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To Share or not to Share? Institutional Exchange of Cadaver Kidneys in Denmark

Published online by Cambridge University Press:  17 May 2012

Søren Bak-Jensen
Søren Bak-Jensen
Affiliation:
University of Copenhagen, Fredericagade 18, DK-1310 Copenhagen K, Denmark; e-mail: sbj@mm.ku.dk
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Information
Medical History , Volume 52 , Issue 1 , 01 January 2008 , pp. 23 - 46
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Copyright © The Author(s) 2008. Published by Cambridge University Press

References

1 On different kinds of donor-recipient exchanges, see Renée C Fox and Judith P Swazey, The courage to fail: a social view of organ transplants and dialysis, University of Chicago Press, 1978, pp. 5–39. Fox and Swazey stress the reciprocity involved in organ donation even when the graft is presented as a gift, and draw on the work by Marcell Mauss on gift exchange. See also Nancy Scheper-Hughes, ‘The global traffic in human organs’, Curr. Anthropol., 2000, 41: 191–224; Margaret Lock, Twice dead: organ transplants and the reinvention of death, Berkeley, University of California Press, 2002, pp. 315–40; Anne Hambro Alnæs, Minding matter: organ donation and medical modernity's difficult decisions, Oslo, Department and Museum of Anthropology, Faculty of Social Sciences, University of Oslo, 2001.

2 Fox and Swazey, op. cit., note 1 above, p. 376; idem, Spare parts: organ replacement in American society, New York, Oxford University Press, 1992.

3 Jeffrey M Prottas, ‘The politics of transplantation’, in B Spielman (ed.), Organ and tissue donation: ethical, legal, and policy issues, Carbondale, Southern Illinois University Press, 1996, pp. 3–18, on p. 5.

4 Prottas, op. cit., note 3 above.

5 Since kidneys from living donors are only rarely exchanged between transplant centres, my focus in the rest of this article is exclusively on the allocation of kidneys from deceased donors. Systematic institutional exchange of kidneys from living donors has been suggested, see, for example, Ejvind Kemp, Jørn Giese, and Paul Peter Leyssac, Clinical transplantation, xenotransplantation and stem cell medicine, Copenhagen, Munksgaard, 2003, pp. 18–20; E S Woodle, ‘A history of living donor transplantation: from twins to trades’, Transplant. Proc., 2003, 35: 901–2.

6 The history of kidney transplantations in Denmark is presented in Eva Bundegaard, Danske nyretransplantationer: om pionerer og idealister, Copenhagen, Dansk Nefrologisk Selskab, 1999. For a comparative overview of developments in different European countries, see Michael A Bos, The diffusion of heart and liver transplantation across Europe, London, King's Fund Centre, 1991.

7 Jørn Hess Thaysen, Dialyse og nyretransplantation. Organisation af behandling. Indberetning nr. 3 fra sundhedsstyrelsens dialyse og nyretransplantationsudvalg, Copenhagen, Sundhedsstyrelsen, 1980, p. 30.

8 Melvin Madsen, et al., ‘Application of human leukocyte antigen matching in the allocation of kidneys from cadaveric organ donors in the Nordic countries’, Transplantation, 2004, 77: 621–3; Melvin Madsen, ‘Scandiatransplant: Nordic collaboration in organ transplantation’, in S A Birkeland (ed.), Transplantation in Denmark, Odense, The Danish Society for Transplantation, 1997, pp. 76–83.

9 In contrast, transplant centres in the USA went through somewhat opposite development during those same years, with more kidneys being exchanged in the late 1980s than in the 1970s, where the centres procured organs almost exclusively for their own use. Prottas, op. cit., note 3 above, p. 6; Alan Ting and Leah Bennett Edwards, ‘Human leukocyte antigen in the allocation of kidneys from cadaveric donors in the United States’, Transplantation, 2004, 77: 610–33. See also Guenter B Risse, Mending bodies, saving souls: a history of hospitals, New York, Oxford University Press, 1999, pp. 571–2.

