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Theoretical and practical premises in building up the health public policies in the field of transplant.

1. European statistical coordinates

The development of medicine in the field of transplantation brings to the fore not only ethical but also a whole range of issues which, from the point of view of the European policies, are located on the side of information and education. The statistics from 2009, 2010 and 2011 (1) show that, at European level, Romania is at the bottom of the hierarchy of organ transplantation comparatively with other European countries. The evaluation of donation intentions suggests that there is not enough information on this subject: only 31% are willing to donate which is well below the European average of 55%. In Romania 34% are willing to donate the organs of relatives in cerebral death, while the European average is 53%. At first sight, these figures show a certain reticence of Romanians towards the organ donation. In fact, the research that we have carried out in Romania between 2010-2012 and which had as starting point exactly the data and the premises which we have mentioned earlier, proved that things are different. The data we have obtained as a result of the research of the population of the city of Iasi have shown that, in fact, there is a poor knowledge and information of the population regarding the possibility of organ donation. Over 55% of the respondents consider that the right informing regarding the diagnostic of brain death and clear information regarding the possibility of organ donation are very important in making the decision regarding the donation. These results obtained in Iasi have been correlated with the results from other researches (interviews of ER doctors, neurologists and neurosurgeons from seven county hospitals, an analysis of the national and local media) carried out by us, fact which allowed us to highlight some attitude profiles which present serious deficiencies regarding the level of informing. In essence, this shows that the issue of transplantation is more complex and does not regard only the medical technique and science.

The organ transplant needs to be understood in a broader context of the political, social and economic changes, and of the health systems reforms which occurred in the central and East- European countries during the 1990s (Anton and Onofrei, 2012, p. 23). In the context of these reforms and of the economic crisis, assuming an effective strategy in the field of transplant becomes a difficult achievement. Moreover, as we are talking about a top field of medicine this involves many costs. The facts that within the health system there are other priorities and that transplant is a luxury field, which we barely can afford, are well known. These are the reasons of modest results regarding the number of transplants achieved by us comparatively with other European countries. The World Health Organization calculates the effectiveness of the health systems considering the report between health spending and the system's results (World Health Organization, 2010, p. 61). Our research shows that beyond a series of statistical indicators of efficiency, mathematically, the issue of transplant goes beyond the calculation of efficiency. It is an aspect that concerns every one because it causes, more than other medical topics, our relationship with the institutions, with the Other, and with the body (Corbin, Coutine and Vigarello, 2009).

Studies (Global Observatory on Donation and Transplantation) show that 40% of the European citizens have approached in the family the topic of donation and transplantation of organs. 73% of those who knew of the existence of the laws relating to the transplantation were willing to donate organs to relatives comparatively with only 46% of those who didn't know the laws in question. People with academic education have a higher availability (65%) for donation comparatively with those with primary or secondary education (45%). In the same way, those in managerial positions, which are supposed to manage more information and are well connected to the social (67%), were more willing to accept the donation than unemployed people or pensioners (49%). The same research shows that the most important factors that influence donation are: information and family discussions, mass-media information etc. (Morgan et al., 2005; O'Neill, 2006).

A study carried out in Spain, for example, identify the television (86%), films (59%) and magazines (56%) as the main informational and educational coordinates of the population in organ transplantation (Colak et al., 2009). Thus, the research indicates a significantly more favorable attitude of teenagers who have received positive information via the media, comparatively with those who were exposed to negative information on organ donation.

It is worth highlighting that the information and education of the population in the field of transplantation involve a cultural variable. Wakefield et al. (2010) showed in their writings that any media campaign loses its effectiveness if it does not show consistency, and if it does not take into account the cultural needs of the population.

On another register, our research on information and education of the population can also be a signal of the effectiveness of the existing national health policies regarding transplantation.

The analysis of the population's attitudes and behaviors can be a barometer of the role of information and the level of education in the construction of effective health policies.

The experience of other states is, therefore, a landmark in the development of assessments and proposals leading to positive outcomes in terms of the attitude of the population towards the collection and transplantation of organs.

2. Attitudinal landmarks in building up public health policies in the field of transplant

The practical premises are based on a research which was carried out in February 2012 on a representative sample of the population of the city of Iasi. The sample was a clustered and multi--stratified one and had 1,079 persons aged over 18, and the margin of error was 3%. The instrument which was used was based on a sociological methodology (Chelcea, 2007) and took into consideration a similar research from the European area (Lauri and Lauri, 2005) regarding the population's attitudes towards organ transplantation and donation, both in general and in specific contexts.

