Health Committee on May 9th, 2018

[Francis Scarpaleggia, Liberal, Lac-Saint-Louis, QC]

Thank you very much.

I apologize in advance if some of these questions seem a little simplistic or naive. I'm subbing here today, and I wasn't here for the first part of the study. I wish I had been, because this has been an extraordinarily fascinating discussion.

I think I need to get some terms straight so that I can better understand. For example, what specifically does a donation physician do? Is that the surgeon who does the transplant, or somebody who studies whether the organ is healthy and can be used, or studies the criteria for a match? What precisely does a donation physician do?

[Dr. Lori West]

We can probably both add to this, but a donation physician.... Oftentimes, if there's someone in an intensive care unit who could become an organ donor, there's a bit of a tête-à-tête or a potential conflict such that the critical care doctor—who's trying to save that patient's life—cannot really ethically be involved in issues related to management of this individual as an organ donor. There's a line here.

The critical care person taking care of that patient needs to back away and let a new person come in. This is the donation specialist, who learns and takes care of how to actually provide medical support for someone who is now deceased by law, if they meet brain death criteria, but who needs to have clinical decisions made as to the right thing to do to support the organs that are going to be used for transplantation, that are going to be donated for transplantation. That's a different kind of specialist.

Maybe Norm wants to comment as well, but that's what we mean by “donation specialist“. It's a very important distinction in the process through which an individual becomes a deceased donor.

[Dr. Norman Kneteman]

A donation specialist can be a nurse or a doctor. In this situation we're speaking specifically about donation physicians and so, as Dr. West has mentioned, that individual will have part of their salary, basically part of their funding, for this separate responsibility. The majority of these physicians are actually critical care doctors during most of their working day, but they will also be, maybe for one day a week or whatever, donation specialists.

If there's no donation going on, they may take part in educational activities for other physicians in the hospital. They may take part in the review of medical records to look for missed opportunities for donations. They'll do these other jobs that are critical for donation, and in the event that a potential donation happens, they will be the individual, as Dr. West has said, who will come in and take over when a decision is made to go forward with donation. Again, the individual who has been caring for that patient in life does have a relative conflict in terms of the donation side of the equation.

[Francis Scarpaleggia, Liberal, Lac-Saint-Louis, QC]

In your estimation, roughly speaking, what percentage of hospitals across Canada would have somebody within the hospital who could fulfill this particular role? I would imagine that would be a key obstacle to...because somebody would have to do it before a donation could be made, I would think.

[Dr. Norman Kneteman]

I think every hospital in the country would have someone who could do this. It's a question of whether they have someone who's funded to do this.

The recommendation is that every hospital that has an active critical care unit should have someone. In fact, in jurisdictions like Spain and such, that's actually the case, so they have many more of these sorts of physicians. Whenever the potential for donation comes up, there is someone who is knowledgeable in the area and comfortable in the area to take the lead in that process.

[Francis Scarpaleggia, Liberal, Lac-Saint-Louis, QC]

It came up a little while ago. Let's say a facility does have that position; how does it work in practice, in real time? If someone is deceased and there's a sense that certain organs are healthy enough, how is contact made with potential recipients? I can't visualize how this whole process works.

[Dr. Norman Kneteman]

It is a complex process, with many simultaneously moving parts. That's one of the reasons we need specialists in the area, and we have the support of donation coordinators, who help with much of this.

In fact, the notification to the organ procurement organization would usually go first to an organ donation coordinator, who would then contact the individuals in the different parts of the system. First we have to understand whether the potential donor has actually progressed to being declared dead or is a potential donation after cardiac death. Those are two different situations.

They may then talk with the potential recipient transplant teams, the physicians and surgeons, who will decide if the organ being offered is suitable to be transplanted. If it is, then the system has to search through the wait-list to find the person who is the best match or is at the top of the list.

From then, there is the organization of the actual recovery of the organs from the donor and the logistics for the transport of those organs to the different centres where the transplants are going to be carried out, which may be across the country.

There are many, many moving parts to be coordinated. All of them, however, are critically important, and that's why the system has to be highly functioning.