10 Rudolph Pichlmayr, ‘10 Jahre Eurotransplant. Rückblick, Gegenwart und Zukunft von Transplantationen’, Fortschritte der Medizin, 1977, 95: 2789; Jon J van Rood, ‘The Eurotransplant story. Part 1: The beginning’, Dialysis & Transplantation, 1982, 11: 515–20; J A van der Does, ‘The Eurotransplant story. Part 2: 1967, the year Eurotransplant started’, Dialysis & Transplantation, 1982, 11: 520–5; H M A Schippers, ‘The Eurotransplant story. Part 3: The first years of the Eurotransplant Foundation’, Dialysis & Transplantation, 1982, 11: 525–8; Bernard Cohen and Guido G Persijn, ‘Twenty-five years of eurotransplant: a truly European collaboration’, Clinical Transplants, 1992, 109–18; Ilias I N Doxiadis, et al., ‘It takes six to boogie: allocating cadaver kidneys in Eurotransplant’, Transplantation, 2004, 77: 615–17; Jean Dausset, ‘L'association France-Transplant’, Nouvelle Presse Médicale, 1972, 1: 2247; idem, ‘The HLA adventure’, in P I Terasaki (ed.), History of HLA: ten recollections, Los Angeles, UCLA Tissue Typing Laboratory, 1990, pp. 1–17, on p. 8; Odile Burrus, ‘France-Transplant’, Revue de l'Infirmière, 1989, 7: 59–63. See also Gauke Kootstra, ‘The history of organ donation and sharing’, in N S Hakim and V E Papalois (eds), History of organ and cell transplantation, London, Imperial College Press, 2003, pp. 55–63.

11 Ingo Braun and Bernward Joerges, How to recombine large technical systems: the case of European organ transplantation, Berlin, Wissenschaftszentrum Berlin für Sozialforschung, 1993, pp. 27–9; Doxiadis, et al., op. cit., note 10 above; Lars U Lamm, A report on the central organisation of transplantation in three European regions, The Nordic Transplantation Committee and The Nordic Council of Ministers, 1988, p. 19.

12 Bos, op. cit., note 6 above, p. 77.

13 In this respect, Scandiatransplant may be pointing the way for the future of many organ exchange organizations, see Peter J Morris and Anthony P Monaco, ‘HLA in the allocation of cadaver kidneys: a global perspective’, Transplantation, 2004, 77: 608.

14 Audun Flatmark, ‘Scandiatransplant 20 years’, Tissue Antigens, 1989, 34: 30–4, on p. 33; Madsen, et al., op. cit., note 8 above, p. 621.

15 Leslie Brent, A history of transplantation immunology, San Diego, Academic Press, 1997, pp. 315–18. See also Nicholas L Tilney, Transplant: from myth to reality, New Haven, Yale University Press, 2003, pp. 229–43; Thomas E Starzl, The puzzle people: memoirs of a transplant surgeon, University of Pittsburgh Press, 1992, pp. 209–14.

16 Ingo Braun, Günter Feuerstein, and Claudia von Grote-Janz, ‘Organ-Technik. Technik und Wissenschaft im Organtransplantationswesen’, Soziale Welt, 1991, 42: 445–72, on p. 457; Braun and Joerges, op. cit., note 11 above, p. 26.

17 Ilana Löwy, ‘Tissue groups and cadaver kidney sharing: socio-cultural aspects of a medical controversy’, Int. J. Technol. Assess. Health Care, 1986, 2: 195–218, on p. 208.

18 Anne-Marie Moulin, Le dernier langage de la médecine. Histoire de l'immunologie de Pasteur au Sida, Paris, Presses Universitaires de France, 1991, pp. 217–18. See also Kootstra, op. cit., note 10 above, p. 62.

19 See the contributions in John V Pickstone (ed.), Medical innovations in historical perspective, Basingstoke, Macmillan, 1992; Ilana Löwy (ed.), Medicine and change: historical and sociological studies of medical innovation, Montrouge, John Libbey Eurotext, and Paris, INSERM, 1993; and Jennifer Stanton (ed.), Innovations in health and medicine, London, Routledge, 2002.

