The scope of the problem
Renal transplantation is now a well established form of treatment for end stage renal failure (ESRF). However, with increasing numbers of patients on dialysis and relaxation in the criteria for accepting patients on to a transplant waiting list, the shortage of available kidneys is one of the major problems facing transplant surgeons today.
While the number of cadaveric kidney transplants in the UK increased from 814 in 1981 to 1736 in 1990, the waiting list for those requiring a transplant grew from around 2000 to just under 4000 in the same period of time.[1] In 1997 the waiting list has risen to 6000 (partly as a result of first and second grafts failing over time) while the transplant rate has remained steady at 1700 cadaveric transplants per year (partly due to the drop in fatal road traffic accidents). A number of solutions to this problem have been discussed. They include increasing the number of living related and unrelated (husband/wife) donors, letting the public opt out of (rather than in to) organ donation, using organs from non-heart-beating donors, the possible use of organs from animals (xenografting) and elective ventilation of potential donors. This article deals solely with the last of these.
What is elective ventilation?
Elective or interventional ventilation is defined as 'the use of artificial ventilation in a comatose patient who is close to death from severe brain damage for the purpose of protecting the organs for donation rather than for the benefit of the patient him or herself'. At the present time it is illegal.
Elective ventilation involves transferring patients to the intensive care unit (ICU) and managing them as potential organ donors until brain death has occurred. It is different to non-heart-beating donation, when death must be pronounced before donation can even be considered. Once death has occurred, external cardiac massage and ventilation with 100% oxygen takes place to limit renal ischaemia.
The history of elective ventilation
Elective ventilation began in Exeter in 1988.[2,3] A working party was set up to look at the provision of organs for transplantation under the auspices of the Joint Medical Staff Committee. This was chaired by Dr John Searle, a consultant anaesthetist who for many years was director of the Exeter ICU. More recently he has been ordained as an anglican clergyman. In a subsequent letter to the BMJ he explained how the committee gave careful consideration to four basic ethical principles.[4]
Firstly they were aware that starting mechanical ventilation in a patient with an intracranial haemorrhage was not for that patient's benefit. However, no intervention of any sort was in that patient's interest as the only possible outcome was death.
Secondly they recognised that such patients are incompetent. Therefore the matter was brought into the open by frank and honest discussion with the next of kin.
Thirdly they considered whether the patient would be harmed or death rendered undignified for the patient, or even more distressing for the relatives as a result of this intervention. Their experience led them to conclude this would not be the case.
Lastly they considered the needs of those awaiting transplantation and the cost benefit of getting patients off dialysis.
Elective ventilation increased the number of kidney donors in Exeter by more than 80% during the 19 months following its introduction.[2] If this were the national rate of increase in availability of donors, it would considerably reduce the threefold gap between transplants and potential recipients. Following a study based on hospitals in South and West Wales, Salih concluded that the supply of donor organs could be increased by the availability of elective ventilation for some patients aged 50-69 dying of cerebrovascular accidents in general medical wards.[5] Elective ventilation would have less impact on liver and heart transplants because of the age group of the patients involved.
Nationwide in the UK in 1993, 28 kidney donors were referred from eleven ICUs following elective ventilation. Most came from medical wards, a few from the accident and emergency department and one from a stroke unit. They represented 3.3% of all donors. None of them were reported to have entered a persistent vegetative state following elective ventilation.[1]
What does the law say?
In October 1994, the Department of Health advised (on the basis of Council's opinion rather than case law) that consent from relatives of the patient for elective ventilation solely for the purpose of organ donation had no basis in law and thus the practice should cease. There is a common law requirement in the UK that medical treatment be directed to the patient's benefit. The central issue with elective ventilation is the intention of the ventilation procedure. It must be for the patient's benefit if it is to be lawful. The relevant judgement is F v The West Berkshire Health Authority and Another, Mental Health Act Commission Intervening. Its main points are:
- Where an individual is incompetent, only doctors may decide on treatment.
- The treatment must be directed towards the patient's welfare. This is of course crucial to the whole question of elective ventilation of organ donors. It was on this basis that the Department of Health legal advisors said that it was unlawful since elective ventilation was not for the patient's welfare.
What are the ethical issues involved?
The practice of elective ventilation is controversial for a number of reasons. The major ethical debate centres around whether it is allowable to do something to a patient who is not yet dead that is not for their benefit and carries the theoretical risk of the persistent vegetative state. It had been suggested that a study be set up to quantify the extent of the persistent vegetative state, initially in three phases. First, to confirm the number of deaths from intracranial pathology; second, to document those suitable for transfer to ICU and look at their outcome; third to do a controlled trial of patients with and without ventilation of those deemed suitable for transfer to ICU. As far as I am aware this has not happened; certainly there would be no prospect of the last phase taking place at the present time as the practice is unlawful. To prevent the harm of the persistent vegetative state, the Exeter protocol was modified so that mechanical ventilation was not started until the moment of terminal respiratory arrest.
Another ethical question is, 'Can the use of scarce ICU beds be justified for these patients?' Anthony Nicholls, consultant nephrologist in Exeter says that while there is a scarcity of ICU beds, each ICU would only need to resource two to four bed days per annum for elective ventilation in order to increase the number of kidneys for transplantation from 28-60 per million population per annum.[7]
Robert Sells, director of the renal transplant unit in Liverpool, argues that many better funded western health services that do not have a shortage of ICU beds would already be caring for these patients on the ICU.[8]
What do official bodies say?
