You’ve got to be kidneying me


by Rohin
19th January, 2008 at 3:17 am    

A straw poll on your views about this tricky ethical issue please.

Gordon Brown recently brought the subject of transplants back into the news by supporting a similar system to the Spanish, who have the highest organ transplant rate in the world. The system is effectively an ‘opt-out’ arrangement and deceased patients with no specific instructions are ‘presumed’ to have given consent for their organs to be used.

The argument for:

More and more patients are dying on transplant waiting lists. Many of these people are young, with congenital conditions like cystic fibrosis, primary liver cancer or autoimmune kidney disease meaning they need new hearts, lungs, livers and kidneys. Less people are dying in road traffic accidents due to improved road safety, but this results in a decreasing source of healthy organs.

No replacement therapy can compare with a transplant. A patient might be tied to a dialysis machine for several hours three times a week, on a cocktail of drugs for anaemia and bone disease and unable to live a normal life. A new kidney is life-changing, just like a new heart is better than any artificial device we have manufactured. One dead body can change several lives.

We are developing the ability to transplant more and more parts of the body, corneas, pancreatic components (for diabetics), skin, hands, eyelashes and faces. Around 8,000 people in the UK are currently awaiting organ transplant and the number grows by 8% a year and it’s not improving. 1000 are estimated to die each year on organ waiting lists.

Three quarters of the public say they would be willing for their organs to be used, yet only a quarter register for this. At present approximately 40% of relatives refuse consent for their deceased loved one’s organs to be used. There is no clear reason why the next of kin should automatically have say over someone’s organs, yet we currently listen to them.

Once someone is dead, they are dead. Eastern cultures such as Parsis and some Tibetan Buddhists have traditionally allowed their dead to be consumed by vultures. Hindus cremate. However, black and ethnic minority donors are pitifully low in number. Renal transplants cost the NHS less than dialysis after a few years.

Recycling is fashionable.

The argument against:

Can you really assume consent for anything? Herein lies the ethical stumbling block, what are the rights of the dead? As many people define death in different ways, feelings differ markedly about whether a dead body is ‘sacred’ or not. Dominic Lawson today made a (in my opinion, somewhat flawed) analogy to necrophilia in the Indy. He said how could we support presumed consent for organ donation when we are revulsed by the idea of someone having sex with a corpse? Surely consent could be assumed in both situations or neither.

Spain’s enviable record of transplant rates has not been directly linked to their consent law. They have an admirable and highly developed transplant network, with more 24 hour-harvest teams and way more road deaths than the UK. If we suddenly increase the number of transplants occurring (the patients are often highly dependent post-operatively), the NHS probably would not be able to cope without more units being opened and existing ones being expanded.

The definition of ‘legally dead’ or ‘brain dead’ is debatable.

The government has announced that more hospitals will have dedicated transplant co-ordinators, whose job description includes persuading families a soon-to-expire relative can save someone’s life. In Spain they have been credited with halving the refusal rate.

What do you think?

Disclosure: I am currently a transplant doc.


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  1. douglas clark — on 19th January, 2008 at 3:45 am  

    Rohin,

    It is obvious to me that once I’m dead, they ought to take anything usable, and, well, use it. If my kidneys should live on after me, then that would be pretty remarkable, don’t you think?

    Because I am a disorganised person, I have no idea where my signed donor card is, and I’d not expect my, hopefully stressed, relatives to find it. So, opting out makes my commitment at the end of my day a lot easier, for I wouldn’t do that. I would never opt out, but I am, apparently crap at opting in.

    I trust you see what I mean.

  2. Desi Italiana — on 19th January, 2008 at 5:18 am  

    The component of this subject (transplants) that interests me is this: with the high rates of unavailable organs for transplants, many in the rich countries seek out transplants from illegal/black markets in which “donors” (or in some cases, they are not “donating” but are forced or duped) predominantly come from poorer countries. This, as you can imagine, and spurred a vibrant but extremely lucrative industry where exploitation and trafficking run rampant. Organs, like everything else by now, have been brought into the “market” where supply must meet demand.