20 John V Pickstone, ‘Introduction’, Pickstone, op. cit., note 19 above, pp. 1–16; Ilana Löwy, ‘Introduction: Medicine and change’, Löwy, op. cit., note 19 above, pp. 1–20; Jennifer Stanton, ‘Introduction: On theory and practice’, Stanton, op. cit., note 19 above, pp. 1–18.

21 Prottas, op. cit., note 3 above; Christian Hiesse, Fabienne Pessione, and Didier Houssin, ‘The case to abandon human leukocyte antigen matching for kidney allocation: would it be wise to throw out the baby with the bathwater?’, Transplantation, 2004, 77: 623–6.

22 Jean Dausset, Clin d'oeil à la vie. La grande aventure HLA, Paris, Odile Jacob, 1998, pp. 178–9. See also Starzl, op. cit., note 15 above, pp. 118–24; Tilney, op. cit., note 15 above, pp. 138–9.

23 Löwy, op. cit., note 17 above, p. 204.

24 Moulin, op. cit., note 18 above, p. 223: “la cyclosporine a rejeté dans le passé historique la recherche de la compatibilité à tout prix”.

25 Ilana Löwy, ‘Choix scientifiques et choix éthiques dans le traitement de la maladie rénale terminale’, Social Science Information/ Information sur les sciences sociales, 1987, 26: 577–605, on p. 592: “se débarrasser des contraintes propres à une distribution centralisée d'organes”.

26 Stanton, op. cit., note 20 above, p. 4.

27 Löwy also conducted interviews with participants in the debate over tissue typing, but she seems to favour written sources for the kind of questions she examines, see op. cit., note 17 above, pp. 196–7.

28 ‘Med helikopter for at få ny nyre’, Jyllands-Posten, 24 Nov. 1971, p. 1; ‘Til hospital med helikopter’, Thisted Dagblad, 24 Nov. 1971, p. 5; ‘Dreng fra Ty blev fløjet til en ny nyre’, Aalborg Stiftstidende, 24 Nov. 1971, p. 3. Arne W S Sørensen, interview by author, 14 Dec. 2005. Sørensen (b. 1926), a nephrologist, headed the dialysis department at Aalborg Sygehus Syd from 1970 to 1995.

29 Moulin, op. cit., note 18 above, pp. 179–80.

30 Tilney, op. cit., note 15 above, pp. 67–75, 129–32.

31 Brent, op. cit., note 15 above, pp. 310–15.

32 Risse, op. cit., note 9 above, p. 588.

33 ‘Hvordan det blev muligt at give syge en ny nyre’, Politiken, 31 May 1964; Bundegaard, op. cit., note 6 above, pp. 24–30.

34 Flemming Kissmeyer-Nielsen et al., ‘Nyretransplantation IV. Immunologiske aspekter’, Ugeskrift for Læger, 1966, 128: 757–69, on p. 766: “at anvendelsen af udvalgte donorer, der kun afviger fra recipienten for få leukocytantigeners vedkommende giver bedre kliniske resultater”.

35 Thomas Schlich, Die Erfindung der Organtransplantation. Erfolg und Scheitern des chirurgischen Organersatzes (1880–1930), Frankfurt/Main, Campus, 1998; Brent, op. cit., note 15 above, pp. 56–63; Tilney, op. cit., note 15 above, pp. 36–43.

36 Experiments quite similar to Simonsen's were carried out simultaneously by William Dempster in London, see Tilney, op. cit., note 15 above, pp. 109–12; Brent, op. cit., note 15 above, pp. 307, 348. See also Morten Simonsen, ‘Immunologi’, in J C Melchior, E Andreasen, K Brøchner-Mortensen, A Gjedde, V Møller-Christensen, and D Trolle (eds), Københavns Universitet 1479–1979. Det lægevidenskabelige Fakultet, University of Copenhagen, 1979, pp. 493–8, on pp. 496–7.

37 Morten Simonsen, ‘Historien om en tom etage’, Ugeskrift for Læger, 1964, 126: 1590–7; idem, op. cit., note 36 above, pp. 496–7.

38 Paul I Terasaki, ‘History of HLA: a personalized view’, in Terasaki (ed.), op. cit., note 10 above, pp. 213–69, on pp. 220–1.

