Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Report on the CMO - Time to Go?
- John J Turner (27 July 2007)
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Presumed consent to organ donation
- David W Evans (29 July 2007)
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Almost true?
- Richard Bartley (30 July 2007)
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Re: Presumed consent to organ donation
- Jonathan H Peterson (1 August 2007)
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Consent: presumed or explicit?
- Andrea Tortora (4 August 2007)
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John J Turner, Consultant Physician University Hospital Aintree L9 7AL
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The report of the Chief Medical Officer Liam Donaldson receives praise on organ donation but well deserved criticism on medical staffing [Presumed Consent Fiona Godlee; Editor's Choice, BMJ 28 July]. The report on the CMO himself is worrying. He has been a major contributor to the malaise at the top of the Department of Health and its entrenched culture of reluctant accountability. Michael Day reviewing the CMO's Report [BMJ 21 July] reports hand hygiene as objective number one with compliance "seldom above 60%". This figure is not credible and is unsupported in our Trust by valid audit evidence. The promotion of Alcogel has been successful in achieving high compliance levels. The campaign has been creative but has projected an over simplistic single message approach embraced with enthusiasm by senior managers. It has failed to address the more comprehensive multi factor approach and investment that is actually required. It has not delivered the message that Alcogel does not adequately kill Clostridium Difficile spores and is not a safe substitute for thorough mechanical hand washing. A welcome but modest fall in MRSA bacteraemia is in contrast to the 22% rise in C. Diff. with 15,592 cases in England in the first quarter of 2007. It is regrettable but rather characteristic that the CMO should pursue a campaign of "dirty" doctors and nurses than provide leadership to face up to the other issues of overcrowded wards, over congested NHS hospital emergency systems and inadequate numbers of single rooms to provide isolation facilities to reduce cross infection. The primacy of the A&E four hour target directly conflicts with the need to have adequate and consistent supervision of surface cleaning protocols between new emergency admissions, especially in high risk older patients in areas such as Medical Assessment Units. High bed occupancy rates are directly linked to cross infection rates but in many UK Medical Specialties true bed occupancy rates are above 100% when medical outliers and short in patient turn around times are included. The emphasis has been very much on individual clinical governance but perhaps we need to look more closely at the serious issues of corporate governance for Hospital Trusts. Competing interests: Lead Clinician Directorate Control of Infection |
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David W Evans, Retired physician 27 Gough Way, Cambridge, CB3 9LN and Queens' College, Cambridge, CB3 9ET
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Editor - Your claim(1) that the readers of the BMJ back "presumed consent" must be seen as decidedly shaky. Only a tiny proportion of the readership took part in the straw poll, the ratio of supporters to objectors being but 3:2. However, your own powerful support, and that of Veronica English(2), is certainly not in doubt. That support appears to be on purely utilitarian grounds, with no evident consideration of the truly ethical problems involved. Hence the need to pose to you both - as prominent spokespersons and opinion-formers for our profession - the following question. How will you feel if, one day, it comes to your notice that a young woman who has never thought much about her death and has never got around to opting out of organ "donation", has her organs removed for transplantation while she is in a state which, had she been told about it, truthfully and in detail, she could not have accepted as her death? The knowledge that she would not have been persuaded to accept the certification of her death for that purpose - on the basis of brain stem (only) testing while her heartbeat and respiration continued, keeping her body and unknown (because untested) parts of her brain still alive - may come to light some time after her use as a source of organs. It may transpire that relatives or friends - some of whom may have protested unavailingly at the time - are found who remember discussions during which she had expressed opposition, distaste or uncertainty, perhaps indicating that she would wish to be better informed before making any binding decision. The latter attitude is, after all, commonplace and may well explain the difference in numbers of those declaring support for organ transplantation in the general, impersonal, sense and those prepared to register as "opt-in" potential donors (albeit inadequately informed in many cases) under the present system. The fundamental ethical issue, which receives almost no notice, is that of truth and its telling. Where attempted redefinitions of death for transplant purposes are concerned, it must be admitted that they are now seen to have failed(3) - on both scientific and philosophical grounds. If people are, nevertheless, to be asked to donate their organs when they are