Organ Transplantation OLD News

Extracts from EEIN 1991-1994. Latest news is at the bottom. Provided by Eubios Ethics Institute , at http://eubios.info/index.html.

The cost of kidney transplants in India is attracting many rich clients from around the world; Lancet 337: 1534. Every year about 2,000 kidneys are bought from live donors, a turnover of 10 million, and it is called a kidney bazaar. Many poor people get for them substantial sums, still less than 1000 for a kidney, enough to buy a house and set up a rickshaw business! The kidneys are sold by the dealers for about 3000. There has also been an illegal trade in live cornea donations, paying 2300 an eye, for people who want to avoid the queues from the dead cornea donor programs. On the general topic of commercial exchange of kidneys see BMJ 303: 110.
The WHO has recently endorsed a set of guidelines for human organ transplantation, and these are reproduced in the Lancet 337: 1470-1. The morality of transplantation to patients with drug imposed injuries, such as alcohol damaged livers, is discussed in JAMA 266: 213-4.
The law on transplantation in the two halves of Germany should soon be unified; Lancet 337: 1403, but it will only outlaw commerce. The question of whether donor cards or presumed consent should be used, is now a question of debate. The Japanese government committee on brain death has released an interim report. A brief background to the committee's mandate is in Soc.Sci.Medicine 33: 215.
A comment on bone marrow transplantation among half-siblings by W.J. Curran is in NEJM 324: 1818-9. It considers an Illinios court case.
A debate over the removal of brains from patients, and the use of tissue in medical research in Philadelphia, USA, is mentioned in Nature 351: 595.
The implant of a fully portable left ventricular assist device is described in JAMA 265: 2930-1. The question of an age limit for heart transplants is discussed in BMJ 303: 70. On the shortage of organs for transplant in the UK see Lancet 338: 245-6.

In Taiwan, criminals that have been sentenced to death are asked about organ donation. In the year this has been underway, 21 out of the 51 asked have agreed to give organs, and these organs have been used. The criminals are anaesthesised, then shot in the head (brain stem) on the operating table, then put on a respirator while organs are removed (heart, liver, kidneys, corneas, etc); Asahi Newspaper (10 Oct 1991), 3. A priest counsels the prisoners and their families, and some are happy to give. However, even if it is better than being shot by firing squad, some people are against the practice because on the question of consent, let alone over the ethics of the death penalty. On kidney trading in Hong Kong, see Lancet 338: 453. On kidney donor problems in the U.K. see BMJ 303:266, 267, 312, 313. Many people, maybe one million people, in China, earn money to live from selling blood; Lancet 338: 501. On blood saving in operations see BMJ 303: 659-60. On the operations of a US tissue bank see JAMA 266: 1329-31.
The Japanese situation concerning the acceptance of brain death continues to be debated. Some of this debate is behind the closed doors of the Prime minister's ad hoc Commission on Brain Death and Organ Transplantation; BMJ 303: 266. In figures recently reported in Japan, in the case of kidney transplants, from 1988 to June 1991, there were 508 cases involving a dead body as donor. In 1988 20% were from brain dead patients, and 80% from "heart" dead patients; but in 1991 only 1 case using a donation from a brain dead body is recorded, suggesting a significant trend in hospitals avoiding any possible legal suits over brain death. The ad hoc committee released an interim report including majority and minority opinions, but the commission has stated that the final report will be unanimous. It is expected to approve brain death as death, and allow organ donation from donors who want to give organs. In opinion polls conducted throughout the last few years, there is an increasing acceptance by the public of brain death as death, about 60% of the public agree with that. In figures released from a study conducted by the committee, from a sample of 2365 public, asked whether in a brain death situation of a patient on a respirator, they can accept brain death; 45% said yes, 25% said no, and 31% said they don't know. Most of the don't know said they did not understand brain death. Asked if they needed an organ transplant to live, 36% said they don't want and 30% said they would take an organ; but 55% said they support organ transplants and only 14% said they reject, 31% said they don't know. Asked about who should decide whether to give organs; 68% said yes if donors and family say yes; 23% said yes if donor said even if family disagrees, and 16% said even if we do not know what the donor said, if the family agrees, they can take organs from the body. The Japanese Lawyers Association has recently opposed the use of brain death as the definition of death, so the situation is still to be debated, even if the Prime Minister's Committee recommends it. Though many hospitals may begin heart and liver transplants from brain dead bodies, if the committee's report in January 1992 supports the use of brain dead bodies as organ donors.
On ethics see L.R. Shaw et al., "Ethics of lung transplantation with live donors", Lancet 338: 678-80. On lung transplants see JAMA 266: 1943-6. The new WHO guidelines on organ transplantation (see EEIN 1:69), are commented on in the BME (Aug 1991), 10-11. On ways to get more organs in the USA see JAMA 266: 1751; Nursing Outlook 39: 192; and in Australia see MJA 154: 643-4. On the law relating to the use of corpses for medical education see Medicine Science and Law 31: 345-54. On anesthesia and organ transplants see a volume of International Anesthesiology Clinics 29 (Summer 1991, 160pp), titled Anesthesia and Organ Transplantation .
On the advantages of using DNA HLA-DR matching of donor and recipient organs see Lancet 338: 461-3; NS (31 Aug 1991), 9. Some graft failures may be due to mistaken HLA matching using serological typing, rather than DNA methods. Antibody therapy may make transplants from unmatched donors acceptable; SA (Sept 1991), 12-3. The effect of race in outcome of renal transplants is in NEJM 325: 428-9. On the transmission of Hepatitis C virus by organ transplantation see NEJM 325: 454-60. Organs should not be accepted from donors positive for anti-Hepatitis C to avoid this.
On research to develop an artificial heart see Science 253: 500-2. On coronary bypass's see BMJ 303: 661-2, and on angiopathies see BMJ 303: 729-30. On heart-lung transplants see papers in Archives of Diseases in Childhood 66: 1013-26.

