The use of “second class” organs is a necessity in transplantation
There are many ethical, legal and religious views with regards to organ donation. Statistics from 2009 by UK Transplant Organisation showed that, there are 8000 people on the waiting list, with only 3000 transplants a year. This shows that we need to increase the demand for organs as many people are dying.
There are two main sources for human organ donation: from the living and from the deceased. Donation from the deceased involves two types: heart beating donors (HBD) and non-heart beating donors (NHBD). HBD has been the primary source for organ donation for the last thirty years, but this source of donation is declining. Scientists are now focussed on using NHBD to revive and increase the donor pool, but this form of procurement is plagued with many ethical problems. It is looked at as a”second class’’ form of donation.
NHBD involves donation of organs from two sources: controlled and uncontrolled. Controlled are donors who have had “irreversible brain injury” but they do not qualify the brain death criteria. Where as, in the uncontrolled, the donor may suffer a cardiac arrest and die after resuscitation may prove futile. The fundamental controversy with this procurement is the definition of death as family members find this very hard to deal with when the need arise for them to make a swift decision . Thus, NHBD procurement remains slightly unpopular even though it has the prospects of increasing the donor pool by up to 30%.
Transplantation is the moving of organs or tissues from one person (the donor) to another (the recipient), or to the same person. The purpose of transplantation is to replace the recipient’s organs or tissues which have failed due to illness or injury to improve health. Organs that can be transplanted includes: the heart, kidneys, liver, lungs, pancreas and intestines. Whereas tissues that can be transplanted include: cornea, skin, veins, bones, tendons and heart valves. Organs or tissue transplanted within the same person is known as an autograph. A transplant between two persons is known as an allograft. .xenotransplantation involves the transplantation or infusion of organs or tissues fron one species to another. For example, the transplantation of a babbon liver into a HIVpatient , performed in 1992. The patient died 70 days later (Greenwell et al., 2007). Xenotransplantation is a dangerous because of the non-compatibility and rejection, which may lead to death (Greenwell et al., 2007).
Transplantation is a very complex and challenging area of modern science. Shortage of donors is limiting transplantation therefore both living and deceased donors are used to increase donor supply. (heart beating and non heart beating), ( Chaib E 2007). The number of heart beating donors (HBD) continue to decreases, therefore the focus now is to use cadaveric organs from non heart beating donors (NHBD). The main problem with this type of donation is how one may define death and who gives consent for the donor’s organs to be used in transplantation. This raises a lot of ethical issues. People started describing NHBD as second class organs, but public confidence has improved as many studies ( Sanchez-Fructuosa et al 2000, Nicholson et al 2000) has shown the that the use of NHBD is a promising alternative to enlarge the donor pool especially in renal transplantation. Countries including the United Kingdom, USA, Spain, Netherlands, Switzerland and Japan have all implemented NHBDs protocols in hospitals (Knoll et al 2003).
Concerns of NHBD as “second class” organs
HBD has been the main source for transplantation in the last 30 years (Chaib E., 2007), but this source of donation is declining thus the emphasis is on NHBD to increase the donation pool as the need for organs keeps increasing. The difference between HBD and NHBD is the definition of death. In HBD, the beating heart donor is brain damaged and on ventilation before death, whereas with NHBD the donor may have suffered a cardiac arrest and resuscitation may be futile.
In 1976 the Harvard Medical Committee used the brain stem testing to declare death, but this was not suitable, therefore, the Maastricht workshop in 1995 declared that death is irreversible cessation of all functions of the brain including the brain stem” .
In 1995 the Maastricht Workshop which is an international workshop divided NHBD s into four categories: category 1 and ll involves the uncontrolled group where donors are dead on arrival or where resuscitation has been unsuccessful. In this group, mechanical ventilation is performed in order to keep the organs viable while awaiting for consent from the patient’s family.
Category lll and lV involves the controlled group where donors are waiting cardiac arrest or who had cardiac arrest while brain dead (Chaib E.,2007). Despite the assessment and definition of the timing of death for NHBDs and its potential to increase donation by 30%, it still faces many ethical, legal and medical concerns.