39 Brent, op. cit., note 15 above, pp. 138–42; Tilney, op. cit., note 15 above, pp. 135–9. For “le psychodrame” of nomenclature, see Dausset, op. cit., note 22 above, pp. 104–6.

40 Brent, op. cit., note 15 above, pp. 153–5.

41 Starzl, op. cit., note 15 above, p. 120.

42 Morten Simonsen, ‘Strong transplantation antigens in man’, Lancet, 1965, i: 415–18.

43 Ibid., p. 415. In Danish newspapers, Simonsen also foresaw that organ transplantations might soon become as simple and predictable as putting a new spare part in your car, see “Vi bliver som biler—alt kan skiftes ud”, Politiken, 30 May 1965, pp. 1–2.

44 Moulin, op. cit., note 18 above, pp. 213–14. See also Hiesse, Pessione, and Houssin, op. cit., note 21 above, p. 623, on “the dogma of HLA matching”.

45 Löwy, op. cit., note 25 above, p. 591.

46 Arne Svejgaard, et al., ‘HL-A haplotypes frequencies in Denmark and Norway’, Tissue Antigens, 1971, 1: 184–95.

47 Brent, op. cit., note 15 above, p. 138.

48 Jon J van Rood, ‘A proposal for international cooperation in organ transplantation: Eurotransplant’, in E S Curtoni, P L Mattiuz, and R M Tosi (eds), Histocompatibility testing 1967, Copenhagen, Munksgaard, 1967, pp. 451–2.

49 Ibid., p. 451. See also idem, op. cit., note 10 above.

50 van der Does, op. cit., note 10 above.

51 Flemming Kissmeyer-Nielsen and Arne Svejgaard, ‘The early history of HLA’, in Terasaki (ed.), op. cit. note 10 above, pp. 151–75.

52 Flemming Kissmeyer-Nielsen and K E Kjerbye, ‘Lymphocytotoxic micro-technique purification of lymphocytes by flotation’, in Curtoni, Mattiuz, and Tosi (eds), op. cit., note 48 above, pp. 381–3. On the importance of this technique for Eurotransplant, see Jon J van Rood, ‘HLA and I’, Annu. Rev. Immunol., 1993, 11: 1–28, on pp. 23–4.

53 The Steno Institute Library, University of Aarhus (hereafter SIL), Love, betænkninger, korrespondancer, mødereferater vedrørende nyretransplantationer i Danmark 1953–1985, arkiv efter Jørn Hess Thaysen (hereafter JHT), Flemming Kissmeyer-Nielsen, ‘Om udvælgelse af patienter til nyretransplantation’ [1967].

54 Flemming Kissmeyer-Nielsen, Transplantation af menneskelige organer, Copenhagen, Munksgaard, 1968, p. 66. SIL, JHT, Flemming Kissmeyer-Nielsen, ‘Udveksling af organer’, August 1968.

55 Flemming Kissmeyer-Nielsen, ‘Vævstypebestemmelser og transplantationer’, Nordisk Medicin, 1970, 83: 205–8; Björn L Lindström, ‘Nordiskt transplantationssamarbete’, Nordisk Medicin, 1970, 83: 532–4. See also idem, ‘The Scandiatransplant organization’, Annales Chirurgiae et Gynaecologiae Fenniae, 1973, 62: 175–7; idem, ‘Scandiatransplant and the Nordic committee of experts on transplantation’, Scand. J. Urol. Nephrol. Suppl., 1981, 64: 8–11; Flemming Kissmeyer-Nielsen, Transplantation af menneskelige organer, Copenhagen, FADL, 1979, p. 69; idem, ‘Scandiatransplant – evolution and development’, Transplant. Proc., 1982, 14: 205–8; Flatmark, op. cit., note 14 above.

56 Flemming Kissmeyer-Nielsen, et al., ‘Scandiatransplant: preliminary report of a kidney exchange program’, Transplant. Proc., 1971, 3: 1019–29, on p. 1022.

