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Viscount Cranborne: My Lords, I am most grateful to the noble Lord for giving way. Does he agree also that it is important, in the case of referendums, for the electorate to see that those referendums are conducted fairly? Therefore does he also agree with me and his noble friend Lord Holme of Cheltenham that it would be sensible to encourage the Government to introduce, as soon as possible, a mechanism by which rules could be drawn up under which referendums in future could be held?

Lord Thomas of Gresford: My Lords, on that issue I have the greatest pleasure in agreeing with the noble Viscount, that rules for referendums, if they are to be held, should be drawn up and applied consistently whenever that issue arises. However, I disagree with the noble Viscount when he talks about monopoly politics, and that the result of co-operation between the parties is monopoly politics. That reminds me of what the Earl of Derby said in 1841:

That has always struck me as an empty mantra, and yet it is so often chanted at us on these Benches when we endeavour to reach a degree of agreement and co-operation with the government of the day.

The adversarial system may be all very well in the law. Everyone understands that lawyers are paid to put forward a particular point of view. No one would ever suggest that politicians should be paid to put forward any particular point of view. The price that is paid for that is that lawyers are not the most highly regarded people; they are not thought to be sincere. That is the price of adversarial politics, where one opposes merely for the sake of it.

I recall the noble Baroness, Lady Kennedy, once saying to me, as she likes the taste of battle and blood, that it was all very well to be a commercial lawyer, like the noble Lord, Lord Alexander of Weedon, and my noble friend Lord Goodhart, but that what we were doing was fun. I have always borne that in mind.

The noble Lord, Lord Harris of High Cross, listed the failures of consensus politics over a period of time. It seems to me that there was the greatest possible confrontation between rival conceptions of government in the 1960s and 1970s. I thought that the confrontation in those days was between socialism and capitalism; and that there were indeed two distinct strands of opinion. Yet those two strands produced what the noble Lord described as consensus politics, which he denigrated for that reason.

Consensus does not last forever. There are always minority views which eventually make their way into the mainstream. Thatcherism was not a concept in 1979; Thatcherism was a minority view which became a majority view in the early 1980s. In the later 1980s it reached its full flow. There are other minority views. I recall my adoption speech in West Flint in 1964.

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There were four key issues: the first, devolution for Wales; the second, proportional representation; the third, closer ties with Europe by joining the Common Market; and the fourth, I regret to say, was reform of the House of Lords.

Those issues in those days represented minority views, but one has seen, over the decades that have passed since then, that those minority views have grown to a consensus, and are now becoming the type of consensus of which the noble Lord, Lord Harris, does not approve. It is events which cause minority views to come forward in that way.

When we have a situation where we on these Benches have put forward issues, values and principles over many years, and we find suddenly that the Labour Party has been moving towards our point of view, that it is adopting devolution, proportional representation and talking about reform of the House of Lords, what are we to do? Are we just to oppose for the sake of opposing, or are we to co-operate to try to improve the detail of the plans it is putting forward? That is what co-operation is and should be about.

I am most grateful to my noble friend Lord Jenkins of Hillhead for introducing this debate. I pay my own small tribute as a foot soldier in his army over the past 12 months or so to the magnificent leadership that he has given us. May I speak for the wider Liberal Democrat Party and say that in his position as our leader he will be greatly missed.

6.28 p.m.

Lord Jenkins of Hillhead: My Lords, I shall make just a brief response. I have never much believed in second bites, certainly not large second bites, of the cherry in these debates. I should like to begin by repairing an omission in my opening speech which is to follow the tribute which the noble Lord the Lord Privy Seal and the noble Viscount, Lord Cranborne, paid to the late Lady Llewelyn-Davies. I should not like that to be an omission, because it so happens that I probably knew her long before either of them did. I first put my foot on the humblest rung of the ministerial ladder when I became parliamentary private secretary to Philip Noel-Baker who was Secretary of State for Commonwealth Relations and she was then his trusted and invaluable personal assistant. If noble Lords rightly thought that she was dazzling when she was Captain of the Gentlemen at Arms I can assure you that she was even more dazzling in the Commonwealth Relations Office in 1949. She will be greatly missed.

I wish to congratulate the four maiden speakers. I begin with the noble Lord, Lord Blackwell. We must look forward to hearing him again, particularly when he is freed from the restraints of being non-controversial, under which he was obviously labouring heavily during his speech today. It was a notable speech. The noble Baroness, Lady Kennedy, added a phrase to our parliamentary language. "Kennedy's kiss" will become like "Angela's ashes", that cult novel of the present time. It was a great comfort to me on my departure to

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hear the successful speeches made by my noble friends Lord Goodhart and Lord Razzall. They are an asset to our Benches.

Clearly, I am in danger of making a speech like the grandfather of a familiar Member of this House, whom I will not identify. It was said that his speeches were remembered only for the compliments which he paid in particular to his opponents. I thank all noble Lords-- I said no obsequies but I did not say no tributes! I assure your Lordships that they have saved time because there need be no tributes when I leave.

The noble Viscount, Lord Cranborne, courteously informed me that he would be a little late. I am not sure when he slipped in, but he obviously thought that he would arrive later. I am reminded of an incident relating to his forebears--in this case a lateral one--who paid what I have always regarded as the best feline compliment I have ever heard. He chaired a meeting of a singularly dull lecture. He complimented the lecturer saying that, unfortunately, due to increasing deafness--which did not apply in his case--he had missed certain parts of the lecture which, clearly, were more significant.

The noble Viscount was obviously afraid that he would miss the more significant parts of my speech as a result of lateness, so he wisely provided himself with the alternative of replying to a speech given by Mr. Simon Hughes in another place. I hope that that was very satisfactory for Mr. Simon Hughes. However, he redeemed the situation by the warmth of his tribute-- I also thank the noble Lord the Lord Privy Seal for his tribute--and I reciprocate his remarks about the pleasure of working together and the assurance that I hope that our personal relations will continue on this basis. I beg leave to withdraw the Motion for Papers.

Motion for Papers, by leave, withdrawn.

Organ Donation

6.33 p.m.

Lord Norrie rose to ask Her Majesty's Government what plans they have to improve the care of patients awaiting an organ transplant and what steps they are taking to encourage an increase in organ donation.

The noble Lord said: My Lords, in tabling this Question, my intention is to debate an emotive issue that is of great importance to thousands of patients awaiting transplants, be they cornea, kidney, heart, lung or liver. First, I wish to hear from the Minister what steps the Government are taking to improve the care which there patients receive. Secondly, I wish to hear what steps the Government are taking to increase the rate of organ transplantation.

I have deliberately cast the net widely so that issues relating to the broader transplant community can be raised. While I intend to set out some of the concerns relevant to all branches of transplant medicine, I shall refer in particular to renal services and will identify areas where I believe progress is necessary. Tonight I speak not only as president of the National Kidney Federation, the only organisation run by kidney patients

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for kidney patients, but also as the parent of a son who has kidney failure. Happily, after four and a half years of dialysis, my son has had a successful transplant.

I am conscious of the pressures on kidney patients and their immediate family. I am also knowledgeable about another important aspect; that is, when the next of kin of a potential donor is faced not only with bereavement but with a decision on whether the organs of the deceased can be used for transplantation.

