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75 Medico-Legal J. 1 (2007)

handle is hein.journals/medlgjr75 and id is 1 raw text is: Medico-Legal Journal (2007) Vol. 75 Part 1, 1-2 © Medico-Legal Society 2007 Editorial: Still an Abhorrent Practice? Dr M A Mansell MD FRCP Consultant Nephrologist m. mansel)kidneylaw co. uk Although it is only some four years since I wrote about the difficult medical and ethical considerations raised by rewarded live-donor kidney transplantation the debate has moved on significantly so that an update seems appropriate.1 It is disappointing, but unsurprising, that the underlying problem is unal- tered or, indeed, somewhat worse; the number of kidneys available for transplantation has shown little increase, more patients are developing end-stage renal failure and the waiting list continues to grow. An adult patient who is not blessed with either a partner or relative to donate a kidney will probably wait between two and five years for their first trans- plant and, of course, some will die during this time because dialysis becomes impossible. A telling statistic comes from the United States Department of Health: Each day, about 74 people receive an organ transplant. However, 17 people die each day waiting for transplants that cannot take place because of the shortage of donated organs. The situation in the United Kingdom is probably even worse. The Human Tissue Act (September 2006) is supposed to reduce the influence of the next of kin in preventing the removal of organs from a potential donor who has previously recorded this clear wish during their lifetime. There are about 1,000 potential donors each year in Britain, although only about 600 actually provide organs, usually because of opposi- tion by the family at the very difficult time when decisions have to be made. The availability of another 400 donors each year would have a signifi- cant effect on all transplant programs and would, incidentally, dramatically reduce the size of the dial- ysis population and the money spent to sustain these patients, currently about 2-3% of the entire NHS budget. However, such is the corporate sensitivity of the transplant establishment that it seems very unlikely that transplant co-ordinators and surgeons will be prepared to increase the encouragement to donate that they give to next of kin, for fear of the shock/horror story which will inevitably follow in the tabloids. Why is there such a disparity between the clearly-expressed wishes of the majority of the population and the spin inevitably placed on this story? Recent initiatives aim to increase the use of marginal (non-heart beating) donors, patients in whom the kidneys have been rapidly retrieved after death has occurred, with perfusion of the organs in vivo in an attempt to preserve their viability. Other marginal donors, both cadaveric and live-related, include older patients and those known to be suffering from diabetes, hypertension or significant renal impairment. Even if all of these marginal kidneys were used for transplantation the numbers are not large and, more importantly, there is a greater risk of problems and smaller chance of long-term graft survival. A potential recipient of such a kidney will need carefully to have considered the risk/benefit analysis long in advance of the event and their informed consent will probably need to be written in blood and witnessed by at least three Law Lords if litigation is not to follow an adverse outcome as surely as night follows day. Rewarded kidney donation is now an accepted fact in many countries, although proscribed in America and most of Europe. The arguments against it usually include exploitation of the poor by the rich, dangerous medical and surgical practice, the real risk of coercion and the involvement of criminal middlemen. All surgical transplant associations and many religious authorities denounce the paid use of paid human organs in terms such as morally and ethically irresponsible or inhumane and unaccept- able. One American anthropologist has described legalisation of organ sales as the assertion of prop- erty rights by one relatively privileged group over the bodies of the disadvantaged.2 Those in favour of donor reward usually empha- sise the increasing importance accorded to patient autonomy, the freedom for people to engage in dangerous and even life-threatening pursuits if they wish and the fact that donation of renewable tissues such as sperm, ova and blood is universally accepted.

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