§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Heathcoat-Amory.]
§ 12.9 am
§ Dame Jill Knight (Birmingham, Edgbaston)Our doctors, like our policemen, are wonderful. They can save lives or sight, which would inevitably have been lost just a few years ago—or at least they could have, but they cannot, because the necessary organs are not available. Instead, these precious pieces of human tissue are discarded wastefully and uselessly every day. They die in the bodies they are part of, though they could give life to another human being.
At present 3,700 people are waiting for kidneys, 420 for hearts, 48 for livers and 600 for corneas to give them sight. That does not mean that we need 4,768 donors—the total number of needed organs—because one donor could give two kidneys, one heart and so on. We are not talking about an impossible target. It could, I think, easily be achieved, and the time has come when we must resolve to achieve it.
It is over two and a half years since the Hoffenberg report on the subject was published. Recommendations were made but to my knowledge none has yet been adopted, and I believe that the matter is now urgent. People are dying needlessly; impoverished peasants are being prevailed on to sell their kidneys; doctors are talking about breeding animals to use their organs in human beings; other doctors are talking about using the organs of aborted babies for the same purpose. That is the stuff of scandal.
Where shortages exist, human ingenuity works automatically to overcome those shortages. When the matter is one of life and death, entrepreneurs will go to any lengths to provide the missing items. If something is not done, the scandals will get worse.
What, then, should be done? Should the "required request" be brought in—that is, should a legal obligation be placed on hospitals to ask relatives whether the dying person's organs can be used? Sir Raymond Hoffenberg did not recommend that in his report, although the committee discussed it. It is possible, however: there is nothing illegal about asking. Some hospitals already do it, and I am told that the practice exists in many American states, where it is said to result in many more organs becoming available. But what worries me, and what I think worried the Hoffenberg committee, is that not all hospitals can deal properly with the matter—which is, after all, highly delicate and acutely sensitive. The agony of the bereaved, or those about to be bereaved, must be respected; it cannot be trampled on. That must be considered and balanced with the desire to save someone else's life.
I am ready to agree that sometimes the bereaved are comforted by the thought that the death has not been a total waste. Not all, however, feel that way. Besides, how on earth would such a directive be policed? Any law that cannot be enforced is a bad law. I do not see how anyone could be certain that the law was being carried out if Parliament directed that it should be. Instead the Hoffenberg report recommends a strong campaign of information, both for the general public and for hospital personnel, to encourage more people to become donors, and I urge that course on the Government.
I cannot agree—and nor did Hoffenberg—with the suggestion that everyone going into hospital should be 972 asked whether he would be willing to donate his organs. I can envisage truly horrendous circumstances arising. Someone might go in for a relatively minor operation, perhaps to have a bunion dealt with, and be asked first the name of his next of kin and then whether he would donate his organs. That course would, I feel, spread alarm and despondency, and I cannot agree with it.
I think that the time to ask the donor volunteers is when people are fit, well and flourishing and not expecting to die. Let us have a sustained poster campaign. Posters could be very well designed and very effective. They could be placed in health clubs, universities and sports facilities. Let us also use television. I am sure that if we embarked on the kind of campaign that the Hoffenberg committee recommended we would find more donors.
Only 20 per cent. of people carry donor cards. We could easily quadruple that, and with the right publicity and effective appeals we could make it the norm and not the exception to carry a card. Some people favour introducing a system which assumes that everyone is willing to be a donor unless they specifically say that they are not. The committee rightly discarded the opting-out system. I pay tribute to the committee and the sensitivity with which it approached a highly sensitive subject. We are dealing with individual freedom and everyone has the right to decide what is done with their bodies and their organs. The opting-out system would not always allow that.
Even when a person carries a donor card, his organs may not always be used, first because if a person is involved in an accident in the street, it is normal practice for him to be rushed into an intensive care unit, where all his clothes are quickly removed, bundled up and taken away. It is not usually the practice to search the injured person's clothes for a donor card, which gets left in the clothing. Secondly, the next of kin must agree, although the person has signed a card to say that he is willing to donate his organs. The next of kin may be the person's wife, who is likely to have been involved in the accident with the injured person. I am told that one difficulty is when they cannot ask the next of kin whether he or she is agreeable. Sometimes the next of kin is too upset to agree or cannot be found quickly enough, because obviously such cases are urgent and if organs are to be used successfully they must be removed within a fairly short time. A great deal could be done to improve hospital practice when donors are known to have agreed to the use of their organs.