Results of the survey indicate a general trend to adopt positive attitudes towards the subject of donation and transplantation of organs (Gavriluta and Ioan, 2012, p. 226). 68% of the surveyed population answered that they would agree to organ donation in the case a member of the family would suffer brain death, and 75% when the decision regards their own person. This shows openness and readiness to accept the donation and transplantation of organs without neglecting, however, ethical issues involving consent and the responsibility of the decision to donate organs.

The ethical aspects are camouflaged in the prudence that the respondents manifest towards their own involvement or of their families when they would be put in a position to make a decision in favor of organ donation for someone close, found in cerebral death. Thus, only 22% of the respondents would agree to organ donation in the conditions in which there are doubts regarding the prior options of the person in brain death. It should be noted in this regard that a large number of people positively value the initial consent of the person for donating organs for transplantation, in the case of brain death (77% of the respondents answered that they would respect the wishes of the person in brain death).

However, we notice that the open-mindedness of the population towards the idea of donation and transplantation of organs is carried out on a lack of information. It is based mainly on the mass-media information.

This fact is also showed in the eight publications and tabloids whose articles were analyzed during 2010-2011. Articles exploit special issues regarding medical achievements and emotional aspects (abundance of formulations such as "double suffering", "mother's help", "donation for Andreia" emphasizes the psycho-emotional side of articles). Neither the titles of the articles, nor the topic or the presentation manner announce a coherent editorial policy regarding the informing of the population.

At the same time, the answers to the questions revealed that the respondents and, by extension, the entire population of Iasi felt the need for more accurate information from the professionals in the medical field (75% of the respondents want clear answers from doctors). In this case, the respondents' expectations are turning to family physicians (70.5%).

The figures resulting from the research indicate people's interest in transplantation (65% would agree to organ donation). At least at the level of principle, the majority of respondents (85%) agree that the transplantation of organs from deceased donors represents a way that could save lives, alleviate suffering, and restore happiness. In general, their answers refer to a series of ethical and moral values that privilege altruism, generosity and unconditional support. Cumulatively, approximately 85% of the respondents consider that organ transplantation saves lives and offers a chance to life and happiness to those who need them.

From this perspective, of the general claims and principles that we can attach to the donation and transplantation of organs, we can say that the population from the study has mostly a positive opinion. This is the foundation that must be taken into account by anyone who wishes to inform and shape positive attitudes and perceptions of the population regarding this topic.

Equally positive figures are also recorded when the respondents do appraisals on the role of the family of the deceased (67% consider that the family has an important role in the organ donation decision, the futility of bodies after death (70% state this fact) or regarding the improvement of patient's life quality when benefiting from organ transplanting (73%)).

The answers change as we go down from the level of the principles to the one of real life and concrete experiences. A number of variables such as the health system (54% of the respondents show their distrust in the health system), the risks of transplantation (46% consider organ trafficking as a risk associated with transplantation), the uncertainty of the diagnosis of brain death (44% state that there is the chance that the patient will recover from brain death), the religion (42% consider that religion forbids transplantation), the integrity of the body (29% consider that transplantation from deceased donors represents a mutilation of their body); all these remodel the options of the persons being investigated. Thus, we find that, behind the healthy principles that betray a good moral and ethical orientation, there are many dilemmas and questions.

Some of them can be based on a series of concrete experiences. For example, distrust of the medical system may be an indicator of some unpleasant experiences in the relation of the person with the institutions of the system. 57% of the respondents who expressed doubt over the health care system also are people who agree with the donation and transplantation of organs. They have, however, doubts about the capacity of the Romanian medical system to manage the problem. The greatest incertitude is related to the brain death stabilization (42% think there is a chance that the patient will recover from the brain death), the functionality of the collected organs (48% consider that the collected organs are no longer functional), the risks of disease transmission by transplantation (49%). This category of incertitude is linked mainly to the medical dimension of the transplantation. They can betray an insufficient knowledge, weak information or even fear of such a possibility.

As figures for this segment of the investigated population show, we believe that the analyzed population is not influenced in an obvious way by a number of elements of the religious education that might be unfavorable to the transplantation of organs. They rather show confusion, an inadequate education and information in this area than attitudes strongly anchored in solid theological principles.