57 Jørn Hess Thaysen, ‘Indberetning nr. 2 til Sundhedsstyrelsen fra det under Sundhedsstyrelsen nedsatte udvalg vedrørende organisation af dialyse og nyretransplantationsbehandling i Danmark’, Fra Sundhedsstyrelsen, 1973, 6: 109–16, on p. 112.

58 SIL, JHT, letter from Flemming Kissmeyer-Nielsen to the Committee on Dialysis and Transplantation, 14 Apr. 1970.

59 See, for example, ‘To nyrer fløjet fra USA til Danmark’, Ekstra Bladet, 18 May 1977, p. 17.

60 Flemming Kissmeyer-Nielsen and K E Kjerbye, ‘Scandiatransplant: a visual matching system’, P I Terasaki (ed.), Histocompatibility testing 1970, Copenhagen, Munksgaard, 1970, 639–41.

61 Melvin Madsen, ‘Scandiatransplant: Nordisk samarbejde om organtransplantation’, Tidsskrift for danske sygehuse, 1994, 70: 18–20.

62 Braun and Joerges, op. cit., note 11 above.

63 Flemming Kissmeyer-Nielsen, ‘The HL-A system and tenal transplantation’, Tissue Antigens, 1971, 1: 53–6, on p. 53; Flemming Kissmeyer-Nielsen and Egill Snorrason, Den humane transplantations kunst. Dens udvikling og nuværende stade, Copenhagen, Mølnlycke A/S, 1972, p. 81.

64 Jørgen Mielche, ‘Scandiatransplant: a matter of life and death’, Danish Journal, 1970, 68: 14–17.

65 ‘Nyre pr. fly fra Göteborg til ÅÅrhuspatient’, Politiken, 1 Mar. 1969, p. 1. ‘Svensk nyre pr. fly til Danmark’, Aalborg Stiftstidende, 16 Jan. 1970, p. 1.

66 ‘En utrolig læge-indsats gør det umulige muligt’, Politiken, 27 Apr. 1969, p. 37. See also ‘Verdens-centrum for bytte af nyrer’, Politiken, 29 Apr. 1969, p. 4. On the plans for a global kidney exchange organization, see also Löwy, op. cit., note 17 above, p. 208.

67 ‘Nu haster det’, Politiken, 29 Apr. 1969, p. 18.

68 Mielche, op. cit., note 64 above; Flemming Kissmeyer-Nielsen, ‘Humane transplantationer i relation til fremtidens medicin’, Medicinsk Forum, 1969, 22: 69–76; idem, ‘Nyretransplantationer og vævsforliglighed’, Tidsskrift for sygeplejersker, 1971, 71: 52–57; idem, Transplantation af menneskelige organer, op. cit., note 55 above.

69 On Kissmeyer-Nielsen's role as communicator of the importance of immunogenetics to young researchers and to the public, see Hans E Johnsen, et al., ‘Flemming Kissmeyer-Nielsen’, Ugeskrift for Læger, 1991, 154: 48.

70 ‘Betænkning afgivet af det under Sundhedsstyrelsen nedsatte udvalg vedrørende organisationen af behandling med dialyse (“kunstig nyre”) og nyretransplantation i Danmark’, Fra Sundhedsstyrelsen, 1969, 5: 5–10, on p. 8: “regionalt samarbejde”.

71 Moulin, op. cit., note 18 above, p. 216.

72 Kissmeyer-Nielsen and Snorrason, op. cit., note 63 above, p. 72: “Selv om andre forhold i visse tilfælde påvirker valg af recipient og donor, er det væsentlige dog vævstyperne hos recipient og donor, og det har derfor været naturligt, at det er blevet vævstypelaboratorierne i regionen, som er det centrale kommunikationsled, der finder frem til de bedst egnede recipienter og etablerer fornøden kontakt mellem donor- og recipientcentrene.”

73 Kissmeyer-Nielsen and Snorrason, op. cit., note 63 above, p. 61. See also ‘Betænkning’, op. cit., note 70 above, p. 7.

74 For the argument that the relevance of an object to scientific interest depends on the expectation that unanticipated observations may come from it, see Hans-Jörg Rheinberger, ‘Cytoplasmic particles: the trajectory of a scientific object’, in L Daston (ed.), Biographies of scientific objects, University of Chicago Press, 2000, pp. 270–94, on p. 273.

