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Too Old to Donate?

Duration:
43 minutes
First broadcast:
Thursday 26 July 2012

Since losing her husband to a terminal illness, and watching his kidneys fail, Pamela has felt a burning desire to try to help someone else escape a similar fate.

A year after his death, she writes to her local hospital to ask if she can become an 'altruistic' donor, and donate one of her kidneys to a stranger. To her horror, she receives a letter back saying that she is 'too old'. Undeterred, she approaches a transplant surgeon at another hospital, and he agrees to see her.

To the surgeon, Pamela appears fit and extremely determined. But for a potential donor, she's also rather unusual - she's eighty two years old.

Should Pamela be allowed to donate? What are the risks to her - both of the operation itself, and of being left with only one kidney? And, if the team allow her to donate, who should receive such an elderly organ?

Producer: Beth Eastwood.

  • THE PANEL

    Chris Rudge, Transplant Surgeon and National Clinical Director for Transplantation (until 2011)

    Janet Radcliffe Richards, Professor of Practical Philosophy at Oxford University and author of ‘The Ethics of Transplants: Why Careless Thought Costs Lives’

    Antonia Cronin, Kidney Specialist at Guys and St Thomas’ Hospital and the MRC Centre for Transplantation

  • SEND US YOUR COMMENTS

    We're interested to hear your views on this case.

    Inside the Ethics Committee - Too Old to Donate? - Blog
  • IEC - Too Old to Donate - Transcript

    THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT. BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY.


    INSIDE THE ETHICS COMMITTEE

    TX DATE: 26.07.12 0900-0945

    PRESENTER: JOAN BAKEWELL

    PRODUCER: BETH EASTWOOD


    Bakewell
    Kidney transplants from live donors are on the increase, generous individuals even volunteer one of their own kidneys to help a total stranger, so why would you refuse such an offer?

    Welcome to Inside the Ethics Committee

    The shortage of kidneys for transplant is increasing. Fewer fatal road accidents among other things mean traditional sources continue to fall short of the need - but the need goes on. On average patients in the UK have to wait three years for a transplant. Pamela heard of the shortage and after her husband's long illness decided she wanted to donate.

    Pamela
    My husband was a disabled officer and I had looked after him for many, many years, all our married life really, and then he suddenly began to fail and the complications got worse and worse and then he had multiple organ failure and the worst of all, really, was kidney failure - it really made him give up. He was going back and forth to hospital, having all sorts of treatment to try to keep the kidneys functioning which didn't really work and he couldn't have renal dialysis because he was too fail and too ill. And he died at home and life was horrible without him.

    Bakewell
    In the year after his death Pamela worked in a local hospital and in her community. She had been involved in nursing all her working life; but the experience of her husband's death had left her feeling that she wanted to do more.

    Pamela
    Since the day my husband's kidneys began to fail I wanted to give him a kidney and I couldn't - he wasn't strong enough, it would have killed him to go through the surgery. And then I read about this gentleman who'd had a kidney transplant and I thought to myself well I'm not as old as he is, by any means, so I decided I would try - to go for it.

    Bakewell
    Three years ago she wrote a letter to her local hospital who had been involved in her husband's care. But she was rather surprised by their response.

    Pamela
    They knew me very slightly because I had been visiting my husband and the answer was because of my age absolutely no, there was not even the possibility of having an interview and that really upset me and annoyed me intensely. And I thought long and hard about it and I didn't know how to go about approaching anybody else because I didn't know anybody. And then I read the article about a surgeon in another part of where I live and I wrote him a letter saying how peeved I was and annoyed about my treatment at my local hospital and I felt that I was very healthy, that there was no reason for anybody not to consider me.

    Bakewell
    Pamela is of an age our society often regards as past it. But she's fit and she's feisty. Yet the team who agree to see her bring with them their own preconceptions. The head of the transplant team.

    Surgeon
    I was standing in the corridor outside the outpatients department and I said to the transplant coordinator: This is an elderly lady who has obviously decided that she wants to give a kidney but really I think she's probably too old to do that and I'm going to go in there and it won't take very long and I'll be able to deal with it quite quickly. In fact what happened was I went into the room and I met this small, wiry, redoubtable, indomitable lady who was convinced that she was going to give a kidney and actually if I just got out of the way she would get on with it. And it was really remarkable to meet her.