Nuanced opinions are also found when the family of the deceased is brought to the fore in the discussions as an important actor in the acceptance of organ donation. However, a fairly small proportion of respondents, between 28% and 32%, do not reject the possibility to increase the suffering of the family of the deceased or the existence of remorse as a result of its agreement with the donation of organs for transplant. These responses are offset by the fact that there are sufficiently many respondents (67%-72%) who believe that donating organs will alleviate the family's suffering, and that a part of the deceased will continue to live in someone else's body.

The repentance and the guilt that some respondents feel can be placed quickly under the sign of a great responsibility that they face when they are in the position to make a decision. Respect, suffering and remorse of the family in the face of such situations are variables which can hide at the same time liability, uncertainty, mentality and also cultural patterns, which raise some question marks regarding a very important decision.

Approximately 40% of the Romanians from Iasi seem to be more attentive to a series of subtle aspects related to the change of beneficiary's personality through organ transplant. Therefore, as a percentage, it's more important what's going on in the body, in the inner life of the person receiving a transplant than the visible part, the body of the deceased donor. Themes such as happiness (85%), saving a person (79%), the chance for life (84%) or altruism (72%) are very important. At the opposite pole, with lower scores, there are others that insist on guilt (31%), lack of respect (26%), religious factors (38%), and bodily integrity (38%). Their positioning according to the scores obtained picture the openness and the positive attitudes of the population towards organ transplantation. Each of these themes is, in fact, a factor favoring transplantation. Moreover, the results indicate possibilities of approaching the transplant topic within an information campaign. We say this because 71% of the respondents agree that 'transplantation is an intervention that people know too little about in order to accept it'.

In the conditions of the weak knowledge and information about the topic, the results show positive attitudes. They could be related to certain solidarity in suffering.

Interesting answers were received when the subjects were asked to indicate a favorable moment in which they could give consent or disagreement concerning organ donation in case of brain death. Though the answers varied, they privileged the relationship with the family doctor. Thus, the agreement through mediation of a medical institution is the most agreed context. In this sense, we can say that the level of information of those investigated is superficial. It can be associated with the information received through media channels, and do not represent a deeper knowledge of the phenomenon.

For this reason, the agreement towards a series of statements expressed from the very beginning of the questionnaire becomes much more valuable. Therefore, we can say that the premises on which the opinions of the population of Iasi are based are positive, and are under the sign of altruism, assistance and giving.

It is worth noticing that the investigated persons' options are not influenced in a visible manner by a series of dependent variables such as: gender, marital status, age or educational level. More significant differences emerge when it comes to the religion of the respondents. For example, persons with a neo-protestant religious education have a stronger negative attitude towards donation decision (85% Adventists, 90% Protestants) than those who belong to other denominations (75% Orthodox, 77% Catholics) in the conditions in which the person in cerebral death has openly expressed the disagreement with the donation during her/his lifetime.

The educational level of the respondents does not make any visible difference in the expression of attitudes towards the transplant. For instance, 83% of the persons with primary education and 79% of the persons with university degree education would not accept organ prelevation from a person in brain death if the person did not consent to it during his/her life time. In our opinion they express rather ethical and human attitudes, and less informed rational choices. We believe that this is the consequence of a superficial media presentation, and of a weak public debate of the issue of transplantation and organ donation. Representing a peripheral topic or even an ignored one in the public debate in Romania, the population's responses are shaped only by moral humanitarian and ethical principles (Frunza, 2010, p. 33). An argument in this case is the fact that in the case of a prior agreement, the positive attitudes in favor of organ donation increase rapidly. According to respondents' level of education, the figures are over 50% and vary between 88%, for those with postgraduate studies, and 63%, for those with primary education.

From the point of view of the religious affiliation, the results are strongly influenced by the person's in brain death previous decision regarding organ donation. The scores are positive in case of previous agreement and become negative in case of refusal. Only respondents who belong to the neo-protestant cults keep their options and reticence in relation to organ donation. 58% of Adventists, 40% of Protestants and 63% of Baptists gave answers related to the negative attitudes, while only 16% of the Orthodox respondents have similar attitudes. Such attitudes may be an echo of the doctrinal issues and religious interpretations in which the body has a special approach. For example, from the Orthodox point of view it is seen as the temple of the soul. A religious education in the spirit of understanding and support of each other (with direct referrals to concrete experiences) would visibly change attitudes towards the organ transplantation.