I wish this to be a purely constructive debate which will produce for the Minister a range of ideas that her department can investigate and can report back in detail. I look forward to hearing the maiden speech of the noble Lord, Lord Hughes of Woodside, whose experience in medical matters I am sure will be a positive asset to this House. I am grateful to the Minister who, during the summer months, gave me time to put across some of my ideas and I thank her for her encouragement in tabling the Question tonight.

At the outset, it might be helpful to identify the large number of patients awaiting a transplant. I wish to acknowledge the help of the UK Transplant Support Service Authority in compiling the figures. Substantially more transplant operations are carried out today than 10 years ago and I pay tribute to the NHS and its staff for that. However, I must express concern that the number of kidney transplants plateaued in 1990 and would now seem to be in decline. I shall deal later with some possible causes for that decline and propose some solutions.

Currently, more than 5,500 people are awaiting a kidney transplant, which is an increase of 5 per cent. on this time last year; 677 people are awaiting a heart or lung transplant, an increase of 9 per cent.; and about 200 people are awaiting a liver transplant, a 6 per cent. increase on last year. In 1996, the total number of kidney transplants was 1,600, which was down by more than 8 per cent. on the previous year. The number of heart transplants totalled 290 and there were 651 liver transplants.

Currently, patients are waiting on average well over two years for a kidney and the number of patients on the waiting list is growing. Patients on dialysis have a poorer quality of life than those who receive a transplant and the cost of renal services to the NHS is increasing because dialysis is more expensive than transplantation. The problem boils down to a shortage of donor organs. There is no one solution to the problem, but I wish to set out some areas where progress may be possible.

The first and most obvious step is to encourage more members of the public to carry organ donor cards. That scheme is backed by the Organ Donor Register, a centrally held list of those willing to donate their organs in the event of their death. I am heartened to see that the register has recently topped 4 million members. I trust that the Government will continue actively to promote the organ donor scheme and encourage the public to make that most precious of donations, the gift of life. Will the Minister tonight pledge to increase the number of people carrying a donor card to 5 million by the end of the century?

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Currently in the UK we opt in to organ donation by carrying a donor card. In other countries, such as Austria and Sweden, consent is presumed. In those countries, an individual who does not wish to donate his or her organs must opt out. A register is set up to record that preference. The BMA does not support a donor scheme where people would have to opt out of the system. I have received representations in favour of a change in our system and I am sure that that is an issue which will continue to arouse lively debate.

I wish to refer to my noble friend the late Lord Finsberg. Lord Finsberg identified the fact that as the law stands the next of kin may overturn the wishes of a deceased relative to donate his or her organs, even when the deceased carries an organ donor card. Lord Finsberg introduced a Bill to back the wishes of the would-be donor in law. Following, I suspect, considerable arm twisting by the Department of Health, that measure did not become law and it was withdrawn. I believe that the measure would command public support and I urge the Government to take a lead in the debate, perhaps through the publication of a draft Bill for consultation.

I should now like to commend to this House the work of the Manningford Trust, a charitable organisation which exists to advance organ transplantation. The trust makes a number of important recommendations in a report published last month on organ transplantation, including the establishment of a national transplant commission. The commission would work to break down barriers to organ donation and consider whether there are lessons we can learn from approaches adopted in other countries.

A national transplant organisation has already been established in Spain resulting in a doubling in the number of organ donors between 1989 and 1995. The Spanish transplant organisation also oversees the recruitment of trained transplant co-ordinators in every hospital and the training of medical staff in counselling for relatives. Those measures have improved the availability of organs and therefore the number of transplant operations conducted.

The waiting list for a kidney transplant went down by almost 20 per cent. in Spain in the five years to 1995 and Spain has the highest rate of liver transplants in the world. That is impressive progress and is a credit to the Spanish transplant organisation. I accept that there is a higher rate of road accidents in Spain which affects the availability of suitable organs. In this country we have been extremely successful in cutting the number of road deaths through seat belt and crash helmet legislation and, indeed, drink-drive campaigns. However, I recommend the Spanish system to the Government. Would the Minister consider arranging a fact-finding mission to identify what we can learn from the progress that has been made there to increase organ donation?

The National Kidney Federation recommends that a thorough examination of elective ventilation should take place in the UK. Elective ventilation is the process whereby, with the consent of relatives, selected patients considered suitable for organ donation are kept breathing temporarily by artificial means when natural

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breathing ceases. In that way, the organs are preserved in a state fit for transplantation following certification of death. That has proved to be an effective means of increasing the number of organs available for transplant in hospitals where it has been practised.

In the Exeter kidney unit at the Royal Devon and Exeter Hospital, notable increases in the number of organs for transplant were achieved through the application of elective ventilation. Indeed, Exeter managed to keep the number of patients on dialysis stable for four years at a time when numbers were increasing everywhere else in the country. It was able to carry out more kidney transplants because it achieved the highest rate of organ donation in the UK through that system of elective ventilation. I regret that on the advice of the Department of Health, that procedure has been discontinued and the transplant rate in Exeter has fallen dramatically.

There are a number of ethical concerns associated with elective ventilation. Exeter worked to a protocol endorsed by the Royal College of Physicians, the Royal College of Nursing, the British Transplantation Society and the BMA. The BMA Ethics Committee addressed the subject and is satisfied that the procedure is acceptable, subject to the enforcement of strict protocols. The National Kidney Federation is also in favour of the procedure. With that in mind, will the Minister not agree that constructive progress is possible? With the co-operation of the Department of Health and the resolution of moral and legal arguments, there are considerable savings to be made through elective ventilation due to the difference in cost between dialysis and transplantation; and more patients will receive a transplant, which of course is the best quality treatment for kidney failure.

Therefore, I urge the Government to be brave and stand up to their official advisers and take a lead in bringing together interested parties to seek a consensus. The medical profession, those concerned with ethics and the law, and the public must be encouraged to participate in that debate. Ministers may be surprised at the public's enthusiasm for organ donation.

I turn now to xenotransplantation. There has been much speculation in this House and elsewhere about the use of animal organs in transplantation. Having persuaded your Lordships, I hope, of the shortage of organs for transplants, this would seem to offer a panacea. However, there are many issues that we need to tackle before transplantation of animal organs into humans becomes a reality. This is at the cutting edge of health technology and there are naturally concerns such as the risk of cross-infection and the moral arguments about using animals in this way. I consider it important that we should move forward with all speed to tackle the ethical and regulatory issues surrounding xenotransplantation, and I know that the noble Baroness, Lady Wharton, intends to refer to these issues in more detail.

It is of paramount importance that the science should develop within a framework that satisfies the concerns of the public with regard to the use of this new technology. But, equally, it would be regrettable were

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progress towards the use of animal organs in human transplantation to be held back by the failure of politicians to agree an appropriate framework. Can the Minister give us any information about the establishment of a statutory body for the regulation of xenotransplantation as proposed in the Kennedy Report? In my view, xenotransplantation is a very exciting development and I wish the scientists well in their research. However, this technology may still be some way over the horizon. That is not an excuse for inaction in addressing the issue of organ shortages now.

I now turn to the care of patients with renal failure. There are an estimated 23,115 patients being treated for kidney failure in England alone. With long waiting lists for a kidney transplant and a shortage of organs for transplant, it is important that patients receive top quality care. There has been progress in that direction, but I want to draw attention to some national and international comparisons to highlight where I believe further progress is required.

