Cooperation and Reciprocity in Organ Transplantation

August 07, 2014 By: Bjorn Rembacken
Image courtesy of Scott & White Healthcare (CC)

Cooperation and Reciprocity in Organ Transplantation

Surely one of the cornerstones of the survival of any species is how individuals participate by means of “Reciprocity” (Oxford dictionary; exchanging things or favours with others for mutual benefit) and “Cooperation” (the action or process of working together to the same end).

But what about those who try to cheat the system, deriving the benefit of others cooperating but without providing any reciprocity? I recall a study of seagulls which prune their own feathers but have to rely on other to prune their own heads. What if a pesky bird would accept others pruning its head but would rather spend his own pruning time catching more fish than pruning others in return? How does nature deal with the problem of the cheat? The observational study found that birds have a long memory and will not prune another bird if it had not returned the favour in the past. 

I remembered this study when reading about the dwindling supply of organ donation. Safer cars have reduced supply and improved survival after heart attacks have increased demand for heart transplants. According to the NHS own website, between April 2011 and March 2012, 3,960 organ transplants were carried out in the UK thanks to the generosity of 2,143 donors. Unfortunately, another 7,593 people were still waiting for transplants at the end of the period. The ratio of 2.1 donors/ 3.9 organs is a little odd as in theory, one donor should provide organs for up to 6 transplantations. 

There is a particular problem with tissue mismatch as Black and Asian people are three to four times more likely to develop kidney failure than the general population but are particularly unlikely to join the Organ Donor Register. This is particularly tragic as people from the same ethnic group are more likely to be a good tissue match. 

To boost supply in England, a Bill has been proposed for an “opt-out transplant system” whereby everyone would automatically be included in the donor registry unless they ask to be taken off the register. Although the bill has already become law in Wales, I must admit that I am sceptical. People may still find a myriad of reasons why Nature’s law of cooperation and reciprocity does not apply to them and opt out of the donor registry. Indeed, Chile has seen an overall fall in the number of organ donors since they introduced an “active opt-out system” and evidence from other countries with an opt-out system indicates that the rise is small with only around 15 additional donors per country per year! 

The Government’s proposed bill has received fierce opposition from Christian churches and from within the Muslim and Jewish communities. I would like to propose a solution which will retain people’s ability to exercise free choice, will not offend religious sensitivities and still provide a fair system, based on cooperation and reciprocity. 

People will only be eligible to receive a donated organ IF they had already joined a donor registry! People would indicate which donor registry’s they would like to join and in turn be eligible to receive a transplanted kidney, liver, heart, lung, small bowel or pancreas. 

It would work similarly to an insurance programme in which it would only be possible to get cover for a new disease. Without this clause, we will soon find cheats who quickly join the donor registry once they have received a diagnosis of cirrhosis. The only problem I can foresee is that of children or people with diminished capacity who are unable to choose. Perhaps in those cases, it would have to be their legal guardians who would have to make the choice on their behalf. 

Wales will reassess the result of their new law in 5 years. Perhaps when they see the paltry number of extra donors, all from white middle classes rather than minorities, they will re-consider my proposal?

About the author

Bjorn Rembacken is at Leeds Teaching Hospitals NHS Trust, Leeds, UK. He was born in Sweden and qualified from Leicester University in 1987. He undertook his postgraduate education in Leicester and in Leeds. His MD was dedicated to inflammatory bowel disease. Dr Rembacken was appointed Consultant Gastroenterologist, Honorary Lecturer at Leeds University and Endoscopy Training Lead in 2005. Follow Bjorn on Twitter @Bjorn_Rembacken



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