- Email: [email protected]
Public attitude toward xenotransplantation: Opinion survey
Public Attitude Toward Xenotransplantation: Opinion Survey A.R. Rios, C.C. Conesa, P. Ramı´rez, M.M. Rodrı´guez, and P. Parrilla ABSTRACT Background. Although xenotransplantation is still in an experimental phase, it is presented herein as a possible solution to the organ shortage. However, there are few data concerning how the general public would accept treatment with animal organs, especially after recent incidents of infections of animal origin, such as “avian influenza” or “SARS disease.” The aim of this study was to determine the attitude of the general public toward xenotransplantation of organs. Materials and Methods. Using an opinion survey, a study was performed on a random sample of 250 subjects in an urban setting. The questionnaire was administered by personnel from the regional transplant coordination center. Completion of the form was self-directed and anonymous for each respondent. The attitude toward donation of human and animal organs was evaluated by analyzing different psychosocial variables that may influence this attitude. A descriptive statistical study was performed using Student’s t test and the chi-square test. Results. Ninety-eight percent of respondents completed the survey (n ⫽ 245). As for human donation, 60% are in favor of cadaveric donation with 21% are in favor of living donation, a rate that increases to 74% if it is for a living partner. As for animal donation, if the results were similar to those obtained with human organs, 74% (n ⫽ 181) would accept an animal organ if they needed it, as opposed to 18% (n ⫽ 45) who were undecided and 8% (n ⫽ 19) against (P ⬍ .005). Analysis of variables that influence attitudes toward xenotransplantation showed that this attitude was more positive among those having had a previous experience with transplantation (P ⫽ .028) and those having a positive attitude toward cadaveric donation (P ⫽ .007). Factors traditionally related to cadaveric donation, such as manipulation of the body or pro-social activities, showed no influence. Conclusions. In the population studied, a positive attitude toward xenotransplantation was greater than toward cadaveric donation, assuming the results of these two types of transplants were comparable. Such an attitude is related to human donation, although it is not influenced by many traditional factors.
G
IVEN the limited number of available transplant organs, xenotransplantation, as an alternative, has received considerable attention in recent years, as it would create an unlimited supply of organs. Advances in immunosuppression and genetic engineering techniques, together with chimerism, make this technique ever more viable and valid.1–3 Although xenotransplantation would minimize the waiting time to obtain an organ, it could cause various psychosocial problems with regard to reintegration of patients into society, xenozoonoses, etc, and may even inspire fear and controversy. Some patients might experience psychologic changes due to the incorporation of animal organs into their body.1,4
There are few data, however, pertaining to how the population would accept this treatment, especially after recent incidents like “avian influenza,” “SARS disease,”
From the Coordinación Regional de Trasplantes de la Comunidad Autónoma de Murcia, Murcia, Spain (A.R.R., C.C.B., P.R., M.M.R.); Centro de Salud de Fortuna, Murcia, Spain (C.C.C.); and Departamento de Cirugı´a, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain (A.R.R., P.R., P.P.). Address reprint requests to Dr Antonio Rı´os Zambudio, Avenida de la Libertad 208, Casillas 30007, Murcia, Espan˜a. E-mail: [email protected]
© 2004 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/04/$–see front matter doi:10.1016/j.transproceed.2004.11.012
Transplantation Proceedings, 36, 2901–2905 (2004)
2901
2902
etc, for which the origin of the infection was animals. Furthermore, most studies providing analyses of this attitude used patients with transplants or those awaiting transplant,5–7 with few studies evaluating the attitude of the general public.8,9 Our objective was to assess the public attitude toward xenotransplantation of organs and to compare it with the existing attitude toward human cadaveric or living donation. MATERIALS AND METHODS Population Study A random sample of 250 individuals was obtained among the population aged ⱖ15 years from an urban area in our autonomous community. Between January and August 2001, an opinion survey was circulated, with a completion rate of 98% (n ⫽ 245). The average age of the respondents was 41 ⫾ 19 years, with 62% (n ⫽ 152) women and 38% men. Overall, 55% (n ⫽ 136) were married, 47% (n ⫽ 116) had educational studies at an average or higher level, and 50% (n ⫽ 122) claimed to know or to have known transplant donors or recipients.