An organisation known as the European Dialysis and Transplant Association has been set up to collect information about patients accepted for dialysis. That is one indicator of how effectively countries are providing for patients with kidney failure. Their data shows that the United Kingdom is 21st in the list of countries ranked according to the number of new patients per million of the population per year accepted for dialysis. We come just ahead of Bulgaria and lag behind a majority of our European partners. Greece, Belgium, Italy and the Czech Republic all accept more new patients for dialysis each year than we do.

I shall put some figures to this analysis. The Renal Association has recommended that a minimum of 80 new patients per million of the population will require dialysis each year. This is a conservative estimate as it does not take account of variations in ethnic mix, to which I shall refer shortly.

The take-on rate of new patients in Greece is 118 patients per million of the population; in Belgium it is 103; in Italy it is 91. These figures refer to 1993, the latest year for which international comparisons are available. At that time the UK total was 60 patients per million.

I sought to shame the previous government into action and I am pleased to report that there has been some progress. A recent Renal Association report estimates the figure in 1995 to be 82 patients per million in England and Wales. This still leaves us some way behind the Czech Republic, with a rate of 92 patients per million of the population.

I shall continue to harry the new Government because the figures as they stand are, still, unacceptably low. There is no such thing as a waiting list for renal replacement therapy--if people with kidney failure do not receive dialysis, they die.

I should now like to focus on what is going on in different parts of the United Kingdom. We see that, just as on a European level, large variations in the take-on rate of new patients exist in different parts of the UK.

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At the laudable end of the scale, the take-on rate of new patients per million per year in Wales is 108. In Merseyside it is fewer than 40. Of course, a majority of regions lie somewhere in the middle. But as the example I have just given shows, there are stark contrasts between regions which lie in close proximity. A patient's access to renal services varies substantially with his postcode. That is fundamentally unfair and unacceptable. I believe that it has been referred to in a different context as the lottery of NHS care.

I should just like to refer to the experience of patients in Lancashire. I have in my possession a letter to Mr. Austin Donohoe, the chairman of the National Kidney Federation, from a consultant nephrologist in Preston. I am pleased to say that in this part of the country there is a very constructive relationship between the department of renal medicine and kidney patients. The unit covers a large population of some 1.6 million people. Of the four purchasers of renal services in the area, it is not really putting in sufficient funds to pay for a take-on rate of 43 patients per million of the population. Let us remember that the Renal Association recommended a minimum take-on rate of 80 patients per million. According to the Preston consultant there is,

    "a lack of commitment from the Purchasers to invest sufficient additional funding into renal medicine ... adequate money is not forthcoming to increase access rates".

The publication today by the Audit Commission of a report recommending improvements in the way in which specialised services ought to be commissioned is a timely contribution to our debate. I know that the Government are committed to tackling these inequalities and I look forward to very early progress.

As I have run over my time, I move on now to my conclusions. I consider that health authorities have a critical responsibility for commissioning high quality renal services. I have already mentioned the Audit Commission's contribution to the debate. I should also point out that Parliament is currently updating the purchasing guidelines for renal services. I hope that they will be promoted by the Minister when they are published.

I should like to come to some conclusions about how we might increase the availability of organs for donation. First, I would strongly urge swift and positive action by the Government to seek a consensus on elective ventilation. Secondly, I would ask the Government to lead the debate on xenotransplantation. The public has yet to form a view on these matters--the Government should be active in this and not leave it to the more sensational branches of the media to shape public opinion. And, finally, I have asked the Government to investigate the Spanish system to see whether we can apply any of their protocols in this country.

6.52 p.m.

Lord Hughes of Woodside: My Lords, I welcome this opportunity to take part in such a debate. I did not expect the transition from the other end of the building to this part to be easy. The transition is far from complete, and, indeed, I have much to learn. However, the generous welcome that I have received from noble

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Lords of all parties and of none and the courtesy and helpfulness of the staff have certainly meant that the transition has been painless so far. I am grateful for that. I should like to congratulate the noble Lord, Lord Norrie, on introducing this debate on the vital subject of those awaiting transplants and the need for more organs to be available. As President of the National Kidney Federation, the noble Lord brings a wealth and depth of knowledge to the debate with which I fear I cannot compete.

I believe the facts are reasonably well known. Currently waiting lists, especially for kidney transplants--the most usual surgery--are increasing. In 1994, 4,851 people were on waiting lists; the current figure is over 5,500. At present, some 30 children under the age of 10 are awaiting kidney transplantation. There are 147 between 10 and 20 years old. If one takes the middle age, if you like, from 30 to 50 years of age, there are 2,400 people waiting. Indeed, there are even four people aged 80 and over waiting for transplants.

The numbers of those waiting for heart, lung and liver transplants, although they are much smaller, are also increasing. It is only in the case of heart-lung transplants that there is some stabilisation and perhaps a smaller reduction in the waiting list. The reason is the immense shortage of donor organs. There are two things which bring that about. First, there is the increase in medical technology which keeps people alive longer; and, secondly there is, ironically, the growth of legislation as regards wearing seat belts and the increased attention by car manufacturers to safety, both of which have brought about a decrease in the number of deaths. Of course, we applaud that immense saving of life. Nevertheless, it is a little like the old engineering principle that,

    "for every action there is an equal and opposite reaction".

What are we to do? I have to say that I reject immediately the proposition that xenotransplants--that is, animal to human transplants--are a solution, although there is much experimentation going on in that respect. The committee under Professor Kennedy of King's College into the ethical and scientific issues approved the procedure on ethical grounds but was unsure about proceeding given current scientific knowledge. There are problems about the transfer of viruses, and so on. Therefore, future generations may well take a different view, but at this moment I believe that it is a bridge too far to cross.

So the question remains: what can we do? The most obvious answer would seem to be to increase the amount of advertising so that more people carry a donor card. That certainly would be worth doing, but it will not solve the problem by itself. I recently learned, much to my astonishment, that the carrying of a donor card does not automatically mean that organs can be used. In any event, as far as I am concerned, I do carry a donor card, but I suspect that the only service which my organs could provide would be as a demonstration to medical students of what happens if you do not follow medical advice about living a healthy lifestyle.

However, the terms of the Human Tissue Act 1961 require that it has to be established that the deceased has not changed his or her mind since signing the card.

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In the case of sudden death, or even an expected death, the next of kin and relatives are undoubtedly traumatised. It is perhaps understandable that relatives are often reluctant to give consent. Figures vary as to how large that consent is. In the case of intensive care patients, the figure varies according to one survey or another between 25 and 50 per cent. That is even more so when the deceased has not exercised the right to carry a donor card.

It must be dreadful to be told one minute that your son, daughter, husband, wife, partner or whomsoever has been killed in an accident and then, moments later, be asked whether you will make the organs available. The wonder perhaps is not that so few people refuse but that so many actually give their consent. Our system is, of course, a "contracting in" system; in other words, you have to carry a card. In the early 1970s, my colleague Tam Dalyell and I canvassed the idea that we should have a contracting out donor card. The outrage at this hugely contentious issue was such that we dropped the idea fairly quickly. Fortunately, the idea has not gone away.

