§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Lightbown.]12.33 am
§ Mr. Michael McNair-Wilson (Newbury)
I think that everyone is aware of the incredible strides that have been made in recent years by medical science with the transplantation of human organs. Today, heart, lungs, kidneys, livers and corneas are regularly taken from donor bodies and used as replacement organs for defective ones in living people. As the science develops, so the success rate improves, in terms of successful transplants and in the length of time that the transplant continues to function effectively. I should like to stress those last words, because I think that many people imagine that a transplant is a once-and-for-all operation whereas, in fact, it is usually for a limited time, depending on the effectiveness of the means used to prevent rejection. Leaving aside cornea grafting, of all the transplants that are carried out kidney transplants far outnumber the rest and show the highest success rate. Currently in this country nearly 6,000 people are enjoying the benefits of transplanted kidneys. That puts the United Kingdom at the top of the transplant league in western Europe and makes up for some of our shortcomings in dialysis.
I would like to outline some suggestions for making the transplant programme still more effective. However, before I do that, I must comment upon some of the reports that appeared in a Sunday newspaper and in some national daily newspapers to the effect that organs are being taken from brain dead people when those people cannot be described as dead. In effect, it is claimed that their lives are being shortened by the removal of their organs. I do not know how such an allegation can be sustained against the criteria for brain death agreed by the medical profession five or six years ago, and re-examined earlier this year by the General Medical Council, not just on the basis of potential transplant donors, but designed to cover the time when a medical team can switch off a ventilator or some other life support equipment.
If Dr. Evans who made the allegations has some new evidence, we must ask whether he has made that available to the General Medical Council. He must know that his allegations are bound to create doubts in the minds of those who will be asked to allow the organs of a brain dead relation to be taken for transplantation, to the detriment of the whole transplant programme. It behoves Dr. Evans and the General Medical Council to clarify the position as a matter of utmost urgency. If, as I am led to believe, his allegations will not be sustained, the question arises: how can more organs be made available from brain dead donors than is currently the case to meet the real demand?
At one time I think that we all believed that the kidney donor card was the right approach. It was a small, easily carried card that stated the wishes of its owners about the use of his or her kidneys in the event of death. Although the idea and implementation appeared simple, the fact is that it has had a negligible impact on the provision of organs. There is no one reason for that. In a letter to me in March, Mr. Michael Bewick, the consultant renal surgeon at Dulwich hospital said:Over the last 5–6 years, 20 per cent. of the population have carried donor cards, yet surveys show that 75–80 per cent. wish their organs to be used. Thus, the donor card scheme has outlived its usefulness. The reason why the card 155 scheme has not been more effective is because it relies on the hospital authorities finding the card either on admission or soon after. As these patients are so desperately ill, the responsibility of the medical and nursing staff is to get the patient better, not to find out what should happen if they die. Thus, no effort is made to look for the donor card and the patient's belongings have been returned to the next of kin and they by now have left the hospital.Mr. Bewick's comments were supported in a letter written by the chief medical officer at the Department of Health and Social Security, Sir Donald Acheson, to a member of the renal transplant unit at the Charing Cross hospital in May 1985. Sir Donald wrote:It is now just over a year since the Government launched its campaign to promote the organ donor card scheme, and the number of kidney transplant operations performed in the UK, according to the UKTS provisional figures, has risen to 1,415, for the year March 1984 to February 1985, an encouraging increase of 30 per cent over the previous 12 month period.However, more needs to be done to improve the availability of donor organs yet further. The evidence suggests that about three quarters of the population are willing for their organs to be used for transplantation, and that about 4,000 people die each year in circumstances where organ donation is possible. This implies that about 6,000 donor kidneys should become available annually, which is more than enough to meet estimated needs. It would seem, however, that one of the constraints on increasing the actual supply is the reluctance of some doctors in, for example, intensive therapy units and neurology departments, to initiate organ donation procedures.I shall enlarge on the last words of that passage later.
