Break from posting until the New Year

To anyone who reads this blog regularly...

THANKS!!!!

but...I'm taking a break from writing posts until the New Year because I assume that most of the readership is from around the ANU, and it will be better if I post somewhat in combination with Woroni publications. This way I will also have time to build up a back-log so there can be regular weekly posts instead of the dribs and drabs that come through at the moment. As a final item I post here a longer version of a piece I wrote for TheConversation.com, which will hopefully be published during DonateLife Week next February.

Thanks again for getting me above 2000 hits! I'm pretty happy with that for a first year of blogging.

A way forward in kidney procurement

Author: Mark Fabian, ANU

Many of you will have come across recent advertisements encouraging you to talk to your relatives and loved ones about your wishes regarding organ donation in the event of your untimely death. This is a manifestation of the government’s latest set of initiatives to increase the organ donation rate in Australia. The plan is to optimise our system for procuring organs from deceased individuals, as opposed to living donors.

The government’s reform package is the best way forward for getting more of those organs for donation—hearts and lungs for example—which cannot be procured from live donors. But in the realm of kidneys, an organ in critically short supply and available from live donors, the package is going to fall well short of what is required.

At present, due to a shortage of kidneys, the average waiting time for a transplant in Australia is 3.6 years. Meanwhile, the patient stays on dialysis. The cheapest form of dialysis costs $251 810 over a five year period. A kidney transplant costs only $103 500 over the same period, with most of those costs incurred in the first year. The inordinate number of people waiting on dialysis is a veritable black hole in our health budget, and is set to expand as the incidence of diabetes, inactivity, obesity and other risk factors for kidney failure continues to climb.   

More importantly, dialysis is not a healthy option. Transplants are widely regarded as the most effective form of treatment for kidney failure, presenting better mortality rates and quality of life scores compared to all forms of dialysis. For the 45-64 years age group, ANZDATA puts the survival rate at 90, 45 and 15 per cent for dialysis patients at 1, 5 and 10 years respectively, compared to 93, 80 and 58 per cent in the case of transplant recipients. That is a 43 per cent difference in mortality at the 10 year mark.

An additional complicating factor is that studies have shown the longer a patient remains on dialysis the less likely a transplanted organ will be accepted by the host’s immune system.

So what are we doing to get more kidneys for transplant?

In 2008, the Rudd government introduced a reform package which implemented most of the recommendations of the National Clinical Taskforce on Organ Donation (NCTOD). What this amounted to was a decision to implement the Spanish model of deceased donor organ procurement. The Spanish approach has been extremely successful there, improving rates of donation from 14.2 donors per million population (dpmp) in 1989 to 34.3 today, the highest rate globally.

The only problem is that Australia has a very different set of circumstances to Spain, which means that no matter how perfectly we optimise our system for procuring organs from the dead, the maximum rate of donation we can hope to achieve would be 18dpmp. At present, we are floating around 13dpmp. This would be a hopelessly inadequate increase.

The problem boils down to the fact that, fortunately, Australia has relatively few people dying while connected to a respirator. Only individuals who die in this manner are suitable for organ donation, as otherwise, organs expire from lack of oxygen long before they can be transplanted. Typically, only individuals who suffer death by cerebral trauma, such as car accident victims, end up dead on a respirator. Such deaths account for less than 1 per cent of hospital deaths in Australia.

We could get the whole country to sign up as organ donors and it would have little to no effect on donation rates, because those people would not die in hospital on a respirator. No matter how much we optimise our cadaveric procurement, it will not be nearly adequate to meet demand.

All this was noted by the NCTOD, so why did the government go ahead with the scheme despite its obvious inadequacy? Why were commercial options not even considered?

The most important reason is that the cadaveric procurement system still needed to be enhanced to increase the supply of those organs that you can’t get from living people, such as hearts and lungs. The second reason is that policy in this area remains hopelessly mired in the gift of life doctrine (GOL), which holds that organ donation should always be a gift—the ultimate gift in fact—and should never be compromised by commercial incentives.

