Editorial

www.thelancet.com Vol 382 July 20, 2013 181

For the NHSBT strategy see www.nhsbt.nhs.uk/to2020/

For more on allocation of organs in Israel see Lancet 2010; 375: 1131–33

For Israeli 2011 data see Am J Transplant 2013; 13: 780–85

For more on German organ scandals see Lancet 2012; 380: 1135

For more on Germany see Lancet 2013; 381: 178

Ensuring fair allocation of organs Last week, the NHS Blood and Transplant organisation (NHSBT) published a new strategy on organ transplantation for the UK until 2020, with the support of UK health ministers. The aims of the strategy are to increase consent rates for organ donation, raise deceased donor rates, boost the number of organs transplanted from donors, and increase the number of patients receiving transplants. Launching the strategy during National Transplant Week, the Director of Organ Donation and Transplantation at NHSBT, Sally Johnson, called for debate on attitudes to organ donation: “Almost everyone would take an organ if they needed one—but only 57% of families agreed to donation when they were asked…is it fair to take if you won’t give?”

Specifi c actions are recommended in the strategy to improve knowledge of organ transplantation, ease registration for donation, and increase adherence to the donor’s wishes—in many cases, family members are unaware of the prospective donor’s wish to donate, or override that decision. Methods of providing support within hospitals are outlined to ensure that each donor can give as many organs as possible, and that surgeons have more options to preserve organs and that they adhere to evidence-based policies for organ allocation.

The most radical action proposed in the NHSBT strategy is to promote national debate on whether those on the Organ Donor Register should receive higher priority if they need to be placed on the transplant waiting list than those who have not registered to donate their organs. Such nationwide prioritisation is in place in Israel and Singapore.

The law in Israel came into force in 2010, and was born out of an acute organ shortage. In addition to organs prioritised for those with donor cards, transplant candidates can move up the priority list if they have a fi rst-degree relative who has signed a donor card, donated an organ after death, or is an eligible live non-directed donor. Preliminary data from 2011 showed that deceased and living organ donation had risen compared with previous years. Critics have pointed out that clinical need should be the only factor determining organ allocation, and also that this system unfairly favours those with large families.

The United Network for Organ Sharing prioritises living donors of organs to receive a transplant from a dead donor, should they need one. In the USA, an

organisation called LifeSharers facilitates donation between members—members commit to organ donation on their death, and other members are given priority to receive the organs.

In Wales, presumed consent for organ donation will come into force in 2015, after a 2 year public education programme to explain that people can register to donate, or opt out of donation. If they do neither, individuals will be presumed to have consented to donate their organs after death. The expectation is that the number of donors will substantially increase in Wales. Consultation on a similar opt-out system has also begun in Northern Ireland. Similar presumed consent systems are in place in Spain and Belgium.

In China, eff orts are being made to ensure fair allocation of organs by enforcing use of a computerised system for organ distribution—the China Organ Transplant Response System—which ranks patients by disease severity, waiting time, and location. The source of organs, though, is still a major concern, with many still being from executed prisoners. Traffi cking of organs, and payment for organs, are still major barriers to a fair system of transplantation in some countries.

Experts in organ transplantation met in Madrid on June 27–28 to share best practice in blood transfusion and transplantation in Europe, in an event partly sparked by recent scandals in Germany where there have been cases of falsifi cation of patients’ data on transplant waiting lists to shorten waiting list times or to misdirect organs.

There are many frameworks within which organ transplantation can operate, but at the heart of any system must be trust. Dying patients must be able to trust their families to respect their wishes to donate, and their doctors to provide the best end-of-life care possible. Patients in need of a transplant must be able to trust in an ethical and fair organ supply, and that their doctors will provide the highest standards of clinical care. Patients who receive transplants must adhere to often punishing immunosuppression regimens and treatment to maximise the life of their new organs.

Clinical need should be the main determinant of organ receipt. Whether clinical need should be the only factor is a matter for debate. Is it fair to take an organ if you won’t give? Let the UK, and broader international, debate begin. The Lancet

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