I would certainly wish to join the noble Lord, Lord Norrie, in paying tribute to the late Lord Finsberg, who, I understand, successfully piloted a Private Member's Bill through this House in 1995, only for it to fall in the other place. I should also like to add a tribute to John Marshall, the former Member of Parliament for Hendon South, who attempted an identical Private Member's Bill in February of this year which, unfortunately, failed due to lack of time. The issue remains contentious, but I believe that recent comment in press reports and elsewhere suggests that the time may be right to move towards this solution.

The trauma of waiting for a transplant--the trauma for the relatives--is immense but there are other issues which we should bear in mind. In addition, there is the anguish of patients and their relatives who are told that a transplant is not an option. The issues that arise there can be very delicate. Of course, such decisions must be taken on purely medical grounds. Some have suggested that lifestyle should be taken into account in bringing about a prognosis on whether someone will survive if given a transplant. Members of the medical profession have immense duties placed upon them as regards who shall and who shall not have a transplant. In fact, it is who shall live and who shall die.

Being on a waiting list in itself is not a guarantee of a transplant. The number of transplants of kidneys, for example, in 1996 in the UK as a whole was only 1,700, made up of 1,416 in England, 136 in Scotland, 90 in Wales and 58 in Northern Ireland. When one thinks of a waiting list of over 5,500 one realises the difficulty that we are in.

There are issues of lifestyle. I once had a constituent whose daughter had an adverse reaction to an Ecstasy tablet and she was not offered a transplant. The parents believe to this day that a judgment was made that she should not have a transplant on ethical grounds rather than on medical/ethical grounds. A public inquiry revealed that that was not the case. However, there are

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clearly fine lines of distinction on these issues. I certainly do not wish to proceed down that particular contentious road this evening.

In conclusion, there are three things that we can do. First, we could certainly have a significant advertising campaign to increase the carrying of donor cards. Secondly, we must clarify the Human Tissue Act of 1961 to allow the automatic use of organs of those who carry a donor card without further reference to relatives. Thirdly, I believe the Government must have the widest possible consultation with a view to moving speedily to a contracting out system of donor cards as soon as possible. We have debated this evening--sadly, shortly--one of the most vital things that we have to give to people: the possibility of prolonged life. I hope this debate will bring some clarity to the issue. I thank your Lordships for your courtesy in listening to my remarks.

7.1 p.m.

Earl Howe: My Lords, it is my pleasure to congratulate the noble Lord, Lord Hughes of Woodside, on his excellent, well informed and well argued maiden speech. The noble Lord comes to your Lordships' House with a wealth of experience in the other place as a former Minister and Front Bench spokesman for his party and with the reputation of one who has acquired in his long political career a depth of knowledge on Scottish affairs, transport and agriculture, to name but a handful of his political interests, which few can match. It is our privilege to have heard him speak this evening on yet another of his areas of expertise, that of health. I am sure all of your Lordships will have found what the noble Lord said both wise and persuasive, as well as elegantly put, and will, like me, look forward to many contributions from him in our debates in the future.

I join other noble Lords in thanking my noble friend Lord Norrie for introducing this important topic. I congratulate him on the clear way he did so. It seems to me that he highlighted the key issues which bear upon his Question. I should like to explore some of them further and elaborate somewhat on his conclusions. My noble friend, not unnaturally, focused particularly on kidney patients. As many kidney transplants are performed in the UK as of all other solid organ transplants combined, and while demand outstrips supply for all transplantable organs, and the need for more donors is self-evidently acute across the board, it is the lack of kidney donors which affects the greatest number of patients in clinical need. At the most recent count the active national transplant waiting list for kidneys--as my noble friend mentioned--stood at some 5,500 people, compared to the number of kidney transplants performed in a year of some 1,600 to 1,700. That gap between demand and supply has been growing steadily for at least 10 years due in part to the progressive decline in the number of deaths from road accidents and, it must be added, the scarce supply of intensive care beds in hospitals.

Unlike the patient awaiting a liver or a heart transplant, the kidney patient has an alternative treatment available; namely, dialysis. But dialysis, although life-saving, is, as my noble friend pointed out,

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a second best option. It does not enable the patient to lead a normal life and it involves considerable physical discomfort. Compared to a transplant it is also much more expensive. A patient on dialysis costs the NHS approximately £20,000 to £25,000 a year. By contrast, a transplant operation costs around £20,000, followed by recurring annual costs of between £1,000 and £3,000.

Therefore, from the taxpayer's perspective, as well as that of the patient, a renal transplant is infinitely the preferred form of treatment for kidney failure. Yet, as we heard from my noble friend, the UK lags behind many of our European Union partners in the percentage of kidney patients who receive a transplant. How might it be possible to increase the number of kidneys available for donation? Raising public awareness of the issues is, I think, essential, and should be a continuous process, but it is not enough. The sad fact is that over the years such efforts have simply failed to make an impact. Public attitude surveys show that about 25 per cent. of the population is actively opposed to organ donation compared, for example, to 5 to 10 per cent. of people in Belgium. Persuading even a quarter of that 25 per cent. would make a huge difference to the available supply of organs.

In parallel with this come the options for legislative change. It does not perhaps need pointing out that any debate to modify the law is necessarily suffused and overlaid with questions of medical ethics. At the moment in the UK, doctors are required to obtain the confirmation of the next of kin that they have no objection to the removal of an organ and that they do not believe the donor would have objected. Frequently, this procedure leads to consent being withheld or, if not withheld, being obtained too late for an organ to be used in a transplant.

Are these requirements too strict? I shall not dwell too long on the arguments for introducing a system of presumed consent for organ donation or "opting out", as it is known. Such a system would cause grave ethical difficulties for the medical profession. But even setting those aside for one moment it seems to me highly doubtful, for a variety of reasons, that it would gain public approval, not least because people would feel that improper pressure was being put on them. A system of opting out has been adopted in both Belgium and Austria, and donor rates are higher in those countries than they are here. But it is far from clear whether one is the cause of the other. Of much more significance, some argue, is the clear difference to be found in those countries in public attitudes towards organ donation.

A more fruitful area for discussion, as my noble friend indicated, is elective ventilation. To permit a protocol of ventilatory support for patients who stop breathing after an untreatable stroke, solely to allow that patient, when brain dead, to become a donor is an idea which many surgeons see as ethically acceptable. For most, if not all, those surgeons, the procedure could take place only if all concerned, including the patient's relatives, had given their informed consent. But there are other practitioners who entertain the most profound doubts about the ethical acceptability of a procedure which does not respect the patient's own autonomy, which carries a risk of that patient being placed into a

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persistent vegetative state, and which is inherently distasteful and undignified in that it manipulates the manner of a patient's death.

Elective ventilation also falls foul of legal difficulties. Here again, the issue of consent is central. Unless the patient himself has previously given specific, unambiguous consent to artificial ventilation for organ donation, that ventilation may not be permitted. No consent from any other source will do. The patient is alive; if a doctor is to administer treatment without consent, that treatment must be for the patient's direct benefit. Anything that falls outside this definition could constitute common law assault. These are the reasons which led the Department of Health to suspend the procedure some time ago.

In fact the difficulties do not stop there. I believe there are important practical issues relating to the capacity of intensive care units to devote resources to a type of treatment which is unrelated to a patient's recovery. However, I shall be interested to hear from the Minister whether she thinks that the legal difficulties are capable of satisfactory resolution. Does she think that the answer simply lies in a system of more detailed and informed consent by prospective donors? Or would she seek to go further and look for ways of permitting elective ventilation without such consent provided that certain conditions were met?

