Factors inhibiting the collection and utilisation of tissues and organs

 

In the preceding sections, we examined the manner in which organs and tissues were procured from donors, especially dead donors, and then allocated to potential recipients. While the particular weaknesses of the individual collection systems were examined in some detail, there are a variety of more general problems that exist regardless of the system in use. Due to these general flaws, it has become clear that efforts at “obtaining organs from cadaver sources is not marked by a high degree of efficiency” [1], with only a fraction of the organs that may possibly exist in the theoretical donor pool being collected and used each year. This section discusses the principal factors that inhibit the collection and subsequent use of organs for transplant purposes, with the review covering both the technical problems that can arise at all stages of the donation process as well as the attitudes of the different individual parties that have an interest in this field and whose actions can affect the possible yield of organs.

 

i) Uncertainty over the diagnosis of brain death

While the brain death criterion has been legally and medically accepted for several decades, this acceptance rests on the assurance that two general medical requirements that adhere closely to the traditional definition of death will always be carried out [2]. First, it is assumed that the diagnosis of brain death can be performed with reliability by a competent physician, and second, despite the performance of aggressive treatment, patients are bound to follow a uniform course of development that will result in the non-resumption of conscience. In spite of this, it is clear that a “lack of clarity can interfere with appropriate organ retrieval” [3],  with reservations continuing to be expressed even recently about whether current methods of ascertaining whether or not a brain has been destroyed are accurate. Such fears have been expressed in particular by anaesthetists, who felt that efforts to control the motor responses of a person while organ removal is underway might hide the fact that brainstem function has not been entirely eliminated in the first place, leading to a premature declaration of death [4]. Despite this, it has been argued that these intuitive physical responses, such as the flexing of muscles, should be ignored by medical staff, no matter how disquieting they seem, and should not be allowed to result in the non-removal of organs [5].

 

More generally, doubts about whether the tests used to determine brain death are fully exhaustive or properly understood persist, with doctors facing immense difficulties when examining patients for signs of life. In one study, medical practitioners from different fields were asked to answer 3 questions relating to brain death and its possible impact on the medical cases of patients they could expect to encounter in real life. The results were disappointing, for while 90% of the physicians and neurosurgeons questioned had previously treated a brain dead organ donor, only 64% of these respondents could get all 3 answers right [6]. While the questions did indeed rest on hypothetical rather than actual medical cases, the rebuttal provided by the authors of the study was that “these problems may actually be exacerbated when clinicians are confronted by real patients, whose clinical situations may be more ambiguous than the straightforward cases we presented” [7]. This validity of this statement is borne out by at least one real life case where although the performance of a required test indicated that a patient was brain dead, upon performance of a subsequent exam 12 hours later, it was found that brain stem function had returned [8]. Therefore, while organ retrieval was at first possible due to the initial reading of brain death, because of the reversal in results obtained after the second test, formal declaration of death and subsequent organ removal was precluded.

 

ii) Inappropriate donor location

For organ procurement to be feasible when brain death is declared, it is important that hospital patients be connected to life support machines that keep their organs functioning until extraction is performed. The problem that arises is that these machines are generally located in the intensive care units (ICUs) of hospitals, which may lead to a loss of organs if brain dead patients are located elsewhere, such as in general wards. While efforts may be made to ensure that potential donors are located in ICUs only, this is not always possible, as an overflow of patients may necessitate their relocation to wards where resources are limited. This movement occurs since ICU staff, whose priorities are different to those of the transplant team, may have a greater interest in ensuring that only the most serious cases remain in their units. At other times, medical practitioners may not want to treat patients outside their own wards, either due to a belief that the facilities and attention that are offered elsewhere are of limited value, or because they may simply be acting to protect their patients from being subject to the examination of other unknown doctors [9].

 

This problem of keeping potential donors away from their best maintenance location is compounded by the fact that requests for organs are less likely to be made from patients who are in general wards than they are from patients in ICUs [10]. This attitude exists mainly because many general medical staff will believe that these patients have nothing worthwhile to offer, even when this is not so, and will thus not ask for qualified individuals to come and request organs from the patient’s next of kin. Finally, in areas where resources are limited, not all hospitals and clinics may have ICUs or their associated equipment, with these specialised medical facilities being situated primarily in urban centres where the number of potential users is greatest. As such, some people that die of brain death in medical facilities in rural areas and small towns may be lost simply because it is impossible to maintain their organs in working order.

