Cash for kidneys might not necessarily be unethical

Meeting the demand for kidney transplants is a big problem worldwide. In the UK, for example, only 18% of patients waiting on the kidney transplant list and 28% on kidney/pancreas transplant list received a transplant during 2008-09.

Donations from living people only made up 37% of the total UK kidney transplant programme in the same period, and as such this approach represents a key method by which to increase the number of organs available.

But how do you convince someone to just give away a kidney?  One very controversial way is to pay donors. Given that kidneys from living donors work so much better than those from deceased donors, even giving donors pretty large payments (for example, $90,000/£58,600) is thought to be a cost-effective way to increase the supply of kidneys available for transplantation.

Unsurprisingly, this approach hasn’t really got off the ground because people are worried about donors blithely selling a kidney without adequately weighing up the risks just to get their hands on some “easy money” or payment disproportionally luring poorer donors. Also, there’s a chance that payments may dissuade altruistic donation or cause potential altruistic donors to request financial compensation.

A study of a hypothetical regulated US market for kidneys has addressed all three of these questions and concluded that “theoretical concerns about paying persons for living kidney donation are not corroborated by empirical evidence.”

The authors surveyed 342 commuters on regional rail and urban trolley lines in Philadelphia County using 12 fictional scenarios in which the risk of subsequent kidney failure in the donor (0.1%, 1%, or 10%), the payment ($0, $10 000, or $100 000), and the recipient of the kidney (either a close family member or the next eligible patient on the waiting list) were varied. Participants responded to each scenario by stating their willingness to donate a kidney on a five-point scale ranging from “definitely would not donate” to “definitely would donate.”

As would be expected, people were more willing to donate to a family member than to a stranger. Lower risk and higher payment also encouraged donation, in particular when the scenario covered donating to a stranger.

More interestingly, incremental household income affected willingness to donate independent of payment – people with a household income of $20,000 a year or less were much more likely to donate than those who earned $100,000 or more. As such, “poorer persons may contribute disproportionately to the supply of organs with or without payment.”

The promise of hard cash didn’t affect people’s perception of the risk involved in living kidney donation: “the magnitude of reductions in willingness to donate associated with increased risk for renal failure was virtually identical across payment levels.” And the effect of a bigger paycheck on willingness to donate was the same across all income strata.

Finally, the introduction of payment for organs did not reduce the level of altruistic donation. “We found no evidence that any of the three main concerns with a regulated system of payments for living kidney donation would manifest if such a market were established,” the authors conclude.

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Halpern SD et al. (2010) Regulated payments for living kidney donation: an empirical assessment of the ethical concerns. Annals of Internal Medicine 152 (6): 358-65. PMID: 20231566

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Robo-doc: Sci-Fi Surgery at the Royal College of Surgeons

Would you let a completely unmanned robot operate on you?  Or what about one manned by a surgeon thousands of miles away?  Sounds out of the question, the stuff of science fiction. But you’d be wrong, robotic surgery is here and has huge implications for medical efficiency and safety, as the Sci-Fi Surgery: Medical Robots exhibition at the Royal College of Surgeons aptly demonstrates.

A robot is “a machine – usually computer controlled – that is capable of movement and interaction with its environment”.  Robots have been used to do manual or tedious tasks in industry for almost 50 years, and now they’re being used for the same purposes in medicine – to support busy nursing staff, for example.

ProbotIn addition, robots are more accurate and have better dexterity than humans.  The reduction in incisions and trauma that can be achieved using surgical machines means a quicker recovery for patients, faster discharge from hospital and a better quality of life after surgery.  Robots also produce consistent results and produce few mistakes, if any.

The first surgical robot was the industrial machine Puma 560, which was used by surgeons in 1985 to position a needle during a brain biopsy.  Fast forward to 1991 and the PROBOT made its appearance on the scene.  The PROBOT is an autonomous device used to remove an enlarged prostate gland in a procedure called transurethral resection of the prostate.  Unsurprisingly, neither surgeons nor patients are happy using a completely “hands off” device like the PROBOT, so newer robots tend to use a “shared control” approach.

