Examination of Witnesses (Questions 80
- 98)
THURSDAY 6 DECEMBER 2007
Sir Liam Donaldson and Ms Triona Norman
Q80 Lord Trefgarne: May we
have an answer, please, to Lord Wade's question? When are they
dead?
Sir Liam Donaldson: I would not like to give
you all the criteria in detail now.
Q81 Lord Trefgarne: You are
a doctor, Sir Liam, are you not?
Sir Liam Donaldson: Yes, but I would not want
to get it wrong. I do not have the exact details in front of me.
I am not an intensive care specialist but there are strict criteria
laid down for brain death that have been very, very carefully
worked out and we can send you those.
Q82 Lord Wade of Chorlton:
The way you are answering the question suggests that there is
a certain amount of doubt and I do not see how there could be.
Sir Liam Donaldson: No, there is no doubt whatsoever.
There is no doubt. There is a form of medical examination and
tests that go on, and criteria are laid down which are reviewed
from time to time.
Q83 Lord Wade of Chorlton:
There is no question then that organs for transplant are taken
out of anybody until they are pronounced properly dead.
Sir Liam Donaldson: No, absolutely not.
Q84 Lord Wade of Chorlton:
And there is a clear definition of how you come to that decision.
Sir Liam Donaldson: In both cases, in the case
of people who are so-called "heart-beating donors" and
in the case of those who are "non heart-beating donors".
Q85 Lord Lea of Crondall:
Chairman, would it be useful to have the answer to another question
which is certainly puzzling me. There must be something time-sensitive
about some organs and not so time-sensitive about other organs.
On the one hand, we are talking about minutes and how long it
takes and so on, and then you have processes of consent which
can go on for hours or days or something. Presumably there must
be big differences. A few minutes ago you mentioned trafficking
in organs, so there must be organs that you can put in a fridge
for 10 days or something. I am probably getting this hopelessly
wrong, but are there different degrees of time sensitivity according
to different organs? Why is an organ time sensitive?
Sir Liam Donaldson: Essentially there are three
clinical situations in which you can retrieve an organ and transplant
it into somebody else. There is the situation with the heart-beating
donor, and that is somebody who is in a coma and they are pronounced
brain dead. Under the present legislation, if you are seeking
consent from relatives or family on that, then you would start
to address that with them when it was obvious that somebody was
not going to recover. You would be then in a position to have
the consent at the point at which they were pronounced brain dead.
The organ would be taken out freshly and transplanted into somebody
else very quickly. It would be in a good state because it would
usually have been well perfused: whilst the person's brain was
dead, their heart would still be beating. That is the first situation.
The second situation is where a living donor has agreed to give
an organ. Let us say a close relative has agreed to donate one
of their kidneys: again that is a favourable situation as far
as the quality of the donated organ is concerned, because one
person giving the organ would be in one operating theatre and
the relative receiving the organ would be in another operating
theatre, perhaps next door, and the organ would be removed and
it would be well perfused and then it would be transplanted quite
quickly. The third situation, which is more difficult as far as
the quality of the organ is concerned, is that of the non heart-beating
donor. Let us say somebody who comes into an accident and emergency
department after having had a heart attack or after having been
in a car crash and they are pronounced dead on admission to the
accident and emergency department: there you have to rely on the
fact that the relatives are in attendance, and you do not just
have to tell them that their relative has died but at the same
time you have to ask them whether they would be willing to give
permission for consent for their organs to be used for transplantation.
That has to happen quickly. In that situation, when the organ
is taken out there is not necessarily the recipient lying anaesthetised
in the operating theatre waiting to receive the organ, so you
then perfuse the organ with fluid to try to keep it going and
you call in the potential recipient as quickly as possible, and
so there is a time interval there. Sometimes the organ is going
to be transported to another hospital in another part of the country,
in which case it is preserved, usually on ice, with preservation
fluid and so on. That is the situation where there is potential
for the organ to deteriorate and its blood supply to be compromised,
so-called ischemia. In that category of non heart-beating donors,
we have another problem, which is that, because of the shortage
of organs, people are becoming donors after their death when they
may not have been very well. They may have had a number of chronic
diseases where their organ is of poorer quality. They may be a
drug addict, where their organ quality is compromised. There is
concern, also, not just about the shortage of organs but about
the quality of organs, particularly in that category of the non
heart-beating donors.
Q86 Chairman: All you have
just said—and many of us have had the benefit of the background
reading and we are grateful to you for elucidating that—simply
demonstrates again the time factor. I would like to go back to
something Ms Norman said earlier about losing many organs because
of the clinicians' lack of intervention. Does the Spanish model
-which we have become familiar with—deal with some of that,
because the complications you have just described clearly affect
all the timings in a busy hospital where people are thinking of
a million other things, not least the emotional impact on the
relatives of the loss of a loved one, at the same time. It is
structural.
Sir Liam Donaldson: It is partly structural
and it is partly training of staff. In the situation I described,
where you have to tell somebody about the death and ask permission,
it is an awkward situation for somebody to handle. I remember
as a junior doctor having to do that and I had had no training
whatsoever. It is a bit better these days, but it is a situation
where it is easier to tell them about the death and sympathise
with them and leave it at that than it is to go on and ask for
consent.
Q87 Chairman: Is this why
having a specialist co-ordinators in hospitals and a team around
them makes such a difference?
Sir Liam Donaldson: Yes, I think it does. They
are trained to deal with those situations. Whether that alone
would boost the supply of organs is what you are here for really,
what you are talking about.
