pressured. Their task is not to persuade, but to inform, support and clarify the dilemmas that families may have. In practice in Serbia, this entire job falls to transplant coordinator doctors and medical staff in the wards where the patient was placed.
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The way in which the death is communicated has a great influence on the emotional reaction of the family. The experiences of doctors in some countries show that it is most effective when there is a special team that approaches the family - one part of the team informs about the death, and the other, in a specially prepared conversation, introduces the topic of donation. And in such an approach, it is important not to create a sense of obligation, but to respect the family and create space for them to make a decision based on valid information.
The psychiatrist with whom "Vreme" spoke believes that the involvement of psychiatrists and psychologists in the transplantation process could better manage the strong emotional reaction at the time of loss. Even when families are not against donation in principle, the emotional trauma can block the ability to think rationally about something so delicate. Without support and prior knowledge, people most often answer "no" - not because they don't want to help, but because they are not ready. However, even when an individual declares that he wants to donate organs, or there is consent that he has, in some way, given, in Serbia this is not enough for it to be implemented, but the family must also give consent after death, which often does not happen despite the wishes of the donor. In addition to the legal omissions in this field, viewed from that aspect, the role of psychologists or psychiatrists would be even more important in adequately approaching the family of a person who has been diagnosed with brain death.
THE GREATEST FORM OF HUMANITY
Anesthesiologist Saša Knežević tells "Vreme" that organ donation is the greatest form of humanity and maturity of a society and not only in medicine, but that it is the sum of all relationships in society - emotional, economic, social, an indicator of empathy, humanity, understanding, care for others. He adds that it is specific that humanity is built extremely slowly and is very sensitive, like a tower of cards, only one small movement can bring it down. That's why, he says, interpretation is important: "Human life depends on every word we say." In previous years and decades, many people who do not understand medicine, from certain politicians to various other branches, commented on transplants and we paid for it with our lives, explains the interlocutor.
In Serbian law, there is presumptive consent, which means that all people who have not signed a statement with their chosen doctor that they are expressly against organ donation - there are several hundred of them at the level of the Republic of Serbia - can become donors in case of brain death, but by law their family must be asked. If they are legally married, their wife or husband is asked if they agree with the donation, if they are not legally married, their parents, children or next of kin are asked.
AWARENESS AND PREJUDICE
In Serbia, there is still deep-rooted mistrust in the health system and suspicion of abuses, which can certainly influence decisions about donation. The public is often not convinced that the donation process will be fair, without interest and in accordance with the law. Media sensationalism in the past has further eroded trust. In practice, however, there are no abuses that worry people because, quite simply, there are established procedures, which was confirmed by several doctors with whom "Vreme" spoke. In addition, death is rarely discussed openly in families, and the decision to donate is made in a moment of shock, without prior preparation. The lack of public education and the absence of a clear strategy for normalizing the conversation about donation make it even more difficult to change attitudes. In many cases, families simply do not know what their deceased member's attitude would have been, because they never discussed it. Death is still quite taboo, death is not discussed. This is precisely why most people do not express their views on donation during their lifetime, which makes the decision even more difficult for families when they are faced with a loss. Also, the social perception of transplantation is often linked to the suspicion that "only the rich get their turn", or that organs are "given to someone through a relationship". These prejudices, although mostly incorrect in practice, significantly impair citizens' willingness to participate in the system - either as donors or as family members of the deceased. If the public does not believe that the organ will go to "the one who needs it the most", the very concept of solidarity loses its meaning.
Cultural differences between smaller and larger communities also significantly influence the decision to donate organs. In larger cities, citizens have more trust in the health system, are better informed and are more inclined to make individual decisions. In smaller communities, traditional values prevail, fear of violating the integrity of the body and suspicion of institutions. The attitude of the local priest or the local community can play a decisive role. Lack of education often leads to the spread of myths, while solidarity in smaller communities is more often linked to "our people" and not to anonymous recipients.