I wonder, too, whether the Minister could comment on another type of procedure where the law is at present unclear, at least to me. This relates to a technique for preserving in situ the kidneys of potential donors who are dead. As the noble Baroness will know, kidneys which have been taken from a patient who has suffered respiratory and cardiac arrest can be transplanted successfully provided they are removed within 60 minutes of the heart stopping. In those circumstances, the best way of protecting the kidneys prior to removal is to cool them by inserting a catheter. This procedure is of greatest use in cases of sudden or unexpected death where the next of kin are not on hand to give consent to the immediate removal of an organ: it buys time. The issue it raises, however, is the legality and ethical propriety of carrying out a procedure on a dead body without permission.

The technique I have described is one which has been adopted successfully in Leicester with, I understand, the approval of the local coroner and with no objections raised elsewhere. If taken up nationwide, it has the potential to increase the supply of organs for donation by a very substantial percentage. Can the Minister add her own perspective to this issue? Can she say whether health authorities might be encouraged by the Government to promote kidney cooling in non-heart-beating donors as part of a wider campaign to raise public awareness?

On a similarly practical level, I mention the role of transplant co-ordinators. This specialist discipline has grown up on a somewhat ad hoc basis over the past 15 to 20 years but is a key component in a hospital's ability to arrange organ transplants successfully. It is felt by many people that there should be a proper managerial structure for supervising and training transplant

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co-ordinators and that this could usefully take the form of a national umbrella body to promote consistency across the country. Can the Minister say how far the Department of Health has progressed in its examination of this issue?

I wish for a moment to revert to the issue of dialysis facilities. For all this country's expertise in the care of patients with renal failure, we lag behind many of our European neighbours in the number of renal units and the number of new patients starting dialysis each year. The sobering conclusion from that is that some individuals needing treatment are not receiving it, or are not receiving it soon enough.

The need for dialysis can vary considerably by region. For example, I understand that renal failure is more common among the Asian community than in other ethnic groups, necessitating greater provision of renal facilities in Asian centres of population. More generally, many patients have to travel a long way in order to attend a renal unit. Indeed, I should like to share with the House some advice well known among patients with kidney failure in the West Country. Do not live in Wiltshire! The health authority there has turned down overtures from patients in the area to fund a renal unit in Swindon. As it is, patients are required to travel to Portsmouth, Oxford or Bristol for their dialysis. Has the Minister any news about the PFI hospital project proposed for Swindon and can she provide any reassurance to kidney patients there that when the hospital is built there will be a dialysis unit in it?

On a separate but related point, will the Minister undertake to look at Wiltshire health authority's purchasing policy for renal services? Concern has been expressed to me that renal care is effectively being rationed in Wiltshire on cost grounds and that elderly patients in particular are being denied the care they need.

As my noble friend mentioned, the publication today of the Audit Commission report, Higher Purchase: Commissioning Specialised Services in the NHS is timely in this context because it identifies a number of ways in which health authorities could improve the manner in which specialised services including renal care are commissioned. I look forward to the Government's response to that report in due course.

The issues raised by my noble friend are of fundamental importance for many thousands of men and women. I hope that the Government will take on board the very real concerns that have been expressed and will confirm their determination to see more resources devoted to this key area of patient care. I look forward very much to hearing what the Minister has to say.

7.15 p.m.

Baroness Wharton: My Lords, I am grateful to the noble Lord, Lord Norrie, for raising this issue tonight. My noble friend Lord Soulsby of Swaffham Prior would have taken part in the debate tonight were it not for the fact that he is on business of the House in Atlanta.

We have spoken many times about the ethical, moral and animal welfare issues involved in xenotransplantation. As an honorary associate of the

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British Veterinary Association, I should like to put forward a view which covers the veterinary aspects as well as the animal welfare of the pig donors.

The first animal-to-human transplant was in 1906 when a French surgeon implanted a pig's kidney into one woman and a goat's liver into another. Needless to say, neither survived. But here we are, 91 years later and on the threshold of a break-through some few years hence. Previous speakers have already mentioned the acute shortage of donor organs and the waiting lists. Therefore I shall not go into that.

The long-term possibility of producing human organs or tissues in vitro, coupled with significant advances in mechanical devices, may eventually provide sources of replacement organs. The immediate need could be solved by the science of xenotransplantation, although some may not agree. The pig is the ideal animal for such work, having a relatively short gestation period (approximately 112 days) and producing an average of eight offspring per litter.

Progress to date in xenotransplantation has been to modify by 0.0001 per cent. the genetic make-up of the pig with human genetic material, so that when it is transplanted into humans it is not immediately rejected. In other words, the pigs are genetically engineered to carry human proteins on the surface of their cells. This will allow pig organs to be used as a temporary bridge for patients awaiting a human organ or, as has happened in the USA in the case of human liver failure, to use pig livers kept alive in a sterile container and perfuse them with the patient's blood, rather like kidney dialysis.

The ethical aspects of xenotransplantation have exercised the collective minds of several committees. The Nuffield Council on Bioethics concluded that the routine supply of pig organs was ethically acceptable and the report also identified the possible transmission of infectious disease as an important consideration. The Kennedy Advisory Committee set up by the Department of Health last year came to similar conclusions and recommended the establishment of the UK xenotransplantation interim regulatory authority to oversee developments in this field.

The British Veterinary Association's ethics committee has recently considered the issue of transplantation between species. The committee considers that it is not unethical to use, to modify genetically and to breed pigs so that their organs may be used in transplants into humans. Xenotransplantation is seen by the committee as an effective means of countering the current organ shortfall, since present and future needs for organs seem unlikely to be met by other means. However, and I stress this, the use of primate organs for transplantation into humans is considered unethical and totally unacceptable. The BVA also considers that the welfare of animals bred for transplantation should be carefully safeguarded and commercial pressures should not be allowed to jeopardise animal welfare standards.

Provided that the very real benefits in terms of the relief of human suffering can be achieved without causing unnecessary suffering to or adversely affect the

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welfare of the pigs concerned, the committee does not object to the practice of xenotransplantation on ethical grounds.

Perhaps the most worrying aspect of xeno- transplantation is the presence of viruses, particularly retroviruses, in donor pig organs which are capable of infecting human cell lines. Although it is not known whether such viruses can become established and cause disease in the recipient, the fact that recipients are immuno-suppressed adds a measure of caution. It may be possible to breed pigs free of retroviruses, though that is considered extremely difficult. An alternative would be to try to genetically engineer pigs so that they lack the ability to harbour retroviruses.

It is right that great caution is necessary in the introduction of that technology to human medicine and it is important that animal-to-human transplants are offered to patients only when there is a good chance that they will work. Obviously the patients themselves will have to be fully informed so that they can make an informed decision before accepting an organ from a non-human donor. I am sure that many committed animal welfarists might find this technology both ethically and morally unacceptable; but we must remember that pigs are already farmed for meat.

The welfare of these animals is paramount. The genetically engineered piglets will be born into a controlled environment. At that stage the unmodified sow will be lost; but it is to be hoped that in the future, when the herd has been built up, the by now genetically altered sow will be able to survive to suckle her young. They will be able to do all the things that pigs normally do and their quality of life will be carefully monitored. The RSPCA is concerned that animals might be reared in a sterile and barren environment; and the society's concerns also relate specifically to the consequences of xenotransplantation for animals.

