A Heart-to-Heart Discussion

Stuart White 24-01-2020 12:00 PM
Categories: HRMC Articles written by Managing Director, Stuart White

A new law comes into effect in the United Kingdom shortly allowing doctors to harvest organs and other body parts from any patient dying in hospital unless they have given specific instructions to the contrary. This turns on its head the previous convention whereby the donor had to have made known their consent or in the case of not having done, permission would then have to be obtained from members of the immediate family to extract transplantable body parts.

Before going any further it’s worth having a look at the history of transplants and the rapid advancement in scope and success.  Though practitioners of medicine had considered the possibility of transplanting body parts for decades, if not centuries (consider Mary Shelley’s famous 1818 horror tale Frankenstein),  the practice only truly began in 1954 when  Dr. Joseph E. Murray  achieved the first successful kidney transplant between identical twins in Boston in 1954.  Murray received the Nobel Prize for Medicine for this pioneering work in 1990.

However, it was 13 years later when arguably the most ground-breaking transplant was carried out, almost on our own doorstep.   On 3 December 1967 at the Groot Schuur hospital in Cape Town, the heart of a young female accident victim was transplanted into a middle-aged man, Mr. Louis Washansky, suffering from intractable heart failure caused by coronary artery disease. He died 18 days later from extensive bilateral pneumonia but this limited success was hailed throughout the world as a major medical triumph and turned Barnard into an international superstar.

His second transplant on a Dr Philip Blaiberg, was carried out less than two weeks later. The donor was a young man who had had a severe subarachnoid haemorrhage while swimming.  Blaiberg survived for 18 months following his surgery.  Many people wondered why the world's first heart transplant came to be carried out in Cape Town, South Africa,  rather than one of the leading centres in the United States or Europe but in fact the standard of medicine in Cape Town in the 1960s was advanced and sophisticated with well equipped research laboratories and an ethos in which research and initiative were encouraged with a staff complement of full time doctors who combined their clinical care and teaching with experimental work in the adjacent medical school, headed by Barnard.

Much damage was done to the image of heart transplantation by the immediate unseemly scramble to get on the bandwagon. In 1968 107 transplants were carried out by 64 surgical teams in 24 countries. These were of poor clinical capabilities, matching of donors and recipients was poor and there was little appreciation of the need for meticulous aftercare and the management of rejection. The major problem was the tendency of the body’s immune system to become activated against the foreign organ and to mount a response designed to kill the invader (rejection). In order to prevent rejection, patients were given strong medications to suppress their entire immune system that in turn left them susceptible to life threatening infections. It was not until 1978, when the immunosuppressive drug Cyclosporin was introduced, that many of the problems of rejection were controlled. Since then, other drugs have been developed and today, one-year survival rates for most organs are between 70% and 90%.

As transplant medicine accelerated, it produced a wealth of legal and ethical concerns, the most critical of which related to the determination of death. Technology had improved to the point where the body could be maintained with artificial support long after the brain had died. A new definition of death was required to include situations where the entire brain and brain stem had irreversibly ceased to function (brain death). This is critical as it allows recovery before cessation of blood flow to the organs. Prior to brain death, organs could only be recovered after the heart had stopped beating, which limited transplants to kidneys and livers only. Brain death allowed the additional recovery of the heart, pancreas, lungs and intestines, eyes and even skin.

Which brings me back to the new British law.  There is no doubt that there is an urgent need for more organ donation.  400 people died last year whilst on the transplant list in the UK and in the US an average of 20 people die daily and certainly some of those deaths could be avoided if people were compelled to agree to post-mortem donation.  But there is a huge moral and ethical leap being made here which assumes that dead bodies are effectively state property and that is a worrying development.   A huge scandal broke out in the UK in the 1990s when it emerged that organs and tissue from children who died in the Alder Hey and Bristol  hospitals had been harvested and stored for use in research without the parents’ knowledge or consent, yet only a quarter of a century later this is now to become state-sanctioned.  In addition, the practise, whilst not specifically banned in any of the major religions, is condemned under differing interpretation of ancient tracts and precepts.  There is further confusion concerning the terminology and litmus test of ‘brain dead’ in the light of new research on long-term, comatose patients.

So, a pioneering step in organ donation and potentially life-saving legislation or a massive state intrusion into that most basic possession of the human being – his or her own body?  We might even say that’s at the very heart of the problem.
 

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