Body Parts
Sergey Avilov, Telegraph "Around the World"
Donor organ transplantation operations remain an urgent issue for Russia. The problem is not only in medical difficulties, but also in the attitude to such operations in our society. There are many programs in European countries whose purpose is to explain to people the importance of donor organ transplants. Transplantology as a promising branch of medicine was blessed and approved by the practice of organ donation by Pope John Paul II.
Today, one of the most important problems of transplantology in Russia is the issue of child donation. The fact is that in our country, organ transplantation from a child to a child is not allowed by law, which deprives hundreds of children of hope for salvation, who cannot be transplanted with adult organs. The Ministry of Health and Social Development of the Russian Federation has developed a document that will legalize the posthumous donation of children – "Instructions for ascertaining the death of a child based on a diagnosis of brain death." Specialists of the leading medical institutions of the country, scientists, lawyers, representatives of public organizations for the protection of children's rights took part in the development of this document. It is assumed that in 2008 the "Instruction" will be adopted. But perhaps the introduction of this fundamental amendment will change little. The cadaver donation system can become effective only when society is ready for it. In our country, the overwhelming majority of the population is sure that criminals cut out organs in order to transplant them to rich people later.
Organ transplantation – legends and practiceThe idea of replacing body parts that have fallen into disrepair, like parts in a mechanism, arose a long time ago.
According to the apocrypha, in the III century Saints Cosmas and Damian successfully transplanted the leg of a recently deceased Ethiopian to their patient. However, they were assisted by angels. The topic of transplantation also fascinated writers: Professor Preobrazhensky transplanted endocrine glands, Dr. Moreau sewed animal heads to his patients, and Professor Dowell – the heads of corpses.
At the beginning of the last century, the cornea of a donor was successfully transplanted to a person for the first time. However, the spread of transplants of other organs was hindered by a lack of knowledge about immunity. The body rejects the transplanted organ if it is not taken from a genetically identical organism. Bologna Renaissance surgeon Gaspare Tagliacozzi (1545-1599), who successfully performed autotransplantation of the skin, in 1597 noted in his work "De curtorum chirurgia per insitionem, libri duo" that when transplanting a fragment of someone else's skin to a person, rejection always occurs.
It was only by the middle of the twentieth century that scientists discovered the mechanisms of immune reactions and learned how to suppress them so that the donor organ could take root normally. Despite this, the forced suppression of the immune response remains an important problem of transplantations: firstly, after organ transplantation, the recipient becomes vulnerable to infections, and secondly, steroids used to suppress immunity have severe side effects.
In recent years, alternative methods of suppressing immunity without the use of steroids or reducing their dose have been developed and applied – for example, scientists at Northwestern University and the University of Wisconsin are dealing with this issue.
Skin, kidney, liver, heart, intestines, lungs, pancreas, bones, joints, veins, heart valves, cornea transplants are well mastered today. In 1998, the hand was successfully transplanted for the first time. Recent achievements include the first face part transplant in France in 2005 and a penis transplant in China in 2006. The world leader in transplants is the USA: 52 kidney transplants, 19 liver transplants, 8 heart transplants are performed annually per million inhabitants.
Pig to man comrade
The shortage of donor organs is the main non–medical problem of transplantologists. Thousands of people are waiting for organs for transplants and die without waiting. There are not enough donors all over the world, so scientists are busy looking for alternative sources of organs. One of the theoretically possible ways to solve the problem is the transplantation of animal organs, but great difficulties are associated with it – a person is genetically far from animals. The exception so far is operations for transplanting pig heart valves to a person. Recently, encouraging results have been obtained on the transplantation of human "pig" islets of Langerhans – special groups of pancreatic cells that produce insulin.
Another area of research is the so–called "organ culture", that is, the cultivation of organs outside the body on a nutrient medium. Scientists are solving the problem of how to "make" human cells not just divide at the bottom of a vessel with a nutrient medium, but also how to learn how to turn them into cells of the right types and form an organ of a given anatomical structure. In the future, this will allow taking the patient's cells and growing a new ideally compatible organ from them "in a flask". The clinical use of "alternative sources" is still exotic. The main sources of organs today are donors, living or dead.
Problems of living donorsAccording to Russian laws, only a blood relative of the recipient can be a living donor.
This is certainly an unnecessary restriction, because a biologically compatible donor may be not only a relative, but also a friend, acquaintance or just a sympathizer who is ready to share his organ. Thus, more than half of the members of the religious group "Christians of Jesus" gave their kidneys to patients in need of a transplant.
Another way to combat the shortage of compatible living donors is the so–called "pair exchange", which is common in the United States. Let's say donor A wants to give his organ to patient B, but they are not compatible. Then they find another donor-recipient pair (C and D), which are incompatible with each other, but at the same time donor B is suitable for patient B, and donor A is suitable for patient G.
Organ trafficking is prohibited in the Russian Federation, as in all other countries, excluding Iran. However, the opinion of the world community on this matter is not as unambiguous as it may seem. The issue of legalizing the organ market is being actively discussed in the United States. It was calculated, for example, that if 0.06% of the adult population of the country sell one kidney, they will provide for all fellow citizens who need a transplant.
The legalization of organ trafficking also threatens serious problems that exist today on the black market: paid donors are primarily representatives of social groups who do not have access to quality medicine and may be carriers of dangerous infections. Intermediaries in the organ market who are interested in culling as few organs as possible increase the risk of infection of the recipient. In 2007, the first case of HIV and hepatitis C infection through a donor organ was recorded due to the imperfection of the organ testing method.
