3xmsn 750 21 March 1970 MEDICAL JOURNAL CONTEMPORARY THEMES Br Med J: first published as 10.1136/bmj.1.5698.750 on 21 March 1970. Downloaded from

Report of the Special Committee on Organ Transplantation

A meeting of the Special Committee* on this sense, and expressed the opinion that and patient education of public opinion. One Organ Transplantation, set up by the Joint implementation would depend on public suggestion which commends itself to the Consultants Committee "to consider the acceptance and on there being a register of Special Committee is that where a patient remaining transplantation problems on a information to which transplant teams could attends an accident and cmergency depart- wide basis, and possible amendments of the have speedy access. ment and details of his blood group are law in relation thereto," was held under the The unanimous opinion of the members of recorded for precautionary purposes, he chairmanship of Sir John Richardson on 27 the Special Committee is that in the present should be invited to co-operate in tissue October 1969, when all memberst except climate of public opinion any attempt to typing, it being explained to the patient that Mr. Myles Gibson were present. It consid- legislate on the basis of contracting out if he is willing for his organs to be made ered the following issues left unsettled by the would be premature, and, if pressed, might available for transplantation after his death, MacLennan Advisory Group. The present well jeopardize the future of transplant sur- essential information would thus be imme- report is confined to these issues: gery. Organ transplantation is by no means diately available. This would also have the "Contracting out" or "contracting in" universally accepted by the public. The cir- educational value of accustoming the pub- (should surgeons be able to remove organs cumstances in which a transplant operation lic-particularly the younger and healthier unless there are definite indications that the is most likely to take place-sudden or members whose only contact with the hos- deceased has objected?); a legal definition of accidental death of a young and otherwise pital this may be-to the idea of organ do- the moment of death; the definition of the healthy person, and the need for an imme- nation as a rational and responsible reaction "person lawfully in possession" of the body diate decision if use is to be made of any of to a growing need. of a patient who has just died in hospital. his organs-are such as to give rise to a strong emotional reaction. Any attempt by a surgeon to carry out a transplant operation Double Contract Contracting Out or Contracting In in the face of opposition by bereaved rela- The MacLennan Advisory Group posed tives, even with the law on his side, would By double contract, the Special Com- mittee means the identification, in a single four possible options: no change in the be likely to provoke a hostile public reaction. existing law; limited amendment of the register, of persons who have expressed willingness and of persons who have ex- Human Tissue Act, 1961, to remove its ambiguities' double contract-that is, the Contracting In pressed unwillingness for their organs to be used after death in establishment of a single public and central transplant procedures. By contracting in, the Special Committee The considerations which apply to contracting register for both consents and objections means the identification of those persons recorded during life; contracting out-that is, in and contracting out apply equally to any who have expressed willingness for their form of double contract. a change in the law to enable surgeons to organs to be used after death in transplant remove organs, unless there are definite procedures. Such identification could be http://www.bmj.com/ indications that the deceased has objected. either by means of a national or regional Subject to safeguards (which present no register or by the carrying of a suitable card Legal Definition of Death small problem) the majority of the or disc-possibly by a combination of both The Human Tissue Act, 1961, does not MacLennan Advisory Group favoured con- methods. One suggestion for the setting up provide any statutory definition of death nor tracting out, but the Group was divided on of a register was to utilize the electoral reg- does it down criteria for the this isssue. lay determining istration machinery. Every householder is moment of death. The only reference is that required by law to complete from time to contained in Section 1 (2) (4) that "No such Contracting Out time a form covering all persons normally removal [of any part of a body] shall be resident in the house upon a given date. effected except by a fully registered medical on 25 September 2021 by guest. Protected copyright. By contracting out, the Special Committee From these returns, the electoral register for practitioner who must have satisfied himself means the identification of those persons the district is compiled and maintained. It that life is extinct."2 who have expressed unwillingness for their by personal examination would theoretically be possible for a question Various attempts have been made to estab- organs to be used after death in transplant to be included in the form in reply to which lish criteria of death and the Special Com- procedures, accompanied by a change in the the names of those willing to contract in mittee noted those drawn up by the Harvard law to enable surgeons to remove organs would be recorded and for the details to be Medical School as characteristic of irrevers- from all persons not so identified. The stored by computer, retrievable at will. This as evidence of MacLennan that ible coma and acceptable Advisory Group indicated would not present any insuperable technical brain death.3 certain other counteies have legislation in difficulties. The Special Committee doubts, considered however, whether public opinion is as yet The Special Committee should be sufficiently adjusted to transplant procedures whether these or similar criteria *The Special Committee was set up as a result of written into the Human Tissue Act, 1961, the on to accept the inclusion of an inquiry of this Joint Consultants Committee meeting 25 such a July 1969, at which the conclusions of the Ad- kind in the electoral registration form. but decided against recommending visory Group' were accepted as far as they went, course. The view taken by the Special but it was noted that certain issues were left A system of disc- or card-carrying, similar Committee is that there is no distinct group unresolved. to the Medic-Alert token or the card car- of clinical signs which, on each and every ried by registered blood donors, appears to tMembers of the Special Committee were: Sir occasion, signify that death has occurred John Richardson, chairman of the Joint Consult- the Special Committee to be a more pro- without possibility of error. The unanimous ants Committee (ex officio); Professor Sir Max mising line of approach. It would be an opinion of the Special Committee is there- Rosenheim, P.R.C.P.; Sir Thomas Holmes entirely voluntary system of enrolment and fore that the determination of death must, as Sellors, P.R.C.S.; Professor T. N. A. Jeffcoate, would, if the token or card were habitually P.R.C.O.G.; Mr. R. B. Wright, P.R.C.P. & now, be a matter of the individual doctor's S.Glas.; Dr. J. G. M. Hamilton, vice-president, carried, permit immediate identification of judgement, and that the procedure laid down R.C.P.Ed.; Mr. Bernard Nolan (nominated by willing donors. This could be combined with in paragraph 5(a) of the MacLennan Report R.C.S.Ed.); Professor C. Keith Simpson a voluntary register of those willing to do- (nominated by R.C.Path.); Dr. Morris Markowe nate organs, which could be built up on a (nominated by the Royal Medico-Psychological 2 Human Tissue Act, 1961. Ch. 54. Association); Dr. W. D. Wylie, Dean, Faculty of regional basis, in the same way as volunteer Anaesthetists; Dr. James Bull, President, Faculty blood donors are registered. 3 Report of the Ad Hoc Committee of Harvard of Radiologists; and Mr. R. Mvles Gibson, Medical School to Examine the Definition (nominated by Chairman of the Central Com- To be effective on any large scale, volun- of Brain Death, 7ournal of the American mittee for Hospital Medical Services). tary enrolment needs to be linked to careful Medical Association, 1968, 205, 337. BRMISH 21 March 1970 MEDICAL JOURNAL 751