[The Chair, Liberal, Bill Casey]

I'm sorry, your time is up. Those were excellent questions and excellent answers, but your time is up.

Now we have to go to Mr. Lobb.

[Ben Lobb, Conservative, Huron—Bruce, ON]

Thank you very much.

Again, I've probably missed this, but how many organ donations are there a year in Canada?

[Dr. Lori West]

How many total donations are there per year? We had about 800 deceased donors last year and just over 500 living donors.

[David Hartell]

That resulted in over 2,000 transplants because of those donors.

[Ben Lobb, Conservative, Huron—Bruce, ON]

That can't be for the whole country, though.

[Dr. Lori West]

That's the whole country.

[David Hartell]

It is.

[Ben Lobb, Conservative, Huron—Bruce, ON]

Thirteen hundred?

[Dr. Lori West]

That's right. That's it. I know—it's amazing.

[Ben Lobb, Conservative, Huron—Bruce, ON]

Yes.

Here's a question then. Give me your ethical perspective on this. Is it unethical to provide a tax credit or to pay people to donate their organs after they're deceased or to put that into their.... Is it unethical to do that? I don't know.

[Dr. Lori West]

This is a matter of great discussion in the transplantation world worldwide. What are incentives, are they really unethical, and can you look at them in certain ways? Can we look at disincentives rather than incentives? It's very complicated. It's extremely complicated, so your question about whether it is ethical can't be answered in a simple way.

There are many things, though, that we can do to remove barriers and obstacles to transplantation. Is it ethical to make a living donor pay for their own surgery for this system, which will save the system thousands and thousands of dollars by the individual recipient having received a transplant? There are many ways that plays out through this entire process.

Do you want to add anything there?

[Dr. Norman Kneteman]

A blatant payment to someone to come and donate a kidney is, to me, in our system, unethical and is not supported, and I don't think any transplant program in Canada would be onside with doing that.

However, as Dr. West has pointed out, there are a bunch of other situations that are in the middle of the line. What do we say if the potential donor, in fact, a relative, for example, lives in the United States and has to travel across international borders, take time off work, incur costs, and rent an apartment in the Edmonton area while their family waits for them to donate? There are a whole bunch of disincentives where they have to pay money out of pocket. Certainly, for those sorts of things, I think there is increased movement to finding ways, and different provinces have different levels of execution of this whereby they will compensate the potential donor for those sorts of costs.

[Ben Lobb, Conservative, Huron—Bruce, ON]

I have never had to make that choice, and hopefully I will never have to make that choice, but I can see some people saying, “Poor Jimmy was in a car accident, and we have to make a decision here. If there is $10,000 to help with his funeral costs, let's just go ahead and do it.” Maybe they hadn't thought about it before. I don't know. I'm sure some people will gasp at even thinking like that.

[Dr. Lori West]

These are some of the very things that are being considered, and they're not only financial.

[Dr. Norman Kneteman]

There are certain jurisdictions, certainly in the U.S., in which that sort of payment is made to cover funeral costs and such, but again, it's a question of how far you stretch it. At the base, there is an ethical contraindication to straight payment of cash for an organ.

[Ben Lobb, Conservative, Huron—Bruce, ON]

Yes, and certainly, your reference to a kidney, I think, was perfect, well in line with what would be considered unethical, for sure.

[Dr. Lori West]

There are also non-financial issues such as a different place on the wait-list. In Israel, if you donate an organ, your relative on the wait-list gets a preferential boost up the wait-list, so there are lots of ways of thinking about this.

[Ben Lobb, Conservative, Huron—Bruce, ON]

You talked about research, and that's vitally important too. In 2015, I and a few other people worked with ALS Canada and with the minister at the time, and there was a round of multi-year funding to put it all together so that they had, I believe, seven years of consistent funding, and it really put it all together.

It seems to me as though this would also be appropriate at this time. I wouldn't want to put a number to it, but certainly, with the Canada Brain Research Fund, they match money, and it would seem as though this would be something as well on which the Government of Canada would work with different groups to pool money together so it all consisted in pulling in the same direction. Maybe that would be something that could come out of this.