Transcript Organ Shortage - مرکز تحقیقات اخلاق و

BRAIN DEATH DONORS
(ETHICAL POINTS)
G.POURMAND, M.D.
Urology Research Center,
Medical Sciences/University of Tehran
Tehran, IRAN
The 2nd International Congress of Medical Ethics in
Iran (Apr. 2008)
CANADIAN TRANSPLANT NUMBERS
(1994-2003)
1836
3966
4001
1814
1803
1901
3514
1623
1632
1573
1746
2874
2829
1530
1500
1484
2000
2159
2500
2522
3000
3229
3500
3800
4000
3990
4500
1994
1995
1996
Waiting
1997
1998
Transplanted
1999
2000
2001
2002
Died While Waiting
250
237
195
170
225
140
171
115
0
114
500
139
1000
2003
DONORS, ORGANS & WAITING PATIENTS
Number of Patients
70,000
60,000
50,000
40,000
30,000
20,000
10,000
0
1990
1991
1992
Wait List at
Year End
1993
1994
1995
Cadaveric
Transplants
1996
1997
1998
Cadaveric
Organ Donors
1999
THE ORGAN SHORTAGE

Organ shortage — the main limitation to saving
lives of critically ill patients — is due to
individuals and their families not considering
organ donation out of
fear,
ignorance
misunderstanding.
THE CRITICAL ORGAN SHORTAGE

60 people
daily transplant,

13 die
non-availability of organs.

5,984 deceased organ donors;

22,953 lifesaving organ transplants performed in 2000 (17,255
cadaveric donor transplants, 5,653 living donor transplants);

77,179 on waiting list as of June 3, 2001;

5,597 deaths while on Wait List at end of 2000.
KIDNEY TX WAITING LIST IN ASIA (2002)

Japan
-
12,974

Taiwan
-
7000

Taiwan
– 1.9 yrs
Saudi Arabia -
4248

Korea
– 2.2 yrs

Korea
-
4000

Hong Kong
– 4.3 yrs

Pakistan
-
1650

Singapore
– 5.8 yrs

Hong Kong
-
1018

Singapore
-
666

Bangladesh -
125

Waiting Time
No Waiting list in Iran for
Kidney Tx.
KIDNEY TX WAITING LIST IN THE WORLD (2002)
Waiting List
#’s
# of donors per
population
Australia
1,764
10 per 1,000,000
Canada
3,990
13.5 per 1,000,000
United States
75,000
34.3 per 1,000,000
DONATION
Deceased donors
Donor has been declared dead by two physicians
independent of the transplant team
Usually occurs only in cases of neurologically determined
death (the brain stops working 1st but the donor is still on
artificial support such as a ventilator to allow the other
organs to maintain a blood supply and remain suitable
for transplant)
Live donors
Patient chooses to donate one or part of an organ to
someone on a transplant waiting list
 Can only occur with organs when removal will NOT cause
grave harm to the donor
INCIDENCE OF ESRD IN IRAN

Prevalence: 357 PMP
Incidence: 59 PMP

Currently,




50% on HD
47.5% transplanted
2.5% on PD
WORLD STATUS OF RENAL TRANSPLANTS
Annual Number of kidney transplantations per
million population (pmp) per year USA -
52
Predominantly Deceased Donors
Europe - 27
Predominantly Deceased Donors
Asia -
Predominantly Living Donors
3
The number of deceased donors has increased steadily in recent years.
Between 2003 and 2006, there has been a 24 percent increase in donation
from deceased donors. Living donation rose sharply in the 1990s and has
remained at a steady level the last few years.
DECEASED DONATION
DECEASED DONOR RATES
The deceased donors per million population
per year