    Pamela
    We shook hands and he asked me why I wanted to donate and I explained my husband's difficulties and I told him about my good health and my mental health.

    Surgeon
    I said that whilst I admired her desire I was concerned that she was quite an elderly lady and that maybe the risks of the procedure were so much that she would come to some harm by going through with this. I have seen people approach me from a very young age, from maybe age 18, all the way through to 60s, 70s, most I would guess would be in the region 30s or 40s, this lady was 82.

    Pamela
    I think they were worried about my age and I'm small, I think they thought I was frail, which I'm anything but - I walk five miles every day getting to and from the nursing home for our work and I'm still doing that at my age now.

    Bakewell
    So what are the medical risks to Pamela of donating a kidney?

    Surgeon
    We know that for a live donor the risks are in three categories. The first is immediately prior to the donation we have to do a lot of investigations and you might find out something about yourself that you're not particularly wanting to know. The second set of risks is going through a significant operation - some people have died following giving a kidney. And then the last set of complications is living with only one kidney for the rest of your life. Now none of these complications is particularly large but it's very important that the donor is aware of those and knows what they're letting themselves in for. In this particular lady's case, because she was elderly, there was a worry that all three of these categories of risk were higher and therefore for her there was a concern that actually this was just one step too far.

    Pamela
    I knew they were going to do everything they could to deter me and I was just as determined that they wouldn't deter me. I'm stubborn as a mule. I think he was a bit appalled at my cheek! (Laughs)

    Surgeon
    Initially she was very much of the opinion that we should just get on with this and that actually I was just standing in her way. By the end of the consultation we'd reached a much better understanding of each other's position. I talked about what would happen if something did go wrong after her procedure. Let's say something really awful happened - let's say she died after the transplant - almost certainly people would say what on earth were you doing operating on an 82 year old - and my whole programme could come under some question. And in those circumstances we had to think through whether it was the right thing to do.

    Bakewell
    Time now to meet our panel of experts. They are Chris Rudge, a transplant surgeon, who until last August was the country's clinical director for transplantation; Janet Radcliffe-Richards, Professor of Practical Philosophy at Oxford and author of the recently published Ethics of Transplant: Why Careless Thoughts Cost Lives and Antonia Cronin, kidney specialist at Guy's and St Thomas' Hospital and the MRC Centre for Transplantation who's written many academic papers on transplantation.

    Now I think I should say at the outset that this is not about selling kidneys, this story is about the donating of a kidney free to total strangers. So Antonia, how serious is the need for kidneys out there?

    Cronin
    The need is very serious indeed, in the UK alone there are over 10,000 people waiting on the transplant waiting list and it's estimated that every year approximately 1,000 of these die, that's approximately three people per day die waiting for a transplant. The main number of people waiting are those waiting for a kidney transplant.

    Bakewell
    And is the situation getting worse?

    Cronin
    I think the disparity between supply and demand is constant, there's an ever increasing number of people who require an organ for transplantation, however, there have been a number of recent initiatives in the UK that have increased the sources of transplants from the deceased.

    Bakewell
    Now Chris Rudge, you've spent your career in transplantation for many, many years, how has it changed and evolved?

    Rudge
    It's changed out of all recognition. I think when I started, which is now over 40 years ago, the big question was can we ever make it work and the results were awful, the complications were awful and I think the surgeons that persevered in the early days and their patients were very brave. And then the next question was can we make it work better, can we get better drugs, can we get better at looking after patients. And really for the last 10 years the biggest question has been why can't more people have a transplant. And so that's forced us to look in detail about where organs are donated from, both the living and the dead, and to push the boundaries but clearly not go beyond the boundaries.

    Bakewell
    Janet Radcliffe-Richards, who would have thought that people would donate one of their kidneys to a total stranger out of the kindness of their hearts?

    Radcliffe-Richards
    Who would have thought it? Well our species actually has a strong strain of altruism in it, so that isn't the problem. It's of course interesting that people do this, the deeper problem for ethics is that this business of moving organs from one person to become a functioning part of another person is totally new, we're not used to thinking of bits of us as transferrable like other bits of property. And this has raised a whole set of totally new moral issues because we have a lot of reactions deep in us about doing this kind of thing.

