The Big Question: Should organs donated for transplant always come from healthy people?
Tuesday 13 October 2009
Why are we asking this now?
Matthew Millington died from lung cancer less than a year after undergoing a lung transplant. He was 31. The donor was a heavy smoker. The case, details of which emerged yesterday, has raised concerns about the screening of donors for transplants. Mr Millington, who was from near Stoke-on-Trent, was diagnosed in 2006 with an unspecified "serious lung condition" and told that without a transplant he had two years to live. He got his transplant in April 2007 and died 10 months later. An inquest into the Iraq war veteran's death concluded that he died of "complications of transplant surgery".
Why did he receive the lungs of a smoker?
Because there is a national shortage of organs for transplant and a reluctance by patients and transplant surgeons to reject any offered unless there are compelling reasons why they should be refused. Not every person who smokes develops lung cancer but everyone on the list for a lung transplant will die without the transplant. It is a balance of risk and benefit. In a statement, a spokesman for Papworth Hospital, Huntingdon, where the transplant was carried out, said: "Using lungs from donors who have smoked in the past is not unusual. During 2008/09 there were 146 lung transplants carried out in the UK. During the same period 84 people died on the waiting list. If we had a policy that said we did not use the lungs of those who had smoked, then the number of lung transplants carried out would have been significantly lower."
Are organs checked for cancer before they are transplanted?
Yes. All donor organs are supposed to be screened rigorously before transplant to check for tumours, injury and signs of damage. If cancer is present in the organ, or develops after transplant, its growth is likely to be accelerated by the use of immuno-suppressant drugs, necessary to prevent rejection of the organ. By suppressing the immune system, the drugs also remove the body's natural defences against the cancer.
What went wrong in this case?
It is unclear. Papworth Hospital said that early screening checks did not detect any sign of cancer in the lungs. But the speed with which the tumour appeared and led to Mr Millington's death is disturbing. He underwent the transplant in April 2007, the cancer was detected six months later and he died in February 2008. His wife, Siobhan, said that when he woke from the surgery his lungs felt like "two deflated balloons." Later, after the cancer had been discovered, he said to her: "They've given me a dud pair of lungs. Get me another." Papworth said it was an "extremely rare case".
Have other patients received diseased or infected organs?
Yes. A kidney sent for transplant was found to be in a poor state but was transplanted anyway. Later the patient haemorrhaged and the organ had to be removed. Further checks revealed the presence of a tumour. The National Patient Safety Agency (NPSA) said it had received 11 reports in which organs had been found to be unsuitable by the surgeons about to transplant them because they were infected with hepatitis or variant CJD, or there was a tumour present or there was damage as a result of trauma. Dr Kevin Cleary, medical director at the NPSA, said: "Although these numbers are small, the NPSA believes this was a significant issue for a number of NHS organisations. We shared our data with the NHS Blood and Transplant Service which is now establishing more robust systems for retrieving organs and enhancing quality."
Are any health checks made on donors?
Only limited ones. Blood is taken and tested for transmissible diseases such hepatitis, variant CJD and HIV. But there are only two conditions where donation is ruled out completely – HIV and variant CJD. Other conditions may rule out the transplant of certain organs but not of others. The decision as to whether some or all of a person's organs are suitable for transplant is made on an individual basis by a doctor, taking account of their medical history. Even people who have been turned down as blood donors may be accepted as organ donors, if for example they were turned down for specific reasons, such as having had a blood transfusion or hepatitis in the past.
So the NHS is desperate for organ donations?
Yes. There is already a critical shortage of organs and it is getting worse. The number of people needing transplants is rising every year, because of the ageing of the population and advances in medical care, but the number of donors is not. Fewer than half of those on the waiting list will get a transplant this year and around 450 will die as a result, according to UK Transplant. People worried about receiving, say, organs from a smoker should ask themselves the question: would you prefer to pass up the offer or take the chance?
Has organ transplantation been a success?
Yes. The first successful major organ transplant – of a kidney – was carried out in 1954. Today, kidney transplants are established as routine. Heart, lung and liver transplants came later and have also grown rapidly. Last year in the UK 977 lives were saved through heart, lung and liver transplants. A further 2,536 received a kidney transplant. In total, last year (2008-09) there were 3,513 organ transplants carried out – but there were still 7,877 patients on the waiting list at 31 March. The biggest constraint is the shortage of organs suitable for transplant.
Could the number of organs for transplant be increased?
The Government launched a £4.5m advertising campaign in March to boost the number of people on the Organ Donor register to 25 million – half the adult population – over the next five years. Membership is voluntary and people signing up agree to give their organs in the event of their death. In practice, however, organs are only taken with the consent of relatives, which is not always granted. Gordon Brown spoke last year of the "aching gap" between the supply of organs and the demand for them and the need to close it. More transplant co-ordinators have been hired. They talk to relatives at the time of a death, a process which experience from other countries, especially Spain, has shown can increase donations.
Are there any other ways of boosting donation?
Some people say an "opt-out" system would be better than our current "opt-in" system. An opt-out system would require people to sign a register if they did not want their organs used after their death. There would then be a presumption that everyone who had not signed the register was prepared to donate their organs. However, a taskforce appointed by the Government to examine the issue rejected the opt-out system last year. They said it could undermine the "vital relationship of trust" between doctors and patients.
Can it be right to transplant organs from a heavy smoker?
*There is a critical shortage of organs and fewer than half of those waiting will get one
*Patients awaiting lung transplants will die if they do not get one within a reasonable time
*Not all smokers develop lung cancer, and the decision whether to use their lungs is made by a specialist
*Patients awaiting a transplant do not expect to receive a diseased or damaged organ
*Transplanting organs from a person with a lifestyle known to damage their health is too risky
*Donors are already screened for diseases such as HIV and variant CJD and should be screened for smoking too
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