is as nearly proof against error as it is transfer, the recipient should be moved to for lawful possession to be vested in the humanly possible to get.' The Special the donor. coroner (or procurator-fiscal) at time of Committee particularly the need death in any case where the law the emphasizes requires Br Med J: first published as 10.1136/bmj.1.5698.750 on 21 March 1970. Downloaded from for careful record taking, as proposed in death to be reported to the coroner (or paragraph 5(a) of the MacLennan Report, Definition of "Person Lawfully in procurator-fiscal), or in any other case because, apart from any subsequent value of Possession" of the Body where none of the relatives named below the record itself, this will ensure that a can readily be found. He would then be The Human Tissue Act does not define careful and detailed examination of the informed immediately of the death of a "the person lawfully in possession of the donor for evidence of death is carried out in potential donor, and his permission to body of a deceased person." In the case of a case. The Committee concurs each Special death occurring in hospital, the Departments transplantation of organs secured. Where with the statement issued the World there is any by of Health have advised4 that, until relatives question of criminal proceedings, Medical Association in 1968, which reads: the coroner (or procurator-fiscal) will claim the body, the person lawfully in pos- obviously entertain no question of the "This determination [of the point of session of the body is the hospital manage- transplantation of organs. In the Special death] will be based on clinical judgment ment committee or board of governors or Committee's view, the consultant who was in supplemented if necessary by a number of anyone designated so to act on their behalf. diagnostic aids (of which the electro- (In Scotland, it is the attendance upon the deceased patient is not is the most board of management.) encephalograph currently help- The Department of Health and Social Se- in a position to determine whether a trans- ful). However, no single technical criterion plant is barred on these grounds. is entirely satisfactory in the present state curity has further indicated that it considers of medicine nor can any one technological that the consultant who has been in charge of The Human Tissue Act does not define procedure be substituted for the overall the patient up to the time of death is a suit- the relatives who should be consulted more judgment of the physician." able person to be so designated. The Royal closely than "the surviving spouse or any surviving relative." The Royal College of The Special Committee is aware that College of Pathologists dissents from this Pathologists has suggested that it might be peculiar problems arise when a potential view and considers that the consultant should restricted to the following: spouse, adult son donor is being maintained artificially alive on never be the person "lawfully in possession or daughter, either parent, adult brother or a respirator which in due time is switched of the body" and the hospital authority only sister, executor or legal guardian of the off. A further complication is that it may then if no relative can be traced. deceased person. be switched on again after death as the most The Human Tissue Act also lays down satisfactory method of perfusing the organ to that no authority may be given or acted upon The Special Committee considers that be transplanted. In the Special Committee's when the person concerned has reason to there is a case for amending the Human view, both these problems are primarily believe that an inquest may be required to be Tissue Act, 1961, in this sense and to this matters of technique and do not invalidate held, or a post-mortem examination made, extent is in sympathy with paragraph 6(ii) of the general proposition that the moment of except with the consent of the coroner (in the MacLennan Report.' The case will be death can be established only by the exercise Scotland, the procurator-fiscal). Legally, a much stronger if some system of identifica- of individual and personal clinical judgement coroner can take charge of a body only when tion of willing donors by card-carrying or by the doctors concerned. he has been officially informed of the death, voluntary registration takes root. The ques- The Special Committee supports the view and this rules him out in some cases and may tion arises whether transplantation should proceed where the donor is known to have of the MacLennan Advisory Group that a be a cause of delay in others. Nevertheless, if been but the near as prospective donor should never be moved ways can be found to bridge the gap in willing relations, defined, object. The between hospitals merely in the interests of a time-and there is evidence to suggest that Special Committee questions whether the wishes of a close prospective recipient. If there is a need for coroners are not unco-operative in this rel- matter-it seems to the Special Committee ative should ever be overridden, even in the that the most satisfactory procedure would be face of proof of willingness on the part of the 1 Advice from the Advisory Group on Trans- donor but recognizes that such proof http://www.bmj.com/ plantation Problems on the Question of might amending the Human Tissue Act, 1961, 4 H.M. (61)98 in England and Wales; S.H.M. be valuable in influencing the views of a Cmnd. 4106, H.M.S.O., London. 1969. (61)72 in Scotland. relative.

