Cadaver transplantation: ground realities

Transplantation is considered the treatment of choice for many patients suffering from diseases resulting in End Stage Organ Failure. Its success continues to improve, creating an increase in the numbers and types of transplants. This increased demand has put a severe strain on the supply of organs. In India the Human Organs Transplant Act was passed in 1994, which recognised brain death paving the way for 'cadaver' transplantation. However, six years since the Act was passed, only a few cadaver transplants have been performed. The problem is at multiple levels.

Health professionals

Health professionals are uncomfortable with declaring brain death and hesitant to explain the concept to the patient's families. Some general practitioners, who were called in by potential donor families, have advised against organ donation. Further, the definition of brain death is specified only in the context of the transplant law. Doctors often interpret this to mean that brain death should be declared only if the deceased's organs will be donated. This linkage has created tremendous confusion. If we are to increase cadaver transplant activity it could be made mandatory to a) document brain death, b) request the family about organ donation and c) document the outcome.

The medical profession has not promoted cadaver transplants. Some nephrologists agree to transplant kidneys from unrelated living donors instead of suggesting a cadaver kidney. Another reason for the low donation rates could be the lack of sensitive communication skills of the doctor when making the request for donation. It needs time to explain clearly that death has occurred and that it is irreversible. The family needs to be given time to come to terms with death before making the request for organ donation. Choosing a private area to talk to the family, away from the bedside of the patient and the general waiting area also helps.

Society

Families are exposed to the idea of organ donation for the first time when a loved one is declared brain dead. It therefore becomes more difficult to give consent for organ donation. Awareness about organ donation should start early in schools and colleges. The media should spread the message by highlighting actual cases, thereby building confidence and helping in overcoming misconceptions in society like religion is against donation, or that organs are allocated with bias to class, religion, etc. In our social system the extended family is often involved in important decisions, and may overrule the immediate family's agreement to donation. Some relative have asked for monetary compensation or waiving of hospital charges as a condition to the donation. From a purely utilitarian point of view this position cannot be totally rejected, but it must be remembered that the introduction of commercial considerations into a system built on altruism and solidarity could have a dissuasive effect and paradoxically produce a reduction in donations. The problem of getting consent to donation is further compounded as public confidence in transplantation has been harmed by the 'kidney rackets' that were prevalent in our country.

The time involved in the process of organ donation also becomes a deterrent, especially, in medico- legal cases. The case has to be reported to the nearest police station and after removal of organs taken for a post mortem. It would help if post mortems can be avoided in cases where the cause of death is not controversial, or done on a priority basis or in the hospital in which the organs are harvested.

It is important to note that donors' relatives have been grateful for the opportunity to donate their loved one's organs. Those not given the opportunity have regretted that their loss was not mitigated by something good out of the tragedy. Everyone in this position should receive comprehensible information to make an informed decision.

Patients

Patients who require transplantation treatment also have reservations. Many are unaware of the option of transplantation. Renal failure patients are looking for a living donor and are unaware about the availability of cadaver kidneys. The cost of surgery and post transplant drugs that have to be taken lifelong is very high. Government involvement in reducing cost of drugs and early enrollment to health insurance schemes can help to make this treatment accessible to a greater number. There have been very few cadaver transplants. So patients fear being the 'guinea pigs' and are hesitant to register. They 'shop' for advice, resort to alternative therapies and in the bargain lose vital time, money and sometimes even their life. The unfortunate scenario has been that even in the rare cases when donor organs have been available there have been no recipients. For example a liver was removed from a donor in Mumbai and sent to Delhi for lack of a recipient when thousands of patients are dying of liver disease. Some of these problems can be overcome by a central body with a transparent protocol for putting patients on the waiting list and distributing organs. This body will require support at many levels - from doctors who identify donors and those who transplant organs, from families who donate organs and from patients waiting for organs. It will work only if people know that it is impartial and in society's interest.

Harsha Deshmukh, Narmada Kidney Foundation, Twin Towers, Prabhadevi, Mumbai 400025. Email:sdeshmukh@vsnl.com