 

iii) Legal restrictions

Sometimes, it may be impossible to extract organs if legal authorities, who may have a prevailing claim enabling them to subject the body to a medico-legal examination, do not make the body available to surgeons so that organs can be extracted. In the USA, for example, this retention of possible donors can be performed if there are criminal investigations, as may happen with cases of homicide or child abuse, where evidence for a legal prosecution needs to be gathered [11]. Similarly, post-mortems might need to be performed on a person in order to ascertain the exact cause and manner of death, which may happen to victims of industrial mishaps or motor vehicle accidents [12]. In these cases, by the time the body is released by the coroner, the organs will have reached an advanced state of decay, with even tissues that do not need immediate removal, such as corneas, no longer being of use.

 

iv) Ineffective methods of signalling donor intent

While many procurement systems rely on donor cards to serve as an indicator of a person’s consent to donate organs, there are limitations in the use of these documents that make them less than effective signals of intent. In particular, they are only effective if people actually happen to physically have them available at the time of an accident, otherwise they are of no use if it is not known that a person has them. As one commentator noted, “to expect everyone everyday to make sure they are carrying the card is unrealistic” [13], with people having various reasons for not carrying these cards at all times. For example, while these cards usually come in a convenient credit card size, potential donors may not always take wallets and purses out when they travel or they may simply lose or misplace these cards and not replace them. This point is borne out by one informal study that found that while 50 of 231 respondents had donor cards, only 35 were actually carrying their cards on the day of questioning [14]. In another study, it was revealed by one American organ procurement organisation (OPO) that of 600 actual donors used in a 7 year period, only 3 were found to be carrying donor cards when they died, with another OPO stating that only 2-3% of its donors had their cards when donating [15]. While these may be exceptionally extreme cases, they do show that while donor cards may be a good way of creating awareness and symbolically indicating a desire to donate, they may not always produce optimal results [16].

 

As an alternative, several other tools of indicating a desire to donate organs have been proposed and introduced, although these too have their own particular drawbacks. One possibility that has been explored has been to issue potential donors with bracelets and neck tags similar to the Medicalert and military “dog tags” which list a person’s contact and medical details. While these are less likely to be lost or detached from a person during a medical emergency, they are still not flawless as some people may not, due to reasons of aesthetics or convenience, wish to wear them all the time. Alternatively, willing donors could be permitted to have their wishes recorded by their physician on their personal records [17] or on a national database [18] when they visit for a consultation. While desirable in theory, this solution is not entirely practical, since not only is it assumed that people will have regular access to the services of a doctor, but compliance by these physicians may, due to factors such as time constraints and personal preferences, mean that not all patients are treated in the same manner. Here, patients may not have time to fully consider the implications of donating and may consequently make a hasty, ill-conceived decision, especially if they feel subtle pressure to act in a certain manner by their doctors. One final approach has been to attach stick-on versions of a donor card to a driving license – while useful in handling one important segment of the donor pool, this method relies unduly on the expectation that licensing authorities across a country will apply donor recruitment protocols in an uniform manner, plus it has no value when applied to other victims of motor vehicle accidents, such as passengers, pedestrians, unlicensed drivers, and drivers with older issue licenses.

 

v) Conflicting family opinions and denial of family consent

Under most systems of organ procurement, families and next of kin of a brain dead donor will often be approached to approve a request for organ removal. In cases where an organ donor card that was previously completed by a brain dead patient is available, such a request is usually conducted as a matter of policy to verify the deceased’s wishes and to ensure that the support of the family is guaranteed, while in cases where there is no record of a patient’s wishes, this request is made in order to find out if the family can provide clarification on the patient’s beliefs or themselves provide permission for removal.