One of the problems faced by those involved in obtaining organs is gaining the consent of next of kin to remove them. The kidney donor card should have overcome that problem because the Human Tissue Act 1961 makes it clear that no second consent is required. However, as Professor Peter Morris, the distinguished renal transplant surgeon in Oxford told me,Most of us feel that there must be permission from the relatives if the relatives are available.I recognise the humanity of that statement, but I wonder whether the emotionalism of the moment may discourage some hospitals from asking relatives for the right to transplant. If so, what can be done to encourage the supply of organs? At this time there are about 26 transplant units in the United Kingdom, about 3,500 people requiring kidneys and an unspecified number needing hearts, lungs, livers and corneas. In terms of kidneys, the present demand could be satisfied by 2,000 donors, as each donor provides two kidneys and only one is transplanted into a patient. Two successful transplants not only give a renewed normality to the recipients but free two dialysis machines for two more kidney sufferers. Thus one donor assists four people.
As I have said, the kidney donor card does not appear to be the best way of obtaining the additional organs, although I admit that it does keep the subject of transplants alive. Where parents carry them, I think that they are making a statement about themselves and their families' willingness to become donors.
More publicity could be given to the whole subject. I suggest that transplanting be written into more television drama—such as East Enders or serials relating to hospitals, which would acclimatise people to the idea that transplants are a natural part of modern living.
When all that has been said, however, the fact remains that there is a shortfall in the number of donors needed. 156 It is estimated that 4,000 donors could become available every year—people of between 20 and 65 years of age with absolutely healthy organs which would more than satisfy the current demand, but we are not obtaining that supply.
In the October-November edition of "Economic Affairs", an article by Mr. Marvin Brams of the university of Delaware suggests that one way to obtain that supply would be to allow people to sell organs. I must say that I do not like the idea. The gift of an organ is an act of altruism. As one who may benefit from a transplant at some future date, I would like to believe that the organ I received was given by someone who wished to give it, not that it had been bought.
The financial argument does have some validity in a different context. When a donor's organs are to be removed, an operating theatre has to be made available, as well as ancillary services, at the hospital where the operation is to be carried out. Currently hospitals providing both the donor and the facilities benefit not at all from the trouble to which they have gone to make the donor's presence known to the local transplant unit. It does not seem unreasonable to me to suggest that the hospitals might be much more willing to help if they were to receive some remuneration for the facilities that they provide.
In simple financial terms, every kidney patient on dialysis costs the Health Service £10,000 a year, while a transplant operation costs about £7,000. If it is successful, the patient costs the Health Service virtually nothing while the transplant works. Clearly, the financial saving to the Health Service of a successfully transplanted kidney is quite enormous.
If financial remuneration of the kind that I have outlined seems difficult to introduce, I believe that we should consider legislation, or perhaps a ruling from the General Medical Council, to produce the necessary effect and make hospitals more forthcoming about potential donors. Such an approach can be encapsulated in the phrase, "required request". It would place a statutory responsibility on every hospital where there is a potential donor—that is, someone suffering from brain death—to request the relatives' permission to remove the organs and when permission is forthcoming to inform the nearest transplant unit that a donor exists. The beauty of required request is that the hospital would be obliged to ask for the organs and would not have to apologise for doing so.
Whether we choose required request or whether we consider financial remuneration, both suggestions seem worthy of careful consideration. Neither forces a potential donor's relatives to do anything against their principles or beliefs and each seems to offer the possibility of a better supply of organs for those whose lives can be restored to normality only through a transplant. I commend both suggestions to my hon. Friend the Minister and look forward to her comments.
§ The Under-Secretary of State for Health and Social Security (Mrs. Edwina Currie)
I congratulate my hon. Friend the Member for Newbury (Mr. McNair-Wilson) on his success in the Speaker's ballot and on raising once again this important subject on which I have heard him speak in the House before. I acknowledge his personal interest in the subject as a dialysis patient, although I know that he is not currently awaiting an organ transplant. He 157 is continuing his important campaign with the distinction, courtesy and detail that he has shown previously and thus, I am sure, helping many people.
I assure my hon. Friend of the Government's commitment to the transplant programmes and we share his objective in seeking to increase the supply of donor organs. Perhaps I could just challenge him slightly on one or two points. As he probably knows, the survival rates of grafted kidneys have improved dramatically in recent times. The cadaver kidney will be alive and kicking in 62 per cent. of patients after one year compared with a best rate, achieved with a sibling live donor, of 81 per cent. That is a 10-year average. The current rate for anyone receiving a cadaver kidney this year is likely to be much better, as the rates are improving all the time and offer real and genuine hope to patients. In other words, the transplant programme is no longer experimental but is a standard procedure and a genuine life saver for those concerned.