The Hoffenberg report said that:
organ donation should always be considered when brain stem death is diagnosed".I do not have time to discuss that point, but it is extremely important because there has been a great deal of controversy as to whether that is right or wrong. Many people have been made nervous by the suggestion that life support machines may be switched off too quickly, with more thought for the person to be helped by the organs than for the person donating them. That, too, is a matter of extreme sensitivity.Some say that we could ask on the census, but I know that my hon. Friend the Minister will say that the Government have turned their face against that suggestion for very good reasons which I do not have time to go into.
The committee suggested that the donor card should be attached to the driving licence. I think that there would have to be an EEC agreement on that, since driving licences come under EEC regulations.
973 The report is not very long, but it is all very interesting. The main thrust of the report is on a national and local campaign to inform the public of the need for more organs and the ease with which they can be donated. The report concludes:
The goodwill of the public can be maintained and increased by publicity about the successful long-term results of transplantation. The wishes of potential donors should be made better known. Health professionals should be encouraged to respond to the generosity and compassion of the public.The public are most wonderfully generous and compassionate. When they see that there is a need, and when they understand the length and breadth of that need and its importance, they respond, but they need to be given a lead by the Government. I think that they need to be given that lead now.
§ Mr. Deputy Speaker (Mr. Harold Walker)Does the hon. Member have the leave of the hon. Member for Birmingham, Edgbaston (Dame J. Knight) and the Minister to take part in the debate?
§ Dame Jill Knightindicated assent.
§ The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman)indicated assent.
§ Sir Michael McNair WilsonI am most grateful to my hon. Friends.
I congratulate my hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight) on her admirable speech on a most important subject. She referred to the kidney donor card. All of us have congratulated ourselves on the number of cards that have been issued. At least 8 million cards were issued in 1987 and 1988. However, when I asked Ministers how many of those carrying donor cards have ended up as kidney donors, they were unable to supply me with that information. That suggests to me either that the card carries no weight with the medical profession, which therefore does not seek it out when people are taken into hospital, or that the card does not have the force of law that donors believe it carries when they sign it.
If that is the case, we should look into the matter and ensure that the card is what it purports to be—the consent of the person carrying the card to have his or her organs taken in the event of death without recourse to next of kin. I understand that in law there is no requirement for hospitals to ask next of kin to remove organs.
We know how many cards have been issued. We do not know how many cards are being carried by donors. There is no national, centralised computer register of donor cards, so I do not think that the Minister will be able to tell me that the Department knows that X number of cards are being carried in people's pockets. All that I was able to glean from his predecessor was the statement:
We wish to see an evaluation of the registers being established by the Manpower Services Commission, for example, in Birmingham and Sheffield, and of a similar scheme operating in Wales before giving further consideration to this question."— [Official Report, 14 July 1988; Vol. 137, c. 364.]974 I do not think that that is good enough. I wholeheartedly endorse what my hon. Friend the Member for Edgbaston said. If only we could garner all the kidneys and other organs that are available but that are being lost through neglect, we should not have the problem of the waiting list to which she referred.
§ The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman)I congratulate my hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight) on her success in the ballot and on choosing a subject that is of such great importance to a growing number of patients. I congratulate also my hon. Friend the Member for Newbury (Sir M. McNair-Wilson) on his brief but trenchant contribution. I pay tribute to him for his fortitude over his own personal disabilities and the great experience, consideration and sympathy that he always brings to these debates.
As transplant surgery becomes increasingly successful, demand grows and we have to concentrate on ways of stimulating the donation of organs. As a Government we have been extremely active in this area during the last year, and in a few minutes I will explain both what we have been doing and the sensitivities which many people feel on the subject.
The United Kingdom record on organ transplants is a credit to all those involved in it. Although we do not yet have firm totals for 1988, provisional figures for the number of transplants show that it was another record year. Last year, the National Health Service carried out 1,544 cadaveric kidney transplants, 332 heart and heart-lung and 212 liver transplants. For kidneys, this implies a rise of 35 per cent. compared with five years ago. Heart and heart-lung transplants rose sixfold, and liver transplants over tenfold over the same period.