USA Europe Asia South America -
20.7
15.9
1.1
2.6
COMMON PROBLEMS & PLATFORMS IN
CADAVER TRANSPLANT
 Incidence of organ failure
 Public and Professionals Attitude to Brain Death
& Organ Donation
 Legal Aspects
 Trained Transplant Co-ordinators /Counsellors
COMMON PROBLEMS & PLATFORMS IN
CADAVER TRANSPLANT
 Media and Scandals
 Reporting of Brain Death
 Hospital Infrastructure
 Religion & Organ Donation
PROBLEMS WITH CADAVER ORGAN
DONATION PROGRAM IN ASIA
Govt. Problem
No Funding for program
Hospital problem
No efforts to identify &
maintain “Brain Dead” donors
Community Problem
No Awareness of “BrainDeath” Concept
For cadaveric donation,
‘ Society remains a crucial aspect in a transplant program’
MAKE LOCAL SHARING PROTOCOLS
6 Kidneys have been wasted in the last four years of the 112
Kidneys shared in the UNOS due to these problems

Poor Retrieval Technique – 2

No Blood for Cross Match – 2

Poor Packing of Organ - 2
PHYSICIANS ATTITUDE TO ORGAN DONATION
A large proportion of Physicians are indifferent to organ
donation process.
Reason cited for this were

Lack of information regarding the donation process (28.7%),

Concerns about the sale of organs (22.1%),

Islamic religious beliefs (21.6%)
MEDIA AND SCANDALS
Doctors May Face Murder Charge
PUBLIC ATTITUDE
Important misconceptions and fears are –

Fear of death,

Belief that removal of organ violates sanctity of deceased

Concern about being cut up after death,

Desire to be buried whole,

Dislike of idea of kidneys inside another person,

Wrong concept of brain death,

Idea of donation being against religious conviction
RELIGION AND ORGAN DONATION
Religion plays major role in promoting Organ Donation.
Common thread that binds all religions of the world –









Saving of life overrides all objections
There is no religion that is against organ donation
What holds back is cultural reservations –
Ignorance of the process of organ donation,
Fear of mutilation,
Lack of emotional support at time of tragedy,
Fear that organs will be sold or used only by the rich
Mistrust of hospitals and health professionals
Myths
MUSLIMS & ORGAN DONATION
Muslims: the most controversial group 
Quran does not forbid tissue donation

Quran states that if by not transplanting an organ or tissue,
the person will die, then it is permissible to donate. It is
allowed for an emergency to save life.

Different interpretations by different religious leaders,
‘ustazs’ and ‘ulamas’
MUSLIMS & ORGAN DONATION
Fatwas declared in several countries

Saudi Arabia : 1985 - permit both living related
and cadaveric donation of organs

Iran – 1989 (parliament legislation: 2000)

Pakistan,

Bangladesh,

Malaysia - 1995

Indonesia
CHRISTIANITY – ORGAN DONATION
STATEMENT BY POPE JOHN PAUL II –
Full support of organ and tissue donation concluded with words
of Jesus narrated by evangelist and physician LUKE:
“give…, and it will be given to you; good measure, pressed down,
shaken together, running over, will be put into your lap (Luke 6 :
38).”
We shall receive our supreme reward from God according to the
genuine and effective love we have shown to our neighbor.
RELIGIONS AGAINST ORGAN DONATION

Greek Orthodox, Shinto and Gypsies are three
religions that do not encourage body donation

Jehovah’s witness is another Christian sect
that is against such acts
HISTORY OF DEATH



During ancient times, most people agreed that
death occurred when a person's heartbeat and
breathing stopped.
For the Greeks, the heart was the center of life
For the ancient Hebrews and Christians, the
breath was the center of life
HISTORY


In the 12th century, Maimonides pointed
toward the head, and the loss thereof, as the
reason for lack of central guidance of the
soul.
During the Enlightenment, the necessity of
heartbeat, breath, and consciousness for the
definition of life was questioned, leading to
questioning regarding the definition of death.
LEGAL DEFINITION OF DEATH

The cessation of life; the ceasing to exist;
defined by physicians as a total stoppage of
circulation of the blood, and a cessation of the
animal and vital functions consequent thereon,
such as respiration, pulsation, etc.