I have talked to the noble Lord, Lord Soulsby, about this problem. He has observed the piglets and assures me that they are happy and well cared for. The RSPCA would also want to ensure that the five freedoms recommended for farm animals by the Farm Animal Welfare Council would be applied as a minimum basis for animal husbandry standards. They are freedom from fear and stress; freedom from pain and injury; freedom from hunger, thirst and disease; freedom from discomfort; and, finally, freedom to express normal behaviour.

The RSPCA's position as a charity would in any case not allow the society to oppose a use of animals that is considered by majority view to be of human benefit, but would ask that every attempt be made to find alternative solutions to the shortage of human organs before resorting further to taking the lives of our fellow creatures. Finally, we must also be sure that pigs do not suffer during organ removal.

7.23 p.m.

Baroness Sharples: My Lords, I thank my noble friend Lord Norrie for initiating this debate. Noble Lords may recall a long time ago a determined campaign by Elizabeth Ward on kidney transplants,

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because her young son, Timothy, had to endure years of dialysis. As a result of knowing the Wards over many years, I decided to change my will in order to donate my organs. My family are all aware of my wishes. I can understand that many people will not see things in the same way. However, I hope that this evening's debate will persuade some noble Lords seriously to consider doing as I have done. I have been told that I am too old for anyone to benefit from my decision! However, there are many young Members in this House who no doubt could, and should, follow my example.

7.25 p.m.

Baroness Robson of Kiddington: My Lords, I, too, thank the noble Lord, Lord Norrie, for introducing the debate. I congratulate the noble Lord, Lord Hughes of Woodside, on his maiden speech. Being the final speaker before the Minister, I have listened to all the speeches. They have been very well-informed and I agree with most of the arguments advanced. I wish to concentrate purely on kidney transplants. I do not intend to talk about the transplantation of other organs.

It is a tragedy that there is such a shortage of donor kidneys. I wonder whether there is a thought in the back of people's minds that the matter is not all that urgent because, after all, people can live on dialysis. That might to some extent account for the lack of people coming forward.

There are, after all, nearly 4 million people carrying donor cards, who are listed on the NHS donor register. That is 7.6 per cent. of the population. It is quite a large number of people. But despite that large number, there have been only 15 donors per million of the population. The number has been more or less constant for the past seven to eight years. So there is something wrong in the way we approach this subject.

As the noble Lord, Lord Norrie, mentioned, the donor rate in Spain is much higher; it is 26.8 per cent. In this country approximately 1,700 kidney transplants take place per annum, of which 10 per cent. of the organs donated come from members of the family. That is a tremendous sacrifice for a family member, but something to which I believe the family member quite happily agrees. In other countries, such as Norway, 40 per cent. of donations are from the family. Noble Lords will realise that when a kidney comes from a member of the same family, the danger of rejection is very much smaller.

Every speaker has mentioned the Human Tissue Act 1961, which created the "contracting in" system. It required written consent by the person who wanted to contract in. However, when, 10 years later, we introduced the donor card, we failed to clarify and resolve whether the card constituted an authorised form of consent. I should have thought that that would be so. I should not personally carry a donor card unless I meant it to apply if anything happened to me. But that has not always been the case.

The problem has been made more difficult because the law has allowed relatives to countermand the wishes indicated by the would be donor. That is rather like allowing relatives to reverse a dead man's will in any

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other form. We must respect the wishes of the donor. It is high time that the Government clarified the position of the donor and, I hope, make it the final arbiter in any decision as to whether an organ can be transplanted.

Those difficulties, as mentioned by the noble Lord, Lord Norrie, have given rise to some surgeons advocating the introduction of a contracting out system to improve the supply of organs. I would not be prepared to go that far. However, I should like to see a strengthening of the law so that where a person has indicated his wish to become a donor his wish may be carried out without interference.

Apart from the shortage of donors, we have the problem which was mentioned by most speakers of the care of people awaiting transplants in the National Health Service. The waiting list was quoted by some speakers. The number of people living on dialysis is highest in the age groups 30, 40 and 50. Only one in three of the people on the waiting list will receive a transplant in any one year.

According to the medical opinion which I have obtained, it is claimed that there is now no shortage of machines, but there is a great and growing shortage of staff, both nurses and technicians. Therefore, it is important that we ensure that the existing centres are fully staffed so that we can make the maximum use of the machinery we have at our disposal. The cost of dialysis was also mentioned. It is very great, much greater than the long-term cost of a transplant operation.

However, quite apart from whether it costs a lot of money, we must achieve a higher output of organ transplants because not only is there the hardship for the patient of having to attend a hospital, sometimes every day or for long periods during the week, but the illness also prevents the patient from living a full life and often from working.

Of course, not all hospitals perform transplants, but it may be that we have too many. The UK transplant audit shows that the relative performance of those hospitals varies by as much as 20 per cent. I do not believe that that is acceptable. The standard should be level over the country. We need proper national standards and larger centres where the staff--both doctors and nurses--get enough experience to be able to achieve the highest standards attainable. We should not accept anything less.

What we also need above all, as was mentioned, in order to counteract the resistance to being a donor, is a nationally organised system of education for the public, emphasising that out of one tragedy there is the chance of giving a new life to someone who needs it desperately. We should be able to persuade the nation that that is what we should all consider. If you resist the thought of someone removing your organs when you are dead, you should turn your mind to the happiness it might give to someone else.

7.33 p.m.

Baroness Jay of Paddington: My Lords, first I wish to thank the noble Lord, Lord Norrie, for giving the House the opportunity to debate these important issues

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by asking his Question this evening. I also wish to pay tribute to the noble Lord's energetic leadership as President of the National Kidney Federation. As I am sure noble Lords are aware, the voluntary sector plays an important part in transplantation and organ donation. I am grateful to the noble Lord and others involved in the voluntary sector for the time they have taken to give me useful personal briefings since I became a Minister. I am also grateful for their important work in the field.

I also wish to congratulate my noble friend Lord Hughes of Woodside on a distinguished maiden speech, in which he revealed an authoritative and long-standing interest in the issues we are discussing tonight. Although he said that his translation from another place had not always been easy, in the context of this evening's discussion we could describe him as a very successful transplant. We look forward to hearing him a great deal in the future.

As is so often the case in your Lordships' House on issues of this kind, all the speeches have been extremely well informed and wise. But even in this brief debate we have seen revealed the variety of strongly held views on the subject which reflect the controversy not only about the ethics but the practice involved in transplant policy.

Perhaps I may begin by replying to the first part of the Question from the noble Lord, Lord Norrie, about the care of patients waiting for organ transplants. I believe that things are getting better. Significant progress has been made in improving the treatment of people waiting for organ transplants and the way that they are looked after, particularly in the area of renal dialysis. When the national review of renal services was first published last year, it was clear that there were marked differences in the provision of services which patients could and should expect. Compared with other European countries, as the noble Lord said, the number of new patients taken on in England for renal dialysis was comparatively low, but much has been done to address that in the recent past.

The NHS Executive has issued guidelines on commissioning renal replacement therapy which include a model to enable health authorities to project the number of people requiring treatment. Taken together with the health needs assessment review that is currently being updated, health authorities and clinicians will be able to work together to ensure that all patients with renal problems receive specialist assessment and, we hope, specialist treatment.