The coherence of the answers regarding certain situations (the previous acceptance or refusal of the person in brain death regarding the organ donation) and the control questions announce a set of values and norms which dictate the ethical behavior. It is not about informed ethical behavior but rather about a uninformed one, based on highly human values and reasoning. In shaping these, the institutions have a minimum contribution. Thus, emerges the need for collaboration with the institutions dealing with the donation and transplantation issue. The figures mentioned above show that in the equation of donating, an important role is played by the behavior and attitudes of medical personnel when a family member or a close person would be in cerebral death. The doctor-patient relation is, in this case, one which overcomes the theoretical models (Oprea, 2009), and must be adapted to the situation. Professional training and the ability of the doctors to assess and suggest solutions may determine the right choices. The doctor continues to enjoy an important symbolic capital that is required at professional and social levels. The answers received show that the doctor-patient relationship is not only perceived at institutional level but also at human level. Thus, the physician is required not only to provide clear and relevant information (91%), but he/she has also to be a good psychologist (87%) and communicator with genuine empathic abilities (86%). The figures present the options and exigencies of the same sample (1,067 persons) regarding the doctor-patient relation. These attitudes can have several justifications:

--The doctor, as the exponent of a socio-professional category, enjoys a symbolic capital which translates into confidence and authority. Thus, the information from him/her is credible and has more weight.

--The context in which the whole scene of organ donation decision takes place in the hospital and the doctors become meaningful to people making a decision.

a. In Romania the doctor-patient relationship is not perceived as a strictly formal one in which the patient and his/her family turn into a customer. Respect, compassion, and patience are the variables that place the doctor-patient relationship in an informal situation; they become closer and thus the relationship is characterized by mutual trust (Cananau and Astarastoae, 2012, pp. 53-54). Such attitudes are understandable from anthropological and social points of view. They are, however, quite harmful from the point of view of the medical act efficiency. From this perspective, prior information during life is more than useful.

In the conditions of poor information on the donation and transplantation of organs, the attitudes expressed through the responses can only be the expression of individual or collective representations in the context of human solidarity.

3. Organizational and institutional landmarks in the functioning of the transplant system in Romania

The researched population perceives and evaluates the medical and transplant system from Romania through their own experiences and expectations. A large proportion of the respondents do not manifest confidence in the system (57%). These numbers show an affected relation between the health system and the patients, respectively the citizens, which has effects on the understanding of the transplant system. This fact proves not only that the patients are poorly informed but also a lack of adaptation and a defective functioning of the system. Furthermore, in an interview for the newspaper Romania Libera the specialist in liver transplant, Dr. Irinel Popescu, said that the number of organ donors is lower than in other countries because of an inadequate organization of the Romanian medical system (Padurean, 2012)

Although the doctors' and the researched citizens' opinions are the same when it comes to the organization of organs collecting and transplant activities in Romania, specialists have a more nuanced perspective on the system. No matter the answers and the social background of the respondents, the emphasis is not on the legislative aspect but on institutional, organizational and human nature data. In Romania, there is an organ transplant law (Law no. 95/2006) which meets the European requirements in this field. From this perspective it is considered that 'the organs transplant does not have major differences compared to the transplantation in the EU countries. What some are saying, that the number of collected organs is below the EU's average, is true, but no one takes into consideration the amount of money allocated for the transplant system. At the moment, though there might be a higher number of donors, dead or alive, there is not a higher number of transplants as there is not enough funding. In other words, the transplant program is not funded enough, similar to other programs in Romania', Vasile Astarastoae (2) declares in an interview applied by us in 2011.

The same opinion is shared by Irinel Popescu who shows that 'funding is the first solution, no matter how much we would try to avoid it'. 'I am not saying this as easy as someone would say: give us more money and the services would be qualitatively higher, but I'm talking about efficiency, and escaping from certain mentalities and aiming at the European ones' Popescu declares. Also he states: 'Funding is not everything. It is true that without adequate funding we will not have quality services, but, on the other hand, increasing professionalism of doctors, the attitude towards the patient, an European mentality, respecting protocols and standards, attention to details, which, unfortunately, sometimes are not totally respected, are also factors which can contribute to increasing the quality of the medical act' (Popescu, 2009).

The specialists in the field especially emphasize the funding of the transplant of organs. The costs connected to transplantation are extremely high. They include several aspects: costs connected to collection, costs of the transplant process itself, costs connected to acquisition and maintenance of the necessary equipment, and human resources costs. To the operation itself, there are added costs related to the collection and to the medication in order to prevent organ's rejection (in the case of a kidney transplant these raise to 2,000 Euros, Ionel Sinescu declared in an interview).

