Womb Transplants in Sweden

The BBC reports that nine women have received womb transplants in Sweden. I'm not clear from the story whether this is a first or not. It mentions that womb transplants have been attempted before but failed to produce babies; the implicature I take it is that the transplant itself was successful. But these nine women haven't yet had babies either, so it's not clear what advance - if any - this is over the previous attempts. Still, if they are able to carry a baby (conceived through IVF), this transplant could apparently aid 15,000 women in the UK. It's unclear where that many wombs would come from though - these were apparently donated by living relatives, I don't know whether wombs can be taken from deceased donors.

Branded Organs

Christmas is, of course, the season for gift-giving, but I've not seen a lot of coverage recently regarding organ donation as the gift of life. One story that has been in the news is that of a surgeon who carved his initials on a patient's liver. The BBC provides an ethical analysis here.

Heart Transplant Survival Record

A British heart transplant patient has entered the record books, surviving 31 years (and counting) since receiving a heart transplant in 1982. A clear demonstration of the potential benefits that a transplant can bring.

Record Transplants in UK

A record number of organ transplants took place in 2012, the BBC reports. The increase of 6% on the previous year is largely attributed to an increase in the number of registered donors, which suggests that the limiting factor on transplants was indeed donations, rather than space in operating theatres. Of course, a dramatic increase in the number of donors may see some other factor, such as space in operating theatres, become the new limiting factor. But, for now, it seems that our focus should be on increasing decisions to donate, whether from individuals or their families.

'Dad has gone from Sick to Superman'

Organ donation doesn't simply save lives, in the sense of keeping people (barely) alive, but it allows them to lead much fuller, more normal lives, as this inspiring story of a father swimming from Alcatraz to shore to celebrate five years since his double lung transplant shows. It's a great example of how much of a difference a transplant can make to the recipient's quality of life, but also comes with important reminders about the limits of what transplants can achieve "The current average survival period of a lung recipient in the US and Europe is five years. Statistics say that the current 10-year survival rate of a lung transplant patient is 30%, meaning that only one out of every three patients will celebrate their 10th anniversary". Still, even five more years of healthy life is a considerable achievement, and especially valuable for someone like Gavin Maitland with young children.

Holby City Controversy

I don't watch Holby City, but it seems that a current story about organ donation has generated some bad publicity, after breaching several guidelines, including a donation proceeding after the withdrawal of consent. According to this BBC article, "This is an ongoing story and in the weeks to come viewers will see the main character Mo face up to the fallout of her actions".

Given that relatives of donors often report some comfort (from knowing good came out of their personal tragedy), while those who refuse consent often report regret, I hope viewers see some of this in the later storyline.

The Role of the Family

Just 3-4 weeks ago we (that is, members of my RSE project on organ donation) were discussing the role of the family in decisions over donation - for instance whether next of kind should be able to override the wishes of the deceased individual (in either direction). Now it's national news!

Welsh Assembly Votes on Opt-Out Donation

The BBC reports here. As usual, 'opt out' is conflated with 'presumed consent'. The role of family is also raised - this is technically separate from whether we have an opt in or opt out system, though since family have different effects in each it is relevant.

Northern Ireland Consults on Opt-Out

Northern Ireland has just launched a public consultation on proposals to switch from an Opt-In to an Opt-Out system. I was particularly pleased to see that the BBC article on this made no mention of 'presumed consent' - an idea that I've criticised elsewhere. Instead, the proposal is put in straightforward terms: it makes donation easier for those who want to donate, while allowing a refusal for those that do not. Notably, however, the proposal is for a 'soft opt-out' in which the next of kin retain a veto: "However, it proposes to make little change to the current key role played by the family in the final decision in relation to donation of organs. A family would still be consulted for additional medical information and asked about any unregistered objection to donation.".

Regrowing Livers

The fact that livers can regrow means that it's sometimes possible to take a liver lobe from a healthy donor, transplant it to someone suffering liver failure, and for both to end up with a fully functioning liver - as reported here. Recent evidence, however, suggests that this same ability means that some people's need for a transplant is only temporary, since their damaged livers may repair themselves.

Despite the focus on transplants saving lives, it shouldn't be forgotten that it's preferable if people don't need a transplant at all, saving them from major operations and a lifetime of immunosuppressant drugs. Perhaps the gap between supply and demand can be reduced, in part, by reducing demand. And, of course, it's preferable that livers that are available for transplant go to those that really need them (long term).