I agree with my hon. Friend that the factor limiting the expansion of the programme is the supply of suitable kidneys. The supply of cadaver kidneys has been expanding steadily, from 842 in 1979 to 1,334 last year. For the first 10 months of this year the figure was already 1,363—more than in the whole of last year—suggesting that we are on course for a record total of more than 1,600 and a 22 per cent. improvement on last year. That is hardly a negligible improvement. My hon. Friend will also realise that many of the thousands of kidneys that may become available might not be suitable in the particular circumstances. There is therefore a limit, although I believe that the figures in the chief medical officer's letter are important and should be more widely known.
More kidney transplants are carried out in this country than in any other Europan country. The figures that I have given compare with about 300 in the Netherlands, 140 in Finland and less than 300 in Belgium. Our closest rivals are West Germany, with about 1,200, and France with about 1,100, so we are well ahead in terms of numbers, although in terms of rate per million population some of the Scandinavian countries are a little ahead. Those figures include live and cadaver donor transplants, so they are slightly higher than the figures that I gave earlier.
We have also seen a welcome increase in multi-organ donation, which has enabled the supply of donor hearts and livers to keep pace with the expansion of the heart and liver transplant proggramme. Here we have some real success stories to tell, especially—I do not wish to make a party political point—under this Government. In 1979 there were only three heart transplants, last year there were 169. In 1979 there were 12 liver transplants, last year there were 88. The figures for this year show that more than 200 heart transplants and more than 100 liver transplants will be carried out. The shortage of donor organs is a serious problem only in paediatric cases, where very close matching is needed. Perhaps I may add the least glamorous of all transplantations—that of corneas. In 1983 there were only 33, in 1985 there were 530. So far this year there have been nearly 600, which gives us an annual rate of nearly 800. The fact that the sight of 800 people has been saved is an amazing statistic, and I congratulate all the staff concerned.
As my hon. Friend said, the waiting list for a kidney transplant is currently more than 3,000. It is estimated that once the list has been cleared about 2,500 donor kidneys will be needed each year, so we are talking about 158 thousands of people and their families. It is not a minority interest, in any sense. As the heart and liver transplant programmes convince us of their success and are expanded, a shortage of those organs could become more of a problem than it is at present.
What have we done? My hon. Friend referred to one or two items. In 1984 the Government launched a major campaign to increase public awareness of the benefits of organ transplantation and to promote the donor card scheme. The results were very encouraging and public opinion polls taken at the time showed that more than 70 per cent. of the population had switched to become in favour of organ donation. That was a major achievement. The campaign coincided with the publicity being given on the "That's Life" programme to the story of Ben Hardwick and his liver transplant. I acknowledge the importance of media coverage in this area, and pay special tribute to the very positive contribution made by Esther Rantzen and all the team involved in "That's Life".
Since 1984 we have encouraged and supported many local initiatives, and I thank all the companies, groups and individuals who put much effort into encouraging people to carry the card. We have taken several initiatives centrally, for example, through the Confederation of British Industry and the Institute of Directors. Some examples of the national initiatives being taken to promote the donor card include Esso agreeing to distribute cards at filling stations. Barclaycard agreeing to send out cards with its bills, the clearing banks and major building societies agreeing to dispense cards and the National Union of Students agreeing to include a card in the welcome package for each student. I have written to the Post Office about getting a set of commemorative stamps, which might serve to remind millions of people using the Post Office of the importance of this service.
I strongly agree with my hon. Friend about the dangers of the sale of organs. I do not think that that is on, either now or later, in the United Kingdom. I listened carefully to and took note of his point about financial encouragement to the hospitals. The fact that, as his figures showed, the cost to the hospital drops dramatically as soon as the patient has a successful transplant should in itself be an encouragement. We take into account the points that he made when deciding on funding for kidney units and, increasingly, on the other units, which are currently supra-regional for livers and hearts.
My hon. Friend mentioned the required request legislation that was recently introduced in several American states. He may know that in March this year my predecessor, my hon. Friend the Member for Wycombe (Mr. Whitney), visited New York—one of the first states to introduce such a law—and found that the arrangements were working well. The Department's chief medical officer wrote to the medical profession's representative bodies about required requests earlier this year, and the replies were very encouraging. I am pleased to say that the Royal College of Physicians is setting up a working party to examine how the medical profession can contribute to increasing the supply of donor organs. It will be meeting in January, and we look forward to hearing its recommendations and conclusions. I hope that it will look carefully at required requests and will consider whether they can make a useful contribution and, if so, whether the better results could come from a voluntary code of practice or from a change in the law.