75 Beretning om de pr. 1. oktober oprettede Statens naturvidenskabelige Forskningsråd, Statens lægevidenskabelige Forskningsråd, Statens jordbrugs- og veterinærvidenskabelige Forskningsråd, Statens samfundsvidenskabelige Forskningsråd og Forskningsrådenes Centraludvalg i tiden 1. oktober 1968 til 31. marts 1970, Forskningssekretariatet, 1971, pp. 65–7.

76 Arne W S Sørensen, interview by author, 14 Dec. 2005.

77 Löwy, op. cit., note 17 above; Moulin, op. cit., note 18 above, pp. 215–24; Tilney, op. cit., note 15 above, pp. 137–9; Brent, op. cit., note 15 above, pp. 156–9.

78 Terasaki, op. cit., note 38 above, p. 232.

79 Starzl, op. cit., note 15 above, p. 122; Brent, op. cit., note 15 above, p. 156.

80 Starzl, op. cit., note 15 above, p. 122; Transplantation today. Proceedings of the Third International Congress of the Transplantation Society. September 7–11, 1970, The Hague, The Netherlands, New York, Grune & Stratton, 1971.

81 M R Mickey, et al., ‘Analysis of HL-A incompatibility in human renal transplants’, Tissue Antigens, 1971, 1: 57–67.

82 Kissmeyer-Nielsen, op. cit., note 63 above, p. 56.

83 Mickey, et al., op. cit., note 81 above, p. 57.

84 Kissmeyer-Nielsen, op. cit., note 63 above, p. 55.

85 Ibid., p. 53 and 56. For other reactions to Terasaki's paper, see Löwy, op. cit., note 17 above, p. 201.

86 Melvin Madsen, interview by author, 13 Oct. 2005; Arne Svejgaard, interview by author, 10 May 2006. Melvin Madsen (1950–2006) specialized in nephrology but worked extensively within clinical immunology as well. He joined the tissue type laboratory at Århus Municipal Hospital in 1977 to do research on HLA-DR, and left to pursue a clinical career in 1982. He was the director of Scandiatransplant from 1992 to 1998. Arne Svejgaard (b. 1937) joined the Blood Bank at Århus Municipal Hospital in 1965 and did early work on histocompatibility testing with Flemming Kissmeyer-Nielsen. In 1971, Svejgaard established the tissue type laboratory at the National Hospital in Copenhagen, which he continues to head.

87 Madsen, et al., op. cit., note 8 above, p. 621.

88 Lars Erik Gelin and Audun Flatmark, ‘Present and future aspects of kidney transplantation in Scandinavia’, Scand. J. Urol. Nephrol. Suppl., 1977, 42: 213–14. SIL, JHT, Minutes from meeting of the Committee on Dialysis and Transplantation (hereafter CDT), 21 Nov. 1972.

89 Madsen, et al., op. cit., note 8 above, p. 621.

90 Kissmeyer-Nielsen, ‘The HL-A system’, op. cit., note 63 above, pp. 55–6.

91 Idem, ‘Scandiatransplant – evolution and development’, op. cit., note 55 above.

92 Thaysen, op. cit., note 57 above, p. 113: “en væsentligt mindre rolle”.

93 Dausset, op. cit., note 22 above, pp. 178–9.

94 Tilney, op. cit., note 15 above, p. 138.

95 Nora Machado, ‘Incongruence and tension in complex organisations: the case of an organ transplantation system’, Human Systems Management, 1996, 15: 55–70, on pp. 64–5. On this tension, see also Prottas, op. cit., note 3 above.

96 A negative cross match, proving that the recipient was not already immunized towards the tissue type of the donor, was always required, see Tilney, op. cit., note 15 above, p. 138.

97 Löwy, op. cit., note 17 above, p. 212; idem, op. cit., note 25 above, p. 591.

98 Hiesse, Pessione, and Houssin, op. cit., note 21 above, p. 623.

99 Löwy, op. cit., note 17 above, pp. 212–13.

100 Ole Fjeldborg, ‘Donorsituationen ved organtransplantationer’, Ugeskrift for Læger, 1989, 151: 2532–4, on p. 2534: “på andet end biologiske forhold”.