Opinion Survey and Variables Studied Opinions were evaluated using a 30-page survey with multiplechoice answers, validated in our geographic surroundings based on previous studies of cadaveric donation,10 living donation,11 and xenotransplantation.9 This survey was self-administered with the process arranged by members of the regional transplant Coordination center. The analyzed variables included: (1) psychosocial variables (age, gender, marital status, level of education, knowledge of donors and transplant patients, participation in pro-social activities and opinion toward cadaveric manipulation); (2) attitude toward human donation (cadaveric, living kidney, and living liver); and (3) attitude toward donation of animal organs (xenotransplant), supposing results similar to those for human organ donation.
RIOS, CONESA, RAMÍREZ ET AL analysis of residues or, if necessary, Fisher’s Exact test. Differences were considered significant at below P ⬍ .05.
RESULTS Attitude Toward Different Types of Donation
As for animal organ donation to humans, if the results could be superimposed on those achieved by human organs, 74% would be in favor, 18% undecided, and the remaining 8% against. The responses with regard to human donation varied according to the type of donor and organ. Thus, with respect to cadaveric donation, 60% were in favor, 7% undecided, and 33% against. However, for living donation, the attitude varied according to whether it was a kidney or a liver transplant and whether it was for a relative. Thus, the attitude toward nonrelated living kidney donation was positive in 28%, undecided in 52%, and negative in 20%, with the percentages for liver being 21%, 54%, and 25%, respectively. When the living donation was considered as being for a partner (family member or intimate friend), the percentages change for the kidney to 88%, 10%, and 2%, and for the liver to 74%, 23%, and 3%, respectively (Fig 1). Comparing attitudes toward different forms of donation, significant differences were observed (P ⬍ .001): attitudes were more positive toward xenotransplant (74%) and living partner donation (88% kidney and 74% liver), and less positive toward nonpartner living donation (28% kidney and 21% liver). There also was a notable percentage of indecision in nonpartner living donation (52% kidney and 54% liver) versus other forms (⬍25% in all others) (P ⬍ .001).
Statistics
Variables Related to Attitudes Toward Animal Organ Donation in Humans
The data were analyzed using descriptive statistics, Student’s t test, and the chi-square test. These analyses were complemented by an
An analysis showed that principally three variables influenced attitudes toward xenotransplantation: level of educa-
Fig 1. Attitude toward animal and human organ donation for human transplantation.
ATTITUDES TOWARD XENOTRANSPLANT
2903
tion; previous experience of donation and/or organ transplantation; and attitude toward cadaveric donation. The attitude was more positive among those who had previous experience with transplantation (P ⫽ .028) and those who had a positive attitude toward cadaveric donation (.007) (Table 1). A profile for someone against xenotransplantation had the following associations: lower level of education (P ⬍ .05); no previous experience in transplantation (P ⫽ .028); and unfavorable attitude toward cadaveric donation (P ⫽ .007). If we compare variables that influence attitude toward different types of donation, we find that the factors that influence xenotransplantation were practically the same as for living organ donation; whether for a partner or not, whereas in cadaveric donation many other factors had an influence (Table 2). DISCUSSION
The idea of xenotransplantation is not new; however, in the last decade of the 20th century, it has been re-adopted for two reasons: first, the extraordinary increase in demand for
organs and the large number of deaths on the waiting list for transplantation; and second, due to new advances in biomedical sciences, particularly in the fields of immunology and genetics with the development of transgenic technology.12 However, although this treatment may be possible in the future, it will be important to know whether the population finds it acceptable or whether it would create a certain social rejection. In the few studies the rates of acceptance of xenotransplants are quite variable, ranging between 40% and 75%.9,13 Our results are in the high range of these values. It is possible that, in the face of an emergency situation, these rates could rise,14 especially without alternative effective treatment. It must be taken into account that healthy individuals generally find it difficult to imagine themselves as being seriously ill to the extent of needing an organ or animal tissue for their own body. This is different among patients who are on the waiting list for a transplant. In a Swedish study on both the general public (n ⫽ 1000) and patients on the waiting list for a kidney transplant (n ⫽ 460), Omnell et al9 observed that acceptance in favor of receiving a xenotransplant was greater among the patients (73% vs 61%). In a study of patients who had received
Table 1. Variables That Influence Opinion Toward Xenotransplantation in the Population Variable
Mean age (41 ⫾ 19 years) Gender Male (n ⫽ 91) Female (n ⫽ 152) D/K* (n ⫽ 2) Marital status Single (n ⫽ 91) Married (n ⫽ 136) Divorced (n ⫽ 3) Widowed (n ⫽ 11) D/K (n ⫽ 4) Level of education Illiterate (n ⫽ 16) Primary (n ⫽ 113) Secondary (n ⫽ 34) Vocational training (n ⫽ 34) University students (n ⫽ 25) D/K (n ⫽ 23) Participation in pro-social activities Yes (n ⫽ 107) No (n ⫽ 138) Manipulation of body Not against (n ⫽ 20) Against (n ⫽ 225) Experience with ODT Yes (n ⫽ 122) No (n ⫽ 123) Cadaveric donation In favor (n ⫽ 148) Against (n ⫽ 17) D/K (n ⫽ 80) *D/K ⫽ Do not know.