'These are specialist-related costs; costs for materials, medication, nutrition ... many things are (...) I think this might be the main reason.' (doctor, Botosani)

On the occasion of the meeting organized by the Association of the Transplanted Persons in Romania in 2013, Alexandru Calin, the Manager of the Medical Assistance Department within the Health Ministry, raised awareness regarding the weak funding in the field of transplant, the money for the National Transplant Program being enough only until the half of the year.

Since the issue of funding is a visible one, and it characterizes several fields in Romania, through the interviews with the doctors from the county hospitals in the region of Moldavia a series of structural and functioning issues in the field of transplantation in Romania has been identified. The ER doctors, neurologists and neurosurgeons that we have questioned within the same research have a rather systemic view on the issue of transplant. Thus, the lack of an efficient organization, which would allow a better managing of transplant, is an important issue. Though there are laws, regulations and specific protocols, cooperation with the transplant coordinators and with the hospitals which can ensure organ collection is quite diminished. For some doctors this formula seems quite complicated, and it does not ensure the continuity of the process.

'This is what I have said: something must be done at county hospital level, so that almost everyone knows that there is a transplant center. First the neurosurgery should be involved because trauma is related to them and surgery, and the ER. In the ER there are taken all of them and there we must talk to the families, so there must be the core. Neurosurgery calls you. You make an assessment. If the neurosurgeon is involved, so is the doctor from the ER.' (doctor 1, Bacau)

The county hospitals often appear as marginal actors in the equation of transplant. This can be explained by the lack of constant cooperation in the field of organ collection. On the other hand, for many doctors transplant is a high performance specialization whose development would first involve solving and controlling all the other situations in the medical system. The specialized human resources are, in the opinion of doctors, an important component of the medical and transplant system. In their lack, transplant cannot be made. The migration of doctors is a well-known fact as well as its motivations: too much workload and the weak wage motivation. Moreover, the new Romanian legislation limits the rate of employment in the state system, the report being of 1 to 7. This makes the transplant to remain a luxury for many doctors.

'We're doing so much volunteering, that (ironically) I don't know what ... the state gives something symbolical. How are the doctors abroad paid and how they are paid here related to the extent of their work ... because practically, there is no primary network ... we see what we're dealing with, emergencies and over 100 consultations for each time we're on duty ... and you leave from work very tired (...) So compared to what you earn you get home exhausted, ... you cannot read a book, as you don't understand what you are reading, in what language it is . we can't be compared to long time ago doctors ... you had time to specialize, to socialize, you had time to train yourself ... here you die doing paperwork (...) of course from time to time you have such a reaction .' (doctor, Bacau)

The material resources are considered an important aspect of the functioning of the system. At the moment, the fact that the county hospitals are facing serious problems regarding the medications and material resources for the treatment of the patients is well- known. Given the fact that keeping a patient in cerebral death involves equipment, personnel and supplementary costs, the issue of collecting organs from persons in cerebral death is out of question.

'The electroencephalogram of the patient in ER is impossible to be done at the moment because of the lack of the right equipment.' (doctor, Suceava)

Besides all these, the transplant system cannot be conceived by not taking into consideration the population, the potential donors. In the absence of an open agreement of the target population, the transplant medical system cannot work, this even in the conditions of the best organization. Practically, in the case of transplant, the connection with the social is more visible. The relation doctor-patient is mainly a 'social experience and not a therapeutically or impersonal one' (Fainzang, 2006, p. 114). To this it is also added the relation with the family or with the close ones. For this reason, we consider that the population's agreement or consent represents the main link of the transplant.


This synthesized diagram is valid in the conditions of a coherent administration of the transplant system, and of the existence of an actual legislation in this field.


From the institutional and legislative point of view, things would be according to the graph presented above. Actually, things are more complex, important elements in the functioning of the system being: funding, material and human resources, functioning and role establishing clear norms and rules, righteous communication and information.

Although the actual legislation regarding organs transplant in Romania is a modern one, in accordance with the legislation existing at the European level, the perception of the doctors from our research, respectively neurologists, neurosurgeons and ER doctors, is that there is a weak organization of the system. More exactly, this would mean a poor informing at the medical level regarding the system's functioning. For example, it is not known that the hospitals which identify and contribute to organ collection receive, according to the law, supplementary funding and recognition within the system. Thus, the organ transplant remains for the most a luxury specialization, somewhat separated from the medical system. Though population's and doctor's information seems to be 'divided and illusory' (Fainzang, 2006), the performances of the doctors who carry out organ transplants and as well the importance of this specialization in the development of medicine are relevant.

