People with many years of life ahead of them should come higher up the organ transplant pecking order than critically ill older patients, says one expert.
But not everyone agrees with Franz Immer, head of national organ association Swisstransplant. Critics are worried about unethical selection and discrimination.
In a working paper for health experts and politicians published last week, Immer said that since demand for organs still outstrips supply in Switzerland – as it does around the world – giving a seriously ill old person a new heart, for example, might not be the best use of a precious commodity.
“According to the law, the top priority is urgency, the second priority is medical benefit and the third is the time spent on the waiting list,” Immer told swissinfo.ch, defining medical benefit as “achieving the optimal solution for the patient”.
Swisstransplant argues that given the current organ shortage – last year 67 people died in Switzerland waiting for a new organ – can society afford not to prioritise and get the maximum use out of every organ?
“I think the time you can obtain from a transplant and quality of life must be a factor,” Immer said. “For example people have to wait two-and-a-half to three years for a kidney transplant, but the side effects of haemodialysis in 18-year-old patients are dramatic, which is why the expert groups suggested prioritising those young patients.”
While pointing out that young people who receive new organs often go on to lead long and productive lives, Immer stressed that he was not advocating a cut-off based on age.
“We have old donors who probably also qualify for old recipients; we have young donors who probably better qualify for younger recipients. But we absolutely do not support making a ranking of social values. It’s only the medical benefit we are looking at.”
Is every human life worth the same? “Absolutely.”
According to Immer, most transplant doctors agree with the proposed changes. Not all politicians on the other hand are so sure.
“Where will it end?” asked Viola Amherd from the centre-right Christian Democratic Party: would people who pay high taxes come above people on benefits? Would a surgeon come above a factory worker?
Other people have raised similar concerns: should prisoners, for example, go to the back of the queue? Should a young mother of three come above a young childless person? Should alcoholics or smokers be refused new livers or lungs?
Bea Helm from the centre-left Social Democratic Party said the value of a life couldn’t be calculated using equations.
For Amherd, a patient’s medical situation was the only objective factor and anything else would lead to tricky debates about whose life was worth more.
Felix Gutzwiller, a doctor and member of the Senate for the centre-right Radical Party who has proposed a motion to change the donor system in Switzerland, acknowledges these concerns but says he does not necessarily share them.
“The legislation is very clear, the constitution is very clear: there cannot be any allocation based on principles other than equal access, in other words a justice criterion,” he told swissinfo.ch.
“Based on this, I really don’t think there’s any risk of socio-economic criteria getting into the decision-making process for organ allocation.”
So older, childless people shouldn’t fear being discriminated against? “Not at all. In the very rare case that you have say three people all on the waiting list – all for the same period of time, all compatible with the organ – then the younger one would probably get priority,” he said.
“But that’s really a theoretical construction, because almost always you have either a compatibility mismatch or you have a disease that’s progressing fast that needs action. Certainly in Switzerland there is no risk of rationing according to such criteria.”
Fewer difficult decisions would have to be made if there were more donors in Switzerland, which Immer admits remains stuck in the bottom third of donor countries in European.
In 2008 there were just 11.8 Swiss donors per million people. By comparison Austria had 20.3 per million, France had 25.1 per million and Spain had more than 30.
To improve this, Gutzwiller is calling for a “paradigm change” regarding the system of consent in Switzerland. At present a person’s organs can be used only if the donor has explicitly given consent.
“We should not have a solution based on explicit consent but rather on presumed consent: if you or your parents don’t say no, you are in principle a candidate for organ transplantation.”
In a motion set to be discussed in parliament this week, he has proposed this and various other measures, such as marking on one’s driving licence whether one is a donor, to increase the availability of organs.
62 people died in 2008 while waiting for an organ transplant.
19 organs were imported from other countries.
942 people were waiting for organs in 2008, up 19% on 2007.
128 people, up 14%, received organs from live donors in 2008.
90 cadavers, up 11.1%, provided organs in 2008.
Switzerland has followed a new framework for regulating transplants since July 1, 2007.
Under the regulations a person's organs can be harvested after death only if consent is given beforehand. The will of the dead person overrides the wishes of surviving relatives.
But if people do not make their intentions clear before dying, the next of kin can decide. If no relatives exist, the organs can't be taken.
In 2008 less than 10% of the organs harvested from cadavers came from people who had filled out a donor registration card.
There is no age limit on who can be a donor. In 2008 an 85-year-old's organs were used. Children are not frequently donors but last year a one-year-old child received a transplant.
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