In favor xenotransplant, n ⫽ 181 (74%)
Against xenotransplant, n ⫽ 19 (8%)
Undecided, n ⫽ 45 (18%)
P
68 (38%) 111 (61%) 2 (1%)
9 (47%) 10 (53%) 0 (0%)
14 (31%) 31 (69%) 0 (0%)
.840
59 (33%) 106 (59%) 3 (1%) 9 (5%) 4 (2%)
12 (63%) 5 (26%) 0 (0%) 2 (11%) 0 (0%)
20 (44%) 25 (56%) 0 (0%) 0 (0%) 0 (0%)
.052
15 (8%) 85 (47%) ⫺18 (10%) 25 (14%) 19 (10%) 19 (10%)
1 (5%) 9 (47%) ⫹5 (26%) 1 (5%) 2 (11%) 1 (5%)
0 (0%) 19 (42%) ⫹11 (24%) 8 (18%) 4 (9%) 3 (7%)
82 (45%) 99 (55%)
7 (37%) 12 (63%)
18 (40%) 27 (60%)
.690
15 (8%) 166 (92%)
3 (16%) 16 (84%)
2 (5%) 43 (95%)
.506
⫹99 (55%) ⫺82 (45%)
⫺5 (26%) ⫹14 (74%)
18 (40%) 27 (60%)
.028
⫹116 (64%) 11 (6%) 54 (30%)
⫺7 (37%) ⫹5 (26%) 7 (37%)
25 (55%) 1 (2%) 19 (42%)
.007
⬍.05
2904
RIOS, CONESA, RAMÍREZ ET AL Table 2. Variables That Influence Public Opinion Toward the Different Donation Options Cadaveric donation
Living donation
1. Age 2. Educational level
1. Educational level 2. Pro-social activities
3. Pro-social activities
3. Previous experience of donation 4. Attitude toward cadaveric donation
4. Attitude toward cadaveric manipulation 5. Previous experience of donation 6. Knowledge of the concept of brain death
xenografts of any type Lundin15 observed that patients had a pragmatic vision and showed that survival had priority over ethical doubts. Our rates of acceptance of xenotransplant are the highest of those described in the studies in our bibliography. In a Swedish study done in 1996 among 1500 inhabitants between 18 and 70 years of age, Sanner13 showed that only 40% would accept animal organs. However, it should be emphasized that our data are the most recent, and various studies have shown that these rates are progressively increasing. In this sense, a study of 6127 respondents done by the United States Gallup Organization in 1993,16 showed a favorable attitude of 50%, whereas, in 1997, a similar study17 in 1200 respondents showed an increase to 62%. It is possible that, if repeated nowadays, the percentage would be similar to ours. We have not evaluated attitudes according to the organ studied, although there are studies, such as the one by Schlitt et al,6 showing that the type of organ has less impact on the acceptance of xenotransplantation. In a recent study of the French population, Julvez et al,14 showed results similar to ours were obtained: 74% in favor. Further, a German study by Schlitt et al6 showed that 77% would accept an animal organ, a rate that decreased to 58% if the risk was greater than that of transplantation of a human organ. Factors that influence attitudes toward xenotransplantation are not those that traditionally influence cadaveric donation (Table 2). Thus, we only observed significance with a previous experience of organ donation and/or transplantation, and level of education. There is, however, a clear relationship between the attitude toward cadaveric organ donation and toward xenotransplantation. An association has already been described by investigators such as Omnell et al,8 whereby if a person is in favor of receiving a human organ, he or she is also willing to receive an animal kidney or animal heart—as long as the final result is similar to that obtained by human organs—with the main fears being functional inferiority and disease transmission.6 In relation to the variable of gender, there seems to be a greater acceptance among men,6,13 without a clear relationship to age,6 although Sanner,13 in a study among the Swedish population, showed that young people were most in favor. In our study, the level of education was a signifi-
Living donation for a partner
Xenotransplant
1. Previous experience of donation 2. Attitude toward cadaveric donation
1. Educational level 2. Previous experience of donation 3. Attitude toward cadaveric donation