In the context of a good organization, the problem of information covers two important aspects: one at the level of doctors, and one at the level of the population. The two cannot be seen separately but as a system, as they are a catalyst of the functioning of the transplant system.

'First of all, people are totally misinformed ... There is no clear information, even at the doctors' level. So you know, you see on TV, how they do it in America, Europe, anywhere ... Here, I told you that there was a case in which everyone kind of babbled: who is responsible for the transplant, or ... the family decided too late.' (doctor, Bacau)

The research carried out by us shows that the topic of information gets a separate approach from the doctors. The scarce situation of the doctor's information and of a weak exercise in the field of transplant appears indirectly, the topic being rather exotic among the issues they have. At the same time they identify the main issue at population level.

'(...) practically at the moment from our experience, the population is not enough informed in order to make a favorable decision in this respect.' (doctor, Suceava)

Such an approach which emphasizes only a dimension of the information takes out of the equation the importance of the doctor and his/her relation with the patient or his/her family (Dinu and Dinu, 2011, p. 73). Moreover, in this context, information and preparing doctors for dealing with donation cases and transplant is not presented well enough. It rather seems neglected.

The analysis of the transplant system in Romania and its functioning show that from a formal point of view, Romania has quite a good situation: there is a law of transplant, there are coordinating centers, and there is a Transplant's Agency, NGOs, transplant doctors who had remarkable successes in the field. Thus, though there is an increase in the number of transplants from one year to another, Romania does not occupy such a good position in the European top. This is caused mainly by the organization and funding of the system.

4. Instead of conclusions

The research we have carried out shows that, by its social and individual implications, transplant topic represents a real social issue which can find its solution by organization and health policies adapted to Romania.

According to the research conducted by us, the main factors that hinder an increase of the number of donors are the poor information of the population about this possibility, and the poor functioning of the transplant system by placing the issue of transplantation in the background.

The solutions, which result from our research, aiming at increasing the number of donors in order to find a solution to the increasing number of requests regard mainly two important points: organization and communication. Furthermore, the fact is also pointed out by a series of important people from the system. 'The transplant activity is a strategic activity at national level which has to remain funded by the Health Ministry; the program of transplant will continue to be funded by the Health Ministry. The less good news, and I refer here not only to the transplant program, but to all the Health Minister's programs, is that at the moment we can fund the programs only for the first half of the month. We will do all we can to supplement the funding for these programs.' declared Dr. Alexandru Calin, manager of the Medical Assistance Department, within the Ministry of Health, on the occasion of the meeting organized by the Association of the Transplanted Persons in Romania ( spital/banii-pentru-transplanturi-ajung-doar-pana-la-jumatatea-anului-ministerulsanatatii- 1221750). However, the solutions of the organization do not necessarily regard only the funding aspects.

A better organization of the donation and collection activities might change the situation of the donation. If in the transplant centers things seem quite clear from the point of view of the system's functioning, existing, in this respect, an exercise of the role exertion and a routine of the activities which transplant involves, at county level things are no longer that certain. Here, it is seen the need for constant training and information in order to clearly establish the role of the institution and of the doctors in the transplant activity as well as a series of institutional advantages which result from this activity.

'Yes, maybe there should be trainings for doctors, this wouldn't be bad, at least every half a year.' (doctor 2, Neamt)

This informing should be completed, in doctors' opinion, with successful models or practices from abroad or from Romania. In this respect, they support the idea of training courses organized by the Doctors' Association.

Another aspect which would clarify things even more from the point of view of organization and of the roles in the activity of collection and transplant is that related to the need for more specialists in order to inform and to obtain the consent of the deceased's family. The answers received from the interviews with the doctors organized by us show that, in general, doctors do not assume the role of communicator; they focus mainly on professional competences.

'First of all we must have the conditions and the possibility to do this, they (specialists trained to communicate with family n.n.) must be very well educated ... not only informed, there must be that medical education, which is with all the necessary information both from the administrative point of view and from the medical one. This I think is very important in order to convince them (...).' (doctor 2, Neamt)

The statements of the people responsible in the field of transplant are quite optimistic. The measures aim at an improvement of the situation: 32 anesthetists have been trained to discuss with the families of the donors in cerebral death; since December 2012 there is a law which first appeared in 2006, and by which more hospitals were included in the transplant program: 'more than 30 hospitals have been involved in declaring the donors in cerebral death, more centers which will make transplants and more centers which will be involved into the program, aiming at helping the transplanted patients', declared Dr. Victor Zota, national coordinator of the National Transplant Agency ( doar-pana-la-jumatatea- anuluiministerul-sanatatii-1221750).

