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EDITORIALS: Colin C Geddes and R Stuart C Rodger Kidneys for transplant BMJ 2006; 332: 1105-1106 [Full text]

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Kidneys for transplant : NOT from the "brain dead", please

David W Evans   (1 May 2006)

Kidneys for transplant: More but not all.

Christopher S Hourigan   (5 May 2006)

Kidney Donation and Harm to the Donor

Michael Potts   (13 May 2006)

Donation of Organs by Ethnic Minorities

Maqsood A Noorani   (27 June 2006)

Bad Drafting Makes Bone Marrow Donations unlawful

Alasdair R Maclean   (29 August 2006)

Kidneys for transplant : NOT from the "brain dead", please 1 May 2006
David W Evans, Retired physician 27 Gough Way, Cambridge, CB3 9LN Send response to journal: Re: Kidneys for transplant : NOT from the "brain dead", please	Editor - It is sad to see the term "brain dead" still being used (1) to describe the state of comatose, ventilator-dependent patients certified dead for transplant purposes. Use of that term was formally discouraged by the RCP Working Party and Conference of Medical Royal Colleges (2) in 1995, the term "brain stem death" being preferred although not factually correct (3), and the Minister of State for Health declared (4), in 1997, that "the term 'brain death' ..... should not be used in the context of organ donation". 1. Geddes CC, Rodger RSC. Kidneys for transplant : more of them, better allocated. BMJ 2006;0:bmj.38833.785984.47v1 2. Review by Working Group of the Royal College of Physicians, endorsed by the Conference of Medical Royal Colleges and their Faculties. Criteria for the diagnosis of brain stem death. J Roy Coll Physns London 1995;29:381-2 3. Evans DW. The demise of "brain death" in Britain. In - Beyond brain death : the case against brain based criteria for human death. Eds : Potts M, Byrne PA, Nilges RG. Kluwer Academic Publishers, Dordrecht, 2000 4. Milburn A. Personal correspondence, 7th September 1997 Competing interests: None declared
Kidneys for transplant: More but not all. 5 May 2006
Christopher S Hourigan, Immunologist with interest in Transplantation Worcester College, Oxford, OX1 2HB Send response to journal: Re: Kidneys for transplant: More but not all.	Dear Editors, Geddes and Rodger (1) provide a useful reminder of the past inequalities in organ allocation and the huge human cost resulting when advances in transplantation are limited by a scarcity of available organs. They do not however address the disparity between those who those who express a desire to be considered as an organ donor after their death (over 90% of the UK population in some surveys) and those eligible who go on to do so. This reflects the fact that while families of those who make a formal statement to this effect (approximately 21% of the UK population currently registered on the National Organ Donor Register) rarely refuse to honour their relatives wishes regarding organ donation, those not formally registered face family permission refusal rates of up to 40%. Of the approximately 1250 potential cadaveric organ donors in the UK in 2004, surveys suggest that over 1100 would have wished to donate, while in reality organs were transplanted from only 750 (2). Increasing public awareness of the National Organ Donor Register as a means to record preferences on this issue is clearly a worthwhile goal. Registering just a modest 25% of those who express a desire to donate organs after death but have not yet placed their names on the national database would likely result, on average each year, in approximately an extra 119 donors giving 330 organs including 206 kidneys (2) resulting in an additional 3500 life years to organ recipients (3) while allowing over 40 million GBP of the NHS budget to be saved from dialysis costs (4). I recently suggested (5) that the current framing the options for donor registration in terms of a simple “opt in” or “opt out” dichotomy is unhelpful. In contrast, a true national census of patients wishes regarding organ donation would however be an effective strategy for recording, and therefore respecting, all patients choices about this most essential of decisions. Surely it is a reasonable public health objective for the government to consider funding primary care targets for asking this most important of questions? Yours sincerely, Dr. C.S. Hourigan References: 1. Geddes and Rodger, BMJ, doi:10.1136/bmj.38833.785984.47 (published 27 April 2006) 2. “More Transplants – New Lives. Transplant Activity in the UK 2004 -2005” UK Transplant Statistics and Audit Directorate. August 2005 3. Schnitzler MA et. al. 2005. The life-years saved by a deceased organ donor. Am J Transplant Sept;5(9):2289 4. Lamping DL et. al., 2000. Clinical outcomes, quality of life, and costs in the North Thames Dialysis Study of elderly people on dialysis: a prospective cohort study. Lancet. 2000 Nov 4;356(9241):1543- 50. 5. Hourigan CS. 2005. Registering organ donor preferences - a third way? Br. J. Gen. Pract. Oct; 55(519):805. Competing interests: None declared