dying, all the relevant facts about the organ procurement procedure must be provided to them, in terms which they will understand. It can never be presumed that they know them - as if they were common knowledge imparted by some infallible Government educational tool. Indeed, it seems unlikely that all those whose names are already on the NHS Organ Donor Register are fully and fairly informed about the offer they have thereby made. Those who do understand that they have agreed to the removal of their organs, without anaesthesia, while still de facto alive although certified dead for legal purposes, must be seen as not merely generous, altruistic and socially responsible but as heroes. Those who have entered their names on the Register without being aware of the worldwide debate about the definition and diagnosis of death - and assuming that the wording "after my death" on the application forms meant that they would be without circulation and respiration before organ removal - have been deceived. David W. Evans References 1. Godlee F. Presumed consent. BMJ 2007; 335 (28 July), Editorial 2. English V.Is presumed consent the answer to organ shortages? Yes. BMJ; 334:1088 3. Evans DW. Seeking an ethical and legal way of procuring transplantable organs from the dying without further attempts to redefine human death. Philosophy, Ethics, and Humanities in Medicine 2007; 2:11 (29 June) http://www.peh-med.com/content/2/1/11 Competing interests: None declared |
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Richard Bartley, Physiotherapist Denbigh, Wales
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Turner suggests that the Chief Medical Officer’s campaign against poor clinical governance fails to face up to the realities of inadequate corporate management. He may be right. But my experience of the day to day practice of hospital clinicians suggests that the sum of individual carelessness and managerial naivety add up to the same thing: unacceptable levels of cross- infection. Although an extreme anecdote, witnessing an A&E nurse fishing for a used phial in a sharps box (for whatever reason) does not inspire much confidence. Competing interests: None declared |
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Jonathan H Peterson, Manager BMJ, WC1H 9JR
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I have been following the presumed consent debate with interest both within the BMJ and in the general media. I do not see, however, why the debate is restricted to organs. The NHS is short of many things that might save a life, not just suitable organs. Why not also presume that the recently deceased consent to donating a modest sum of cash from their estate? Those who wish to opt out may do so, making it explicit in their will. I'm sure the extra money will go far. At the moment, those who would be happy to let others benefit from what they no longer need, must go to the trouble of explicitly writing the NHS into their will. Currently, many people die unexpectedly, before they have got round to doing this. As a result, much needed donor cash isn't reaching the patients who would benefit from it. 'Presumed consent' would would benefit all: * Those who wish to donate life-saving cash to the NHS need take no action, and can rest easy knowing that they will help someone live after their death. * Those who wish to opt out can do so explicitly via an existing, well respected legal instrument (their will). * Families are saved making a difficult decision, at a time of grief. * Patients benefit from the extra money. Everyone's a winner. Competing interests: I work for the BMJ |
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Andrea Tortora, administrative employee Gaetano Rummo Hospital (post code: 82100 Benevento, Italy)
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Dear friends of BMJ, first of all excuse me for my bad English. I'm very interesting in the public debate about the best policy to improve organ donations, 'cause of organ shortage. I'm very lucky because I know some doctors and nurses working in this field, with passion and competence. (I work in the administrative staff of an Italian hospital - Rummo Hospital, in Benvento, Southern Italy). Italian Parliament approved a legislation in 1999 about organ donation and transplantation: our law is based (it would be based!) on the principle of "informed presumed consent". During the debate in Parliament, there were a lots of arguments against the principle of presumed consent, so the final result has been the approval of transitory rules that are still in force! In brief, the situation in Italy is as follows: - if an adult dies without any written diposition about organ donation, the familiy has the ultimate decision (partner, first of all; then sons). Probably the principle of "informed presumed consent" will not be enforced and the transitory rules will continue to regulate this matter. My opinion is that the best way to encourage people to donate thier organs after death is a clear, honest and effective public campaign. I think THE REAL PROBLEM IS THAT PEOPLE DON'T WANT THINK ABOUT DEATH, SO HEALTH SYSTEMS SHOULD ENCOURAGE AND PROMOTE THE EASIEST WAYS TO EXPRESS EXPLICIT CONSENT: WHY NOT EXPRESS OUR WILL ABOUT DONATION ON OUR DIRVING LICENSE, OR WHEN DOING OUR INDIVIDUAL INCOME TAX RETURN? Thank you in advance for your attention, Andrea Tortora (Gaetano Rummo Hospital, Italy) Competing interests: None declared |
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