Compared with our European neighbours, we are among the leaders both in terms of transplants performed and the technical excellence of our programmes. In terms of numbers of kidney transplants per annum, Germany and France are slightly ahead of us but have about the same activity rate per million of population.
We do not have good figures on the number of heart and liver transplants performed in other European countries, but we know that our programmes are held in high regard by our neighbours. We commenced our transplant activities much earlier than other European countries.
Despite the record figures, the numbers waiting, particularly for kidney transplants, are too high, and I agree with my hon. Friends about that. We are not alone in this. Most countries have substantial waiting lists and in many they are growing significantly. In round terms, the United Kingdom waiting list for kidneys is 3,500, that for hearts and heart-lungs stands at 400 and livers at between 40 and 50. The figures given by my hon. Friend the Member for Edgbaston probably included those for the Republic of Ireland, whereas I am giving figures for the United Kingdom. In the case of cadaveric kidneys, about 35 per cent. of patients wait for less than a year. Those with rare tissue types may face a much longer wait because of the difficulty of providing a well-matched donor.
Organs for transplant can be obtained from two sources. They can be donated after death or from living organs. Live donation applies only to kidneys. Since 975 humans are endowed with two kidneys, and it is quite possible to function with one, close relatives sometimes donate a kidney. Where the genetic relationship between donor and recipient is very close, this can often produce a good match and lead to a successful graft.
With other organs live donation is not possible, except in one special and rather interesting case. In recent years our surgeons have been successfully transplanting the heart and lung as a single unit. This is often carried out on patients whose lungs are in chronic failure, as happens, for example, with cystic fibrosis. In such patients, the heart is often in good condition, so instead of wasting it the cardiac surgeons put it into another patient needing only a heart transplant. Providing the donor consents—and why should they refuse?—this is one way of maximising the use of available organs.
Our largest heart transplant centre, Harefield hospital, has performed these so-called "domino" operations successfully in significant numbers in the last two or three years, and we pay tribute to their skill. However, this is a special case. The point remains that live donation is essentially possible only with kidneys. But live donation, even between close relatives, is not our preferred source of supply of kidneys. European Health Ministers held a special meeting on transplantation in November 1987, and agreed that
the use of organs from living donors should be restricted and, where possible, gradually eliminated.The best way of making this happen is, of course, to boost donations from those who have died to make live donation less necessary. In the United Kingdom we are fortunate in not having to rely heavily on live kidney donors; in 1987 well over 90 per cent. of our transplants were from those who had died.One source of organs is totally unacceptable both to this and other European Governments. This is the purchase of kidneys from unrelated donors. Recent allegations of trading in organs have evoked feelings of disgust in virtually all of us, and the Prime Minister has denounced the practice in this place. Hon. Members will be aware that the health authorities concerned have moved quickly to investigate the allegations, and that the cases have been referred to the General Medical Council, which will consider whether professional misconduct has occurred. We are urgently considering legislation.
The Government have been concerned about the shortage of cadaveric organs for some years. In 1986, as my hon. Friend said, the Department of Health sought advice from the Royal medical colleges on why there was a shortfall, and ways of remedying it. The colleges set up a working party under the chairmanship of Sir Raymond Hoffenberg, the then president of the Royal College of Physicians, which reported in 1987. The working party stressed that many factors contributed to the shortage, and accordingly made recommendations covering several areas. We have acted on two proposals in the report which appear to be the key points.
The first recommendation was that each health authority should have an operational policy for organ donation, including procedures for identifying potential organ donors an referring them to the transplant units. Associated with that was the recommendation that a national audit be undertaken of deaths in intensive care, to show how many potential donors exist and the reasons why sometimes donation does not take place.
976 In December 1988, we issued a health circular giving effect to that recommendation. Health authorities were asked to report to the Department by 30 June this year, confirming that procedures have been drawn up. They began the audit on 1 January. It is too early to reach a conclusion, but we shall be reviewing the first three months' data so that any problems encountered in conducting the survey can be sorted out. After six months, we expect to see some useful pointers emerging—but given the relatively small number of donors, it may be one year before reliable patterns can be discerned. The audit will run for two years, with the possibility of extending it if necessary.