The good progress that has been made recently is evident in the preliminary information from a national survey which we will publish shortly and to which the noble Lord, Lord Norrie, referred. The survey was commissioned by the NHS Executive as a follow-up to the national renal review. I am pleased to report that it shows a significant increase in the numbers of patients receiving dialysis during the past few years since the original review was carried out and a significant reduction in the variation in new patients taken on for dialysis which was a feature of the previous survey.

There are as well increases in the numbers being prescribed important specialised drugs, in those using the modern disconnect system and those receiving

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dialysis three times a week. As noble Lords will know, there is considerable variation in the proportion of patients using the disconnect system, but it is beneficial to many. For the benefit of anyone unfamiliar with it, as I was before I was well briefed by the noble Lord, Lord Norrie, and others working in the field, I should explain briefly that it is an enhanced system of continuous dialysis which enables the patient to be more mobile, to have more control and therefore to have a better quality of life.

The variations in the provisions of the system are not viewed with any complacency by the Government, and I hope that it will be feasible for all patients to have access to this higher quality, though it has to be said more costly, system as soon as local resources permit. However, inevitably it will take some time to achieve, given the pressure on renal services in some parts of the country, to which noble Lords have drawn attention. That is largely due to the increased numbers being taken on for treatment and the overriding need to ensure that patients are offered dialysis as soon as they need it. That has to take priority.

I am pleased to say that the new report also shows that since 1992 there has been a marked rise in the number of renal satellite units and a significant rise in the number of consultant nephrologists. Both the national renal review and the local report of the London Implementation Group a few years ago made recommendations for the future configuration of renal services which suggested that people adopt what is known colloquially as the "hub and spoke" approach, which included the use of more satellite units. That should reduce the distance which patients have to travel for treatment. As we know, that can place an unacceptable burden on the elderly and infirm and it can bring with it considerable costs.

The noble Earl, Lord Howe, raised the question in relation to Wiltshire of whether there was specific discrimination on the grounds of age in regard to kidney dialysis. I wish to make it clear that nationally we firmly adhere to the principle that NHS treatments should be open to all on the basis of clinical need. We would regard it as unacceptable for appropriate treatment to be denied on grounds of a patient's age alone. However, there are clearly issues like the general health of the patient that are taken into account when discussing with a patient and carers whether to embark on renal replacement therapy. But I can assure the House that there are many patients over the age of 70 who are currently receiving renal dialysis.

The noble Earl, Lord Howe, raised that question specifically in relation to the PFI undertaking in regard to the new hospital in Swindon. All I can say at the moment is that there are threatening matters which seem to suggest that a successful conclusion of the PFI arrangement may not be reached as quickly as we had hoped. It was one of the arrangements which was prioritised by the new Government in the summer. We hope that it will meet its deadlines and milestones by financial close, which should happen by the end of the year. If the PFI deal does reach a successful conclusion, it is expected that there will be adequate renal services included in it.

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Perhaps I may return briefly to other national initiatives which we think will be helpful. They include the National Renal Registry, funded in part by the NHS Executive, which will provide an up-to-date clinical audit covering several aspects of treatment. The NHS Executive is also funding an update of guidance on how to conduct an epidemiological needs assessment of renal failure. We hope that that will help health authorities in assessing a likely level of need in their population.

In addition, the NHS Executive funded a health technology assessment of renal dialysis based on a comprehensive review. That will be widely disseminated. Finally, a report on standards of renal dialysis will be published shortly by the Renal Association and the Royal College of Physicians. The executive intends to help with the cost of disseminating that to the NHS.

In connection with those national initiatives on service standards and clinical effectiveness, I emphasise that it is this Government's clear intention to pursue a policy of national benchmarking for all types of complex therapies and treatments. I hope that when our White Paper on the NHS is published, which will be shortly, noble Lords will see that among its primary objectives is the establishment of monitoring methods for measuring the quality of care and the outcomes for patients. Those will be the touchstones of success by which the NHS will be judged in the future, and I expect them to produce greater consistencies of treatment across the country for all types of therapies.

I turn to the second part of the noble Lord's question in relation to the donation of organs for transplant. Each year in the UK some 1,500 kidneys, 300 hearts, 150 lungs and 600 livers are transplanted from fewer than 900 donors. Sadly, in 1996, for the first time there was a fall in all of those kinds of transplants. The main constraints for all transplants is on the pool of potential donors, and that is something to which noble Lords referred this evening. That pool has been shrinking for some years due to the reduction in the number of road accidents and the improvement in the treatment of stroke and other sudden brain injuries. What is clearly a great improvement in the well-being of one section of the population, for one set of patients, has paradoxically been a major disadvantage for another--for those waiting for transplants.

As all noble Lords who spoke in the debate emphasised, we all want to see donations increase. We shall therefore continue to encourage organ donation through national and local publicity campaigns aimed at persuading people to join the NHS donor register, to carry a donor card at all times and, very importantly, as noble Lords emphasised this evening, to tell their families of their wishes. Already, as the noble Lord, Lord Norrie, said in introducing the debate, 4.5 million people joined the organ donor register and applications are coming in at the rate of 20,000 a week. I do not believe it is a rash pledge to make: I am pretty confident that we will reach 5 million by the year 2000, as the noble Lord asked me to project.

People can register as donors at their family doctor surgery when applying for a driving licence or passport or they can obtain a form by ringing a freephone

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number. I have no shame in your Lordships' House in giving a commercial for that freephone number. It is 0800 555 777. Perhaps if it is recorded in Hansard we shall reach 5 million tomorrow.

I have had a series of meetings over the past few months with representatives of the medical profession and organisations involved with organ donation, including, as I said at the beginning, the noble Lord, Lord Norrie. They have been helpful in producing different views on the ways in which donations could be increased. I commend the actions of those organisations; I was greatly assisted by my discussions with them. But I draw attention also, as did the noble Baroness, Lady Sharples, to the work of the British Kidney Patient Association and its president, Mrs. Elizabeth Ward. The BKPA is supporting the work of the organ donor register by carrying out an intensive recruitment drive in one area. I shall be interested to see the results of that exercise, which may prove to be a pilot for a wider programme.

In some parts of England programmes of training are being held to help clinicians deal with grieving families and to try to find the best ways of discussing donation with them--a subject raised by several contributors to tonight's debate. That has the aim of securing their agreement that organs may be taken. In other programmes some hospitals are looking into ways in which they might identify and maintain more potential donors and so increase the number of organs. Again, I am keen to learn the outcome of those different methods of approaching the problem. Several of them may produce models for national programmes.

As the noble Lord, Lord Norrie, suggested, we will continue to examine information received in relation to donation and transplantation programmes abroad. We need to learn all the lessons that we can from them. The noble Lord, Lord Norrie, specifically requested that people should visit Spain. I can say to him that consultants working for the UK Transplant Support Service Authority have already visited that country and prepared a report on their findings. We are also in touch with the Spanish transplant community through the Council of Europe. If more information is needed, we shall certainly consider another visit to Spain.

As several noble Lords emphasised, the law in this country allows organs to be taken from a person who has died and left instructions to that effect. It also allows organs to be taken if the deceased person left no such instruction, provided that the family does not object. Unfortunately--I was surprised to learn this--relatives object in around one-quarter of all cases. My noble friend Lord Hughes of Woodside drew attention to some of the reasons why there may be concern among families.