101 Villy Posborg Petersen, et al., ‘Nyretransplantation I’, Ugeskrift for Læger, 1966, 128: 723–33, on pp. 724–5; Villy Posborg Petersen, et al., ‘Nyretransplantation II. Kirurgiske aspekter’, Ugeskrift for Læger, 1966, 128: 733–40, on pp. 734–5; Bundegaard, op. cit., note 6 above, p. 26.

102 Kissmeyer-Nielsen, et al., op. cit., note 56 above, p. 1022.

103 Legislation required the ventilator to be turned off and cardiac arrest to occur before the patient could be pronounced dead and the organs removed. Standard procedure in Danish transplant centres around 1970 was then to re-apply mechanical or manual heart massage and perform the nephrectomy while circulation was maintained, cf. Richard Malmros, ‘Om udvælgelse af donorer til transplantation’, Ugeskrift for Læger, 1970, 132: 400–2. On other steps taken by surgeons to limit warm ischaemia times before the introduction of brain death criteria, see Kootstra, op. cit., note 10 above, p. 59.

104 Teddy Østerlin Koch, ‘Ulovlige transplantationer’, Sygeplejersken, 1993, 93: 4–14. Bundegaard, op. cit., note 6 above, pp. 77–83. Brain death criteria were not introduced in Denmark until 1991.

105 Lov om udtagelse af menneskeligt væv (Law concerning the excision of human tissue). SIL, JHT, CDT, 21 Nov. 1972.

106 Jørgen Kvist Kristensen, interview by author, 15 May 2006. Kvist Kristensen (b. 1937) has been involved as a surgeon in donor nephretomies and transplantations from the mid-1960s, first at the urological department at Gentofte Hospital and later at the National Hospital in Copenhagen, where he now heads the urological clinic.

107 I have no detailed information on whether relatives were informed of the possibility that the organs they allowed to be donated might be sent to another hospital. Yet the exchange of kidneys between different hospitals may have influenced relatives in their decision to allow donation or not, and may consequently have made it more difficult for doctors and nurses involved to obtain consent.

108 SIL, JHT, Scandiatransplant Necroreport, 1 Jan. 1969–31 Mar. 1972.

109 SIL, JHT, Scandiatransplant Necroreport, 1 Jan. 1969–30 Sep. 1976.

110 SIL, JHT, Balance i nekronyreudveksling, 1 Jan. 1969–31 Dec. 1981.

111 SIL, JHT, CDT, 8 Oct. 1981.

112 Madsen, op. cit., note 8 above, p. 79.

113 Lars U Lamm, ‘Activity and follow-up 1978’, Scand. J. Urol. Nephrol. Suppl., 1980, 54: 6–10; idem, ‘Scandiatransplant – 1980: activity and follow-up’, Scand. J. Urol. Nephrol. Suppl., 1981, 64: 16–28. The last report actually included a table showing the imbalances between the centres, but this was not commented on in the text.

114 SIL, JHT, CDT, 8 Oct. 1981: “truer på alvorlig måde samarbejdet indenfor Skandiatransplant-organisationen”. In France, surgeons and anaesthesiologists openly suggested a stronger local basis for kidney allocation, with immunologists like Jean Dausset strongly opposing a weakening of regional exchange, cf. René Küss, et al., ‘Les prélevements de reins encore insuffisants: vers une régionalisation de la transplantation’, Bulletin de l'Académie Nationale de Médecine, 1981, 165: 381–94. For Küss, regionalization was opposed to national cooperation. On conflicts between transplant centres in France, see Ilana Löwy and Anne Marie Moulin, ‘Du don à l’échange. Les institutions de transplantation’, Culture Technique, 1985, 15: 157–63, on p. 163.