  3. Rohin — on 19th January, 2008 at 7:22 am  

    Ah thank you Italiana – I did mean to make that point and entirely forgot (see time I posted…sleep deprivation!)

    Absolutely right. The pressure for donors has led to an infamous black market trade in organs which is quite abhorrent. Some could argue well it’s just market forces, but as you say the donors are almost inevitably not aware of the risks/long term complications and just see the (paltry) amount they are paid.

    Major point, thanks for reminding me.

    I’m with you Douglas, on the disorganisation front as well as the hope that I might be able to help once my clogs are popped. I was neutral in the post, but I’m entirely of the belief that once dead, the body is just an ‘empty shell’ to coin a phrase. Not bothered what happens to my giblets.

  4. Desi Italiana — on 19th January, 2008 at 8:28 am  

    Rohin:

    No worries, I was just writing what came to my mind when I saw “kidney” and “transplant” :) Sleep deprivation is totally understandable :)

    But here are some articles that may be of interest:

    http://query.nytimes.com/gst/fullpage.html?res=9C0CE0DD163EF930A15756C0A9629C8B63&sec=health

    Organ trade growing in Baghdad: http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2005/05/22/wirq22.xml&sSheet=/news/2005/05/22/ixworld.html

    And a more recent article on organs on sale online:

    http://news.bbc.co.uk/2/hi/health/6240307.stm

    And unfortunately, India is a “warehouse” for the kidney trade, and Pakistan is another major hotspot for trade/trafficking.

    State of organ trafficking around the world: http://www.who.int/bulletin/volumes/85/12/06-039370/en/index.html

  5. Don — on 19th January, 2008 at 9:57 am  

    Like Douglas, I’m sure I have a donor card somewhere but damned if I could put my hands on it quickly. So in my case the presumption would be correct.

    Those who actually object to giving up their organs for whatever reason could opt-out, assuming they remember to carry their cards. In the long-term a better solution might be a yes/no box on driving licences or when you register with a doctor.
    That way we avoid presumption altogether.

    As for those who just object to presumption, I can see there could be emotional reasons around the idea. For some it may be important that organs should be donated as a freely given gift, not lifted as a matter of course. Families could feel that ‘ownership’ of the body had been taken (it would be hard to argue that logically, but we are not obliged to be entirely logical at these moments).

    The only rational objection I can think of would be the slippery slope argument, which presumes doctors would get a little scalpel-happy if you lingered more than was convenient. I don’t see that.

    Then there are the anti-statists who just object to any extension of the governments reach. But don’t we already work on the assumption that an unconcious patient consents to blood-transfusion/organ-donation unless clearly stated otherwise?

    Also, what would be the ethical position of someone who opted-out of giving, but opted-in to getting?

  6. Yaz — on 19th January, 2008 at 10:35 am  

    I don’t know what all the fuss is about. Most people who need a donor organ would take it at a drop of a hat. It’s just people being selfish, happy to take but not to give. Anyway, with an opt out clause, if you really didn’t want to donate you make your feelings known beforehand.

    I get the impression that those who are really against this idea would quickly register to opt out just to make a point (whatever that point is? i’m still not sure what they’re complaining about).

    Its ridiculous that in modern Britain people are left dying because no organ is available. I agree more investment is needed in this whole area, but that can only be a good thing.

  7. marvin — on 19th January, 2008 at 11:38 am  

    1. Uncooked kidney beans are poisonous. Not a lot of people know that…

    2. Surely if you are one of the superstitious/religious types, and you felt strongly that another human being should not benefit the gift of life from your death, then you would feel strongly enough to spend 2 minutes registering your opt-out.

    Case closed!

  8. Tim Worstall — on 19th January, 2008 at 12:48 pm  

    “Less people are dying”….Fewer…..

    For kidneys the solution is this:

    http://www.timesonline.co.uk/tol/comment/columnists/guest_contributors/article1878559.ece

  9. Bert Preast — on 19th January, 2008 at 1:02 pm  

    Yeah, the opt out system makes far more sense than the opt in. Especially as most of those dying with lovely healthy organs are the young, who as a rule haven’t given much thought to death yet.

