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The British Medical Association (BMA) has published a report laying out options to increase the supply of organs for transplant. Some of the options considered are highly controversial, including the keeping of patients alive solely in order to harvest their organs, taking hearts from newborn babies, and retrieving organs from high-risk donors. Hearts could also be taken from recently deceased patients and restarted in those needing a cardiac transplant, under the proposals. The report justifies such measures on the grounds that up to 1,000 people a year die in Britain for want of an organ transplant.
 
The BMA report has revived the intense ethical debate about how far doctors should go to help save the lives of the growing number of patients with organ failure. It calls for a debate about the use of “elective ventilation”, an ethically contentious practice in which patients pronounced brain dead are kept alive purely to enable organ retrieval. While such patients are usually put on artificial ventilation for a short while to enable their relatives to say goodbye or for organ donation, 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 was carried out by the Royal Devon and Exeter hospital from 1988 to 1994 when it was declared unlawful by the Department of Health. During that time it led to a 50 per cent increase in the supply of organs. There are fears, however, that elective ventilation could induce a persistent vegetative state, and concern it is unethical to give patients treatment to benefit other people rather than them. “I worry about it. It’s very difficult,” said Dr Kevin Gunning of the Intensive Care Society. But Dr Vivienne Nathanson, the BMA’s head of ethics, said the practice, which is used in Spain and the United States, might be deemed permissible, at least for patients who had signed the organ donor register.
 
One of the report’s other radical suggestions is that 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. At the moment only livers, kidneys and lungs are retrieved from such patients. The report admits that some intensive care doctors oppose the practice, questioning whether the desire to increase the number of organ donors has resulted in interventions that could undermine public confidence in all forms of donation. Opponents argue that such practices are “at the very edge of acceptability”.
 
Sally Johnson of the NHS 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 that many issues, ethical and clinical “need to be considered and addressed before anything can be introduced in relation to heart donation from donors after circulatory death.”
 
A Department of Health spokesman warned that 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.
 
The report also suggests:
 • Testing for brain stem death in newborns aged less than three months so their hearts can be retrieved.
 • Easing the exclusion criteria that forbid some people from donating because of their age or medical history.
 • Encouraging A&E staff to identify more dying patients who might donate, as relatives of up to 400 people who die in A&E each year are not being asked about it.
 • Advertising campaigns to reduce the 35 per cent refusal rate among families who are asked to donate their relative’s organs.
 • Action to highlight the “moral disparity” of those who say they would accept an organ but would not donate one.
 • Extending the obligation, introduced last summer, to answer a question about donation when applying for or renewing documents, such as a driving licence or a passport, tax returns, registration with a GP or even admission to the electoral roll.
 
Refusal rates are “a huge problem”, said Nigel Heaton, professor of transplant surgery at King’s College Hospital, London, and accessing more kidneys would save the NHS “huge amounts of money” as each patient on kidney dialysis—as 85 per cent of those on the transplant waiting-list are—costs the service about £25,000 a year. 
The Guardian. February 13. British Medical Association. February 13.