cant variable, but with a doubtful interpretation, as there were only clear differences with respondents with a lower level of education. However, Sanner13 did show a clear relationship in favor of xenotransplantation among the Swedish population with a higher level of education. Different investigators have shown that the general population favors at least continuing research in this area. Thus, the study by Omnell et al8 showed that 80% of the general public favored continued research into xenotransplantation, with this attitude being greater among patients awaiting a kidney transplant (n ⫽ 460), at 90%. The study by Julvez et al14 showed that the French population (75%) generally believes xenotransplantation will be a biotechnology of the future; 69% suggest that this may be a routine 10 years. When we compare all organ donation options for transplant, if animal donation was possible and if it showed similar results to those obtained by human organs, it would be a preferred option. Our findings do not coincide the results obtained by Sanner,18 who showed that animal organs would currently be the least preferred ones for transplantation in humans. In conclusion, in the general public, favorable attitudes toward xenotransplantation are greater than toward cadaveric donation, if the results were similar to those obtained with human organs. Such a belief is related to the attitudes toward human donation and is not influenced by many traditional factors. REFERENCES 1. Appel JZ III, Alwayn IP, Cooper DK: Xenotransplantation: the challenge to current psychosocial attitudes. Progr Transplant 10:217, 2000 2. Beschomer WE, Sudan DL, Radio SJ, et al: Heart xenograft survival chimeric pig donors and modest immune suppression. Ann Surg 237:265, 2003 3. Butier D: Poll reveals backing for xenotransplants. Nature 591:315, 1998 4. Ramı´rez P, Rı´os A, Yélamos J, et al: Estado actual del xenotransplante de órganos. Cir Esp 72:222, 2002 5. Mohacsi PJ, Thompson JF, Nicholson JK, et al: Patients’ attitudes to xenotransplantation. Lancet 349:1031, 1997 6. Schlitt HK, Brunkhorst R, Haverich A, et al: Attitude of patients toward transplantation of xenogeneic organs. Langenbeck’s Arch Surg 384:384, 1999
ATTITUDES TOWARD XENOTRANSPLANT 7. Arundell MA, McKenzie IFC: The acceptability of pig organ xenografts to patients awaiting a transplant. Xenotransplantation 4:62, 1997 8. Omnell M, Persson NH, Ranstam J, et al: Xenotransplantation public perceptions: rather cells than organs. Xenotransplantation 10:72, 2003 9. Omnell M, Persson NH, Ranstam J, et al: Attitudes toward xenotransplantation—patients waiting for transplantation versus the general public. Transplant Int 14:334, 2001 10. Conesa C, Rı´os A, Ramı´rez P, et al: Psychosocial profile in favour of organ donation. Transplant Proc 35:1276, 2003 11. Conesa C, Rı´os A, Ramı´rez P, et al: La población ante una nueva realidad del trasplante: el donante vivo. Encuesta de opinión. Cir Esp 74:228, 2003 12. White DJ, Yannoutsos N: Production of pigs transgenic for human DAF to overcome complement mediated hyperacute xenograft rejection in man. Res Inmunol 147:88, 1996
2905 13. Sanner MA: Giving and taking—to whom and from whom? People’s attitudes toward transplantation of organs and tissue from different sources. Clin Transplant 12:530, 1998 14. Julvez J, Tuppin P, Cardoso J, et al: “Population and xenograft” investigation. Preliminary results [in French]. Pathol Biol (Paris) 48:415, 2000 15. Lundin S: The boundless body: cultural perspectives on xenotransplantation. Ethnos 64:5, 1999 16. The Gallup Organization, Inc: The American public’s attitudes toward organ donation and transplantation Boston: Partnership for Organ Donation; 1993 17. National Kidney Foundation: Executive summary: Public and professional attitudes toward xenotransplantation and other options to increase organ availability. Richmond, Virginia: Southeastern Institute of Research, Inc; 1997 18. Sanner MA: People’s feelings and ideas about receiving transplants of different origins— questions of life and death, identity, and nature’s border. Clin Transplant 15:19, 2001