The major news item in Japan is that the Prime Minister's ad hoc Committee on Brain Death and Organ Transplantation has released its draft report (26 December), and it has recommended unanimously that organ transplants from brain dead donors that have positively expressed a desire to donate organs should be permitted. They also say that no organ transplants should be performed from patients that have said they do not want to give organs. The final report will be issued at the end of January.
The committee also says that organs can be donated if family members agree that the deceased expressed a wish to donate organs, and that there has been no pressure on the relatives to make this decision. They recommend a third party (unnamed) should look at these cases to ensure there is no undue pressure to consent. In addition to these unanimous findings, there was a majority agreeing that brain death is real human death. A minority of 4 members said that brain death is close to human death, but is not, though this is not surprising since one of this minority went on Japanese television one year ago to say that a human being is not dead until every cell in the body is dead!
There will be further decisions required to expand the use of organ donations from cadavers in Japan, though some are already performed (EEIN 1: 82). A system for the expression of the willingness could be rapidly implemented in Japan if there was willingness to do so, because all driver's licenses must be renewed every 3 years, so they could adopt the widely used practice of recording consent on driver's licenses. A problem in Japan may be that people are only beginning to learn how to express their opinion concretely about any issue, let alone issues associated with new technology.
A background discussion to obstacles to brain death and organ transplants in Japan is in Lancet 338: 1064-5. The major barriers to the acceptance are education and members of the medical profession, plus suspicion of the medical profession by the public. The rate of consent to donate organs after brain death of Japanese is over half, with only about 15% against, in a 1990 poll.
Even in countries with a longer history of organ donation there are still shortages of organs, and debate over how to create more incentives; Lancet 338: 1441-3; NEJM 325: 1243-9. A short book review of C.D. Keyes, New Harvest: Transplanting Body Parts and reaping the Benefits (Clifton, NJ: The Humanic Press 1991, 288pp., US$30) is in Amer. J. Law & Medicine XVII: 325-6.
A model looking at why people may want to donate organs is R.L. Horton & P.J. Horton, "A model of willingness to become a potential organ donor", Social Science & Medicine 33: 1037-51. Two models were looked at, and applied to medical students. The case of organ donation after execution in Taiwan (EEIN 1: 82) is reported in BMJ 303: 1420. The situation in Hong Kong is being examined to try to encourage more donors; Nature 354: 343.
There have been experiments involving rats, which were kept alive using an "artificial liver", containing live liver cells as a bioreactor; NS (23 Nov 1991), 26. It may be useful for short term life support. Parents decision's for the use of bone marrow transplantation for sickle cell disease are reported in NEJM 325: 1349-53, and on bone marrow transplants to treat multiple myeloma see NEJM 325: 1267-73. Pretransplantation blood transfusion may increase transplantation tolerance; NEJM 325: 1210-3, 1240-2; on pancreas transplants see NEJM 325: 1278-83; and on kidney function see NEJM 325: 1097-9. The shortage of tissue for scientific research is discussed in Nature 354: 427.
Accounts of falsified data on heart valves have been made; BMJ 303: 1222, whereas a success is in JAMA 266: 2666-7.