    Not wrong that a main part of the reason Spain is so successful in this is our phenomenal rate of road-kill though, the meat mechanics get to harvest at least 50 every bank holiday weekend – and we have a lot of bank holiday weekends. Maybe in the UK drivers should be encouraged that a bottle of wine aids concentration?

  10. El Cid — on 19th January, 2008 at 1:39 pm  

    Bert Preast — ha.
    It’s true though, the road carnage in Spain is regular front page news in Spain, sadly.
    The opt-out system makes sense.
    My only concern is that doctors might be encouraged to decide someone is dead too quickly.
    After all, doctors like any profession can be an arrogant and self serving bunch behind that cloak of social respectability (e.g. Harold Shipman)
    I am being devil’s advocate of course as some of my very best friends are in the business.

  11. Sid — on 19th January, 2008 at 1:49 pm  

    I don’t mind opting in as a default but would like to take my magnificent thighs with me, if that’s ok with you. Does that mean I have to carry a card to specify which bit they get to lance and which bits I get to keep?

  12. pounce — on 19th January, 2008 at 1:54 pm  

    It isn’t just organs, I give blood (B+) and everytime I give blood I am nearly always the only person with coloured skin in there.
    To be honest I hate giving blood, (it a part of me) but I feel it’s my duty in which to be able to help somebody not as lucky as me.
    Yet NHS stats show that in the UK Only 3% of those who donate blood are from the ethnic minority background..
    “Only three per cent of those who gave blood last year were Asian, African and Afro-Caribbean descent.”
    http://www.hia.nice.org.uk/page.aspx?o=newsfeed.Aug2005&item=15025680

    Hey I’m not demanding that everybody opens up and I’m not playing the I am more righteous than you card.(I’ve admitted I abhor having a big needle stuck in me) But it would be nice to see a few more coloured people in the room as me. Do as I do, take a mag, an MP3 player and before you know it Bobs your aunty.

  13. marvin — on 19th January, 2008 at 2:19 pm  

    Someone must disagree?! What would the sky fairies think?!

  14. El Cid — on 19th January, 2008 at 2:34 pm  

    that’s a shit headline btw, despite the nice accompanying picture :)

  15. Cath — on 19th January, 2008 at 3:03 pm  

    I agree that once you’re dead you’re dead and so I have no objection to my organs being used to help someone else once I’ve popped my clogs (although for some reason I really don’t like the thought of them taking my eyes…)

    My worry is that a lot of the discussion around this is setting up false hope for some people. Obviously you know a lot more about this than I do Rohin, but even if we all donated our organs it doesn’t automatically follow that everyone who needs a transplant is going to be saved.

    My cousin had two kidney transplants, but her body rejected both. Eventually, when she was in her early fifties, after spending most of her life on dialysis, she decided she’d had enough and took the decision to stop all treatment. She died shortly afterwards.

    I wonder sometimes if instead of this constant emphasis on life at all costs, we should be more open about talking about death and facing up to the reality that at some point it’s going to come for all of us.

  16. Jai — on 19th January, 2008 at 5:12 pm  

    For some it may be important that organs should be donated as a freely given gift, not lifted as a matter of course.

    Agreed with Don. This is the first thing that occurred to me.

    Families could feel that ‘ownership’ of the body had been taken (it would be hard to argue that logically, but we are not obliged to be entirely logical at these moments).

    Extrapolating this, problems would arise as “ownership” of the deceased’s body generally falls to their family members. Due to their emotional ties to the deceased person concerned, I can imagine them having considerable objections if the body was essentially being raided for parts without explicit prior permission, particularly if some kind of religious ceremony around the deceased’s body prior to cremation/burial/etc would normally be involved which their family members would be the major participants in.

    To a great extent this is more of an emotional issue rather than one involving cold brutal logic, to echo what Don said.

