November 18th, 2008

Mrs. Buggins (footnote) has just defied Gordon Brown.

In fact it’s Mrs. Elisabeth Buggins, a senior professional manager in the English NHS, and Chair of a blue-ribbon committee set up to deal with the shortage of British organ donors. This has just snubbed Gordon’s preferred solution of a switch from opting-in donation to opting-out, via a change in the law to presumed consent. People who don’t know much about this, like Gordon, Wikipedia, the British Medical Association – and until yesterday yours truly – tend to favour presumed consent; those on the front line, intensive-care doctors and transplant surgeons, tend to be against. Why? In a word, Spain.

Spain has the world’s highest rate of organ donation: 34 per million, against Britain’s miserable 13. In 1989 Spanish law was changed to presumed consent, but the people responsible in Spain – the Organización Nacional de Trasplantes (ONT) – say it’s irrelevant. The ONT has a full handbook in Spanish on its website. This states (p.19, my translation):

In every single case the permission of the family must be sought. This is not specifically required in our legislation, but custom, social mores and the attitude of a fair number of judges has made it into an obligatory practice in Spain and in most of our neighbouring countries.

So if it’s not presumed consent, then what? Ibid p.15:

However many nuances you might wish to add, the basis of the Spanish model is as simple as this: to have in every hospital professionals specifically trained to follow through all the steps on the path to enabling a donation.

One essential “nuance” is that the post of donation coordinator in a Spanish hospital is always held part-time by a doctor, a regular member of the ICU staff, not a nurse or administrator called in at the whim of untrained front-line doctors.

The map of organ donation rates doesn’t bear any relation to the usual ranking of health care systems, or to their overall type. In many other respects, the Spanish health-care system is so-so. The famed Nordic countries have donation rates under 20 per million, near the EU average of 17. The USA actually comes in pretty high; at 26 it’s close to France (25) and Belgium (28). More data, including extensive non-European coverage, in this fact-packed newsletter from my old employer, the Council of Europe. The only obvious cultural correlate of the disparities is religious tradition: Catholic countries tend to have higher donation rates than Protestant or Orthodox ones. But this is not a strong explanation. Spaniards were more Catholic in 1989 than now, and the donation rate has risen from 14 to 34.

Even if the USA already ranks pretty high, matching the best would make a big difference. The waiting list for transplants is 96,000. In 2007, 7,082 patients died while on waiting lists, and many more had their survival chances reduced by the delay. Increasing donors from 8,000 to 10,500 (matching the Spanish rate) would allow an extra 8,700 operations a year, as each donor on average yields 3.6 organs. Many of the kidney patients would live anyway on dialysis with a lower quality of life, but for those receiving a heart, liver, or lung, it would mean life: say 5,000 lives a year.

Spain doesn’t invest much in advertising campaigns for organ donation. I’ve seen nothing here comparable to a sensational poster I once saw on a Dutch railway station: a grainy, cinéma-vérité black-and-white photograph of a naked couple making passionate love on a beach, taken from above, so his face was invisible, hers in abandoned ecstasy. The slogan – “Give your heart a second chance!”- appealed to the imagination brilliantly if unrealistically, since healthy young women up to sex on beaches are rarely candidates for transplants. Great fun. But the Dutch donation rate is stuck at a plodding 17. So the only serious model in town is the Spanish. Let me say it again: have a donation coordinator in every hospital ICU (1), as a part-time appointment (2) for one of the staff doctors (3) who should get special training (4) and specialist nursing and administrative backing (5).

When President Obama talks to José Luis Zapatero, he could do worse than ask to see Rafael Matesanz, the head of the Spanish organ transplant service. Or fly him over.

Footnote 1

Buggins’ turn is a BrE phrase coined by Admiral Jackie Fisher of the Edwardian Royal Navy, meaning “appointment by rota or seniority, not merit”. Since the estimable Mrs Buggins has rescued the honour of her maligned clan, an AmE equivalent could be “Lieberman’s turn”.

Footnote 2

Neither the Bush Administration, normally a reliable friend to free-market ideologues, nor the ultra-conservative Pope Benedict, has taken issue with the current economic model for scarce human organs. This is neither capitalism nor socialism, but niche communism: a cashless allocation according to need. Free-marketeers do produce pamphlets arguing for markets in organs, but most people think that such revisionism is far too dangerous.

Update 19 November – breaking news

Surgeons in Barcelona have successfully carried out a trachea transplant, using inert tissue from a deceased donor and stem and tissue cells from Ms Castillo, the patient, grown in a lab in Bristol. As Americans know only too well, this sort of cutting-edge medicine is very weakly related to the quality of everyday care, but the news should reassure anybody who thought Spanish doctors were backward provincials from whom nothing can be learnt.

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