The major news item in Japan is that the Prime Minister's ad hoc Committee on Brain Death and Organ Transplantation has released its final report, and it has recommended unanimously that organ transplants from brain dead donors be allowed (EEIN 2: 12). A fuller description was given in the last newsletter.
One week after the release of the report, an 18 year old man was killed in an accident. His family requested that his organs be donated. The transplant was not possible within time of his death because the police wanted to expect the body. The Osaka police say that they must examine every accident victim after the heart has stopped, and only after such an examination can the remains be used for donation. Until this law is changed there is not likely to be many organ transplants from dead bodies, because over half the possible donors are accident victims; Asahi Newspaper (31 Jan 1992), 3. This is not the first time this has occurred, but it made national news because it was so soon after the influential report was released. The next step is for the law to be changed, the time it takes is very unpredictable!
An example of a presumed consent organ transplantation law is discussed in B. Teo, "Organs for transplantation. The Singapore Experience", Hastings Center Report (Nov 1991), 10-13. On the problems of getting enough kidneys for transplant to American blacks see W.B. Arnason, "Directed donation. The relevance of race", Hastings Center Report (Nov 1991), 13-9. On the use of incentives to get organs, and a list of current US costs of different organs, see Lancet 339: 185.
On the organ shortage in the USA, there are more than 23000 patients waiting for organs in the USA, and of the potential number of organ donors each year (6900-10700) organs are only taken from about 4000 a year. A number similar since 1986; R.W. Evans et al., "The potential supply of organ donors. An assessment of the efficiency of organ procurment efforts in the USA", JAMA 267: 239-46; F.P. Sanfilippo et al., "Factors affecting the waiting time of cadaveric kidney transplant candidates in the USA", JAMA 267: 247-52; BMJ 304: 138. It would be realistically possible to increase the number of donors used in the USA by 80%. See also JAMA 267: 213.
The results of Australian experience with "domino-donor" operations in heart and lung transplantation are in MJA 155 (1991), 589-93. On single lung transplantation for pulmonary emphysema see Lancet 339: 216-7. Single lung transplants work, and double the number of patients treatable.
The possibility of treating diabetes by cell transfer and gene therapy is raised by the results of PNAS . A modified cell from the pituitary gland was made to act as a pancreatic cell and to secreting insulin; NS (25 Jan 1992), 29. The technique of immune isolation has been shown to work in rats and mice in; R.P. Lanza et al., "Xenotransplantation of canine, bovine, and porcine islets in diabetic rats without immunosuppression", PNAS 88 (1991), 11100-4; P.E. Lacy et al., "Maintenance of Normoglycemia in Diabetic mice by subcutaneous xenografts of encapsulated islets", Science 254 (1991), 1782-4.
Related to ideas of feelings about the human body and remains, a call has been made to return all the skeletons of Australian aborigines from museums, medical schools and scientific institutions; BMJ 303 (1991), 1564. On death rites see Lancet 339: 175.

A working party of the British Paediatrics Association has issued a report on the diagnosis of brain stem death in infants and children, and some of the key points are in BME (March 1991), 10. The testing of brain stem death in adults can still be improved, and a study has shown that prompt testing could result in a 20% increase in donations; S.M. Gore et al., "Organ donation from intensive care units in England and Wales: two year confidential audit of deaths in intensive care", BMJ 304: 349-55; 716.
An example of organ donation in the US from a body of a murdered British tourist; Times (25 April 1992), 6, is something that could not happen in Japan because the police keep the dead body beyond the stage that viable organs can be removed.
In New Zealand in March there were several cases involving the retention of selected body parts, such as parts of the brain, by police, while forensic studies were completed. Traditional Maori people like to have the body in wake, and bury it intact, not unlike people of any race as was pointed out by some non-Maoris in New Zealand. A practice that they had not known about, until funeral directors told them, was that certain body parts had been retained. Calls were even made for a separate coroner to be established in Auckland. There must be a balance between autopsy demands and burial, and we can hope that forensic tests can be done quickly and sensitively.
The Australian situation and liver supply is discussed in MJA 156: 63-5; A.G. Ross Sheil et al., "The first five year's clinical experience of the Australian National Liver Transplantation Unit", MJA 156: 9-16. A total of 126 patients received 137 liver grafts (transplants). The success rate for non-malignant liver disorders is said to be more than 80%. On liver transplantation in children; A. Salt et al., "Liver transplantation in 100 children: Cambridge and King's College Hospital series", BMJ 304: 416-21, 396-7. In one Australian hospital, Brisbane Royal Hospital, 39 Japanese children have received liver transplants from brain dead donors, and there are currently another 4 children waiting in the hospital. About 50 Japanese surgeons are training in that hospital also, so it is hoped that they will be able to perform liver transplants in Japan soon from brain dead donors; Asahi newspaper (20 April 1992), 30. Some patients are waiting for livers from brain dead donors in Japan, for example, Kyushu University Hospital's ethics committee has approved of three patients receiving livers should donors become available. In Japan, liver donation is from live relatives, and a paper on liver regeneration has found that livers regenerate faster in recipients than in donors; Lancet 339: 580-1.
In Japan, the bone marrow bank has issued guidelines for operations using unrelated bank material. Recipients must be less than 45 years, and do not have relatives who could provide material. Donors must be between 20-50 years, and weigh 45kg (male), 40kg (female). Only operations performed in hospitals where there have been 15 cases in the last three years and 5 cases in the previous year will be supported; Asahi newspaper (11 April 1992), 31.
A related research story is that liver transplants may reverse alcoholism based cognitive effects in the brain; Science 255: 1638. This would alter our thinking of alcoholism and the brain.
It may be possible to prevent graft rejection of unmatched organs using antibodies; Science 28/2; Science News 141: 132.
In Beijing, China blood donation is to become compulsory; Lancet 339: 545.