    ******************

    Speaking generally, I do think that a deceased person is the main “owner” of their body even if “they” aren’t in there anymore, and that the body should therefore be treated accordingly by third-parties. It’s just a matter of basic human respect for the deceased, even though (perhaps, more accurately, “especially if”) they’re not around to prevent any mistreatment of their body after they die. And yes, I have similar concerns about the treatment of human remains found via archeological/historical explorations, but that’s a separate issue and not one directly connected to this thread’s main topic.

  17. Laban — on 20th January, 2008 at 12:20 am  

    Do you think the government will extend the new ‘presumed consent’ doctrine to cases of alleged rape ?

  18. Don — on 20th January, 2008 at 2:27 am  

    I know it is still only January, but may I nominate that for stupidest comment of the year?

  19. Rumbold — on 20th January, 2008 at 9:36 am  

    This is a terrible policy, and the best objections are nothing to do with religion. The state does not own you, and cannot just dispose of people the way that particular civil servants and ministers see fit. Why is everyone always so willing to hand over powers to the state? Would you hand over power to the person who lives at the end of the road? If not, why not? What is the difference? Why agree to give one person this power and not another?

    Before anyone asks, I have a donor card and plan to donate my body to medical research. But that is my choice.

    Too many people seem to have a very ‘utilitarian’ way of looking at thigs, at the expense of the individual. If it could be shown that installing chips in people’s heads reduced crimw, would that be a ‘Good Thing’? Or do people not object to abhorrent policies which do not directly affect them? Children are killed on the road every year. Should vehicles be banned (they should in India, or at least de-horned)? It would save lives.

  20. Laban — on 20th January, 2008 at 11:28 am  

    Some people have no sense of humour.

  21. Jai — on 20th January, 2008 at 12:12 pm  

    Rumbold,

    Very good post by you (#19), and pretty much along the same lines as my own stance on this issue, especially your comments about the fact that the state does not own us or our bodies after death, and (most of all) your concerns about the dangers of excessively “utilitarian” attitudes.

    *********************

    Rohin,

    Excellent and well-balanced article, by the way. Some more thoughts by me, to supplement what I said in #19:

    Can you really assume consent for anything?

    No, although it depends on what the prevailing norms are in any particular culture and whether the majority of people affiliated to that culture actually subscribe to those norms.

    Herein lies the ethical stumbling block, what are the rights of the dead?

    The right to assume that other people will not mishandle, mistreat, or disrespect their remains after death.

    Surely consent could be assumed in both situations or neither.

    That’s a very good analogy, since both involve someone else tampering with the deceased’s body without their explicit prior concent. It’s an extrapolated version of the scenario of messing around with the body of a comatose person; just because someone isn’t aware of what’s happening and isn’t in a position to object to it, this doesn’t mean one should take advantage of their helplessness.

    whose job description includes persuading families a soon-to-expire relative can save someone’s life.

    I find the notion of doctors “persuading”, soon-to-be bereaved family members during what is probably an extremely traumatic time for them to be sinister and exploitative.

    Gently, succinctly, and diplomatically placing the option in front of them is one thing (and something I would support, at least if there was no pressure or repeated coercion involved), but actively “persuading them” is very distasteful; my objection to this is partly due to the dangers of overenthusiastic doctors (as per El Cid’s example in post #10) but also due to the insensitivity and — in my view — general immorality of such behaviour.

  22. Katy Newton — on 20th January, 2008 at 3:35 pm  

    I am not concerned about people having to opt out as opposed to opt in. I’ve already asked my family to ensure that if anything happens to me anything that might help someone else is removed before I’m buried. If you’re bothered enough you’ll make the effort to opt out, and if you don’t that’s tough.

    But I do think that there should be a choice, and that bodies should not be stripped of their assets by the State like companies in liquidation, and I am concerned that this is only a stepping stone to the choice being removed altogether.