159 We have seen the establishment of computerised registers in Glasgow and Manchester, and this year Lifeline Wales was launched, which aims to cover the entire Welsh population. The idea of some of these schemes is that the names of all those who are willing to be organ donors should be recorded on a computer and that all intensive care units should have access to it, so that whenever a potential organ donor dies, doctors can ascertain whether his or her name is on the register. I am sure my hon. Friend will recognise that such a system is expensive to initiate and maintain. We are being kept informed of how the Welsh scheme is progressing, which is more comprehensive than the others. If the increase in donations is significant, we would consider extending the scheme to cover the whole of England. We would need to be sure, however, that there was a genuine improvement in the number of donor kidneys coming forward, or we would be spending money and not improving the service.
We have taken some initiatives with the Health Service professions. The Government are supporting a study which is now in the pilot stage and which aims to improve our understanding of the numbers of those who die in circumstances which make them suitable as organ donors and of the reasons why a number of potential donations are missed. Refusal of consent by bereaved relatives is only one possible reason among many and this is an issue which the royal college is considering for us and on which it will be advising us.
I turn to the important and serious issues which my hon. Friend raised about the articles which appeared in yesterday's newspapers and in today's, which seemed to cast doubt on the concept of brain death. I have discussed these articles and the issues which they have been raising with the Department's medical advisers and with Professor Sir Raymond Hoffenberg, president of the Royal College of Physicians, and chairman of the conference of the medical royal colleges and their faculties, whom I know from many years during my time at Birmingham. Sir Raymond has long been associated with the Queen Elizabeth hospital, Birmingham.
I am able to confirm yet again that the conference of medical royal colleges remains completely satisfied with the concept of brain death and with the criteria for establishing it. My hon. Friend may know that the criteria are set out in the code of practice on the removal of cadaveric organs for transplantation drawn up by a working party chaired by Lord Smith of Marlow and circulated to all hospital doctors in 1980. This code of practice requires that tests to establish death are carried out by two doctors, not one, who are both independent of 160 the transplant team—they have nothing to do with that team. Tests are carried out on two separate occasions even if the first results appear to be conclusive. The tests include checking for pupil reaction to light, for corneal reflex and eye movement, for motor responses in the cranial nerve distribution in response to stimulation of the face and limbs, for gag reflex and cough reflex, and for respiratory movement.
The idea of including EEG testing, as Dr. Evans has suggested in the past, and again yesterday, as requirement has been considered on several occasions and rejected as superfluous and on occasion unreliable. Apparently the machine will "jump" if someone walks past the bed. It would seem that it might produce the wrong results entirely. There is nothing to stop doctors from carrying out EEG tests, however, in addition to all the other tests if they so choose.
Professor Hoffenberg told me this evening that no case of recovery by a patient in whom brain death had been established, using these criteria, has ever been recorded.
I shall put that another way. There is no evidence that anyone showing brain scan death, according to the criteria, has ever survived. That is the position throughout the world. Dr. Evans was challenged to produce some evidence of his case five years ago and he has failed totally to do so.
Perhaps I may add—I am sure that my hon. Friend will agree—that we deplore the emotional and unfounded remarks that are reported in yesterday's press, medical and otherwise, of those who have been attacking the transplant programme. They have been challenged repeatedly to produce evidence and they have failed repeatedly to do so. If they wish, they are entitled to challenge transplantation, especially of hearts, on other grounds, such as ethical grounds or religious objections. They are entitled to raise difficult questions, especially when the work first starts and so many failures occur. They are entitled also to challenge us, if they wish, on the allocation of resources. I can quite understand a cardiologist disapproving of a transplant programme in his own hospital which is costly and which may drain funds from his own work. That is quite legitimate, but we do not accept the remarks of someone who is flying in the face of the overwhelming body of medical opinion, which has considered his representations over and over again, including several times this year. I am therefore satisfied that what we are doing is not evil or reprehensible—indeed, far from it. This is good work that saves lives, and it is worth pursuing. I am grateful to my hon. Friend for giving me this opportunity to say so.
§ Question put and agreed to.
§ Adjourned accordingly at one minute to One o'clock.