A review article is J.E. Murray, "Human organ transplantation: background and consequences", Science 256: 1411-5. It traces the history of renal transplants, and is based on his Nobel Prize lecture.
India has outlawed commercial trade in human organs, and will be acknowledging brain death; BMJ 304: 1333. Indonesia and Sri Lanka have already made commercial organ tade illegal. However, it must still be introduced to each state of India. In a rather horrifc disclosure, it has been found that some patients of a mental institution were killed for organs in Argentina; BMJ 304: 1073-4.
A study of the potential for cadaveric organ retrieval in New South Wales, Australia is in BMJ 304: 1339-43. Related is the paper, B. Teo, "Is the adoption of more efficient strategies of organ procurement the answer to persistent organ shortage in transplantation", Bioethics 6: 113-29. The results of a US survey on the use of presumed consent for organ donation (39% yes, 53% no, 8% don't know, N=801) is in NEJM 326: 1025-7. Also on the shortage of transplant organs see NEJM 326: 1024-6. A book review of New Harvest is in Int. Digest of Health Legislation 43: 214-5. The results of small bowel transplantation are still not good, and comment on such cases is in BMJ 304: 1453-4. Neither were the results of lung transplants but now they are improving as the operation becomes more common, with a total of 567 heart-lung transplants being performed by the end of 1991; Lancet 339: 1021-2.
A description of a large transplant database of the Collaborative Transplant Study is in Lancet 339: 1346-7.
In Japan, Kyushu University is applying for permission from their ethics committee to obtain liver tissue from overseas for patients on their waiting list should their condition become critical. Several patients has died, in the absence of donors, as they are unable to use accident victims for donor tissues due to Police regulations on autopsies; EEIN 2: 26; Asahi newspaper (23 June 1992), 31.

The number of Italians and other foreign nationals coming to France to obtain organs has led to fears that French people may be missing out, and guidelines may be introduced; Lancet 340: 108. We can see problems in the 1993 integration of the EC, though the French are also making attempts to increase organ retrieval by the establishment of an organ donor register. Because about 50% of the families refuse to consent to giving organs if asked, they want to set up a register to record individual's donor status. Limitations of organ transplantation in clinical practice should be viewed in a broader perspective than merely calling for the donation of greater numbers of organs; B. Teo, "Is the adoption of more efficient strategies of organ procurement the answer to persistent organ shortage in transplantation", Bioethics 6: 113-29.
Another and perhaps the best option is the development of artificial organs. Researchers at MIT, Boston, report that they have grown liver, cartilage, bone, small intestine and other tissue by seeding polyester scaffolding with tissue-specific cells; GEN 12(7), 1, 28; SA (Aug 1992), 4-5. Over time, the biodegradable synthetic polymers used for the scaffold are replaced by natural scaffolding. They are currently using pigs to develop liver transplant strategies using the new tissue. They have also made a cartilage ear, using a mould.
In 1991, 419 liver transplants were performed in the UK, the approximate annual costs are 13-14 million; Hansard (11 June 1992), Cols. 479-80; BME (June 1992), 2. The costs may include follow-up costs of patients who received liver transplants in earlier years. The recipient of a Baboon liver in the USA, is critically sick at the time of writing after two months in a hospital in reasonable condition. He has developed sepsis, but is said not to be rejecting the liver.
The preservation of organs such as liver by perfusions of some fish proteins has been suggested, following studies in rats; GEN 12(9), 25. Anything which may extend the time possible in which to perform operations should be welcome. A European Multicentre study on the preservative solution used for kidneys is reported in Lancet 340: 129-37.
On pancreatic transplants see NEJM 327: 217-3. A report from the North American Pediatric Renal Transplant Cooperative Study is in NEJM 326: 1727-32. Of 1550 children, 43% of the kidneys came from a living related donor and 57% from cadavers, with better acceptance from living donations.
A report on a recent UK television program on the commercial sale of organs is in BMJ 305: 63. Iranian policy on organ donation is in Lancet 340: 300. Book reviews of interest in SSM 34: 1300. On death see JME 18: 26-42; J. Clinical Ethics 3: 78-82.