G
IVEN the limited number of available transplant organs, xenotransplantation, as an alternative, has received considerable attention in recent years, as it would create an unlimited supply of organs. Advances in immunosuppression and genetic engineering techniques, together with chimerism, make this technique ever more viable and valid.1–3 Although xenotransplantation would minimize the waiting time to obtain an organ, it could cause various psychosocial problems with regard to reintegration of patients into society, xenozoonoses, etc, and may even inspire fear and controversy. Some patients might experience psychologic changes due to the incorporation of animal organs into their body.1,4
There are few data, however, pertaining to how the population would accept this treatment, especially after recent incidents like “avian influenza,” “SARS disease,”
From the Coordinación Regional de Trasplantes de la Comunidad Autónoma de Murcia, Murcia, Spain (A.R.R., C.C.B., P.R., M.M.R.); Centro de Salud de Fortuna, Murcia, Spain (C.C.C.); and Departamento de Cirugı´a, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain (A.R.R., P.R., P.P.). Address reprint requests to Dr Antonio Rı´os Zambudio, Avenida de la Libertad 208, Casillas 30007, Murcia, Espan˜a. E-mail: [email protected]
© 2004 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/04/$–see front matter doi:10.1016/j.transproceed.2004.11.012
Transplantation Proceedings, 36, 2901–2905 (2004)
2901
2902
etc, for which the origin of the infection was animals. Furthermore, most studies providing analyses of this attitude used patients with transplants or those awaiting transplant,5–7 with few studies evaluating the attitude of the general public.8,9 Our objective was to assess the public attitude toward xenotransplantation of organs and to compare it with the existing attitude toward human cadaveric or living donation. MATERIALS AND METHODS Population Study A random sample of 250 individuals was obtained among the population aged ⱖ15 years from an urban area in our autonomous community. Between January and August 2001, an opinion survey was circulated, with a completion rate of 98% (n ⫽ 245). The average age of the respondents was 41 ⫾ 19 years, with 62% (n ⫽ 152) women and 38% men. Overall, 55% (n ⫽ 136) were married, 47% (n ⫽ 116) had educational studies at an average or higher level, and 50% (n ⫽ 122) claimed to know or to have known transplant donors or recipients.
Opinion Survey and Variables Studied Opinions were evaluated using a 30-page survey with multiplechoice answers, validated in our geographic surroundings based on previous studies of cadaveric donation,10 living donation,11 and xenotransplantation.9 This survey was self-administered with the process arranged by members of the regional transplant Coordination center. The analyzed variables included: (1) psychosocial variables (age, gender, marital status, level of education, knowledge of donors and transplant patients, participation in pro-social activities and opinion toward cadaveric manipulation); (2) attitude toward human donation (cadaveric, living kidney, and living liver); and (3) attitude toward donation of animal organs (xenotransplant), supposing results similar to those for human organ donation.
RIOS, CONESA, RAMÍREZ ET AL analysis of residues or, if necessary, Fisher’s Exact test. Differences were considered significant at below P ⬍ .05.