  23. Riz — on 20th January, 2008 at 3:43 pm  

    In some areas, imposing the choice works quite well; I believe in New Zealand, workers have to opt-out of their pensions. Because they have to choose to opt out versus opting in, the take up of pensions is higher than in the UK. However, these are my organs, and ‘to the highest bidder’, I say! And how would this work, I hear you ask…what use be money to me when I am dead. Here is the system as I see it: People group together to form an ‘organ collective’ – they pay a few pounds each to buy a future contract on my kidneys, livers, etc. I get to enjoy the money in the here and now, and when I die they can enjoy breaking me up for spare parts. There are a few problems…such as being hunted down by the consortium because a member suddenly needs a new liver. The idea needs to be tweaked:

    In the meanwhile, if you can’t be bothered to carry your donor card with you, fill in donor register on-line. I’m doing it now.

    http://www.uktransplant.org.uk/ukt/how_to_become_a_donor/how_to_become_a_donor.jsp

  24. Don — on 20th January, 2008 at 5:45 pm  

    ‘There are a few problems…’

    Riz, that’s not a problem, that’s a scenario. Work on the pitch, I see Jude Law as the fugitive with Michelle Yeoh as the Reaper. I see Michael Caine as the sleeze-ball wanting his offal. I see a franchise. Have your girl call my girl, we’ll do lunch.

  25. Don — on 20th January, 2008 at 6:37 pm  

    Rumbold,

    Can’t agree. Of course it is paramount that choice remain, but under these proposals it does. I don’t accept the slippery slope argument, properly managed this can work without outraging anybody’s self-hood or dignity. OK, ‘properly managed’ is a bit Pollyanna-ish given the system’s current performance, but in principal it works.

    Currently you opt in. As the article shows, only about a third of those who are inclined to opt-in actually get around to it. As Bert pointed out, the ‘best’ donors are the least likely to think about it.

    And how many of those have left the card in their other jacket during the crucial hours? So people die who might have lived.

    With the opt-out system, those who have a problem with donating will have a reason to register. Their wishes will be respected. And if the system falls down, then yes the consequences will be bad, but they won’t entail unnecessary deaths. Lesser of two evils.

    I’m assuming that registered preferences will be on some super NHS data-base (which probably won’t work, but again in principle…)and of course family will have the final say under these proposals.

    You say these proposals are ‘at the expense of the individual’. I don’t see that. The individual retains sovereignty over the remains, should he/she choose to exercise it. The only people it effects are those who don’t care enough to put a tick in a box.

    ‘ Why is everyone always so willing to hand over powers to the state? Would you hand over power to the person who lives at the end of the road? If not, why not? What is the difference?’

    I don’t get to vote who lives at the end of my road?

    ‘Children are killed on the road every year. Should vehicles be banned…’

    No. Should their speed be regulated by the state? Should the state insist on checking their brakes regularly?, Should the state require drivers to demonstrate basic competence before being let loose on the roads? I’d say yes. The state does have a role to play which entails telling people that some reponsibilities are mandatory.

    I don’t believe the dead have rights. I believe that it is important for the dignity of any civilized society that the wishes of the dead be given respect, but it often happens that events overtake that. After a disaster, or in the event of serious communicable disease, or to serve justice, those wishes may be over-ridden for the good of the living. But that is not to disregard or disrespect those wishes, just putting them in perspective.

    I still think that just asking your preference next time your GP up-dates your records is the best system, but if it comes down to opt-out or opt-in then I come down on the side of opt out. And in this instance I don’t see the word utilitarian as needing quotes.

  26. Sunny — on 20th January, 2008 at 11:36 pm  

    As people have pointed out – the choice still exists. If people don’t like it – opt out!

    I’m for this system of course. As the Buddha famously said, everything including our bodies is transitory. To be worried about what happens to your body when you’re dead is the height of stupidity.

    Someone else pointed out that laws apply for when you die, so legally we can still retain our bodies after we die. That’s fine… and people are welcome to write in their wills that they don’t want to have their organs donated. Simple as.

    The libertarians are crying about it… and the conservatives are… but I’m betting most of the country see it as a sensible policy.

  27. sonia — on 21st January, 2008 at 12:19 am  

    once you’re dead you’re dead! its just carbon what’s left behind, obsession with that is really silly as far as i can see, there’s plenty to worry about while we’re alive, let’s focus on the living. Its bizarre, this obsession with death and what happens to our bodies afterwards, really bizarre..it’s not us any more..the worms are eating at it! do we want protection against decay now?