Rob017_largeAnother interesting type of robot that was developed in the 1980s is “master-slave” robots.  These robots are used to do remote surgery – that is, to perform procedures when the surgeon and the patient are in different physical locations.  The first master-slave robot was called da Vinci Surgical System and was developed by the US army for use in the field, but is now commonly used to remove prostates.  Another telemanipulator, Zeus, was first used by a surgeon in New York to remove a gallbladder from a patient in France.

I was particularly interested in the flash new capsule endoscopes on display at the exhibition.  Capsule endoscopes are pill sized cameras that are used to record images of the gastrointestinal tract in patients suspected of having diseases like colon cancer.  The patient swallows the endoscope and the doctor can view on a screen the whole of their digestive tract.  This approach is considerably more comfortable for patients than normal endoscopy, where a camera on the end of a tube is inserted either in the anus or mouth.

ARESOne problem with capsule endoscopy at the moment is that the endoscope flies down the patient’s digestive tract and the doctor has no control over its speed or where its pointing.  A doctor could spot a dodgy looking region of the gut but won’t be able to go back and get a good look at it because the endoscope is still heading down and out.

New prototype endoscopes on display at the Sci-Fi Surgery exhibition hope to solve this issue.  The Scuola Superiore Sant’ Anna in Pisa, Italy, has developed a remote control endoscope that has “legs” it can use to propel itself through a patient’s gastrointestinal tract.  The design of this particular robot is based on the motion of worms and insects.  Dr Arianna Menciassi, Associate Professor of Biomedical Robotics at Scuola Superiore Sant’Anna, Italy, explains: “We turned to biological inspiration because worms have locomotion systems suited to unstructured, slippery environments and are ideally suited for use in the human body.”

The Scuola Superiore Sant’ Anna has also developed a reconfigurable robot that researchers hope can be swallowed in separate segments that will assemble themselves in the gut into a larger device capable of carrying out surgical procedures.

Bloodbot

By far the most disconcerting robot as far as I was concerned was the Bloodbot.  Developed by researchers at Imperial College London, the Bloodbot is designed to help doctors find a vein when taking blood samples.  A probe presses down on the patient’s arm to sense a vein, then inserts a needle under force control.  I don’t know about you, but I’m not keen on having an inanimate object sticking needles in my arm!

With processes in all industries becoming more automated, it was only a matter of time before surgery followed suit.  This little exhibition provides a great primer on the use of machines in medicine.

  • Sci-Fi Surgery: Medical Robots is running at the Qvist gallery in the Hunterian Museum of the Royal College of Surgeons until Wednesday 23rd December 2009. The museum is free and is open Tuesday – Saturday 10.00am – 5.00pm.
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What makes relatives agree to organ donation?

donor-cardThe BMJ has just published an interesting paper on the factors that determine whether family agree to donate the organs of a brain dead relative.

According to the meta-analysis by researchers at the University of Oxford, careful timing and having a transplant coordinator make the request are key factors in whether relatives consent to organ donation.

This time last year, more than 7,500 people in the UK were listed as actively waiting for a transplant.  The biggest barrier to living organ donation is refusal of consent by the relatives of the donor. A 2006 audit of all deaths in nearly 350 intensive care units around the UK found that as many as 41% of relatives refused to allow organ donation.

The authors of the BMJ study analysed 20 observational studies and audits, and identified the following six categories of modifiable factors that apparently influence relatives’ decisions to allow organ donation:

  • Information discussed during the request
  • Perceived quality of care of the donor
  • Understanding of brain stem death
  • Specific timing of the request
  • Setting in which the request is made
  • Approach and expertise of the individual making the request

The most important factor, quite understandably, was whether the request for donation occurred at the same time as the notification of death or testing for brain stem death.  In addition, medical professionals are involved with the request process had a considerable effect on consent rates – a combined approach by hospital staff and coordinators from an organ procurement organisation improved consent, as did the use of race-specific requestors and a dose of common courtesy.