RESULTS Attitude Toward Different Types of Donation
As for animal organ donation to humans, if the results could be superimposed on those achieved by human organs, 74% would be in favor, 18% undecided, and the remaining 8% against. The responses with regard to human donation varied according to the type of donor and organ. Thus, with respect to cadaveric donation, 60% were in favor, 7% undecided, and 33% against. However, for living donation, the attitude varied according to whether it was a kidney or a liver transplant and whether it was for a relative. Thus, the attitude toward nonrelated living kidney donation was positive in 28%, undecided in 52%, and negative in 20%, with the percentages for liver being 21%, 54%, and 25%, respectively. When the living donation was considered as being for a partner (family member or intimate friend), the percentages change for the kidney to 88%, 10%, and 2%, and for the liver to 74%, 23%, and 3%, respectively (Fig 1). Comparing attitudes toward different forms of donation, significant differences were observed (P ⬍ .001): attitudes were more positive toward xenotransplant (74%) and living partner donation (88% kidney and 74% liver), and less positive toward nonpartner living donation (28% kidney and 21% liver). There also was a notable percentage of indecision in nonpartner living donation (52% kidney and 54% liver) versus other forms (⬍25% in all others) (P ⬍ .001).
Statistics
Variables Related to Attitudes Toward Animal Organ Donation in Humans
The data were analyzed using descriptive statistics, Student’s t test, and the chi-square test. These analyses were complemented by an
An analysis showed that principally three variables influenced attitudes toward xenotransplantation: level of educa-
Fig 1. Attitude toward animal and human organ donation for human transplantation.
ATTITUDES TOWARD XENOTRANSPLANT
2903
tion; previous experience of donation and/or organ transplantation; and attitude toward cadaveric donation. The attitude was more positive among those who had previous experience with transplantation (P ⫽ .028) and those who had a positive attitude toward cadaveric donation (.007) (Table 1). A profile for someone against xenotransplantation had the following associations: lower level of education (P ⬍ .05); no previous experience in transplantation (P ⫽ .028); and unfavorable attitude toward cadaveric donation (P ⫽ .007). If we compare variables that influence attitude toward different types of donation, we find that the factors that influence xenotransplantation were practically the same as for living organ donation; whether for a partner or not, whereas in cadaveric donation many other factors had an influence (Table 2). DISCUSSION
The idea of xenotransplantation is not new; however, in the last decade of the 20th century, it has been re-adopted for two reasons: first, the extraordinary increase in demand for
organs and the large number of deaths on the waiting list for transplantation; and second, due to new advances in biomedical sciences, particularly in the fields of immunology and genetics with the development of transgenic technology.12 However, although this treatment may be possible in the future, it will be important to know whether the population finds it acceptable or whether it would create a certain social rejection. In the few studies the rates of acceptance of xenotransplants are quite variable, ranging between 40% and 75%.9,13 Our results are in the high range of these values. It is possible that, in the face of an emergency situation, these rates could rise,14 especially without alternative effective treatment. It must be taken into account that healthy individuals generally find it difficult to imagine themselves as being seriously ill to the extent of needing an organ or animal tissue for their own body. This is different among patients who are on the waiting list for a transplant. In a Swedish study on both the general public (n ⫽ 1000) and patients on the waiting list for a kidney transplant (n ⫽ 460), Omnell et al9 observed that acceptance in favor of receiving a xenotransplant was greater among the patients (73% vs 61%). In a study of patients who had received
Table 1. Variables That Influence Opinion Toward Xenotransplantation in the Population Variable
Mean age (41 ⫾ 19 years) Gender Male (n ⫽ 91) Female (n ⫽ 152) D/K* (n ⫽ 2) Marital status Single (n ⫽ 91) Married (n ⫽ 136) Divorced (n ⫽ 3) Widowed (n ⫽ 11) D/K (n ⫽ 4) Level of education Illiterate (n ⫽ 16) Primary (n ⫽ 113) Secondary (n ⫽ 34) Vocational training (n ⫽ 34) University students (n ⫽ 25) D/K (n ⫽ 23) Participation in pro-social activities Yes (n ⫽ 107) No (n ⫽ 138) Manipulation of body Not against (n ⫽ 20) Against (n ⫽ 225) Experience with ODT Yes (n ⫽ 122) No (n ⫽ 123) Cadaveric donation In favor (n ⫽ 148) Against (n ⫽ 17) D/K (n ⫽ 80) *D/K ⫽ Do not know.