Black’s Law Dictionary (4th edition)
UNIFORM DETERMINATION OF DEATH

An individual who has sustained either


Irreversible cessation of circulatory and respiratory
functions
Irreversible cessation of all functions of the entire
brain, including the brain stem is dead. A
determination of death must be made in
accordance with accepted medical standards.

Uniform Determination of Death Act (1980)
BRAIN DEATH

In 1959, patients were described as being in
"coma depasse" or beyond coma.

In 1967, the first successful heart
transplantation took place, with the organ
coming from a brain-dead, beating-heart donor.

Farrell MM and Levin DL. Critical Care Medicine. 21(12):1951-65, 1993 Dec.
... ‫الناس ممياا‬
‫ و َمنَ َاحياها َف َكاَ نما َاح َيا‬...
َ
And he who saves a man’s life shall be
considered as one who has saved the life
of mankind as a whole
32 ‫سوره املائده آيه‬
Imam
Khomeini’s
(the supreme leader
of
Iran)
positive
response to the letter
of the Iranian exminister of Health on
the permissibility of
organ donation from
brain death patients.
IRAN FACTS:

The oldest organ transplant (Cornea) was performed in 1314 (1935).

The first kidney transplantation was performed in Shiraz in 1346 (1967).

The total number of transplants in 2005 was 19501 kidneys, 203 livers, 104 hearts,
13 lungs, 28362 corneas, 1468 bone marrows, 1382 heart valves and 1283 bone
transplants.

One, five and ten years survival rate is reported to be 92.8%, 83.7% and 73.3%,
respectively.

Iran is the only country who doesn’t have any waiting list for kidney transplant & the
patients can receive the necessary organ in less than 2 months.
ENCOURAGING PEOPLE TO DISCUSS
ORGAN DONATION
When the wishes of the deceased are not known, only 50%
of people will agree to organ retrieval from their relatives
Encouraging people to speak about organ donation and
transplantation and to make their wishes known to their
relatives could change the picture resulting in 93-94% of
people allowing donation
PROJECT POSITIVE ASPECTS
Many donor relatives have stated that donating
their loved one's organs does not make the
pain of their death disappear
Bereaved families can experience comfort that
their loved one's gift gave another person a
second chance at life
PRESENCE OF FAMILY MEMBER DURING
BRAIN DEATH TESTING

Most families faced with brain stem death of a relative find the
concept difficult to understand and have trouble in accepting
that their relative is actually dead

Family members were given choice to be or not to be present
during brain stem death testing

It is suggested that presence of family members during brain
stem death testing not only helps families to accept this concept
of death but also promotes the grieving process
ACTION REOUIRED – MUSLIM COUNTRIES

Most people are ill- informed about their religions attitude
towards organ donation.

More public education needed to change cultural beliefs and
practices although Islam does not forbid Organ or tissue
donation

Constantly addressing masses through media by religious
head may help to improve sentiments
CONSENT FOR DONATION

Pre-mortem – via Donor Cards, Driving License

Consent of his family following death

Some form of a combination of the two are necessary

‘Supererogatory permission’ - Underlying premise of such a
consent would be that “organs of dead people are public
goods”, and donation must be considered “similar to other
compulsory civil obligations” within society

The permission is a moral rather than a legal requirement
MANDATED CHOICE

This requires people to state their ’willingness
to donate or not’ when filing some state of
institutional return such as a driving license or
income tax form.

The information would be kept on a central
register, accessible at time of death
PROMOTE ORGAN DONATION AMONG
BLOOD DONORS

Study shows that blood donors have better knowledge of
organ donation and are more willing to donate their organs
and sign an Donor card than general public.

A substantial proportion of blood donors have not signed a
Donor Card.

It would be useful to design promotion programs to facilitate
blood donors' participation in organ donation.
CONCLUSION
Organ Shortage is a Crisis, however the Crisis has a Cure

We need to Network and start thinking of sharing resources,
expertise and organs

Set up Collaborative projects

Use Television Media for Promotion

Get Religious heads to Participate regularly

Have Transparency in program

Set up regional Transplant coordinators Forums