Lack of information is one of the problems. In the educational system, there is no content that would cover the topic of donation and transplantation. Unlike countries that have a high donation rate, in Serbia there are no continuous educational programs that address different groups - young people, parents, the elderly, religious communities. National campaigns exist sporadically and rarely have a long-term effect. Donation is still perceived as an exception rather than a civic value. On the other hand, many citizens do not even know which documents they should sign if they want to be donors. In countries where education about organ transplants has been raised to a higher level, donors are portrayed through campaigns as heroes, and recipients as grateful people who live a new life. In this way, collective feelings of meaning and value of donations are built.
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Then there is the stigma of instrumentalizing the body. There are citizens who feel uncomfortable with the idea of their loved one's body being "opened" and an organ "taken". This bodily perception of death is imbued with deep emotional and cultural symbols: the integrity of the body is associated with dignity and peace after death. The lack of public education leads to transplant being perceived as a "disruption" of that peace.
Anesthesiologist Knežević also agrees that the biggest doubts come from insufficient information. He believes that it is not about a lack of humanity and selfishness, as one might think at first glance, but rather about insufficient information and prejudices. Many of us are slaves to the small communities from which we come and to the various customs, judgments and prejudices that prevail in those communities, says the interlocutor. He told us about a case of organ donation. The people came from a small village in eastern Serbia, they were humane and they agreed that the organs would be donated, but with the request that it not be known, which is their discretion because the people in the village would think that they sold those organs. In some areas, we are slaves to prejudices, customs, worries about what others will say, concludes the interlocutor and adds that it is a completely different situation when one of us needs an organ.
Transplantation is at least medicine, explains Knežević and adds that nothing could be done without citizenship, without understanding, that it is a process where there can be no rivalries, be they political, racial, or religious. The imperative must be that it is for the benefit of all of us. We can clash, confront and disagree about everything else, but here we must be united. It is a common interest and what we should all work on, the anesthesiologist is clear.
ATTITUDE OF RELIGIOUS COMMUNITIES
The issue of organ donation is often linked to religious beliefs. Nevertheless, the majority of traditional religious communities in Serbia - Orthodox, Catholic, Islamic - do not oppose organ donation, and some even actively support it, emphasizing the idea of saving lives as an act of mercy. The problem is that these messages are rarely communicated to the public in a clear and systematic way.
As the Serbian Orthodox Church also has a significant influence on the formation of attitudes and beliefs in Serbian society, the question is often raised about the relationship of this institution to the very act of transplantation. Although there may be prejudices in part of the public that church communities potentially do not agree with transplantation, or at least that they do not look favorably on this procedure, the situation in practice is exactly the opposite. In 2022, the SPC confirmed its position on organ transplantation, stressing that the decision is correct if the donor voluntarily gave consent. In the statement, she referred to the decision of the Holy Synod of Bishops from 2004, which adopted a position agreeing with organ transplantation if the donor voluntarily bequeathed his organs and if the donor's family gave their consent posthumously. In the same announcement, it was said that the Holy Synod of Bishops also affirms the transplantation of organs of living persons, as long as the donor's life is not endangered.
On the other hand, as early as 1994, the Catholic Church presented a view in which organ donation is viewed as a morally good act of mercy and love. The position that the church encourages organ donation after death and transplantation as a morally and ethically acceptable act is supported by the official statements of the Vatican. A good example of how the church encouraged organ donation is Spain, a country with an extremely developed donor system. In Spain, the Catholic Church legitimized and supported the idea of donation in a way that allowed social trust in the system, without the obstacles that in other countries came from religious beliefs. Its role was cultural-intermediary and moral, not legal-institutional. The Church normalized donation through religious support, helped the public to accept "presumed consent" (according to the Spanish system, all individuals are potential donors except those who expressly refuse it, and priests are often present in hospitals when families are informed of the death of a loved one).
Islam also allows organ transplantation under certain conditions. Most Islamic legal authorities (especially in Sunni schools) consider that organ donation after death is permissible and praiseworthy if it is done voluntarily, without commercial gain, and if it saves the life of another person. Transplantation must take place with respect for the body, and it is also important that there is a clear consent of the donor. Some more conservative views still express concern about the violation of bodily integrity after death, but in most Muslim countries today there is widespread religious support for organ donation.
The text was created in cooperation with the Hemofarm Foundation
