The facts are starkly detailed in this 35-page report. There is an increasing gap between organ supply and organ demand. There were 7% fewer organ transplants in the UK during 1998 than in 1997, and the waiting list for transplants increased by 3%. Since then the gap between supply and demand has increased, and the waiting list has swollen by a further 3%. The final decade of the 20^th century witnessed a steady number of transplants but a growing waiting list. During 1995-1999 about 1,000 patients died while waiting for either a heart, a heart plus lung, a lung, or a liver transplant. ‘Many more will have died’ without even reaching the waiting list, and there are the ‘thousands who die’ because of ‘insufficient dialysis facilities’.

The legislative framework behind the current situation is also unsatisfactory. The Human Tissue Act 1961, which controls modern practise, needs amendment. It gives the right of decision to the ‘surviving spouse or any surviving relative’ in an age when partnerships are increasingly abundant. The Act is not even clear who is lawfully in possession of a body after death. If death occurs in hospital it is ‘generally accepted’ that the hospital is the possessor. If death happens elsewhere ‘practicable’ steps be taken to find suitable relatives for their consent about organ removal. So what procedures constitute this ‘reasonable enquiry’?

About 70% of us are willing to donate organs but only 20% of us carry a donor card. When a death occurs without such a card, or without opinion having been expressed by the patient about organ removal, 30% of relatives refuse the medical request. In any case, donor card or not, only a small proportion of those who die are suitable for donation. Forget those over 75, for example.

As further problem the NHS Organ Donor Register, set up in 1994, is in a poor state. People are not routinely removed from the register when they die. Nor is there an established system for keeping names and contact details up to date. Nor is the list necessarily examined when a potential donor is identified, and when the family is being asked about possible donation. Currently about 14% of the UK population is registered.

The report was prepared by the BMA Medical Ethics Committee, this entirely composed of medical individuals, and it is not conspicuously forthright in detailing any medical fault connected with the current organ shortage. The BMA, in general, supports the notion ‘of a system of presumed consent with safeguards’. It may be that relatives dither, and possible donors also dither in their lifetimes, because medical safeguards have been shown to be deficient in recent years, with considerable malpractice and even murder hitting the headlines. Internal regulation has not been as effective as it should have been, and perhaps a medical ethics committee should include lay people (much as practising scientists must be fewer that 50% of the Human Fertility and Embryology Authority). ‘Presumed consent’ can ring alarm bells in many quarters.

Among the options positively rejected by the BMA are: payment for donors; the automatic availability of organs regardless of a patient’s wishes; a ‘mandated choice’ from every individual about organ donation; and ‘conditional donations’ with donors affirming who may receive their organs.

On balance it is a good report, giving the facts and also the BMA’s opinion what should be done. It so happened that this reviewer received it by the same post as a letter from the local borough suggesting that residents should join the register. After reading of the register’s deficiencies, and having to pay if telephoning the organ donor help line, it is possible to feel less enthusiastic about donation.

Anthony Smith