As several noble Lords suggested, it could be that the loss is overcome by introducing an opt-out system whereby organs may be taken from any person unless that person had expressed objection. However, on the other side, it has also been said that relatives would be just as likely to object if such a scheme were introduced. Some people would like to see relatives prevented from objecting to the donation, and several noble Lords

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referred this evening to the attempts of Lord Finsberg to bring that into law. As my noble friend mentioned, a further unsuccessful attempt was made in another place.

Common sense suggests that it is difficult to imagine doctors asserting a right to remove organs against the wishes of a grieving family. In any case, refusal by the patient's family is almost unknown when the relatives know that their loved one wished to donate. That is why our publicity stresses and will continue to emphasise, "Let your family know your wishes". That point was eloquently reinforced by the noble Baroness, Lady Robson.

The problem in regard to elective ventilation is one that has--if I may mix my metaphors--been well aired this evening. The noble Lord, Lord Norrie, gave us an eloquent explanation of the case for that. I fully understand the motivation for looking at the potential means of increasing organ donation through that route. However, it is a controversial and difficult subject and we would need to take both the legal and moral issues carefully into consideration. Addressing the point raised by the noble Earl, Lord Howe, there are anxieties in relation to the legal situation which may be resolved if more clever brains than mine were put to it. But it is not easy to respond to that point in a debate such as this.

What does elective ventilation involve? The process is that patients on ordinary wards who are expected to die shortly would be, with the permission of their families of course, taken to intensive care and placed on life support systems so that once death was pronounced their organs could be maintained until they could be removed for transplantation. At the moment--this is where we enter the legal minefield--as the law stands the practice is illegal. As the noble Earl, Lord Howe, made clear, any intervention made without the patient's consent must be in the patient's best interests or it will be judged as an assault. Clearly, elective ventilation in the circumstances I have outlined cannot be described as of benefit to the patient being treated. The procedures involved are not minor and could clearly be interpreted, in the legal niceties, as assault.

Elective ventilation is illegal at the moment, so why not change the law to overcome that obstacle? Again, as I said just now, this is not simple. A change in the law would hinge around consent to treatment. As one who sat for nearly two years on the Committee on Medical Ethics of the noble Lord, Lord Walton of Detchant, I know how difficult and how long drawn-out these discussions can be. The general principle that a person may not, without consent, be given treatment which is not in his or her own interests is an important one. It would be very difficult to modify it, as we have discussed in many different contexts.

On the other hand, my noble and learned friend the Lord Chancellor is reviewing the recommendations of the Law Commission on mental incapacity and consent. There will, I am sure, be further opportunities to look at all of these issues, but I would emphasise that, even in the broadest terms as described under the Law Commission's recommendations, an advance directive, as it is called, cannot direct doctors to do what is illegal. I suspect that we would very soon enter into the

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problematic area of definitions of what constitutes death. We all remember the controversies of a decade and a half ago when disputes about the definition of death as being brain-stem death led to a collapse in organs being offered for transplantation. It was thought that they might be taken at a time when brain-stem death had been agreed but that was not publicly or culturally accepted.

To attempt any such change in the law we would also have to be sure that elective ventilation was the best way forward in terms of practice. Can we be certain about that? The noble Earl, Lord Howe, made the point that many people both inside and outside the medical profession have grave reservations about the possibility of subjecting a patient to invasive procedures which would be of no benefit to that patient but were aimed solely at maintaining organs for eventual transplantation into others. Indeed, a report by the British Transplantation Society found that, of 97 intensive care units which had considered elective ventilation, almost 60 per cent. were opposed to the practice. That is not surprising because, as I have tried to describe in a very short time, the issues are difficult and the questions surrounding anticipated death are worrying for many people. Any move forward in this direction must have the confidence of the general public in order to be sure that we do not raise difficulties and scares which might lead to a worsening of the situation rather than the improvement which we all want to see.

The noble Earl, Lord Howe, referred to the question of cooling kidneys and the possible potential for taking that forward. He referred in particular to the practice that has been occurring in several local areas. As he will know, this is known as non-heart beating donors. We are aware that some protocols are in operation in different parts of the United Kingdom. But, again, the issue is not clear-cut. To decide on a legal change, it would be necessary to look at each protocol and see what was proposed. I would be very interested to hear what the outcomes of this practice are. But we need to emphasise again that public confidence must be maintained. This could be another area where bad publicity could arise, which, I believe, is what happened in the United States when non-heart beating donations in some areas resulted in a fall in organ donation.

We are talking here about general cultural attitudes, a point raised very eloquently by the noble Baroness, Lady Robson, at the end of her contribution. It is difficult to foresee how we make changes to the law which in a sense run ahead of changes in cultural attitudes to transplants. My belief is that we need to work more firmly and directly on the kinds of considerations that the noble Baroness raised about the need for gifts of life before we can seek to change the law in an area where many people may feel threatened.

Several noble Lords who spoke, notably the noble Lord, Lord Norrie, and the noble Baroness, Lady Wharton, raised the possibility of transplanting animal

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organs into humans--the process known as xenotransplantation. I would say to the noble Baroness, Lady Wharton, that the questions of animal welfare are being taken very much into account in the protocols surrounding the interim authority which is looking after these issues.

Several noble Lords raised the question of the Kennedy Report about transplanting animal tissue into humans. The report concluded that the potential benefits of xenotransplantation made it an important avenue to explore, but there is insufficient evidence to justify an immediate move to clinical trials involving humans. We are all concerned not just about the possible infection risks but about the likely efficacy as well as the ethics of any such procedure. We must be as sure as we can be, for the good of both the individual patient and for our wider population, that the procedure may work, that the organ will not be rejected and that infection will not be transmitted to the patient and thence to a wider population.

Having said that, we clearly see the potential of xenotransplantation. Recently, I visited Imutran, a British firm which is at the leading edge of developing this technology. I was extremely interested to hear about its work and to see the transgenic pigs it is breeding. The United Kingdom Xenotransplantation Interim Regulatory Authority, very wisely chaired by the noble Lord, Lord Habgood, is charged with advising the Government on these important developments. I am very grateful to it. The authority has worked hard during its first six months. We are now looking at its proposals to take its work forward and considering whether or not it is appropriate for it to become a statutory commission.

I have covered much ground today. I am aware that time is running on and that, although the debate is not timed, I should now conclude. I simply want to say that further management as well as medical developments need to be considered before we take any further decisions about the reorganisation of the transplant system. The noble Earl, Lord Howe, raised the question of an umbrella body to look after transplantation policy. Certainly, a review of the Transplant Special Health Authority is being looked at. That is something I shall want to consider.

On the general question of organ transplantation, we are looking at all the different issues raised by various noble Lords today which have been expressed in ways which reveal, as I said at the beginning, both their authority and their wisdom on the subject. I say to the noble Lord, Lord Norrie, that I hope he will accept that we have an open mind, that I do not think we are afraid of being brave in this area, but that any action the Government take must be based both on widespread consultation, as my noble friend Lord Hughes suggested, and also on the basis that the public will come with us and will not be frightened by any measures we take.

        House adjourned at three minutes before eight o'clock.

19 Nov 1997 : Column 643

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