The theory goes that if individuals receive their life saving organs from anonymous individuals it will reaffirm the social contract—the notion that we look out for each other because we are all part of the same society and we care about each other. Anonymous donation thus enhances social solidarity. Commercial systems, on the other hand, discourage people from donating an organ unless it is in their interest, specifically, their financial interest. In such systems, the primary motivation for saving a life is one of selfishness. This, in theory, leads to social atomisation, which is to be avoided.

The GOL doctrine finds its origins in the work on blood donation of Richard Titmuss, and continues to underpin much of the debate on this issue today. Its influence is quite apparent, for example, on the Australian Organ Donor Registry website: ‘organ donation is the greatest gift one human being can give another’; in the NHMRC guidelines: ‘donation of organs and tissues is an act of altruism and human solidarity’; and in the ANZICS guidelines: organ and tissue donation is ‘an unconditional, altruistic, non commercial act’.

Advocates of commercial approaches generally acknowledge that this is all good and well, but that any positive gains derived from social solidarity are offset by the suffering of individuals on dialysis, which is a rather unpleasant treatment. Few approaches to procuring kidneys satisfy the criteria of the gift of life model. Commercial options are explicitly ruled out. But real world examples of commercial systems are quite effective at getting kidneys. In Iran, which operates a quasi-market system, the waiting list for kidneys has been eliminated.

Unfortunately, commercial systems throw up a host of issues relating to coercion, exploitation and affronts to individual autonomy. As Jeremy Shearmur has pointed out, many people tend to be uneasy about the image of wealthy westerners travelling to impoverished parts of the world to procure kidneys from marginalised individuals in desperate circumstances. The developing world tends to agree: the Iranian system is closed to non-citizens; the Philippines, once the ‘transplant tourism’ capital of the world, has now outlawed the practice of selling kidneys to foreigners.   

Many of these issues aren’t quite so severe in Australia, where the welfare safety net ensures that people in really desperate circumstances aren’t common. But the social solidarity argument of the gift of life doctrine still holds and the Australian medical profession — a key stakeholder in this issue — remains vehemently opposed to the commercialisation of organ procurement. Progress on a commercial response seems unlikely.

I remain hopeful that this state of affairs will change, as I see some commercial proposals as very sound both ethically and in terms of kidney procurement. There also remain a great many untapped veins of research in the analytical philosophy on this subject that may yet yield a breakthrough. But in the meantime, we really need to implement something to augment our cadaveric procurement system. One option is kidney exchange, which has proven effective in the Netherlands, Korea and notably Japan, which has strong cultural opposition to deceased donation.

Kidney exchange systems work in the following manner. Say you have kidney failure and I offer to donate you one, but we are tissue or blood type mismatched. We are placed into a database which matches us to another pair in a similar situation. My kidney happens to be compatible with the other recipient, and vice versa. A swap ensues in which both people in need of a kidney receive one. A sufficiently large database ensures the possibility of five-way swaps, which maximise efficient distribution. This has been proven algorithmically.

Kidney exchange means that any kidney is a good kidney, including old donors for young recipients and similar otherwise compromised cases. As a result, recipients can tap into their extended social networks—sports clubs, workplaces, unions etc—to try and find anyone willing to donate, and then be matched with a donor more suitable to them. This involvement of broad social networks and directed donation facilitates altruism and builds community solidarity on a micro level. Groups are drawn together through their shared involvement in bettering the life of one of their members. While it is not quite as great as anonymous altruism, which operates on a macro level, it nonetheless appeases the gift of life doctrine’s desire to build social harmony. In also produces an increase in the kidney supply. It is also legal, as Australian law permits live donation provided there is no commercial exchange involved.   

It is important to acknowledge the complexity of the kidney supply issue and not be too hasty in dismissing any aspect of it as insensitive, squeamish, soft, unethical or inhumane. There is no quick fix or simple answer. At the same time is imperative that we recognise the suffering of those individuals confined to dialysis and seek, with urgency, ways of alleviating the shortage of kidneys that keeps them there. Kidney exchange is one option going forward.

Mark Fabian is a researcher at the School of Politics and International Relations at the Australian National University. He completed his Philosophy honours thesis on the Kidney Supply in 2010.