The public fears include:
I. concern on whether the donor is really dead
There are two criteria for death donor rule, defined by the Uniform Determination of Death Act (UDDA): an individual is dead if both circulatory and respiratory functions have stopped and if all functions of the entire brain, including the brain stem has stopped.
This rule is quite crucial in NHBDs donation and states that death must not be rushed for the act of donation. Families are quite apprehensive that stopping cardiac pump activity and cardio respiratory functions does not qualify death and that the 10 minutes “stand off” period to qualify for both cardiac and brain stem death criteria is not enough ( Zamperetti et al 2003).
II. Concerns on the withdrawal of care
In the controlled setting ( Maastricht , category lll and lV ) families are sceptical about the decision to remove life support ventilators and may have fears that doctors may have biased interest in the in hope of harvesting organs and mistreating their loved ones. They worry if whether leaving their loved ones on life support may eventually bring them back to life and what state will they be in during prolonged life support or the options of resuscitation.
There are also many doubts form medics who think that NHBD is a “shameful act of cannabilism” ignores the likelihood of auto resuscitation and that the brains of these patients are not actually dead (Potts M., 2007) as well as the fact that the brains of these patients are not truly dead. They believe that the drugs given to the dying donor may be of benefit to the donors organs but detrimental to the donors health. Also the process of removing the organs for donations causes death in the patient and that NHBD must be banned as it goes against the practice of medicine (Verheijde et al 2007).
With all the apprehensions with regard to NHBD, a major limitation has been the lack of oxygen reaching the organs during the period when ventilations is withdrawn, known as warm ischaemia. . Warm ischaemia can be a problem as it can affect the viability organs, but scientists are investigating new technology in preservation.
The necessity of NHBD as second-class organs for transplantation
A report in a urology journal in 2009 described how some American surgeons transplanted a cancerous kidney. They removed the tumour and then transplanted it into the patient ( BBC.,2009). The reason for this shows that the demand for organs keeps raising while the supply is quite low. In the UK, in December 2009, there were 8000 patients on the waiting list for organs, with only about 3000 transplants per year. Many people are dying due to this shortage, therefore surgeons maybe using risky organs. There are many reports showing the benefits of NHBD in reducing this shortage and there is more pressure for it to be successful. A recent UK data showed that the success rate of NHBD are quite similar to HBD (UK transplant 2006). Many studies have shown good graft survival with NHBD especially in renal transplantation despite the warm ischaemic damages ( Nicholson et at 2000, Wijnen et al,1995) .
A report in between 2005-2006 shown that there were 125 NHBD transplants compared to 2004-2005 with only 87. A small but significant increase (UK Transpkant., 2006).
NHBD is cost effective, for example, a renal patient on dialysis cost an estimated ?21,200 per year. With a successful transplant with a NHBD kidney, a median graft survival of 9 years, the total cost benefit over 9 years will be ?191,000 (UK Transplant). Thus reducing the burden on the National Health Service and a better life for the patient.
NHDB as a technique was abandoned in the 1970. It has now revived due to the long waiting list and the fact that many people are dying because of organ shortages.
This type of organ donation offers great potential but its use is very divisive. There are so many ethical issues and benefits associated with both the controlled and the uncontrolled forms donations. In the uncontrolled donor (category I & ll), the presumed consent to perfuse the organs in the absence of the family or in the controlled donor (category lll), the administration of drugs to improve the viability of organs seems so unethical and considered conflicts of interests being divided between the responsibility of care to the dying donor and the possible transplant recipient.
In some ethnic groups, families of brain dead donors may be happy to donate as it gives important meaning to their tragedy that they are able to help give life to someone else.
NHBD programmes are faced with many challenges. In order to improve it:
There must be more educational programmes or talks to the public about the different criteria of death
Clinicians and the transplant teams must follow the legal guidelines by the Department of Health, adhere to the NHBD protocol and consent from the dying donor‘s family must be given before the process of harvesting organs for NHBD to reach its full potential. It maybe a long road but public confidence is definitely required.
BBC (2009) Risky donor kidney transplants prove successful.
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