Prioritising existing donors to receive organs would boost donation from ethnic minorities
BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f5036 (Published 20 August 2013) Cite this as: BMJ 2013;347:f5036All rapid responses
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The article ‘Prioritising existing donors to receive organs would boost donation from ethnic minorities’ by Adnan Sharif (1) highlights an important paradox in the area of solid organ and cell transplantation. The prevalent attitude against donation in ethnic minorities also extends to blood donation (2). The introduction of a system of reciprocity and prioritization is a novel and fair concept to promote organ donation. The fundamental problem with this system though is firstly, those who are donors are unlikely to be in need of organs (3). Secondly as highlighted by the authors, only a third of actual donors were actually registered on organ donor register (4) . Therefore, the actual rate of donation is not a true reflection of the deceased being registered on organ donor registry.
Whilst it is not possible to detract that the real rate of consent for organ donation remains low among ethnic minorities (30.3% v 68.5%) (5) , there are other factors to consider. Of particular relevance is deceased kidney donation. As stated by the authors, ethnic minorities are over-represented on the waiting list (24% on WL, 10.8% of population), most of this discrepancy existing in the renal transplant waiting list. This fact alone suggests that ethnic minorities, particularly Indo-Asian and Afro-Caribbean populations are more likely to develop renal failure. Indo-Asian UK residents are five times more likely to develop diabetes and one and a half times more likely to develop hypertension compared to their Caucasian counterparts (6). One has to assume therefore, that transplanting kidneys from unscreened ethnic minority donors will potentially increase the risk of non-function or premature graft failure after transplantation. We support the author’s view of promoting donation from ethnic minorities but at the same time propose a strategy of careful assessment of donors from ethnic minorities prior to utilization of kidneys for transplantation. Those who register for donation should be offered initial screening through their GP. The same caution should be applied to living kidney donation among ethnic minorities
References
1. Sharif A. Prioritising existing donors to receive organs would boost donation from ethnic minorities. BMJ. 2013;347:f5036.
2. Shaz BH, James AB, Hillyer KL, Schreiber GB, Hillyer CD. Demographic patterns of blood donors and donations in a large metropolitan area. J Natl Med Assoc. 2011 Apr;103(4):351-7.
3. Ibrahim HN, Foley R, Tan L, Rogers T, Bailey RF, Guo H, et al. Long-term consequences of kidney donation. N Engl J Med. 2009 Jan 29;360(5):459-69.
4. Transplant NBa. Activity Report 2011-2012. . 2012; Available from: www.organdonation.nhs.uk/statistics/transplant_activity_report/.
5. Health Do. NBTA report on black, asian and minority ethnic organ donation and transplantation data. 2012; Available from: www.nbta-uk.org.uk/wp-content/uploads/2012/12/NBTA-report-on-BAME-Organ-....
6. Raleigh VS. Diabetes and hypertension in Britain's ethnic minorities: implications for the future of renal services. BMJ. 1997 Jan 18;314(7075):209-13.
Competing interests: No competing interests
Prioritising existing donors is clearly an interesting and controversial proposal with the potential to increase organ donation rates. It represents a shift beyond the currently assumed primarily altruistic motivations for donation towards more self-interested motivations, which will inevitably present a challenge to organ donation’s highly altruistic self-image. Whether it is better to have a slightly less altruistic donation system with higher rates of organ donation, or a more altruistic donation system with lower rates of organ donation is a complex question, but the consistent number of people dying while waiting for a transplant suggests that something has to change. A similar proposal has proved reasonably effective in Israel, and beyond the effectiveness in terms of promoting donation, such a system may have advantages with regards to the general fairness of allocation.
There is, for me, one possible problem with systems that prioritise existing donors, and this is to do with part of their fundamental justification of reciprocity. There appears to be an assumption that it is inconsistent to be unwilling to donate, yet willing to accept a transplant (Sharif describes this as being “dissonant”). While this looks superficially appealing, some unpicking will show that it is not obviously true in all circumstances. For those who think all organ donation is wrong, it may be inconsistent to accept a transplant. As Sharif correctly points out, transplantation cannot exist without donation. I think, however, that if one considers the perceived personal cost of organ donation, the situation may be more nuanced. Take, for instance, someone who personally thinks that organ donation is a good thing, but is aware that donating will cause significant distress to her family, and reputational harm to both her and her family. The perceived cost of donating in this situation may be high, so this person may choose to not be a donor. Similarly, someone who considers it particularly important that their body remains intact after death may perceive the cost of donation as being unreasonably high for them, but not consider the cost of donation to be unreasonable for those for whom post-mortem bodily integrity is unimportant. It seems to me that one could reasonably take the moral position that people ought to donate their organs, but not at any cost (indeed, I suspect that most of us do take this position). Given that the perceived and actual costs of donation may differ significantly from person to person, one may consider one’s personal situation to render the costs of donation excessive, yet still think it right that other people (with lower costs) ought to donate. A personal unwillingness to donate does not necessarily reflect an opposition to organ donation more generally.
This is not necessarily hugely problematic for reciprocity-based donation/transplantation systems, as such systems would have to be sufficiently nuanced anyway. People would presumably not have to agree to donate their organs at any cost in order to receive priority if they need a transplant –otherwise a John Harris style survival lottery may quickly ensue. A system based upon reciprocity may have to consider the varying costs of what people are required to contribute in order to receive priority: although in some sense it is equal because everyone is expected (in principle) to contribute the same thing -their organs - this does not mean that the cost of donating is the same for everybody.
Competing interests: No competing interests
Re: Prioritising existing donors to receive organs would boost donation from ethnic minorities
In his article Adnan Sharif advances an argument that the prioritisation of individuals who have already donated an organ or who are on the organs donation register (ODR) will improve organ donation rates among ethnic minorities. This reciprocity-based system of organ allocation is already in place in Israel which has seen an increase in organ procurement with a reduction in waiting times since its inception.
This is a system that would move us away from organ donation as a 'gift' to a system with reciprocity and obligation as its tenets. This may appear initially appealing: the system appears to have an innate 'fairness' about it. On further scrutiny however I believe there are serious and fundamental difficulties with this approach.
The donation of organs is prohibited by some religious and spiritual philosophies. Would this not be a form of discrimination? To what extent do we choose the religious group to which we belong?
Poorly educated members of our society from poorer socio-economic backgrounds are less likely to become members of the ODR. Should we permit the prioritisation of organs to those who are likely to be better informed?
Why should an individual be penalised for being poorly informed? Is there not a collective responsibility in society for the ignorance of those who choose not to join the ODR? The challenge of apathy
Competing interests: No competing interests