Back From the Dead?

I think stories like this, about people being brought back from the dead, fuel unease about posthumous organ donation. People quite reasonably worry that, if they register as donors, they will be left for dead, when they could have been saved/revived.

It's worth emphasising that the story here is about cardiac death ("Most people regard cardiac arrest as synonymous with death, he says. But it is not a final threshold"). The definition of death used for organ donation is brain death. As the article goes on to say, "[Dr Jerry] Nolan stops short of saying that Carol was brought back from the dead. Hospitals do not declare death, he says, until they have ruled out all processes that can be reversed."

Nonetheless, this article serves to highlight the ambiguity and confusion surrounding death. Of course, public misunderstanding is somewhat to be expected, given current medical practice - e.g. the family may be informed that, since their relative is [brain] dead, doctors intend to turn off life support, in order to 'let them die'.

In the words of Dr Nolan, as quoted in the article, "We used to think death was a sort of sudden event - we stop the oxygen going to the brain and after a few minutes that was that. But actually, we know that the dying process at the cellular level goes on for a period of time". Our understanding of, and attitudes towards, death and dying are obviously crucial for organ donation (provided, of course, we continue to accept the assumption that it is only permissible to take organs from the dead, except in special circumstances).

Lab-grown Kidney

The reason for encouraging organ donation is to enable life-saving (and life-improving) transplants, but future technological breakthroughs might make this unnecessary. If scientists could produce artificial organs in labs, then we wouldn't need other people to donate their organs, since it would be possible to grow new organs to meet the demand.

This optimistic image may have come a step closer today, with the news that scientists have successfully grown a rat kidney. This is, however, only one step along a rather long road. The BBC article points to several unknowns, such as how long this artificial kidney will last. There's also the issue of cost: even if organs could be grown on-demand, if the technology is much more expensive than traditional transplants, then the latter are likely to continue. Finally, it seems that this particular mechanism requires an old organ in order to grow a new one, so this method will never avoid the need for donation in any case. That, I assume, is something that scientists will keep working on; in the meantime, donation is as useful as ever.

UK Donor Increase

Organ donation is in the news today. Since the Organ Donation Taskforce, which reported in 2008, there's been a significant increase in the number of registered donors and, consequently, in the number of transplants performed.

This is welcome news, but it shouldn't blind us to the fact that demand still exceeds supply, with three people dying each day in the United Kingdom because of a lack of transplant organs (figure from the BBC article, linked above). It's important to consider ways in which we might continue to do even better, including for instance an opt-out system.

It's also notable that, according to the first article, "Last year, 125 families overruled an individual's intention to donate". The UK's present system allows relatives of the deceased to override his/her expressed wishes. Whether this is justifiable or not ought, I think, to be more debated. It's an issue that we intend to examine in the next RSE workshop.

Transplanting Disease

It's well known that organ transplants can save lives. It is, sadly, also true that they can cost lives - and not only through surgery. I reported last year on the case of a young woman who died of lung cancer after receiving a smoker's lungs. In the US, one man has died and three others are receiving treatment after being given organs from a donor who died of rabies in 2011. Again, this is a tragic case, but - lest donation rates be harmed by negative publicity - it's worth stressing the concluding statement that the benefits of organ donation generally outweigh the risks: even those who die due to an infected transplant may well have died without it.

Warm Transplants

Organs need to be transplanted very quickly, since they soon deteriorate when deprived of oxygen. The normal procedure is to cool them to prevent this deterioration, though this freezing may itself cause damage. Surgeons in London have recently achieved a first: the transplant of a 'warm' liver.

Here, the liver was kept alive, and at body temperature, artificially, being supplied with oxygenated blood and nutrients. This allows the liver to be preserved for up to 24 hours, rather than having to be transplanted within 10-12 hours: so speed is still important, but this is a considerable increase in the timeframe.

Priority for Donors

Last night, the following query was posted on the Philos-L mailing list:

In a recent book, "The Ethics of Transplants", Janet Radcliffe Richards proposes that organ donors should get preferential treatment on the donor waiting list compared to those who refuse to donate their organs. This seems to be to be a relatively commonsense, "anti-hypocrisy" measure. Indeed, it is so commonsense that I cannot help but feel that this proposal has been made elsewhere. Unfortunately, I have reached a dead-end in researching this idea; most discussion regarding hypocrisy in organ donation, sadly, revolves around organ selling.
Can someone point me in the direction of other bioethicists who have proposed a similar position regarding punishing those who refuse post-death organ donation?

