Global Nephrology: "If You Love Somebody Set Them Free"

On Valentine's day, Sting's lyrics from the song "If You Love Somebody Set Them Free" are appropriate for this article on the shortage of organs:

If you need somebody, call my name

If you want someone, you can do the same

If you want to keep something precious

You got to lock it up and throw away the key

If you want to hold onto your possession

Don't even think about me

Still, more seriously, the British Medical Association (BMA) ignited controversy in Britain yesterday when it released a report from it’s Medical Ethics committee about approaches that Great Britain should consider in order to reduce it's shortage in organs for transplantation. The BMA is Britain's largest physician organization.

Britain has an organ donation rate (12 per million population) approximately one-third of Spain (Fig. 1). According to news reports hundred of patients die each year waiting for an organ. The BMA is bringing to the forefront for debate changes that, if implemented, could be transformative. The New York Times had an interesting discussion about this issue in 2009.

Listed below are some of the conclusions in the BMA’s report:

1. The BMA wants a debate around “elective ventilation", in which patients diagnosed as dead using brain stem tests – such as those who have suffered a massive stroke – are kept alive purely to enable organ retrieval.

This procedure led to a 50% 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. Notably, Spain and the US already use the technique.

Fig.1
Source: Rieu et al, J Med Ethics 2010 

2. The BMA favors an opt-out system, similar to one used in Spain. The opt-out system is where a patient is presumed to give consent for their organs to be used unless they have expressly said they do not want this.

The opt-out system is associated with higher rates of organ donation (Fig. 1) than the current opt-in system used in the UK and elsewhere, including the US.

3. Bringing in a test for brain stem death in newborns aged less than three months so the UK can retrieve hearts from babies who have died, for example of birth asphyxia, and stop importing hearts for this age group.

4. Easing the exclusion criteria that prevent some people from donating because of their age or medical history. "Slightly stretching" eligibility rules, particularly revising the upper age limit, argues the BMA report, could cut the 7,800-strong transplant waiting list.

5. Encouraging emergency room 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.

7. Advertising campaigns to reduce the 35% refusal rate among families who are asked to allow their loved one's organs to be retrieved.

8. Action to highlight the "moral disparity" of those who say they would accept an organ but would not donate one.

9. 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.


The bottom-line: the BMA should be congratulated for bringing these issues up for debate. Back to Sting: "If you want to hold onto your possession, Don't even think about me."