Kidney Donation and Harm to the Donor 13 May 2006
Michael Potts, Associate Professor of Philosophy Methodist College, Fayetteville, NC USA 28311 Send response to journal: Re: Kidney Donation and Harm to the Donor	No one can deny the tragedy of those who die prematurely from kidney failure or live debilitated lives due to complications from dialysis. Although kidney transplantation offers a more effective form of treatment than dialysis, medical personnel must take care not to harm the donor. A recent BMJ editorial (1) calls for more transplant organs (to be better allocated) from two sources: the "brain dead" and "non-heart beating donors." Removal of organs for transplant from the "brain dead" is morally problematic, for it is not at all clear that individuals diagnosed as "brain dead," especially under the UK "brainstem death" criterion, are really dead. These individuals still function as organic wholes at the physiological level, retaining circulatory and respiratory functions (the ventilatory function is taken over by a machine but oxygen and carbon dioxide exchange continue at the cellular and tissue level in just the same way as before) (2). In addition, as Evans (3) and Hill (4) have both noted, it is not clear that the brainstem, much less the rest of the brain, is dead. If such donors are not dead, removing vital organs harms them, violating nonmaleficence. Removal of organs from "non-heart beating" donors is morally problematic for other reasons, as Renée Fox (5) notes. "Treatment" is not oriented toward the patient but toward the goal of preserving organs. Proper comfort care for the dying patient may be omitted because the donor is considered as a repository for organs rather than as a person. The patient may be pronounced "dead" prematurely after circulatory cessation and the place and timing of its certification may be orchestrated in the interests of the organs to be removed. This is a form of technological death befitting "things" and not "persons" in which dying individuals are "treated" solely on the basis of their utility for others. Non-heart beating donation may be morally acceptable if the patient receives standard care (as for any other patient dying of the same condition) beforehand, there being no non-therapeutic interventions for the sole purpose of protecting the wanted organs, and if the patient is pronounced dead according to the same circulatory-respiratory criteria applied to other patients in similar situations (and in general use). Then, if warm ischemic time has not been too long for the kidneys to be of use, they may be removed without harming the patient—even then, care must be taken to avoid even a remote potential for the patient to experience distress. Only when no harm is done can the removal of organs from donors be considered morally justifiable. (1) Geddes CC and Roger RSC. Kidneys for transplant: more of them, better allocated (editorial). BMJ, doi:10.1136/bmj.38833.785984.47 (published 27 April 2006; accessed 11 May 2006). (2) Potts M. A requiem for whole brain death: a response to D. Alan Shewmon’s ‘The brain and somatic integration.’ J. Med. Phil. 2001;26:479- 91. (3) Evans DW. The demise of ‘brain death’ in Britain" In Beyond Brain Death: The Case Against Brain Based Criteria for Human Death, ed. M Potts, PA Byrne, and RG Nilges, pp. 139-58. Dordrecht, The Netherlands: Kluwer Academic Publishers, 2000. (4) Hill DJ. Brain stem death: a United Kingdom anaesthetist’s view. In Beyond Brain Death: The Case Against Brain Based Criteria for Human Death, ed. M Potts, PA Byrne, and RG Nilges, pp. 159-69. Dordrecht, The Netherlands: Kluwer Academic Publishers, 2000. (5) Fox RC. An ignoble form of cannibalism’: Reflections on the Pittsburgh Protocol for procuring organs from non-heart-beating cadavers," Kennedy Inst of Ethics J 1993;3: 231-39. Competing interests: None declared