 

While one significant poll found that about 92% of family members stated that they would respect and enforce a relative’s desire to donate organs [19], real life experience demonstrates that these individuals do not always follow up on their words and actually honour these wishes. Rather, it has been found that a rate of family consent ranging between 25% [20] to 70% [21] of all requests has been granted in what are generally perceived to be enlightened societies with a high awareness of organ transplantation, with the corresponding figure likely to be substantially lower in countries with lower awareness of organ donation. There are various reasons for this widespread refusal to donate organs. First, family members will often not consent to organ removal if there is some degree of uncertainty about a deceased relative’s feeling towards this concept, with there being some hesitancy to grant permission for this act even though they are empowered to do so. Second, there may be disagreements in a family about this issue, with some members being in favour of donation while others may oppose this process. Here, organ removal is unlikely to take place due to the inability of requesters to obtain clear and unanimous consent from the family [22]. Third, family members who do not fully understand what donation is about if they either feel that a patient has endured enough pain while alive or if they are still unable to come to terms with a relatives death. Finally, some family members may simply impose their own preferences by refusing a request for donation, even though the deceased completed a legally valid donor card signifying a desire to donate. Essentially, this means that these individuals are simply not following their duties as custodians of the deceased’s wishes properly.

 

A few important points that may sway the decision of the family in favour of agreeing to donation are not always followed, even though the adoption of these procedures can increase the rate of consent. Firstly, they should be given time to acknowledge the death that has just occurred, as asking for permission to remove organs once they fully understand what has happened is likely to be more fruitful than making a request at the same time as the notification of death is declared [23]. Depending on the individual circumstances, this interval between declaration and request can be a variable period of time, although efforts should be made to ensure that the person who declares death does not also ask for the organs, as family members may suspect that there is a conflict of interest where not enough effort was made in saving the patients life. In addition, it is also important that the use of terms such as life support and brain death should be avoided, as these can mislead the family into thinking that survival or a return to life is possible, thereby delaying or eliminating consent. Finally, the use of terms such as organ harvesting should, in general, be avoided, for although such phrases continue to be used in medical literature, they can be offensive to the sentiments of many people, indicating as they do a certain lack of respect by medical professionals for the patients whom they profess to care for.

 

vi) Cultural and religious attitudes towards organ donation

Even when a request for donation is made with the required amount of empathy and respect, people may still not consider donating organs due to religious and cultural attitudes on the topic. The different faiths of the world each have their own positions on transplantation, which may lead to problems for some potential donors if they find that following their individual conscience may suggest acting in a manner that is contrary to the positions adopted by their religious leaders on this issue. Similarly, organ donation may also be influenced by the attitudes that are prevalent amongst a person’s peer group towards this form of activity, with superstitions and traditional cultural beliefs often negatively influencing individual perceptions of donation.

 

Among most Christian religious organisations, transplantation is accepted by theologians to be a morally righteous act that is worthy of encouragement. This is in marked contrast to the position that prevailed almost 50 years ago, when organ donation was generally forbidden as it was deemed to be a form of mutilation of the dead that had adverse religious connotations to it. As it is, variations in theological policy on transplants remain, with the Orthodox churches still harbouring doubts about whether there is a link between organ removal and the need for bodily conservation to achieve resurrection, while the Roman Catholic church has expressed disapproval of transplants of a reproductive nature, which it feels are contrary to natural forms of sexual creation [24].

 

From a Jewish perspective, organ donation is acceptable across the different groupings that make up this religion. However, while more liberal groups are likely to follow mainstream policies regarding donation, Orthodox Jews, who follow laws based on scriptural precedents, may be bound to follow special procedures that could affect their donation behaviour [25]. In particular, they have their own method of ascertaining death in terms of cessation of heartbeat that differs to the secular definition of brain death. This is of significance because although patients may be legally dead, according to religious custom they are still alive, which could affect the timing with which consent for removal is finally granted, and thus the type and number of organs collected [26].

 

While organ donation was, for many years, a taboo topic amongst Muslims, in the past two decades, general approval for this form of surgery has been granted following intensive consultation among Islamic legal scholars, although objections regarding certain points of order remain [27]. Like Christianity, concerns about bodily mutilation that may affect the resurrection of people has been expressed, with an added fear being that if donated organs go to non-Muslims, these may be cremated upon the recipient’s death, in contravention of Muslim custom [28]. In addition, some Muslim scholars, have, like the Orthodox Jews, expressed reservations about the time and nature of death, leading once more to the loss of organs where even though brain death has been diagnosed, organ removal is not permitted as the heart continues beating [29].