Approved Names

The third supplement to the January 1969 consolidated list of Approved Names is printed below. Communications relating to Approved on 25 September 2021 by guest. Protected copyright. Names should be addressed to the Secretary, British Pharmacopoeia Commission, 8 Bulstrode Street, London, WlM 5FT.

Approved Name Other Name Action and Use Approved Name Other Name Action and Use -~~~~~~~~~~~ Amidephrine . . 3-(1 -Hydroxy-2-methylaminoethyl)- Vasoconstrictor; Lorazepam 7-Chloro-5-(2-chlorophenyl)-1,3- Tranquillizer methanesulphonanilide nasal decongestant dihydro-3-hydroxy-1,4- MJ 5190 is the mesylate benzodiazepin-2-one Betahistine 2-(2-Methylaminoethyl)pyridine Diamine oxidase Wy 4036 Serc is the dihydrochloride inhibitor 2-Chloro-1 1-(4-methylpiperazin-l- Tranquillizer Clotrimazole . . 1-(a-2-Chlorophenylbenzhydryl) Antimycotic agent yl)dibenz-[b,f][1,4]oxazepine imidazole SUM-3170 FB b 5097 .. 1-(3-Chlorophenyl)-4- [2-(5- Psychotropic agent 8-Chloro-1 1-(4-methylpiperazin-1-yl)- Sedative methylpyrazol-3-yl)ethyl] 5H-dibenzo[b,e] [1,4]diazepine H 4007 is the dihydrochloride HF 1854 Octacosactrin . al-28h Corticotrophin Synthetic Dimepregnen . . 313-Hydroxy-6a, 16a-dimethylpregn- Anti-oestrogen corticotrophin 4-en-20-one Panidazole 2-Methyl-5-nitro- 1- [2-(4- Amoebicide St 1411 pyridyl)ethyl]-imidazole . . 1-(2,3-Dihydroxypropyl)-4- Antitussive Pendecamaine . NN-Dimethyl-(3- Surface active agent Katril, palmitamidopropyl)aminoacetic Catabex, Tussilex acid betaine Enpiprazole 1-(2-Chlorophenyl)-4-[2-(1- Psychotropic Present in Tego-Betaines methylpyrazol-4-yl)ethyl] 6-(4-Methylpiperazin-l-yl)-1 1H- Hypnotic piperazine dibenz [b,el-azepine H 3608 is the dihydrochloride HF-2333, AW-142333 Fluprednidene .. 9a-Fluoro- 1 13, 17a,21-trihydroxy-16- Glucocorticosteroid Pivampicillin . 6-[D(-)-a-Aminophenylacetamido]- Antibiotic methylenepregna-1,4-diene-3,20- pencillinate dione Pondocillin is the hydrochloride StC 1106 is the 21-acetate Pramiverine 4,4-Diphenyl-N- Spasmolytic Formocortal 21-Acetoxy-3-(2-chloroethoxy)-9a- Topical isopropylcyclohexylamine fluoro-6-formyl-1 ,1 -hydroxy- corticosteroid HSp 2986 16a, 17a-isopropylidenedioxypregna- Temazepam 7-Chloro-3-hydroxy-l-methyl-5- Tranquillizer 3,5-dien-20-one phenyl-1H-1-4-benzodiazepin- Isoprednidene .. 11 ,17a,21-Trihydroxy-16- A.C.T.H. inhibitor 2(3H)-one methylenepregna-4,6-diene-3,20- Vidarabine 9-0-D-Arabinofuranosyladenine Antiviral dione CI 673