Some of the sociological issues raised by organ transplantation are discussed in R.C. Fox & J.P. Swazey, "Leaving the field", HCR (Sept.-October), 22: 9-15. A review of liver transplantation for children (2-3,000 cases have been performed worldwide) is J. Chiyende, "Liver transplantation", Archives of Diseases in Childhood 67: 1124-7. Transplantation in the UK is discussed in Lancet 340: 779-80; and in Australia in MJA 157: 3-4.
The organ procurement rates in Spain are reported in Lancet 340: 733, together with a summary of the international donor rates. The family refusal rate in Spain is about 25-30%, and organs are only taken following family consent. The donation rate has been increasing following the establishment of a network and training of counselors. The procurement rates in France have fallen following a complaint that a cornea was removed from a body without consent; NS (3 Oct 1992), 9. Corneas have a special law in addition to the general presumed consent law for all organs, so the situation is less clear. The number of refusals has increased by 30% in general, more for corneas, following public reaction against this.
An editorial titled "every kidney counts" is in NEJM 327: 883-5, and on long-term survival of kidney allografts see S. Takemoto et al., "Survival of nationally shared, HLA-matched kidney transplants from cadaveric donors", NEJM 327: 834-9; D.E. Butkus et al., "Racial differences in the survival of cadaveric renal allografts. Overriding effects of HLA matching and socioeconomic effects", NEJM 327: 840-5. Followup for over 20 years after transplant is reported in Lancet 340: 807-10. The use of oligonucleotides for HLA typing is described in Lancet 340: 870-3.
The case of the failed baboon liver transplant in Pittsburgh is commented on in Time (13 July 1992); Nature 359: 180. The man was infected with HIV and died 71 days after the transplant. The topic of xenotransplantation is discussed in a conference review in Lancet 340: 475-6. In Los Angeles a pig liver transplant failed in a 26 year old woman after 2 days; Yomiuri Shimbun (14 Oct 1992), 30. It had only been intended as an emergency measure.
Organ rejection continues to be a serious problem. There are various anti-rejection drugs being made, and recently a peptide based on a segment of human HLA was successfully tested in rats; GEN (15 Sept 1992), 1, 17; NS (5 Sept 1992), 15. This peptide is selective, only stopping Class I HLA immune responses, so it has an advantage over broad immunosuppression because general immune response to infectious agents can be maintained. It is being developed by a Californian company, SangStat. The use of microencapsulated hepatocytes in an artificial liver is reported in Artificial Organs 16: 336-41. The continuing practise of some rich people to freeze their dead bodies is discussed in NS (26 Sept 1992), 36-9.

Brain Death In Germany the brain dead pregnant women who had been used as a fetal incubator; Lancet 340: 1028; EEIN 2: 83; has been removed from the "respirator" and the fetus allowed to die. In a related case, a dead baby was disconnected from a respirator 6 days after becoming brain dead, in the U.K.; Lancet 340: 1154-5.
Letters on the diagnosis of brain death are in JAMA 268: 1859-60.
The Japanese government has postponed for yet another year the discussion of a legal bill to allow brain death and to remove the requirement for police to examine bodies after accidents only when they have been left dead off machines - a requirement which means that the organs are decayed too much after this examination to be used for transplants. A letter on brain death in Japan is in Lancet 340: 1164. The public acceptance of brain death and organ transplantation is steady, as reported in Nature 359: 770. The latest public polls show 52.2% support, 22.6% against and 25.2% unsure; Yomiuri Shinbun (11 Dec 1992), 15-17. The University of Tsukuba is conducting a university survey on brain death guidelines, as reported in the general Medical Ethics section.
A Catholic theologians discussion of brain death is in Thomist 56: 435-50.