The British Transplantation Society working party on organ donation has reviewed the policies and practices of organ donation in the UK. It found that 18 renal transplant units have held discussions about elective ventilation. Thirteen had reached a consensus and of those ten were in favour. Fifty five percent (118 of 215) of ICUs were undecided or had not discussed elective ventilation. 97 units had a opinion: 41 were in favour, 56 opposed.[1]
The legal and ethical aspects of elective ventilation have been considered in considerable detail by the medical ethics committee of the BMA. They supported elective ventilation for the purpose of organ donation alone: this is subject to ICU adherence to a comprehensive protocol and full consultation with relatives, partners or other close personal friends of the patient. These views were endorsed in an editorial by the Royal College of Physicians.[9]
Elective ventilation has the approval of the British Transplant Society, the Transplantation Society, the BMA and several of the Royal Colleges. In October 1995, the BMA called upon the government to introduce legislation that would allow the resumption of elective ventilation.[1]
Is there a Christian consensus?
What is the Christian approach to this subject? The Bible does not deal specifically with many of the issues we face in medicine today and in many of these areas Christians may disagree. The thinking we bring to bear on a subject such as this is a reflection of our Christian background and understanding of ethical principles in the light of Scripture. We often end up steering a difficult course between Scylla and Charybdis. If we are not personally involved in these issues, it is easy to sit on the sidelines and make statements that are unhelpful, inaccurate and incorrect. If we are personally involved, we may not always see the wood for the trees; it is possible that a course of action becomes expedient rather than right, the end justifying the means.
We need to weigh up the principles involved and be prepared to discuss our views with others. It is very helpful to have Christian friends who will do this; they need not be in the medical field. I am thankful for a number of pastors and clergy who are close friends I have used as sounding boards over the years for ethical problems. They need to be prepared to listen and accept that they are not in the front line. However, they can be very helpful in allowing us to view the problem from a different perspective.
As in other areas, elective ventilation finds Christian doctors trying to reconcile different Christian principles that are in conflict in the complexities of modern medicine. We need divine wisdom to hold things together in balance. John Searle has thought deeply about these issues from the medical and Christian point of view; his four principles in coming to the conclusion he reached have already been outlined above.
What does the Bible say?
While the Bible does not deal specifically with elective ventilation it has clear principles that may be helpful as we consider this area.
The first principle is that of stewardship. As doctors we also have God given medical skills to use for his glory (Gn 1:26-28) when serving the needs of others. We have an obligation to employ these wisely and not to let the end justify the means. Transplant surgery is part of our armamentarium.
The second principle is that of self sacrifice. The Bible esteems those who are prepared to undergo suffering or injury for the welfare of others. Jesus said that the greatest love is that which 'lays down its life' for another (Jn 15:13; Rom 5:8). Paul commends the Galatians for the depth of concern that 'would have torn out [their] eyes and given them to [him]' (Gal 4:15). Voluntarily giving part of one's own body to help another is real virtue and the parallel with the love of Christ is obvious. Contrary to the decision of the Department of Health legal advisors, patients may choose interventions which have the prime aim of benefiting others rather than themselves. Living related kidney donors already fall into this category.
The third principle is honouring the desires of the dead (or dying). The last requests of Jacob, Moses and David were honoured by those in their community. In the same way, the apostles and indeed Jesus himself gave instructions for those 'left behind'. As death is not the end, the wishes of deceased (or dying) people are important. If a person has requested (or would have requested, given the opportunity) that his organs be donated, that wish should surely be honoured, providing it is ethical, reasonable and legal.
The fourth principle is the sanctity of life. The Bible forbids intentional killing (Jas 2:10-11), even for compassionate motives. It follows that patients must never be killed (even with consent) to provide organs for others. Previously accepted criteria must not be changed simply to facilitate elective ventilation. Take for example brain death. As has been stated in a previous article, brain stem death did not evolve to satisfy the needs of transplant surgeons but in response to the increasing medical technology that is now part and parcel of all ICUs.[10] If transplantation was superseded tomorrow by better treatment of organ failure, brain stem death would still occur wherever ICUs were established and ventilators would continue to be switched off.
The code of practice in the treatment of these patients was evolved over many years at Harvard in 1968, Minnesota in 1971 and through the British Royal Colleges in 1976 and 1979.[11,12] These must not be changed (as some have suggested) for the sake of expediency. The nearly dead must not be treated as the really dead.[13] To allow organ transplants from PVS, head injured or otherwise brain damaged (but not brain dead) patients would be wrong. It would also mean embarking on a slippery slope towards the excesses seen in some developing countries where prisoners, street children and the poor have been 'cannibalised' for their organs. Any step, however small, down that path must be firmly resisted.
Fifthly the family and hospital staff looking after the potential donor must be in agreement along with the transplant staff. Procedures must not be 'railroaded' through without concern; patient persuasion rather than coercion should be used. God invites rather than imposes. In the same way, we must never manipulate or force patients or relatives into organ donation but rather support them in whatever decision they make. The law too must be respected. While civil disobedience may at times be biblically justifiable (Acts 5:29), obedience to the governing authorities shows respect for the authority of God (Rom 13.1).
Finally we must be prepared to modify our views in the light of further discussion and reflection on biblical principles. No-one has a monopoly on biblical truth and we should not become entrenched, unmovable or unprepared to listen to the views of others.
Conclusion
The issue remains open for debate but certain principles remain clear. There must not be any short cuts in the proper treatment of those who are dying; no harm must be done to them. Discussion must be open and honest with all parties involved. The current law must be respected. It is very important to have the confidence of the public at all times, lest the very end one seeks has the opposite effect: a resultant decrease in organs available for transplantation.
As Christian students and doctors, we need divine wisdom to hold these difficult decisions together in the right balance, graciousness in explaining why we do what we do, gentleness in dealing with those who disagree with us, and courage to take the necessary action.