I hope that my hon. Friend accepts the value of the action we have taken to establish in as many cases as possible the circumstances surrounding a death, the existence of a donor card, procedures followed by the intensive care unit and by the doctors and nurses involved, the reactions of the relatives concerned—all of which will enable us to reach a conclusion as to how best we can improve the methodology and hospital procedures.
The working party's other key recommendation concerned publicity. Numerous surveys showed that the public generally are in favour of organ donation. About three-quarters of the population state that they would be willing to become donors after their death. But those sentiments are not always translated into action. The working party recommended more publicity both among the general public and among the medical profession. In response, we increased the Department's publicity expenditure. In the current financial year, 1988–89, we are allocating about £250,000 for that purpose. That sum is split between publicity directed towards the professions and that aimed at the general public.
My hon. Friend the Member for Edgbaston asked whether that was the right order of magnitude and whether we would consider also the use of television and poster advertising. I give my hon. Friend an assurance that I shall look further into how that money is being spent, and at how best to improve the carrying of the message to the general public of the donor programme's importance.
In 1988 we distributed more than 14 million donor cards, compared with about 5 million in 1987. In October 1988, in collaboration with the Healthcare Foundation, we began an initiative to make donor cards available in high street stores. In January, I was delighted to participate in a venture by the Reader's Digest, which carried an article on transplants coupled with the issue of more than 5 million donor cards. In the spring, we plan to release a video, displays and leaflets for use by transplant co-ordinators, who perform valuable education and publicity work.
The donor card has attracted its critics. My hon. Friend the Member for Newbury asked me questions on that aspect, which I shall answer in a moment.
§ Dame Jill KnightI am delighted to learn that so many donor cards have been made available. However, my hon. Friend the Member for Newbury (Sir M. McNair-Wilson) made the point that we do not know how many cards were signed, or the addresses of those who signed them. As far as I know, no register is kept of those people. Can something be done about that?
§ Mr. FreemanMy hon. Friend reminds me of the criticisms made by my hon. Friend the Member for 977 Newbury. The first concerned the status of the card and whether it is a valid legal document. I assure my hon. Friends that it is, and that it conveys the necessary consent to the doctors concerned. However, as was mentioned, the clothing of the victim of a tragic accident is sometimes removed, and the card goes unnoticed. In such circumstances, it is quicker for the nurses and doctors involved to consult the victim's relatives. The donor card stands on its own as a valid legal document, which is all that is needed in the absence of relatives.
The second question that my hon. Friend asked is whether we can have a computer register of those who sign the donor cards so that we know exactly who in the general public have them. It has occurred to me that we have no firm record of who holds the millions of cards in existence and of their age profile. However, the prime purpose of the card is as a signal to the friends and relatives of an individual that that individual wants his organs donated. Thus the donor card has two purposes. One is as a personal declaration to the medical profession and the other is as a signal to friends and relatives.
The donor card has proved a valuable peg on which to hang numerous publicity campaigns, both local and national, but I shall reflect on my hon. Friends' suggestion about a computer register. However, as I am sure they understand, it is fraught with difficulties.
In the last minute available to me let me deal briefly 978 with the "required request" legislation. Various American states have enacted laws in recent years which require hospitals to request the donation of organs in all suitable cases. Those were followed by federal legislation along the same lines in 1987. Some believe that we should enact similar legislation here. The Hoffenberg working party advised us that there was a better approach, which I have described already, and we intend to give those measures time to work before considering any other proposals. American evidence on the effect of its legislation is unclear. It is by no means certain that the laws have had a sustained impact on donation which we cannot achieve by alternative means.
I would be most reluctant to move down the path of opting out at present. We have to carry British society with us in that regard. Although that is the practice in France, I should hesitate to move down that path at this time.
I hope that I have shown that the Government have been vigorously tackling the issue of organ donation in the past few years. For the sake of all those waiting for transplants by our skilful surgeons we need to encourage the public to a greater consciousness of the value of donations after death, and our medical professions need to review hospital procedures to ensure that all possible acts of generosity in agreeing to donations at times of often tragic circumstances are followed up. I hope that 1989 will see yet another advance in transplant activity.
§ Question put and agreed to.
§ Adjourned accordingly at twenty-three minutes to One o'clock.