Q88 Lord Kirkwood of Kirkhope:
Sir Liam, I would like to ask a quick question about research
and information because I think it is important that the Committee
should understand everything that is in the Government's mind
in that department. Before I do, I cannot resist asking you a
little bit about how you felt your 2006 Annual Report The Waiting
Game was received by ministers. Presumably, you are an experienced
hand in the department: you have seen secretary of states come
and go, and presumably you have some weight in helping ministers
allocate political priorities. Did you think there was an adequate
response to the very powerful piece of evidence that you had put
in the public domain in your Annual Report 2006?
Sir Liam Donaldson: I think ministers are entitled
to take time to consider a recommendation like that and they were
also waiting for Elisabeth Buggins' Taskforce Report, so I think
it is reasonable of them to have taken time to consider it, and
they have asked for the subject to be looked at. The last controversial
recommendation I made in an annual report was for smoke-free public
places and workplaces, and that caused a lot more controversy.
It was hugely more controversial.
Q89 Chairman: But you got
there.
Sir Liam Donaldson: In the end. I think it helped
that public opinion changed on that. I think it changed because
the subject was kept in the public domain.
Q90 Lord Kirkwood of Kirkhope:
Reassure me about this, because you said earlier that the press
are not interested much. You got the flurry of activity, rightly,
after The Waiting Game was published, and then you seemed
to slip into the drip, drip, drip approach. The press are not
that bothered. 1,000 people are dying each year. Can you reassure
us that you are personally committed to knocking on Mr Johnson's
door regularly? You slightly worked around the question about
priorities that was addressed to you by saying that it is partly
NHS priorities. Of course it is. Everything is partly NHS priorities.
What priority is there in the department and with your staff in
terms of making this a key issue, so that you get the same success
in this area as you did with smoking?
Sir Liam Donaldson: The declared department
policy prior to my report was not to support the idea of opt-out.
Because it was debated at the time that the Human Tissue Act was
passed and there was a Government whip on it and, therefore, if
they had been in favour of it then it would have been done in
a different way.
Q91 Lord Kirkwood of Kirkhope:
Is there a change of political heart now, do you think?
Sir Liam Donaldson: To an extent. They have
said they would like to look at it and they have tasked the Taskforce
with looking at it and they could have just ignored it. I have
made other recommendations that have not necessarily been acted
on in earlier annual reports, but not as major as this issue or
the smoking one. But I think they are giving serious thought to
it. I cannot tell you what is in ministerial minds. There is a
degree of inscrutability about ministers.
Q92 Lord Kirkwood of Kirkhope:
That is an incontestable statement. You can reassure the Committee,
can you, that this is a live issue, under active consideration
by the professionals in the department?
Sir Liam Donaldson: Yes.
Q93 Lord Kirkwood of Kirkhope:
And the ministers are being left in no doubt about what the importance
of this subject is in terms of making progress in the immediate
future?
Sir Liam Donaldson: I absolutely assure you
about that. As far as my own commitment, I am strongly committed
to this. I do not make recommendations about things that I think
are not well-founded or not sensible or likely to be totally unacceptable
to the public. I think this is one where I feel passionately.
I do not like to think of people in these numbers dying. Where
lives can be saved, I am always active to try to persuade and
influence.
Q94 Lord Kirkwood of Kirkhope:
Thank you for that answer. I am very reassured. Perhaps I could
turn briefly to the question of research and knowledge. You have
dealt with stem cells in your earlier answers. Would it be possible
to compile a list of things that are actively in consideration
or decent pieces of research—and some of it social as well
as scientific—in terms of some of the cultural stigmas and
taboos that there are around? I am always frightened of complacency.
The drip, drip, drip approach to life sometimes takes a long time,
and in the long run we are all dead.
Sir Liam Donaldson: We can write to you with
a comprehensive list.
Lord Kirkwood of Kirkhope: Thank you
very much. That would be very useful.
Q95 Lord Trefgarne: Many years
ago I had the privilege of being junior minister for what was
then called the DHSS. The Chief Medical Officer was someone called
Sir Henry Yellowlees and he was brilliant at beating up ministers
to get their priorities right. You might take a leaf out of his
book.
Sir Liam Donaldson: Okay. Thank you very much.
I wrote a history of the Chief Medical Officers, My Lord Chairman—with
myself kept out of it—three years ago and I did give an
account of how things sometimes get decided. It is fascinating
to look back on history and see how some decisions were taken
and how the Chief Medical Officer might have influenced those.
I will send you a copy.
Q96 Lord Trefgarne: I dare
say Sir Henry features in your book.
Sir Liam Donaldson: He does, yes.
Q97 Chairman: We are very
grateful for the influence you have brought to bear here. We asked
the European question earlier, but, just before we go, because
we are really looking at an EU dimension, do you have anything
else to say about the way we should be looking at the way the
EU confronts this issue?
Sir Liam Donaldson: No, the categories I identified
or the levels at which the EU could become involved, I would not
want to modify that earlier answer, thank you.
Q98 Chairman: We hope you
have influenced us enough for us to be of some influence in this
area when we bring our report, because that may be another opportunity,
once the evidence is gathered, for this issue to come to the fore
again. You may want to talk to some members of the Committee again
at that stage. Could I thank you both very much for coming and
answering, at an angle, if you like, the questions that have been
put to you.
Sir Liam Donaldson: Thank you, My Lord Chairman.
Perhaps I could add that, before I came across, I was in a meeting
with Lord Darzi and he advised me where the defibrillator was
kept! I am relieved that I have not had to use it.
Chairman: We are all relieved that Lord
Darzi is now on the front bench and can leap over benches—he
knows how to use the machinery and will save lives!
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