Unsurprisingly, there was a correlation between staff training in organ donation request and donation rates. In fact, the consent rate differed throughout the year in accordance with the training programmes of medical residents.

The fact that the authors of this study were looking at modifiable factors is important – it’s no good looking at whether factors like religion influence the likelihood of relatives consenting to donation as doctors can’t influence such beliefs.  In order to increase the number of people agreeing to donation researchers need to identify elements of the decision making that they can have an effect on.

Targeting these modifiable factors could have a huge effect donation rates and could save lives. The authors point out that “organ donation may be of sufficient benefit to society generally, and to organ recipients specifically, to justify the study and modification of organ donation requests to maximize consent”.

Let’s hope that doctors and hospitals take this information on board and start to approach the families of potential donors with a renewed appreciation of the delicacy of the task.

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Simpkin A et al. (2009) Modifiable factors influencing relatives’ decision to offer organ donation: systematic review. BMJ 21 April 2009 DOI: 10.1136/bmj.b991

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Gallbladder removed through the vagina

So, it’s Friday.  You’re tired and don’t want to plough through a post on some complicated issue.  Perfect time to revive my neglected Weird medical stories series then.

gallbladder

And here’s today’s bizarre case study: surgeons at Northwestern Memorial Hospital in Chicago have successfully removed a woman’s gallbladder through her vagina.

Heather Lamb, a junior high math teacher, was diagnosed with gallstones and had been experiencing severe abdominal pain for weeks. Surgeons at Northwestern decided to remove the offending gallbladder, but by using natural orifice translumenal endoscopic surgery (NOTES) rather than more-invasive laparoscopic or open surgery.

“I went home the day of surgery and felt nothing more than a little discomfort the following day,” said Ms Lamb, “I returned to work a few days later and I’m feeling great.”

The gallbladder concentrates bile produced by the liver, which is then released into the small intestine during the digestive process and helps to break down fatty  food.  In some people in balance of bile components gets out of whack, causing gallstones to form in the gallbladder.  Gallstones can make the organ inflamed and painful and can cause bile to become trapped in the gallbladder, leading to infection.  In such individuals this non-essential organ then needs to be removed.

NOTES can be used remove organs such as the gallbladder, kidney and appendix through the body’s natural orifices, such as the vagina or mouth, instead of via openings created in the skin by a surgeon’s scalpel.

Eric Hungness, a minimally invasive gastrointestinal surgeon at Northwestern Memorial Hospital who led the team that performed the surgery, says, “NOTES reduces the number of and may eliminate the need for abdominal incisions compared with traditional laparoscopic surgery, and may reduce pain and shorten recovery time for patients. This technique may also eliminate the risk of post-operative wound infections or hernias.”

In another recent example of NOTES, surgeons at Johns Hopkins University in Baltimore managed to successfully remove a healthy kidney through a donor’s vagina.  Even more remarkable, the kidney was then transplanted into the donor’s niece. Transvaginal kidney removals has been performed before in order to remove cancerous or nonfunctioning kidneys that endanger a patient’s health; however, this case is the first time that a healthy organ has been removed and then transplanted.

Speaking to the BBC, Dr Robert Montgomery, chief of the transplant division at Johns Hopkins University School of Medicine, Maryland, who led the team that performed the operation, said: “Surgeons have been troubled by the need to make a relatively large incision in the patient’s abdomen after completing the nephrectomy to extract the donor kidney.

“That incision is thought to significantly add to the patient’s pain, hospitalisation and convalescence. Removing the kidney through a natural opening should hasten the patient’s recovery and provide a better cosmetic result.”

It’s quite astounding that a relatively large organ like the kidney can be teased past connective tissue and other organs to be removed through a natural orifice such as the vagina.  Gross, but astounding.

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