The results of the research highlight the need for developing an information strategy related to organ donation and transplant at the level of population. There are two mechanisms of informing agreed by the respondents: the use of mass-media and specialized information carried out through family doctors.

'(...) there's no use, if there is no education activity at national level using commercials; TV stations should not accept money for something like this, as they help . There is altruism too in the end. There are not only commercial TV stations. This is what I think. And as they show commercials related to not eating too much salt and sugar they could show this kind of commercial too. Just one. The Ministry of Health should first of all get involved. If they have to pay they should make a commercial and broadcast it.' (doctor 1, Bacau)

On the occasion of the meeting organized by the Association of the Transplanted Persons in Romania, they have announced that they will organize a caravan 'in 12 cities around the country, the aim of the action being to inform the population about the role and importance of organ donation' (Gheorghe Tache, the chairman of the Association of the Transplanted Persons in Romania).

Thus, beyond a series of regulations already existing and of positive intentions and actions justified by the promotion of the transplant, it emerges the idea of a clear and coherent methodology of application of the existing norms, and also of using some strategies of communication, information and education of the population.

In this respect, we think that the transplant system, by its implications, is one of the fields which proves in a practical manner the importance of communication and of an 'ethical culture at the individual level' (Maxim, 2013, p. 75). This fact might have beneficial effects on the increasing of the efficiency of the functioning of the transplant system in Romania. Moreover, in this case, communication becomes an important means to rediscover and revalue the human relations. It is a tool by which we get to the Other and also a way to discover and promote the self through the Other (Jaspers, 1994). Thus, the efficient functioning of the organizations and institutions depends on the way in which they communicate and how the roles of the involved actors are assumed. 'The ethical culture, at the level of the individual, and, mostly, at the level of the organization, becomes decisive for supporting a community attitude responsible for challenges of the knowledge based society' (Maxim, 2013, p. 74).

All these are, in our opinion, aspects which are related to the ability to administer a system which is at its beginnings.

* Acknowledgement: This article was co-financed from the European Social Fund by the Sectoral Operational Programme Human Resources Development 2007-2013, within the project Post-doctoral Studies in the Field of Healthcare Ethics' Policies implemented by the University of Medicine and Pharmacy G.T. Popa Iasi, the number of the identification of the contract is POSDRU/89/1.5/S/61879. This material does not necessarily represent the opinion of the European Union or of the Romanian Government.


[1.] Anton, S.G. and Onofrei, M., 'Health Care Performance and Health Financing Systems in Countries from Central and Eastern Europe', 2012, Transylvanian Review of Administrative Sciences, no. 35E, pp. 22-32.

[2.] Cananau, M. and Astarastoae, V., 'The Concept of Patient-Doctor-Media Confidentiality Relationship in Mass-media', 2012, Revista Romana de Bioetica vol. 10, no. 3, pp. 106-115.

[3.] Chelcea, S., Metodologia cercetarii sociologice. Metode cantitative si calitative (The Methodology of the Social Research. Quantitative and Qualitative Methods), 3rd edition, Bucuresti: Economica, 2007.

[4.] Corbin, A., Coutine, J.J. and Vigarello, G. (coordinators), Istoria corpului uman (The History of the Human Body), vol. III, Mutatiile privirii. Secolul XX (The Mutations of Look. XXth Century), (volume coordinated by Coutine Jean-Jeaques), Bucuresti: Editura Art, 2009.

[5.] Colak, M.Y., Hekimoglu, D., Ersoy, K., Sozen, F. and Haberal, M., 'Health Content Analysis of Organ Donation and Transplantation News on Turkish Television Channels and in Turkish Print Media', 2009, Transplant Proceedings, vol. 42, no. 1, pp. 134-136.

[6.] Dinu, C.E. and Dinu, A.L., 'Medical Profession, Vocation and Contextuality', 2011, European Journal of Science and Theology, vol. 7, no. 4, pp. 67-74.

[7.] Fainzang, S., La relation medecins-malades: information et mensonge, Paris: Presses Universitaires de France, 2006.