 

According to the traditional Hindu view, where all forms of life are to be revered, organ donation is an acceptable policy due to its ability to relieve suffering, with the belief in reincarnation rather than resurrection being understood by some scholars to imply that there are no obstacles to organ removal, as the soul is able to move freely out of the body after death. By association, transplantation is also acceptable among Buddhists, who share similar attitudes to the body and soul. While there is no absolute Buddhist position on this matter, it has been considered to be a way for people to gain enlightenment, since it permits them to share in the suffering of some (the donors) and the joy of others (the recipients) [30]. Despite these common views, it has been argued by that organ removal may be an undesirable act in most Eastern religions, for the view that the body is a temple housing the soul means that the body should be held intact after death, otherwise reincarnation may be impossible [31]. This desire for bodily integrity is best expressed by Shintoists, whose religious leaders have clear reservations that cadaver organ donation may be unacceptable as it may displease a person’s ancestors.

 

Even when there are no religious restrictions on organ donation, the presence of pervasive cultural attitudes against donation may result in many otherwise suitable donors not donating their organs. In the USA, studies have been conducted to examine the popular beliefs of people from minority ethnic groups in order to determine why their organ donation rates were not in proportion to their share of the national population. Amongst Asian Americans, it was found that members of this group have a relatively low sense of community interest, a greater desire to retain the body intact after death (possibly influenced by their religious beliefs), and generally negative attitudes towards the donation of organs (although, somewhat hypocritically, receiving organ transplants is not objected to) [32]. Meanwhile, with African Americans, it is alleged that organ donation does not always occur due to a perceived sense of injustice at the general political establishment, a misguided belief that black organs will go to white recipients rather than blacks, and a distrust of the medical establishment, which has discriminated against them in the past [33]. Whether these attitudes are inherently acquired is not clear though, as it is possible that people of different cultures may simply not donate organs because measures to address their specific concerns on this issue are not introduced. Indeed, anecdotal evidence suggests that that with the introduction of special information programmes, the number of organs provided by members of minority groups has steadily increased to levels approximating the national norm.

 

vii) Use of inappropriate organ procurement personnel

Families are not always asked to consent to organ donation, with one study finding that out of 497 brain dead potential donors, in 33 cases, the question of organ donation was not even raised with the patient’s next of kin [34]. While requests for donation may sometimes not be made due to a wish not to add to the distress of family members, a fear of poor publicity [35], or a desire to avoid exposure to another source of legal liability [36], they are probably most often attributable to a lack of comfort on the part of people entrusted with asking for organs. This is an undesirable situation, for the skill and comfort which these individuals have in asking for organs is an important factor as to whether a donation will be made or not.

 

Various types of people have been used to ask the family for consent to organ removal, including chaplains, social workers, ICU staff and medical practitioners [37]. Some of these individuals are not really suitable in this role, either because they may have other functions that could result in a conflict of interest in asking for organs, or they may simply lack the appropriate training or aptitude for this particular activity. For example, chaplains and social workers may feel uncomfortable in asking for organs if their primary function is to provide solace, while ICU staff may be unhappy about asking for organs if they wish to dedicate their time and effort to those critically ill patients still under their care [38]. Meanwhile, the use of medical practitioners has mixed results, for although they have been used to successfully procure organs in some areas [39], they may not always feel comfortable in this role, with conflicting opinions being expressed on whether senior or junior doctors should be used in this role.

 

To a large extent, the lack of suitable requesters has been overcome through the use of dedicated personnel known as transplant coordinators or organ procurement coordinators. While these individuals, who first appeared in the USA in the early 1970s, can be nurses or renal technicians involved in general transplant work, in recent years they have become medical specialists in their own right. This is since their roles have gradually expanded to cover not only asking for organs but also to be public relations specialists and intermediaries between the different medical and support personnel involved in this field. While these individuals are superior to general staff in requesting organs and have probably been a factor in increasing the organ procurement rate, financial constraints have limited their effectiveness. As only a few of these trained individuals have been available for use, mostly in major centres, less suitable individuals have had to continue asking relatives for organs in other under-serviced areas.