Donation of Organs by Ethnic Minorities 27 June 2006
Maqsood A Noorani, Consultant Surgeon Transplant Unit, Royal London Hospital, Whitechapel Send response to journal: Re: Donation of Organs by Ethnic Minorities	Dear Madam/Sir, This is with reference to the articles “Kidneys for Transplant: Clinicians Ask but Relatives Refuse” published in BMJ, 13th May 2006. The data published is very impressive. The changes in the new Human Tissue Act were long awaited but I would have called these changes radical only if this law would have said that every person resident in this country is a potential donor irrespective of consent. I believe that the new law is not really going to make much difference in practical terms, even when there is no legal requirement to establish lack of objection on the part of relatives if the donor has registered their wishes on the organ donor register. I think this law should have gone one step further; every family in the UK should be sent a declaration form regarding the donation of organs. Any family that declares not to be included on the donor register without an acceptable reason should be barred from receiving the donation of organs. Being a surgeon of Asian origin I feel embarrassed that our community is not contributing towards such a noble cause (35% of the white population refuses consent for donation compared to 70% of ethnic minorities) when there are no specific reasons for them not to donate organs. The reasons for not giving the consent by the relatives tabulated in the paper are all non-specific and can be over ruled by the authority. Pertaining to Asian people, the most common reason for refusal of donation is attributed to religion. As far as Islam is concerned, it actually encourages donation by saying “If you save one life you save the whole of humanity”. I think that their refusal is more the result of lack of awareness and myths regarding the actual donation process and the way that they have been approached in the past has largely contributed to their refusal. The authorities need to make it clear that if they refuse organ donation without proper thought and reason, simply because it is a more convenient and comfortable option than refusal, they cannot realistically expect to receive and hence drain an already extremely limited pool of organs in this country. Thanking you, Yours sincerely, Professor M A Noorani Consultant Surgeon. Competing interests: None declared
Bad Drafting Makes Bone Marrow Donations unlawful 29 August 2006
Alasdair R Maclean, Senior Lecturer in Law University of Dundee, DD1 4HN Send response to journal: Re: Bad Drafting Makes Bone Marrow Donations unlawful	Sir While the Human Tissue Act 2004 may be welcomed for its potential effect on kidney donations, poor drafting of the Human Tissue Act 2004 (Persons who Lack Capacity to Consent and Transplants Regulations) Regulations 2006 SI no.1659 means that bone marrow (and blood stem cell) donation by competent persons may be unlawful when the Act comes into force on September 1st 2006. Section 33, subsections(1),(2) of the Act make it unlawful to perform live donation/transplantation unless disapplied by regulations made by the Secretary of State (s.33(3)). In r.10(1) the Regulations define the relevant 'transplantable material' as: (a) an organ, (b) bone marrow, and (c) blood stem cells, but states that this definition is subject to the subsequent paragraphs (2) and (3). Paragraph (3) states: 'The material referred to in paragraph (1)(b) and (c) is transplantable material for the purposes of section 33 of the Act ONLY in a case where the' donor is an incompetent adult or child (emphasis added). The problem lies in where the drafter has placed the 'only'. Instead of the 'only' relating to the transplantable material, it relates to the donor subject. The effect of this, on a literal reading, is that ss.33(1),(2) are only disapplied where the donor is incompetent. This means that it is an offence to harvest or use bone marrow from a competent person, which is clearly not what was intended. It should be noted that the same problem does not arise in the Scottish legislation. It should also be noted that s.33(5) provides a 'get out of jail free' card in that it provides that no offence is committed where the persons involved in the donation/transplant 'reasonably believed' the dissaplication applied. Of course, once you have read this letter it would no longer be reasonable to believe that. Competing interests: None declared