In favor xenotransplant, n ⫽ 181 (74%)
Against xenotransplant, n ⫽ 19 (8%)
Undecided, n ⫽ 45 (18%)
P
68 (38%) 111 (61%) 2 (1%)
9 (47%) 10 (53%) 0 (0%)
14 (31%) 31 (69%) 0 (0%)
.840
59 (33%) 106 (59%) 3 (1%) 9 (5%) 4 (2%)
12 (63%) 5 (26%) 0 (0%) 2 (11%) 0 (0%)
20 (44%) 25 (56%) 0 (0%) 0 (0%) 0 (0%)
.052
15 (8%) 85 (47%) ⫺18 (10%) 25 (14%) 19 (10%) 19 (10%)
1 (5%) 9 (47%) ⫹5 (26%) 1 (5%) 2 (11%) 1 (5%)
0 (0%) 19 (42%) ⫹11 (24%) 8 (18%) 4 (9%) 3 (7%)
82 (45%) 99 (55%)
7 (37%) 12 (63%)
18 (40%) 27 (60%)
.690
15 (8%) 166 (92%)
3 (16%) 16 (84%)
2 (5%) 43 (95%)
.506
⫹99 (55%) ⫺82 (45%)
⫺5 (26%) ⫹14 (74%)
18 (40%) 27 (60%)
.028
⫹116 (64%) 11 (6%) 54 (30%)
⫺7 (37%) ⫹5 (26%) 7 (37%)
25 (55%) 1 (2%) 19 (42%)
.007
⬍.05
2904
RIOS, CONESA, RAMÍREZ ET AL Table 2. Variables That Influence Public Opinion Toward the Different Donation Options Cadaveric donation
Living donation
1. Age 2. Educational level
1. Educational level 2. Pro-social activities
3. Pro-social activities
3. Previous experience of donation 4. Attitude toward cadaveric donation
4. Attitude toward cadaveric manipulation 5. Previous experience of donation 6. Knowledge of the concept of brain death
xenografts of any type Lundin15 observed that patients had a pragmatic vision and showed that survival had priority over ethical doubts. Our rates of acceptance of xenotransplant are the highest of those described in the studies in our bibliography. In a Swedish study done in 1996 among 1500 inhabitants between 18 and 70 years of age, Sanner13 showed that only 40% would accept animal organs. However, it should be emphasized that our data are the most recent, and various studies have shown that these rates are progressively increasing. In this sense, a study of 6127 respondents done by the United States Gallup Organization in 1993,16 showed a favorable attitude of 50%, whereas, in 1997, a similar study17 in 1200 respondents showed an increase to 62%. It is possible that, if repeated nowadays, the percentage would be similar to ours. We have not evaluated attitudes according to the organ studied, although there are studies, such as the one by Schlitt et al,6 showing that the type of organ has less impact on the acceptance of xenotransplantation. In a recent study of the French population, Julvez et al,14 showed results similar to ours were obtained: 74% in favor. Further, a German study by Schlitt et al6 showed that 77% would accept an animal organ, a rate that decreased to 58% if the risk was greater than that of transplantation of a human organ. Factors that influence attitudes toward xenotransplantation are not those that traditionally influence cadaveric donation (Table 2). Thus, we only observed significance with a previous experience of organ donation and/or transplantation, and level of education. There is, however, a clear relationship between the attitude toward cadaveric organ donation and toward xenotransplantation. An association has already been described by investigators such as Omnell et al,8 whereby if a person is in favor of receiving a human organ, he or she is also willing to receive an animal kidney or animal heart—as long as the final result is similar to that obtained by human organs—with the main fears being functional inferiority and disease transmission.6 In relation to the variable of gender, there seems to be a greater acceptance among men,6,13 without a clear relationship to age,6 although Sanner,13 in a study among the Swedish population, showed that young people were most in favor. In our study, the level of education was a signifi-
Living donation for a partner
Xenotransplant
1. Previous experience of donation 2. Attitude toward cadaveric donation
1. Educational level 2. Previous experience of donation 3. Attitude toward cadaveric donation
