Medical School interview course - Article 1

Organ Donation

Patients could be kept alive solely so they can become organ donors as part of an urgent medical and ethical revolution to ease Britain’s chronic shortage of organs, doctors’ leaders say today.

It is one of a raft of measures contained in controversial proposals from the British Medical Association intended to stop up to 1,000 people a year dying because of the country’s chronic shortage of organs. A new BMA report also suggests hearts could be taken from newborn babies for the first time and body parts could be used from high-risk donors. The BMA wants a debate about the use of an ethically contentious practice called “elective ventilation”, in which patients diagnosed as dead – such as those who have suffered a massive stroke – are kept alive purely to enable organ retrieval.

While such patients are often put on artificial ventilation for a short while to enable their relatives to say goodbye, the report says, “elective ventilation is different in that it involves starting ventilation, once it is recognised that the patient is close to death, with the specific intention of facilitating organ donation”. This procedure led to a 50 per cent jump in the number of organs available when it was carried out by the Royal Devon and Exeter hospital from 1988, but it was declared unlawful by the Department of Health in 1994.

Spain and the US already use the technique, said Nigel Heaton, professor of transplant surgery at King’s College hospital London. He said: “People have qualms about it. The concern is that you are prolonging or introducing futile treatment that has no benefit for the patient. But I expect that views will gradually change around this [in its favour]. It’s an ongoing tragedy that so many people are still dying in this country for want of an organ.

One of the report’s other most radical suggestions is that – with the permission of the deceased’s family – surgeons could remove the heart of someone who has just suffered circulatory death, maintain its function by putting blood and oxygen into it, and give it to a patient who needs a new heart. “The fact that an individual is declared dead following cessation of cardio-respiratory function but the heart is subsequently restarted and transplanted into another person is a difficult concept and one that requires careful explanation,” the report says. At the moment only livers, kidneys and lungs are retrieved from such patients. The surgery, which has been used successfully in the US, is “an acceptable and important area of research to pursue” and “represents a possibility of both increasing the number of hearts available for donation and also facilitating the wishes of more people who wish to be donors”, the report says.

Dr Vivienne Nathanson, the BMA’s head of ethics, said: “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.” But the report admits that some intensive care doctors oppose the practice, “questioning whether frustration over the falling number of DBD [donation after brain death] donors has resulted in ‘interventions that could jeopardise professional and public confidence in all forms of donation’ and arguing that such practices are ‘at the very edge of acceptability’”. However, Heaton said the technique was “an important development”, which was the subject of much ongoing research and that “it will come through into clinical practice eventually”.

Sally Johnson of the NHS’s Blood and Transplant agency said the critical shortage of organs meant it was “keen to engage in any discussions about increasing the donor pool and availability of healthy, viable organs”. But she warned: “Many issues, ethical and clinical … need to be considered and addressed.” A Department of Health spokesman said: “Any action taken prior to death must be in the patient’s best interests. Anything that places the person at risk of serious harm or distress is unlikely to ever be in the person’s best interests.” The BMA said it welcomed recent increases in organ donation, but wanted more action, including a switch to an opt-out system, where everyone would be assumed to be a willing organ donor unless they explicitly said otherwise.