 

viii) Miscellaneous factors

In addition to the main factors affecting the yield of organs acquired from donors that have just been discussed, several lesser factors may also have a bearing on the issue of how many organs are collected and used in transplant recipients.

 

First, the introduction of various health and occupational safety laws, as well as increased road safety restrictions have had a role in limiting, or even reversing, the growth rate of parts of the possible organ donor pool [40]. In particular, laws that have made the constant utilisation of helmets and other safety equipment at home and on the road mandatory rather than optional have reduced the potential for individuals to be injured in conditions that are favourable to organ donation. While people are still likely to have accidents, if their heads are protected from potential damage, then organ extraction is unlikely, as brain death may be less likely to occur. Even when people do actually suffer head trauma, the increasing availability of ICUs and improved surgical techniques means that their survival prospects are significantly greater now than they were even one decade ago – while this is obviously desirable, since a patient’s life is not lost, from a transplantation perspective this is less pleasant, as the opportunity to collect organs is lost.

 

A second factor affecting the availability of organs concerns the performance of retransplantation, where organ recipients receive additional organs should their previous graft have failed due to immune rejection of other medical complications. This procedure has come under some criticism for being unfair in that it favours some individuals, by giving them a second opportunity at regaining health, while discriminating against others, who have not even been able to have their first transplant. While retransplants may be medically necessary, as happens when a heart graft fails, surgeons may also have a personal interest in providing their patients with another organ, as this can serve to show that they are unwilling to abandon them and will do everything they can to help them recuperate [41]. Despite this, retransplantation may not be a desirable policy, for in addition to preventing the even distribution of resources, it is not always guaranteed to succeed in helping the patient. For example, patients that received additional livers were found to have poorer survival prospects than recipients who still have their first organ, even when the transplants were performed by experienced at centres staffed by experienced doctors [42].

 

Finally, even when permission is granted for the extraction of organs, these may not always be used, with failure to utilise organs being attributable to several factors. One restriction that applies to all organs is that they should not contain transmissible diseases such as HIV and hepatitis. Unfortunately, patients may not know that they have these diseases, so consent to removal may be granted only for doctors to find out later that these organs are infected, in which case transplantation can not take place. Alternatively, organs may suffer from more general medical impediments that prevent their use in recipients, such as having flaws that were previously undetected and which could place the health of recipients at some risk in the future. Organs can also be damaged during the extraction process – while surgeons have immense skill, accidents can happen, with organs being irreparably damaged during removal, examination, testing or transportation. Finally, as was previously discussed, extracted organs have a limited lifespan in which transplantation can be performed, even though they are conserved in a preservation solution. Sometimes, organs may go unused because they cannot be transplanted soon enough or if no suitable candidate can be found at a particular moment to receive them. While storage banks exist for tissues such as bones, the same is not yet possible for organs, leading to their disposal even though a patient who could receive them might appear some time in the future. In none of these cases can the failure to use donated organs be deemed a waste though, for given present levels of scientific knowledge, there are no feasible ways of overcoming these problems in order to ensure that collected organs are used in a better manner than they currently are.

 

While it is clear that new measures can and always will be implemented to both increase public awareness of the benefits of transplantation as well as evolve more efficient ways of overcoming the technical difficulties that exist, there are nonetheless limits to which such activities can succeed. This is since enormous amounts of time, money and effort have been spent, both directly and indirectly, to increase the awareness of transplantation, with any further increases in spending being likely to provide only diminishing marginal returns relative to the effort expended. Here, those organs that can be collected with comparatively little effort are acquired first, with the collection of each extra organ requiring relatively more effort than was expended on the acquisition of the organ immediately preceding it. At a certain point, the work involved in collecting one last organ becomes so great that doubts are raised as to whether procurement should continue from the present resource pool or whether attempts should be directed elsewhere. As we shall see in the following section, new ways of acquiring organs from alternative sources have been considered for implementation that might be cheaper on a unit basis to exploit while avoiding the quantity restrictions that exist with utilising current sources of transplantable organs.

 

Link to:  <Contents>  <Previous Section>  <Following Section>