cant variable, but with a doubtful interpretation, as there were only clear differences with respondents with a lower level of education. However, Sanner13 did show a clear relationship in favor of xenotransplantation among the Swedish population with a higher level of education. Different investigators have shown that the general population favors at least continuing research in this area. Thus, the study by Omnell et al8 showed that 80% of the general public favored continued research into xenotransplantation, with this attitude being greater among patients awaiting a kidney transplant (n ⫽ 460), at 90%. The study by Julvez et al14 showed that the French population (75%) generally believes xenotransplantation will be a biotechnology of the future; 69% suggest that this may be a routine 10 years. When we compare all organ donation options for transplant, if animal donation was possible and if it showed similar results to those obtained by human organs, it would be a preferred option. Our findings do not coincide the results obtained by Sanner,18 who showed that animal organs would currently be the least preferred ones for transplantation in humans. In conclusion, in the general public, favorable attitudes toward xenotransplantation are greater than toward cadaveric donation, if the results were similar to those obtained with human organs. Such a belief is related to the attitudes toward human donation and is not influenced by many traditional factors. REFERENCES 1. Appel JZ III, Alwayn IP, Cooper DK: Xenotransplantation: the challenge to current psychosocial attitudes. Progr Transplant 10:217, 2000 2. Beschomer WE, Sudan DL, Radio SJ, et al: Heart xenograft survival chimeric pig donors and modest immune suppression. Ann Surg 237:265, 2003 3. Butier D: Poll reveals backing for xenotransplants. Nature 591:315, 1998 4. Ramı´rez P, Rı´os A, Yélamos J, et al: Estado actual del xenotransplante de órganos. Cir Esp 72:222, 2002 5. Mohacsi PJ, Thompson JF, Nicholson JK, et al: Patients’ attitudes to xenotransplantation. Lancet 349:1031, 1997 6. Schlitt HK, Brunkhorst R, Haverich A, et al: Attitude of patients toward transplantation of xenogeneic organs. Langenbeck’s Arch Surg 384:384, 1999
ATTITUDES TOWARD XENOTRANSPLANT 7. Arundell MA, McKenzie IFC: The acceptability of pig organ xenografts to patients awaiting a transplant. Xenotransplantation 4:62, 1997 8. Omnell M, Persson NH, Ranstam J, et al: Xenotransplantation public perceptions: rather cells than organs. Xenotransplantation 10:72, 2003 9. Omnell M, Persson NH, Ranstam J, et al: Attitudes toward xenotransplantation—patients waiting for transplantation versus the general public. Transplant Int 14:334, 2001 10. Conesa C, Rı´os A, Ramı´rez P, et al: Psychosocial profile in favour of organ donation. Transplant Proc 35:1276, 2003 11. Conesa C, Rı´os A, Ramı´rez P, et al: La población ante una nueva realidad del trasplante: el donante vivo. Encuesta de opinión. Cir Esp 74:228, 2003 12. White DJ, Yannoutsos N: Production of pigs transgenic for human DAF to overcome complement mediated hyperacute xenograft rejection in man. Res Inmunol 147:88, 1996
2905 13. Sanner MA: Giving and taking—to whom and from whom? People’s attitudes toward transplantation of organs and tissue from different sources. Clin Transplant 12:530, 1998 14. Julvez J, Tuppin P, Cardoso J, et al: “Population and xenograft” investigation. Preliminary results [in French]. Pathol Biol (Paris) 48:415, 2000 15. Lundin S: The boundless body: cultural perspectives on xenotransplantation. Ethnos 64:5, 1999 16. The Gallup Organization, Inc: The American public’s attitudes toward organ donation and transplantation Boston: Partnership for Organ Donation; 1993 17. National Kidney Foundation: Executive summary: Public and professional attitudes toward xenotransplantation and other options to increase organ availability. Richmond, Virginia: Southeastern Institute of Research, Inc; 1997 18. Sanner MA: People’s feelings and ideas about receiving transplants of different origins— questions of life and death, identity, and nature’s border. Clin Transplant 15:19, 2001