[8.] Frunza, M., Expertiza etica si bioetica. Studii de caz (Ethics and Bioethics Expertise. Case Studies), Cluj-Napoca: Editura Limes, 2010.

[9.] Gavriluta, C. and Ioan, B., 'Organ Transplantation from Ages and Informing Strategies Point of View', 2012, Analele Stiintifice ale Universitatii "Alexandru Ioan Cuza" Iasi, Sectiunea Sociologie si Asistenta Sociala, Tom V, no. 1, pp. 219-228.

[10.] Jaspers, K., Philosophy, Munchen: Taschen, 1994.

[11.] Lauri, M.J. and Lauri, J., 'Social Representations of Organ Donors and Non-donors', 2005, Journal of Community & Applied Social Psychology, vol. 15, no. 2, pp. 108-119.

[12.] Maxim, S.T., 'Ethics and Organizational Culture in the Communication Society', 2013, European Journal of Science and Theology, vol. 9, no. 1, pp. 71-76.

[13.] Morgan, S.E., Harrison, T., Long, S., Afifi, W., Stephenson, M. and Reichert, T., 'Family Discussions about Organ Donation: How the Media Influences Opinions about Donation Decisions', 2005, Clinical Transplantation, vol. 19, no. 5, pp. 674-682.

[14.] O'Neill, R.D., '"Frankenstein to Futurism": Representations of Organ Donation and Transplantation in Popular Culture', 2006, Transplantation Reviews, vol. 20, no. 4, pp. 222- 230.

[15.] The World Health Organization, Global Status Report, 2010.

[16.] Oprea, L., 'An Analytical Review of the Doctor-Patient Relation (part I)', 2009, Revista Romana de Bioetica, vol. 7, no. 2, pp. 125-137

[17.] Padurean, C., 'Cum va fi reorganizat sistemul romanesc de transplant' (How Will Be Reorganized the Romanian Transplant System), in Romania Libera Newspaper from December 4, 2012.

[18.] Popescu, I., 'Costs and Quality of Healthcare Provision in the Romanian Health Insurance System', 2009, Management in Health, vol. 13, no. 3, pp. 1-2.

[19.] Wakefield, J.G., McLaws, M.L., Whitby, M. and Patton, L., 'Patient Safety Culture: Factors that Influence Clinician Involvement in Patient Safety Behaviours', 2010, Quality & Safety Health Care, vol. 19, no. 6, pp. 585-591.

[20.] *** Global Observatory on Donation and Transplantation, [Online] available at http://, accessed on January 10, 2014.

[21.] *** Interview with PhD Vasile Astarastoae, the chairman of the Doctors' Association in Romania, conducted in 2011.

[22.] *** 'Banii pentru transplanturi ajung doar pana la jumatatea anului--Ministerul Muncii' (Money for transplants are enough up until the half of the year--Ministry of Health), [Online] available at anului-ministerul- sanatatii1221750, accessed on August 12, 2013.


Professor, Faculty of Sociology and Social Work, Alexandru Ioan Cuza University, Iasi, Romania Postdoctoral researcher, Center for Health Policy and Ethics, University of Medicine and Pharmacy 'Gr. T. Popa', Iasi, Romania

Tel.: 0040-0741-363.764


(1) The data regarding the transplantation activity is generally reported in the next year (e.g. in 2011 there are presented the data from 2010). The data is available, in Romania, on the website of National Transplantation Agency, For comparison with the data available at European and international level the data provided by Global Observatory on Donation and Transplantation can be used ( home.aspx). For the year 2011 only partial data for the international activity were available at the time this article was written ('2011 International donation and transplantation activity. Preliminary figures', 2012, Organs Tissues & Cells, June, vol. 15, no. 2, pp. 75-78).

(2) Vasile Astarastoare is the President of the Romanian Physicians Association and the Rector of 'Grigore T. Popa' Medicine and Pharmacy University, Iasi.
Table 1: Compared costs of various types of transplants,
EU versus Romania

TRANSPLANT TYPE        ROMANIA                 EU

Kidney transplant    25,000 Euros         50,000 Euros
Liver transplant    50,000 dollars       100,000 Euros
Spinal transplant    25,000 Euros    100,000 -120,000 Euros
Cornea transplant    4,500 Euros       1,000-10,000 Euros
Heart transplant     60,000 Euros        120,000 Euros

Source: Author's findings
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Author:Gavriluta, Cristina
Publication:Transylvanian Review of Administrative Sciences
Date:Dec 1, 2013
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