  28. douglas clark — on 21st January, 2008 at 3:21 am  

    Rumbold,

    To take a philosophical twist on this, is it better that someones’ liver turns to rock, as mine surely will, or would it be better for it to help someone else out? As mine probably wouldn’t? The point being that they will both turn to rock eventually, seems to me that if it can do something useful meantime, well, you see the point.

    I doubt many folk have thought about what happens, naturally to their bodies once their gone, and I wish Sonia had not reminded me, but you can be pretty certain that in the long run, the Universe will have these damned atoms back!

    It is quite remarkable that there are folk now alive because of the generosity of donors. Personally, I can’t understand why anyone would not be a donor, but, there you go.

    An aside, if anyone gets my left leg, they will quickly discover that, on a football park, it was only useful for standing on!

    Ooh! we still haven’t got preview.

  29. Rumbold — on 21st January, 2008 at 10:16 am  

    With respect, most of you are missing the fundamental point about state control. There are essentially two theories about why the state exists. One is that it is a necessary evil, and as such should only interfere in areas that would be very difficult for individuals to manage (such as defence). The other theory is that the state by its very nature is good, so it should have power over everything unless it can be proved that power over a particular thing would be terrible.

    The latter theory is what most of you seem to be aiming for, i.e. the idea that the state can do anything it wants to us on the basis that it may make things better. Some of you talk about ‘opt-outs’, but why not then yet the state control everything, with opt-outs for anything? Let them decide who can breed, who can get married, what job you get, and if you want to choose yourself then you can always opt-out.

  30. Niels Christensen — on 21st January, 2008 at 11:58 am  

    Meaby you should ask the spanish or austrian people if they ‘fee’ the state has taken more control because of their rules regarding to organ transplant.
    You could theorize a lot around this question.
    For me ( and I’m a dialysis patient) it’s more a practical question. And a cultural one.
    Take a look at Denmark conta Sweden and Norway. Were are often sad to be much alike in culture ( strong secular protestantic societies) but when it comes to organ donation ( by family members and friends). Sweden and Norway has in the last 10 years increased donor rates and transplantation rates in such a rate that you don’t have to change the rules regarding to dying donorpatients.

  31. sonia — on 21st January, 2008 at 7:19 pm  

    let’s worry about the state controlling us/affecting us while we’re alive Rumbold, ( like dropping bombs on live people’s heads, which some people seem to have less objection to! bizarre set of priorities some of us have) – there’s plenty of material there – rather than when we are about to turn into carbon. As Sunny points out, people can opt out if they don’t like it – isn’t that enough of having a say? i think we’re flogging a dead horse here.

  32. Don — on 21st January, 2008 at 7:27 pm  

    Did the horse opt-in to being flogged?

  33. Desi Italiana — on 12th February, 2008 at 5:12 pm  

    ” Although several kidney rings have been exposed in India in recent years, the police said the scale of this one was unprecedented. Four doctors, five nurses, 20 paramedics, three private hospitals, 10 pathology clinics and five diagnostic centers were involved, Mohinder Lal, the police officer in charge of the investigation, said.

    “We suspect around 400 or 500 kidney transplants were done by these doctors over the last nine years,” said Mr. Lal, the Gurgaon police commissioner.

    The case has enthralled India’s newspapers. Editorial writers have been particularly incensed by the failure of the police to capture the main doctor, who has many names but was known most recently as Amit Kumar.”

    http://www.nytimes.com/2008/01/30/world/asia/30kidney.html?_r=1&oref=slogin

    And Amit Kumar has been arrested (in my future home– Nepal!):

    “Nepal handed over to India on Saturday Amit Kumar, who is suspected of running an illegal kidney transplant racket there, an Indian embassy official said.

    Kumar was arrested at a hotel in southwest Nepal on Thursday. He is accused of duping or forcing hundreds of poor labourers into donating their organs to wealthy clients.”

    http://in.reuters.com/article/topNews/idINIndia-31848920080210

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