I'm no expert on where this idea first came from, but I sent him a recent paper of mine from Bioethics which touches on the issue and has a couple of relevant references (in footnotes 21-22). Apparently, such a priority scheme already exists in Israel. An ethical analysis of this policy appeared in the journal Transplantation last year: here.

Needless to say, this is the kind of policy proposal that I'm very interested in exploring...

Double Arm Transplant for Iraq Veteran

I recently posted on the UK's first hand transplant. That's a worthy story in itself, but one American Iraq veteran and quadruple amputee recently received a double arm transplant. Medical advances really can be life-changing, as well as life-saving. As ever though, there are serious questions about who gets to benefit given resource scarcity. These distributive questions are primarily moral questions, as are certain questions about how resources (such as the supply of donor organs) can be increased. (Since I first saw this, the story has been picked up by the BBC here.)

Mixed Defaults

Since organ policy is a devolved matter, the Welsh Assembly has been pushing ahead with plans to switch to an opt-out policy. It emerged recently, however, that certain body parts - including hands, limbs, and faces - will not be included.

What does this mean? As far as I can see, it means that if you die without having registered any preferences over the use of your bodily remains, then your kidneys may be used but your hand may not be used. If you object to the use of your kidney, then you need to opt out of kidney donation. But if you're happy to have your hand used, then you need to opt in to hand donation. And, if for some reason, you're happy for your hand but not your kidney to be used, you need to opt in for hand donation and opt out of kidney donation.

There's no logical or principled reason why the default shouldn't take this mixed form but it seems to me to be undesirable in practice. Firstly, many people are now going to have to register preferences if they want their bodies treated according to their wishes (though this may not be such a bad thing). But it seems to invite potential confusion over what body parts will and will not be used and under what conditions.

Traditional opt in and opt out systems have a clear default: either everything will not be used or everything may be used (respectively). It's fair enough to allow individuals a choice over which parts to opt out or in, so that they can if they wish register as a kidney donor but not a hand donor. But I don't see the point of mixed defaults, which merely complicate and confuse the status quo.

Altruistic Donation

The UK's first altruistic liver transplant (that is, one from a live donor to a stranger) was performed last month. The unusual thing about the liver is that one can donate a liver lobe and then one's liver can re-grow so, unlike donating a kidney, one may be no worse off in the long term. In the short term, however, the donor may suffer as a result of the operation, which in this case took four hours and left a 6" scar, as well as the risk of infection and/or psychological problems. This pieces also highlights the risk of death: approximately 0.5%.

Given these costs, it's unsurprising that Dr Aluvihare - transplant specialist at King's College Hospital - is quoted as saying "I personally have some reservations about altruistic donations. I believe if we did everything we can to improve the supply of donations after death we wouldn't have a need for this type of donation". So the case for favouring posthumous donation isn't simply that people's organs are of little use to them after they die, but also that the costs of removing those organs are much lower.

Hand Transplants

I'm not sure if this is technically an organ transplant - it's certainly not one of the cases that one usually thinks of - but Mark Cahill recently received the UK's first hand transplant.

The BBC article includes a useful history of organ transplants (cornea 1905; kidney 1954; heart 1967; hand 1998). It does, however, make the slightly odd claim that "Hand transplants raise more ethical questions than other transplants, such as the heart, as they improve the quality of life rather than saving a life".

This is puzzling because, while many transplants do save (i.e. prolong) lives, many simply improve the quality of the recipient's life, for instance a kidney transplant spares someone having to undergo dialysis. In this recent example (which I already linked to here) a donor is said to help four people but, as Norfolk coroner William Armstrong is quoted as saying in the article, "One life has been saved and the quality of three other lives have been immeasurably enhanced". Mr Savory's heart saved the life of someone who might otherwise have died, but his lungs and kidneys 'merely' improved the quality of life of three people not it seems in immediate risk of death. This still seems a very worthwhile achievement and not to raise particular ethical questions.

One feature of hand transplants - like face transplants but unlike internal organs such as kidneys - is their visibility, as illustrated by the case of Clint Hallam, who received the world's first hand transplant (pictured at the end of the BBC article). In his case it seems that while he hasn't physically rejected the transplant, he has psychologically: he feels that the hand isn't really part of him. This is a particular danger, it seems, for external transplants and something that may raise distinctive ethical questions.