Right: A surgical team performs a life-saving organ transplant, the donor having been declared brain-dead.Arguments suggesting Australia needs more rigorous guidelines to protect organ donors
1. New South Wales has more rigorous guidelines than those which apply nationally
Critics of the national guidelines claim they do not offer the same quality of protection for donors that the New South Wales guidelines do.
Under rules introduced by the NSW Government last year, doctors cannot give drugs to donors to optimise their organ function while they are still alive. Other interventions to increase the viability of organs, including the insertion of cannulas into vessels to enable rapid cooling of organs, are also banned when the donor is alive.
In June 2007 the New South Wales Minister for Health, Reba Meagher, announced the introduction of new guidelines aimed at providing greater clarity on organ donation following cardiac death.
'NSW is the first state in Australia to develop and introduce organ donation after cardiac death guidelines,' Ms Meagher said.
'These new guidelines will provide greater clarity on a number of clinical, legal and ethical issues and will hopefully see an increase in the number of donations - particularly kidney donations.'
Ms Meagher further stated, 'Having clarity on donation after cardiac death, in addition to brain death, means many more patients who have expressed a desire to donate, can now be considered for this life-giving and generous act...
This initiative will help families and doctors make important decisions based on clear and comprehensive information and an understanding of the benefits that organ donation can bring to others.
Importantly, these guidelines affirm that comfort and care of the dying patient who wants to be an organ donor is the absolute priority and is not comprised by this donation process.'
2. Some critics have claimed that Australian guidelines allow the harvesting of organs from those who are not 'brain dead' and from who blood circulation may not have stopped irreversibly.
Associate Professor James Tibballs, of Melbourne, is an intensive care specialist at the Royal Children's Hospital. The professor has stated his belief that doctors could not be sure all brain function or blood circulation had ceased irreversibly when organs were taken.
The Professor has called for brain death tests to be strengthened and for Australians to be fully informed of how organs are retrieved to ensure informed consent.
Dr Tibballs has claimed that clinical practice clashed with the law, which says organs can be taken from a donor when they have either irreversible cessation of all functions of their brain or irreversible cessation of blood circulation.
He said guidelines used to diagnose brain death and cardiac death (cessation of blood circulation) could not prove irreversible cessation and that some interventions to ensure the viability of organs could actually harm or cause the death of a donor. 'The question of when is it permissible to retrieve organs is now phrased not in terms of whether death is present or not, but rather "how dead is enough",' Dr Tibball has claimed.
Dr Tibballs has called for a test of brain blood flow to be made mandatory to improve the certainty of brain death diagnosis.
The same position has been adopted by Associate Professor Nicholas Tonti-Filippini, PhD, a consultant ethicist and associate dean and head of Bioethics at the John Paul II Institute, Melbourne. Professor Tonti-Filippini has stated, 'Death of the brain stem alone is not death. Diagnosis of death requires evidence of the damage to the other parts of the brain such that all function of the brain is destroyed. I advise families to ask for an image showing loss of blood supply to the brain. They can then be confident that death has occurred.'
3. Some organs are currently being donated without properly informed consent
Melbourne bioethicist Dominic Wilkinson, an intensive care specialist now based at Oxford University, has claimed there is a tendency for the medical profession to gloss over the details of how organs are retrieved because it could confuse or alienate potential donors.
Dr Wilkinson stated his view that informed consent was vital and that all Australian laws governing donation should required that informed consent be given prior to donation.
'We think that it is important for individuals to give informed consent for their organs to be used after they have been declared dead. That means that they should know exactly what they are agreeing to when they sign on to an organ donation register,' he said.
Associate Professor James Tibballs, an intensive care specialist at the Royal Children's Hospital, has indicated that donors should know exactly what could happen to them so that they could give informed consent.
'If someone can't understand the arguments during a time of peace, how could they be expected to understand it when they are looking at their severely injured child or loved one in hospital,' Dr Tibballs has asked.
4. Clear guidelines would lead to increased confidence among potential donors and recipients
Rigorously applied guidelines for determining when death has occurred are not inconsistent with high organ donation. Some critics of our current practices have argued that the more stringent the guidelines and procedures the more likely people are to be prepared to donate because they will have confidence that their own care will not be compromised should they be on the organ donor register.
Associate Professor Nicholas Tonti-Filippini, PhD, a consultant ethicist and associate dean and head of Bioethics at the John Paul II Institute, Melbourne, has stated, 'Many countries with successful donation programs, including Spain, France and Singapore, adopt regulations that would comply with the recommendations that (Professor) Tibbals makes (that we guarantee irreversible brain death has occurred)...
To facilitate organ donation, there does need to be community discussion about procedures undertaken before withdrawal of treatment and hence before death.'
Professor Tonti-Filippini has indicated that he himself has refused a kidney transplant for twenty years because he is not satisfied about the procedures which surround the taking of organs from organ donors. Professor Tonti-Filippini's concerns indicate that some organ recipients' peace of mind may be compromised if they are uncertain about or not satisfied with the manner in which organs are taken from donors.
5. Clear guidelines would give peace of mind to the relatives of donors
The secretary of the Department of Health and Ageing, Jane Halton, has said it was important the public had confidence in Australia's organ donation system so more lives could be saved. Ms Halton has stated, 'It is very important that we provide assurance to the community that they can have complete confidence in the system.'
The virtualmedicalcentre.com gives the following overview of the situation in Australia. The Centre's Internet site states, 'Although most Australians are comfortable with organ donation, relatively few register their legal consent. In the face of uncertainty, relatives usually opt not to proceed with donation.'
The Centre's Internet site also notes, 'Public perceptions may also contribute to the low donation rate in Australia. It is hoped that basic education about the process and procedures involved will allay some unfounded fears. In particular, the concept of 'brain death' appears to be widely misunderstood.
Some people mistakenly believe that retrieving organs from a brain dead person will cause them to die prematurely. Also, there is the fear that allowing organ donation is agreeing to mutilation. Again, information about the surgical procedure itself may reassure family members and make them more comfortable with the decision to donate.'
Given the apparent popular fears already in existence about 'brain death', there are those who are that relatives will only have peace of mind about allowing their loved ones' organs to be used for transplants if they are confident that rigorous guidelines exist and are adhered to ensure that brain death has irreversibly occurred.