Organ Transplants
A report by B. Blasszauer on the "Hypophysis scandal" in Hungary is in BME (Oct 1992), 29-32. An illegal scheme for selling pituitary glands extracted without consent or knowledge from dead person's in Hungary is described, together with the subsequent debate on organ donation. The English text of a proposed Czech law on Health applying to transplants is in BME (Oct 1992), 26-8. In November, Russia passed a law banning the selling or buying of human organs, in efforts to curb an organ trade; BMJ 305: 1178. On the question of legal property rights in human tissue see Melbourne University Law Review 18: 601-29. Legal issues in the medical uses of corpses are reviewed in Medicine, Science & Law 32: 313-8.
The use of living kidney donors in a US facility is reported in V.L. Hannig et al., "Utilization and evaluation of living-related donors for patients with Adult Polycystic Kidney Disease", AJMG 44: 409-12. The use of live donors in the U.K. is reported in BMJ 305: 956; Lancet 340: 1354. An editorial in Medical Ethics Advisor 8: 97-100, asks whether minors who donate an organ to siblings really have a choice. A US study of 1123 heart transplant patients between 1984-6 shows the merits of heart transplants, NEJM 327: 1220-5. The impact of a child's liver transplant on the family from a mother's perspective is analysed in Pediatric Nursing 18: 461-66. Current problems in the public acceptance of the French organ transplant service are discussed in BMJ 305: 853; EEIN 2: 83-4.
The transplants of myoblasts for treatment of muscular dystrophy is discussed in SA (Nov 1992), 14-5; BMJ 305: 844-5. Techniques to grow cells to form organs are discussed in Science 258: 1084.
A review of S.B. Foote, Managing the Medical Arms Race, is in Science 258: 831-2. A comment on the inappropriate name of "artificial blood" for oxygen-carrying macromolecules is in Artificial Organs 16: 445-7. On motives for blood donation see Lancet 340: 976-7. Canada intends to become self-sufficient in blood products; Lancet 340: 1341-2.

Brain Death The results of a survey of University of Tsukuba staff about brain death and organ transplantation are to be released in March. About 50% agree with brain death criteria and organ donation, the same as the population in general. The response rate to the survey was about 50%, and 98% said that they were interested in the topic (though some like me who said that they were not, may think that brain death is not an issue). In mid-January the 11th Japanese boy to receive a foreign heart transplant returned home (many more have obtained liver transplants overseas). In a another survey of 116 emergency centers in Japan, 75% said that there were no transplants because of the law, 39% said because the police did not accept, and 70% said a major reason was the lack of social consensus; Yomuiri Shinbun (22 Jan 1993), 1; (23 Jan 1993), 13. The main cause of brain dead patients they reported was stroke (61%), 22% were from traffic accidents, and 5% from heart attacks or other secondary reasons.
A dismissal of the claim that the adoption of brain death criteria represents a technology-induced moral change is in J. Med. & Phil. 17 (1992), 407-17. Letters on the subject of whether coronary bypass to increase blood flow to maintain organs for donation in brain dead donors are in Lancet 341: 238-9. The conclusion of the German case where a brain dead pregnant woman was kept on a respirator to act as a fetal incubator is discussed in Newsweek (9 Nov 1992), 53.

Organ Transplants
Recent statements on ethical guidelines for organ transplantation in the UK by the General Medical Council are in BME (Nov 1992), 8-9. They continue the ban on commercial donations, and say that live donations are permitted, but attempts to increase the number of cadaveric donors should continue. A review of the Philippine law on organ donation is in IJB 3 (1992), 169-71. Germany is still trying to develop a unified transplantation law, and it may be a compromise between opting in and opting out; Lancet 341: 364.
Discussion of the University of Pittsburgh baboon liver transplants is in Hospital Ethics (Nov/Dec 1992), 4-5; NS (30 Jan 1993), 3. There are actually only several hundred baboons available in the USA, and wild baboons may have harmful viruses, so it is not a realistic solution. It may be more feasible to use pig organs, from transgenic pigs. Many factors can contribute to organ rejection. A review of the role of carbohydrates in cell recognition is in SA (Jan 1993), 74-81.
The state of Pennsylvania in the USA is discussing a proposed presumed consent law for organ donation, but it is not expected to be passed. Discussion of opting in or out schemes is in BMJ 305 (1992), 1380. At least donor card schemes need more use.
The results of a Dutch study showing the negative side of liver transplant programs is in BME (Dec 1992), 33-9. The negative effects include rejection as candidates,, waiting periods, technical failures, and complications.
Reviews of transplantation success and indications for different organs include: kidneys, NEJM 328: 212; bones, Lancet 340: 1443; liver, MJA 157 (1992), 545-8; heart and lung, MJA 157 (1992), 475-8, BMJ 306: 98-101; pancreas/islet cells, MJA 157 (1992), 579-80; NEJM 327 (1992), 1861-8. A book review of Spare Parts. Organ Replacement in American Society, is in Science 259: 109-11.
The ethical issues involved in having a child to become a bone marrow donor for an existing child are discussed in JME 18 (1992), 125-7. The question of whether sickle cell anemia patients should be given bone marrow transplants is discussed in BME (Dec 1992), 40-3.