Problems of dead donorsThere are organs that a living donor cannot give away – the heart, for example.
Therefore, the second source of organs for transplantation are the dead. For some time after death, the organs remain viable. Post-mortem donation is also associated with a number of serious problems, for example, with the legal definition of death and the need for relatives' consent to take organs.
It seems to be immoral to take organs from a deceased person without the consent of relatives. But, on the other hand, why do relatives need the organs of the deceased? The loss of time to obtain consent for someone can turn into a tragedy, because organs quickly become unsuitable for transplantation. So far, in Russia and some other countries (for example, Poland, Brazil, Spain, Italy), there is a presumption of consent regarding organ harvesting, that is, by default, it is assumed that relatives agree.
The presumption of consent seems ethically questionable, but it makes life much easier for transplantologists. With the current public attitude towards transplantation, it is doubtful that most relatives would give their consent. Recently, the presumption of consent was abolished in Ukraine, which actually led to the termination of the collection of cadaveric organs: relatives do not give consent. There is no presumption of consent in most Western countries, but there public opinion about doctors and transplantation is very different from ours. Organ donation is actively promoted. In addition, the future posthumous donor can dispose of his organs in advance in writing. In California, for example, they offer to do this when obtaining a driver's license. A note is put in the driver's license whether a person agrees to take his organs, so that in case of death, time loss is minimal.
"Doctors' case" in RussiaThe most difficult issue of cadaveric donation is determining the death of the patient from whom the organs will be taken.
Because of this, in fact, the scandalous "case of transplant doctors" arose. On April 11, 2003, a patient with a traumatic brain injury in extremely serious condition was taken to the twentieth hospital in Moscow. Doctors recorded brain death and began to prepare for organ harvesting. But police officers intervened, who "had data that the biological death of the patient had not yet occurred." Doctors who arrived with the police recorded signs of life in the donor: heart contractions and blood pressure. If brain death really happened, then the contractions of the heart will not save the deceased. The heart is generally a very autonomous organ, it can contract for hours just in a jar with a nutrient solution.
The Supreme Court twice overturned the acquittal of the Moscow City Court and sent the case for a new trial. Only at the end of 2006, the Supreme Court agreed with the acquittal, which was handed down, since brain death was recorded before the start of organ harvesting.
"The Doctor's case" in AmericaCriminal scandals around transplants arise not only in Russia and other countries with "immature" legislation.
In the country of advanced transplantology and the most detailed legislation – in the USA – there is a loud "Doctor's Case". On February 26, 2008, a preliminary hearing of the case of a transplant surgeon began in a California court, who is accused of prescribing excessive doses of drugs to a seriously ill patient in order to hasten his death. It is really unclear why it was necessary to inject horse doses of painkillers – morphine and the antidepressant ativan to a patient who was in a coma and was unlikely to suffer from pain and depression? But these are just "flowers": the doctor prescribed an injection of betadine – external (!) antiseptic, the ingestion of which is dangerous for a healthy person. And in general, transplantologists should come to take organs after death, and not prescribe "treatment" to living patients. According to American standards of practice, a transplant surgeon should not be in the same room with a dying patient at all until his death is confirmed.
It can be argued that the patient was in a coma and was considered hopeless, his mother had already agreed to turn off the ventilator, which supported the patient's life. In this question, Christian morality gives an unambiguous answer – you can not rush anyone's death.
However, the malefactor doctor tried in vain: firstly, the patient died only the next day after the "therapy", and secondly, his organs were not taken for transplantation, because more time passed between the shutdown of respiratory equipment and cardiac arrest than allowed, and the organs "deteriorated". The hasty transplant specialist faces 8 years in prison and a fine of $250,000.
Regarding the scientific definition of irreversible death – brain death, some ambiguity remains. At what exact moment should the doctor state death and stop resuscitation? In fact, the limit of irreversibility depends on the level of medicine: a hundred years ago, any cardiac arrest meant death. It is now believed that irreversible changes in the brain occur 7-10 minutes after the cessation of blood circulation in this organ. After that (and if there are also some other criteria for death), organs can be taken. But there are precedents that make us doubt the irreversibility of the process. For example, in 2000 in Norway, the life of a skier was saved, who spent more than 7 hours in a state of clinical death, however, at the same time her body temperature dropped to 14 ° C. Then the doctors continued resuscitation for several hours, and did not rush to disembowel the hopeless patient.
Transplantation of children's organsTaking children's organs for transplants is associated with special difficulties.
Unlike an adult, a child cannot consent to organ harvesting by himself. It means that parents or guardians should decide, and in relation to the homeless, it is generally unknown who.
The child's body is different from an adult, so the automatic transfer of "adult" criteria for brain death to children may be incorrect, which is why it became necessary to develop a special "Instruction". A gap in the legislation excludes all abuses related to the taking of children's organs, and leaves no chance for children who need a heart transplant – a child cannot be transplanted with an adult's heart. The general ban on post–mortem donation of children is undoubtedly a radical measure to prevent abuse.
Children's post-mortem donation is also associated with serious psychological problems. Organs from a child should be taken shortly after brain death, but breathing and heart contractions may still persist. Naturally, parents do not want to put up with the fact of the child's death, it seems to them that the doctors did not do everything possible to save him.
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The solution to the problems of Russian transplantology could be not total bans, but a detailed legislative framework that leaves no loopholes for possible abuses and, of course, thoughtful measures that could change the negative attitude towards transplantation in modern society.
Portal "Eternal youth" www.vechnayamolodost.ru
21.03.2008