Donation after brain stem death
66. The mainstay of donation in the UK has been
donation after the diagnosis of brain stem death (DBD). However,
the January 2008 report of the Organ Donation Taskforce[18]
stated that, between 2000 and 2006, the annual number of such
donations in the UK fell from 739 to 633.
67. The medical criteria for identifying brain
stem death are well established, and Sir Liam Donaldson,
Chief Medical Officer for England, supplied us with a document,
prepared on behalf of the Intensive Care Society (p 40),
which set out guidelines for the certification of death by brain
stem testing[19]. This
document stated that, in addition to their wide acceptance by
the medical profession across the world, "the criteria for
the diagnosis of brain stem death have also been adopted by the
courts in England and Northern Ireland for the certification of
death".
68. Despite this background, there are still
a limited number of groups and individuals who disagree with this
way of defining and confirming death as a replacement for the
traditional process of establishing that there is no heartbeat
and that breathing has stopped. Dr David Hill, a retired
consultant anaesthetist, put it like this, "death can only
be assured by complete cardio-pulmonary failure over a period
of time and at normal temperature" (pp 223-225). Dr David
Evans, a consultant cardiologist, also took this view, asserting
that "so-called 'brain stem dead' patients who are designated
as organ donors are self-evidently alive" (pp 213-216).
The views of faith groups on this issue are reported in chapter
10.
69. A view, more in line with the mainstream
of opinion, was expressed by the Patient Liaison Group of the
Royal College of Surgeons (England), who identified the need for
more public education about the concept of brain stem death in
order for organ donation from such patients to be more widely
accepted. They took the view that "the heart beating donors
issue is a difficult one and the public will need reassurance
on the ethics of it as well as greater clarification about how
it is defined. Issues related to the diagnosis of brain stem death
must be transparent, with clear guidelines and nothing left to
clinical judgement. Public education on understanding of brain
stem death as opposed to cardiac death is important" (pp 48-52).
70. Mr Keith Rigg, British Transplantation
Society, told us that the Academy of Medical Royal Colleges (AMRC)
was working on an up-dated Code of Practice for the diagnosis
of death (Q 241). We subsequently heard from Dr Martin
Smith, a consultant in neuroscience critical care at University
College London Hospitals who was involved with this work, that
the AMRC code had been agreed some time ago but was awaiting the
endorsement of the Department for Health before it could be published
(pp 250-251).
71. Dr Smith explained that the code agreed
by the AMRC consisted of two parts: the first dealing with the
diagnosis of death; and the second with related issues affecting
organ donation. While the code did not alter any essentials of
the existing guidance for the diagnosis of brain stem death, it
did provide additional clarification in some areas which had been
a cause for concern. Dr Smith added that the code also included,
for the first time, guidance on the diagnosis of death by cardiovascular
criteria.
Donation after cardiac death
72. Donation after cardiac death, or non-heart
beating donation, takes place from donors who have suffered a
cardio-respiratory arrest sometimes, but not always, subsequent
to the withdrawal of treatment. The Organ Donation Taskforce reported[20]
that, after specific support from UK Transplant, between 2000
and 2006 there was an increase in the annual number of such donations
from 38 to 146.
73. Dr Paul Murphy, Leeds General Infirmary,
told us that post cardiac death organ donation (NHBOD) most commonly
occurred after the planned withdrawal of life-sustaining therapies
for patients in intensive care units, for whom there was no prospect
of recovery. In order for a donation to occur, a surgical team
had to be assembled (usually from another hospital), and only
when they were ready could treatment be withdrawn. This inevitably
meant that the patient might have to be maintained on therapies,
which would otherwise have been withdrawn because there was no
hope of preserving life, purely to maintain the organs in a suitable
state for transplantation (pp 122-132).
74. Against this background, Dr Murphy emphasised
to us, "The committee should recognise that many ICUs are
resistant to the introduction of NHBOD—certainly in the
absence of a binding and authoritative statement on the ethico-legal
probity of the process".
75. Once again, the situation across the EU differs
widely with regard to donation after cardiac death, with the UK
having one of the most permissive regimes in this regard. According
to the Impact Assessment which accompanied the Commission's Communication[21],
Croatia, Germany, Hungary and Poland legally prohibit the practice.
Moreover, while it is legally permitted in other Member States,
some countries have not developed any programme to implement such
donations, notably, Italy, Portugal, and France.
Cross border donation
76. Dr Chris Rudge, UK Transplant, supplied
us with the statistics shown in Table 4 which show the extent
to which organs were exchanged between the UK and other countries
during a recent 12 month period.
TABLE 4
Solid organs exchanged between the UK and
other countries:
April 2006 to March 2007