Brain Death The results of a survey of University of Tsukuba staff about brain death and organ transplantation have been released, and generally follow national trends with 19% saying that they would disagree with a doctor who said that brain death was human death. Although they decided that brain death was human death they made a conflicting and illogical guideline. They said that they will only use brain death criteria when the patient, or their family, has indicated that they believe it is human death. If they don't agree with brain death than they will not judge it! They also said that they will not do organ transplants from cadavers until a national law is made - this is largely due to the sensitive case of a cadaveric pancreas transplant performed a decade ago. The legal suits by lawyers could be indirectly blamed for the delay in organ transplants in Japan - which costs many people their lives. The Japanese Parliament may consider the issue of organ transplants and brain death in the session that ends 20 June, if it is not further postponed.
Comments on the recent German case of a dead mother who was keep on life support as a fetal incubator is in Hospital Ethics (Jan/Feb 1993), 13-4.

Organ Transplants
A moving and enlightening account of a mother's decision not to attempt liver transplantation for a dying baby is L. Paulette, "A choice for K'aila", Humane Medicine 9: 13-7. The paper provides some insights on the spiritual values of Canadian Indians, some which may be shared by many people around the world. The use of pig livers as a temporary life support for patients waiting for a human liver has been successfully used for a US man, whose liver suddenly failed due to hepatitis; HCR 23(2), 4. Letters on hepatitis C and organ transplants are in NEJM 328: 511-3.
On the 3 April a small aircraft crashed into the sea in Scotland carrying a donor liver. The pilot intentionally crash-landed in the sea to avoid damage to the liver, and escaped. A diver recovered the liver, and it was used to save the life of the recipient. This event should make us think about the waste of life caused by absence of donor livers.
A French bill concerning the donation and use of parts and products of the human body, and medically assisted procreation, is under consideration by the French government. An English translation of key parts is in BME (March 1993), 8-11. French officials are attempting to regulate the Italian use of French organs; Lancet 341: 684-5. A review of antimicrobial strategies in care of organ transplant recipients is in Antimicrobial Agents & Chemotherapy 37: 619-24.
The Honduran government has launched an inquiry to investigate the claims that crime rings are kidnapping children for use in adoption and as organ donors. In the last 6 months 600 children have been reported missing, most thought to be sold for US$5000 for adoption. However, on the 16 April a child's body minus major organs was found, supporting claims that an organ trade also exists.
Progress in developing artificial heart and lungs is reported in JAMA 269: 966-73. The reuse of a transplanted heart is reported in NEJM 328: 319-20. The issues involved in informing recipients of a faulty heart valve are discussed in HCR 23(2), 22-8. The experience of the transplant team affects the outcome; NEJM 328: 514-5. A report on 462 unrelated bone marrow transplants in the USA is in NEJM 328: 593-602. Also on organ donation see BMJ 306: 517-8.
In 1992 in Australia there were 105 heart, 19 heart/lung, 30 lung transplants with one year survival rates of 91%, 76% and 80%, respectively. The cost is about A$75-100,000. A variety of useful information about medicine and ethical issues in Australia is in The Bulletin (March 30), 1-35 (a supplement to Newsweek ).

A paper looking at the quality of life in liver transplant patients in Melborune is M. Okada-Takagi & T. Williams, "The quality of life in transplanted patients and their thoughts about ethical issues", Bioethics News 12(3), 12-30. 90% of the patients who received a transplant achieved the quality of life that they expected one year after, and 50-75% returned to work. The organ donation rate in Australia is the lowest among the major developed countries permitting donations; Lancet 341: 1530.
In a case in Japan where parents and four brothers and sisters supporting organ donation from a brain dead donor, after learning that they would not receive money they refused. the case occured in May at Tokyo Women's University; Yomiuri Shinbun (4 July 1993), 30. It was said that they had no money for a funeral (expensive in Japan!). The donor policy and law is being workerd out in Japan, but no commerce will be allowed. Five hospitals have been chosen as approved sites for liver transplants using cadaver organs, from 11 which applied, including Tohoko, Tokyo Women's, Nagoya, Osaka and Kyushu University Hospitals. At the moment it is estimated that about 30% of patients needing a live in major hospitals die before receiving treatment or a living donor transplant.
Despite the 1st May introduction of a Russian law prohibiting commerce in organs, it is likely that people will donate kidneys for money still; BME (May 1993), 24. The ideas on paid blood donors in Europe are discussed in NS (24 April 1993), 8; on the US system, JAMA 269: 2239-45. The upper house of Parliament of India has passed the Transplantation of Human Organs Bill, 1992; Lancet 341: 1270.
On the ethical issues of organ transplants see JAMA 269: 2769-74; NEJM 328: 1204-5; Phil. & Phenomenological Research LIII: 173-9.
A review of tissue engineering is in Science 260: 920-6. Insulin implants are discussed in SA (June 1993), 7-9; NEJM 328: 1496-7. In the future patients with high cholesterol may be able use an enzyme implant. An implant of phospholipase A2 has been used in rabbits and lowered low density lipoprotein levels (from high fat diets) by 40%; GEN (1 May 1993), 1, 23. The application has received a US patent number (5,178,864).

