As proposals from the British Medical Association reignite the organ donation debate, John Humphrys considers the issues and asks your views
The availability of transplant organs has been growing fast in recent years. But not fast enough. Many people, including young children, are dying for want of donated organs. So the British Medical Association (BMA) wants a new national debate to try to get the figures up, and has kicked it off with a report that floats ideas some people oppose on ethical grounds. How far should we go to help keep people alive by using the organs of those who have died?
Since the Organ Donation Taskforce was set up back in 2008 to increase the availability of organs for transplant there has been considerable progress. By last year the number had risen by 25% and may reach 34% this spring. For the first time the waiting list for organs fell last year, by 157 to 7,800. The number of transplants rose to an all-time high (2,695) as did the number of donors (1,010).
But the target of increasing availability by 50% by 2013 looks likely to be missed and it is estimated that about a thousand people still die every year for want of a donated organ. The BMA thinks more can be done.
Organ donation has to be a voluntary act. In Britain, if we want our organs to be used after our deaths each of us has to deliberately opt-in to donation and then, having done so, carry our organ donation card around with us. But the trouble with this system is that it’s not just people who have made a firm decision not to donate their organs after their death who keep the number of available organs low. There are also all the rest of us who have never got round to making a decision about the matter one way or the other. Because we haven’t positively opted to be donors our organs usually cannot be used.
An obvious way to increase the number of organs available would be to turn the system round by changing the law so that it would be assumed we were happy for our organs to be used after death unless we had explicitly opted out. Such a system operates in other countries and Wales (which runs its own health service) is proposing legislation to bring this about later this year.
Opponents of the idea argue that such a change may be all well and good for increasing the numbers of transplant organs but it takes into account only half of the picture. Our bodies should not simply be regarded as storehouses of working parts that, by default, could be raided after our death for anything that might still be useful. The body is part of a whole human being with a dignity, even a sacredness, which demands respect. It is one thing, they argue, for any individual to choose to donate an organ after death but quite another for it to be assumed that anyone’s body can be treated as such a storehouse without the individual having given their consent. If we go that route, they argue, we will soon lose all sense of the dignity and unique status of the human person.
In order to deal with this objection, what has been called a ‘soft’ opt-in system has been floated too. This would assume a dead person’s organs were available unless that person had explicitly opted out, but would give the person’s relatives a veto. A version of this system already operates in that in some cases, doctors approach the relatives of someone who has died without having become a registered organ donor for permission to extract an organ. But the refusal rate is quite high (43%), largely because relatives may simply not be confident that that would be what their dead relative would have wanted. The BMA is airing the idea of mounting an advertising campaign to try and get this refusal rate down.
Other proposals include what’s called ‘mandated choice’, or making it obligatory for each of us to make up our minds about whether or not our own organs should be used after death. Ideas to encourage us to agree to organ donation are also being proposed. One, the notion of ‘reciprocity’, would mean that anyone who opted in for organ donation would have priority over those who didn’t if he or she ever needed a transplant themselves. Financial incentives might also be provided, either direct payments or help with funeral expenses.
Pushing the boundaries
Much the most controversial of the BMA’s ideas, however, are about pushing the boundaries in order to access organs that are currently beyond reach. It suggests we should consider using more organs from older people. In Spain, for example (where overall rates of donation are over twice what they are in Britain), 45% of donors were over sixty in 2009, compared with only 30% here. It also wants people to think about whether accident and emergency departments should be encouraged to think of potential organ donation when they deal with cases that prove terminal. We ought also to consider, they argue, whether for the first time we should be ready to extract the hearts of newly-born babies who die in order to transplant them into other newly-born babies who would die without them.
Another controversial innovation is the technique that would revive the heart of someone who had died following the cessation of cardio-respiratory function by pumping blood and oxygen into it to make it available for transplant. At the moment only the livers, kidneys and lungs of a person who had died in this way are available for transplant. In these circumstances, such a technique would not enable the potential donor’s life to be saved, but the heart itself could be.
One problem is that it would not necessarily be easy to explain this to bereaved relatives, though it is not impossible.
“When it’s well explained, relatives understand that their loved one’s heart isn’t being jumpstarted and going back to normal or near-normal function in the way that it is with someone with an arrhythmia, the way you see it in Casualty or Holby City,” Dr Vivienne Nathanson, the BMA’s head of ethics, said.
But the report itself acknowledges that some intensive care doctors oppose this practice (which is already in operation in the United States) on the grounds that it could jeopardise professional and public confidence in all forms of donation, and is ‘at the very edge of acceptability’.
The BMA is keen to point out that it is not itself proposing any of these changes. Rather, it wants the country to debate them. As transplant techniques become more and more advanced, it is a debate we can hardly avoid.
What’s your view?
- In general terms are you in favour of organ transplants or do you find the whole idea abhorrent?
- Do you think the current opt-in system for organ donation is adequate or too restrictive?
- Would you favour an opt-out system, or the ‘soft’ opt-in proposal, in which consent was assumed but relatives given the power of veto?
- Should we be forced to decide one way or the other whether we want our own organs to be available for transplant after death?
- What do you make of the various incentive ideas such as giving those who sign up for donation after their death priority if they need transplants themselves?
- Should people be paid to sign up for donation?
- Should we be ready to use more organs from older donors?
- Should it be possible to use the hearts of newborn babies who have died for transplant?
- Should we allow the revival of the hearts of those who have died from the collapse of their cardio-respiratory function in order to use them in transplants?
- And, finally, how worried are you (if at all) that the more we expand the scope of organ donation, the more we shall come to regard a dead person’s body as merely a storehouse of organs for all our use, and less as the material form of a unique human being whose dignity should be respected and even revered?
Let us know what you think using the comments box below.
