Abstract

Many of you will have come across advertisements encouraging you to talk to your loved ones about organ donation. This is a manifestation of the government’s latest set of initiatives to increase the organ donation rate. The plan is to optimise our system for procuring organs from deceased individuals.

The government’s reform package is the best way forward for getting more of those organs for donation — hearts and lungs for example — which cannot be procured from live donors. But in the realm of kidneys, an organ in critically short supply and available from live donors, the package is going to fall well short of what is required.

The problem is that Australia, unlike Spain and other countries with high cadaveric procurement rates, has relatively few people dying while connected to a respirator. Only individuals who die in this manner are suitable for organ donation as otherwise organs expire from lack of oxygen long before they can be transplanted. Typically, only individuals who suffer death by cerebral trauma, such as car accident victims, end up (brain) dead on a respirator. Such deaths account for less than 1 per cent of hospital deaths in Australia.

We could get the whole country to sign up as organ donors and it would have little to no effect on donation rates, because those people would not die in hospital on a respirator. This was noted by the National Clinical Taskforce on Organ Donation, who acknowledged (pg. 160) that the maximum rate of organ donation achievable by a cadaveric procurement system in Australia would be 18 donors per million population — significantly lower than what is required.

So why did the government go ahead with their scheme despite its obvious inadequacy?

The fact is that health policy remains hopelessly mired in the gift of life doctrine (GOL), which holds that organ donation should always be a ‘gift’ and should never be compromised by incentives. Note for example, the ANZICS guidelines on organ donation: [organ and tissue donation is] ‘an unconditional, altruistic, non commercial act’.

The GOL argues that if individuals receive their life saving organs from anonymous individuals it will reaffirm the social contract — the notion that we look out for each other because we are all part of the same society and we care about each other. In contrast, commercial systems discourage people from donating an organ unless it is in their interest. In such systems, the primary motivation for saving a life is one of selfishness. This leads to social atomisation.

Advocates of commercial approaches to kidney acquisition generally acknowledge that this is all well and good, but that any positive gains derived from social solidarity are offset by the suffering of individuals on dialysis.  These advocates want to see a system that gets more kidneys.

The debate between the commercial and GOL camps is currently at an impasse in Australia. Until ongoing research provides a major breakthrough, any policy proposals must satisfy both the ‘more kidneys’ criteria, and the ‘social solidarity’ criteria.

One option here is Kidney exchange, which works in the following way. Say you have kidney failure and I offer to donate you one, but we are tissue or blood type mismatched. We are placed into a database which matches us to another pair in a similar situation where my kidney is compatible with the other recipient, and vice versa. A swap ensues in which both people in need of a kidney receive one. A sufficiently large database ensures the possibility of five-way swaps, which maximise efficient distribution.

Kidney exchange means that any kidney is a good kidney, including old donors for young recipients and similar otherwise compromised cases. As a result, recipients can tap into their extended social networks — sports clubs, workplaces, unions etc — to try and find anyone willing to donate, and then be matched with a donor most suitable to them. This involvement of broad social networks and directed donation facilitates altruism and builds community solidarity on a micro level, satisfying the GOL. The unpaid live donor system is optimised, and a great deal of publicity pertaining to the kidney shortage is achieved on an intimate level, rather than through impersonal national advertising campaigns.

In places where it has been implemented, kidney exchange has led to marginal improvements in kidney supply. This includes Japan where, due to a scandal at the time of the country’s first heart transplant (there were allegations that the donor was not quite dead) there is strong opposition to both commercial and cadaveric procurement. A similar system for blood procurement in the post-war years was also effective. There, recipients of blood transfusions were required to pay back the blood, often in quantities they were unable to provide themselves (such as in the case of haemophiliacs). They would consequently activate their social networks to donate the blood on their behalf, entrenching community bonds and publicising the blood shortage.

It is important to acknowledge the complexity of the kidney supply issue and not dismiss aspects of it as unethical or squeamish. At the same time, many people are experiencing very real suffering, and we need to look for possible ways forward. The introduction of a kidney exchange program, possibly in combination with the UK, seems a matter of routine prudence.

Mark Fabian is a reseacher at the School of Politics and International Relations, Australian National University. He completed his philosophy Honours thesis on the Australian kidney situation in 2010.