A discussion of the ethical problems in the French organ transplantation system is NS (3 July 1993), 12-3. The UK General Medical Council statement on organ transplantation from live donors is in IDHL 44: 370-1. The ethical problems in Europe are nothing compared to the situation reported in Brazil , were 8 people were arrested accused of buying a baby (for US$200) and planning to ship the organs to Germany, where they can get about US$35,000 for a kidney. There are suspicions that 50 babies may have been taken.
Papers on a market system for US organ procurement are in J. Health Politics and Policy 18: 175-88, 189-202. Another solution to help the organ shortage is to use kidneys from older donors, which is being considered in Australia , MJA 58: 588-90. On selling organs in India , Lancet 342: 45.
General books on transplants are in JAMA 269: 3040-1. A review of the issues involved is JAMA 270: 262-4. A woman who received a heart transplant who is pregnant is reported in AJOG 169: 33-4. A discussion of ethical issues in the use of postmortem procedures for medical teaching is JME 19: 92-8.
An antifreeze (cryopreservant) solution has been developed for preserving organs for transplantation; NS (31 July 1993), 17. The fluid has been applied to rabbit tissue, which is very close to human tissue in characteristics. It still requires high pressure to prevent freezing of water, and consists of propylene glycol, formamide and dimethylsulphoxide, but is soon expected to be suitable for use at lower pressures. On the use of robots for operations; FDA Consumer (Jul/Aug 1993), 25-9.

A review of the success of liver transplants in babies under one year is BMJ 307: 825-8. Of 25 babies in two Birmingham hospitals, the survival rate overall (4 months to 4 years) was 88%, with dramatic health improvements.
In the USA a patient has been kept alive for 14 hours using an artificial liver (after her liver was removed), while she waited for a donor liver. It was at the Cedars-Sinai Medical Center. The US company Cellex is moving forward with clinical trials of its bioartificial liver , GEN (1 Sept 1993), 1, 12, 21.
Comments on the multiple organ transplant to a child reported (for its expense) in EEIN 3: 69, are in BME (Sept 1993), 1. A paper on ethical issues in living organ donors and an advance directive organ registry is in Bioethics News 12(4), 16-24.
In Japan there has been renewed debate over brain death following a Kyushu University Department of Medicine, liver transplant from a brain and heart dead donor on the 22nd October. A tube was put into the liver immediately after brain death was judged, ant preserving fluid was used upon heart death. It has been major news because of the legal issue of bran death. The taped conversation to the recipient and family has been released, to show informed consent. This is the first time to release, but it was because of the medical risks involved. Also in Japan, it has been recently decided to establish an organ donor system based on 5 regions, to replace the existing 14 region kidney transplant system Yomiuri Shimbun (22 Sept 1993), 1.
A call for recognition of cortical death is made in R.M. Veatch, "The impending collapse of the whole-brain death definition of death", HCR 23(4), 18-24. Once the higher brain is dead a person is dead, and this will change the definition of death, he question is how soon. In Japan, they are still getting over the first stage. The German case of a brain dead pregnant woman being keep moving as an incubator for her fetus is discussed in Bioethics 7(4): 340-50.
The European Parliament has condemned the sale of organs for transplants, and is urging the Council of Ministers to ban the sale of organs in the EC; BMJ 307: 756. Racial disparity in kidney transplants in the USA is reviewed in JAMA 270: 1352-6. The system for HLA matching means that because there are less black donors there are less black recipients. The waiting time is about double for Blacks as for whites on average. A paper showing the beneficial effects of transplants compared to renal dialysis is in JAMA 270: 1339-43.

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