The report coincides with NSW government consideration of public responses to the NSW Health Department's discussion paper on organ donation in NSW [including a detailed response by myself and colleague Dr Bonython]. The UK report proposes several controversial measures, arguably so controversial that they will not be adopted in the UK and Australia.
They include -
• a shame campaign to draw attention to the "moral disparity" of people who decline to donate, but are happy to accept an organIn discussing elective ventilation the report comments that -
• elective ventilation (ie keeping "brain dead" patients alive solely so they can become organ donors, a practice restricted after Health Dept advice in 1994)
• "retrieving" hearts from newborn disabled babies (there are currently no standard UK tests for diagnosing brain stem death in neonates, so that neonatal hearts are not donated in the UK, with neonatal hearts instead being imported)
• using body parts from high-risk donors including the elderly, people with cancer, drug users and people with high-risk sexual behaviour.
• making donation after cardiac death "a normal source" for organs
• a presumed consent system for organ donation
• payment of funeral expenses for donors
Once a patient has been diagnosed as dead using brain stem tests, artificial ventilation is usually continued for a period of time to allow the family time to say goodbye or, if organ donation has been authorised, for arrangements to be made for the organs to be retrieved. 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 system was introduced, with strict controls, in Exeter in 1988 and led to a 50% increase in the number of organs suitable for transplantation. It was stopped abruptly in 1994, however, when the Department of Health advised that the practice was unlawful.
The law requires that, when patients lack the capacity to consent, procedures or interventions must be in their best interests. The use of elective ventilation is not intended to be for the clinical benefit of the individual but to facilitate donation. The Mental Capacity Act 2005, however, takes a broad approach to ‘best interests’ (and a similar broad approach to ‘benefit’ is likely under the Adults with Incapacity (Scotland) Act 2000) and there has recently been a formal recognition that taking some steps before death to facilitate donation could be in an individual’s best interests (see section 4). The BMA has long argued that where an individual had expressed a wish to donate organs after death, some steps to facilitate that wish may be seen as in that person’s best interests or benefit (or at least not contrary to his or her interests). Individuals who are sufficiently informed may also wish to give specific, advance consent, to permit elective ventilation to take place. The UK Donation Ethics Committee has called for further debate on this issue, to more clearly define the appropriate balance between benefits and harms and the types of interventions that could reasonably be undertaken. The BMA would also welcome further clarification on this issue. From an ethical perspective one of the major concerns with elective ventilation is the level of the risk to which the incapacitated adult may be exposed. Fears have been expressed that, in theory at least, elective ventilation could induce a persistent vegetative state (pvs). Although the chance of harm occurring is considered to be very low, inducing pvs would be a very significant harm and, if elective ventilation were to be permitted, very careful safeguards would be needed to minimise this risk. This might include, for example, restricting elective ventilation to those patients dying of spontaneous intracranial haemorrhage (since these patients rarely, if ever, develop pvs) and stating that artificial ventilation must not be started until natural respiratory arrest has occurred. There are also practical difficulties associated with the lack of ICU beds and competing demands for limited resources. In the BMA’s view, priority would always need to be given to the use of intensive care facilities for those who have a chance of recovery rather than for those who are being ventilated to facilitate donation.
Elective ventilation is not an easy option but it has been shown to increase donation rates, and to facilitate the wishes of a group of patients who want to donate and would otherwise be unable to do so. The BMA is not calling for the law to be changed to permit elective ventilation but believes this may be an issue that would benefit from debate both to assess the clinical, legal and ethical issues raised and to assess public opinion about its use.