115 Brent, op. cit., note 15 above, pp. 316–18; Tilney, op. cit., note 15 above, pp. 236–8.

116 Hans Dieperink, Niels Erik Frandsen, and Ejvind Kemp, ‘Cyklosporin A. Lysere tider for organtransplantationer?’, Ugeskrift for Læger, 1983, 145: 2749–52; Vagn Andersen, ‘Immunsuppression: nye udviklinger’, Ugeskrift for Læger, 1983, 145: 2775–6; Bundegaard, op. cit., note 6 above, p. 116; Søren Madsen, et al., ‘Kliniske resultater af immunosuppression med cyklosporin A ved nekronyretransplantation’, Ugeskrift for Læger, 1984, 146: 951–4.

117 Jørgen Ladefoged, ‘Cyklosporin-A. Bedre resultater ved nyretransplantation’, Ugeskrift for Læger, 1984, 146: 989–90, on p. 990: “anvendelse af cyklosporin vil også betyde, at den tidrøvende udveksling af nyrer mellem de europæiske lande og indenfor Skandinavien, som hidtil har været nødvendig for at opnå optimalt vævstypeoverensstemmende nyrer, vil aftage betydeligt”. Similar predictions of the organizational implications of the new immunosuppressant were voiced internationally, see Roy Yorke Calne, ‘Organ transplantation: from laboratory to clinic’, Br. med. J., 1985, 291: 1751–4; Moulin, op. cit., note 18 above, p. 223.

118 Ladefoged, op. cit., note 117 above, p. 990. A Danish trial of cyclosporine was not able to confirm this finding, see Madsen, et al., op. cit., note 116 above, p. 953.

119 K R Harris, et al., ‘Azathioprine and cyclosporin: different tissue matching criteria needed?’, Lancet, 1985, 326: 802–4.

120 G Lundgren, et al., ‘HLA-matching and pretransplant blood transfusions in cadaveric renal transplantation: a changing picture with cyclosporin’, Lancet, 1986, 2: 66–9, on p. 68.

121 Nils H Persson, F Pedersen, and Lars U Lamm, ‘Compliance with the rules of kidney exchange in Scandiatransplant’, Transplant. Proc., 1992, 24: 339.

122 SIL, JHT, CDT, 25 Mar. 1982.

123 SIL, JHT, Notat om drøftelser og hovedkonklusioner fra et møde i Sundhedsstyrelsen den 29. maj 1984 vedrørende etablering af udrykningshold til nyreudtagning. See also Jes Søgaard, Cost-effectiveness analyse af etablering af udrykningshold og ny immunsuppressiv behandling af nyretransplanterede patienter ved Cyclosporin A, Odense Universitet, 1984.

124 SIL, JHT, CDT, 6 Feb. 1986. Ole Fjeldborg, interview by author, 16 June 2006. Fjeldborg (b. 1928) was the surgeon who performed the first kidney transplantation in Denmark. He spent his entire career at Århus Municipal Hospital, performing most of the kidney transplantations there and also carrying out important work in the organization of kidney procurement in the local area. He retired in 1991.

125 Lamm, op. cit., note 11 above. Lamm also shows how the need to deal with organs other than kidneys led Eurotransplant to develop new procedures. As a rule, hearts, lungs, and livers were exchanged through direct contact between local centres, while kidneys were still allocated by the central office.

126 Braun, Feuerstein, and von Grote-Janz, op. cit., note 16 above, pp. 457, 468.

127 Moulin, op. cit., note 18 above, p. 223.

128 Dausset, op. cit., note 22 above, p. 183: “la contrainte du HLA”.

129 Gerhard Opelz, ‘The benefit of exchanging donor kidneys among transplant centers’, N. Engl. J. Med., 1988, 318: 1289–92.

130 This is indeed the starting point in Susan Leigh Star and James R Griesemer, ‘Institutional ecology, “translations” and boundary objects: amateurs and professionals in Berkeley's Museum of Vertebrate Zoology, 1907–39’, Soc. Stud. Sci., 1989, 19: 387–420.

131 For a comparative study on the diffusion of medical technology with special attention to different levels of control, see Thomas Schlich, ‘Degrees of control: the spread of operative fracture treatment with metal implants: a comparative perspective on Switzerland, East Germany and the USA, 1950s–1990s’, in Stanton (ed.), op. cit., note 19 above, pp. 106–25.