    Bakewell
    But it has become an accepted part of medical treatment hasn't it, that you know that when you have trouble with a kidney well there'll be a period of treatment then you move into dialysis and then if you're lucky you'll get a transplant, so what dilemmas remain?

    Radcliffe-Richards
    There are a great many restrictions on where organs can come from. You said we weren't talking about selling but that's not allowed, there are all kinds of restrictions depending on when people are regarded as dead, there are restrictions which don't actually prevent organ donation but prevent certain ways in which people can donate, for instance specifying who a deceased organ goes to. And this kind of thing may for all we know prevent some people from coming forward to donate.

    Bakewell
    Did it surprise you that someone wanted to donate in their 80s? I have to warn you being wary about this because I'm not far from that age myself and I don't regard people as past it in their 80s.

    Radcliffe-Richards
    I feel exactly the same for rather similar reasons. But I think she sounds wonderful and I'm delighted that people are doing this and the more the better.

    Bakewell
    Antonia, does the offer of someone who is older open up new hopes for you or new dilemmas at the same time?

    Cronin
    I think it opens up all sorts of things including dilemmas and hope certainly. Old age in and of itself should not be an absolute contraindication to becoming a living donor.

    Bakewell
    So are you surprised at people volunteering a kidney Chris?

    Rudge
    I'm not surprised to hear of an 82 year old offering to donate her kidney, I've been involved myself with donors of that age. The extra complexity that Pamela produces is that she's offering to donate her kidney to a stranger, not to a member of her family or a close friend or somebody that she's known for many years. If we go back 20 or 30 years ago I think many transplant surgeons received the occasional letter out of the blue saying I want to come along and give a kidney and I think most of us, if we're honest, dismissed those letters with varying degrees of suspicion or scorn, almost scorn, we thought people were mad. That clearly was wrong, clearly there are people and I think it's extraordinary but I also think it's wonderful that there are people that want to do this for a stranger.

    Bakewell
    And what about the matter of the temperament of the person who wants to do it? I mean we've seen that she's determined, she said so - she's absolutely resolved. But other people who might be inclined to be altruistic, generous, might not have her persistence. Janet.

    Radcliffe-Richards
    Well this is one of the things we're looking into now of course; we're considering whether too many obstacles are being put in the way of people who want to give because certainly they did run into obstacles for a long time from the profession. And presumably if we want to save more people by transplants, which we do, we need to be sure that the obstacles we put in the way are justified.

    Bakewell
    Antonia.

    Cronin
    One of the things that is very different about the practice of giving donor kidney transplantation is the idea that people are willing to come forward for friends and for relatives and indeed for strangers and incur or be voluntarily able to risk to incur harm to themselves. And this I think we need to take really seriously. But I don't think it's unreasonable for the profession to tread very carefully in the development of this programme of work, I think they have and to support people through this choice so that they have appropriate information available to them about the risks they might incur during the procedure.

    Bakewell
    Right, well let's now go back to the story… at the point where the transplant surgeon first met the 82 year old Pamela.

    Surgeon
    This lady was particularly elderly and before I met her there was no chance in my mind that we should go ahead with this procedure, it was only after I saw that actually on a quick meeting of her that she was a very fit lady, heard that she walked her dog five miles a day and actually probably did so at quite a pace, looking at her, that maybe we should think very carefully.

    Pamela
    And he said well we'll put you through some tests and see how you progress and whether you can handle it.

    Surgeon
    The investigations were to determine whether this 82 year old lady was actually as fit as she said of somebody many years younger. We did the normal tests that we do for any donor, in these circumstances we felt that we had to do some extra testing because obviously to do an operation and remove a kidney is a significant level of stress, so you're trying to reproduce that in the hope that if there were problems that you're likely to encounter during an operation you find them earlier on.

    Pamela
    They bloody minded put me through every hoop I could possibly jump and I was determined I would stick with every one. It took me a good year to have all the tests and they involved x-rays, blood tests, physical tests - I can't remember all the rest but they went on and on and every time I got a letter I knew it was another test. But I wasn't going to give up.

    Surgeon
    One of the things after discussion with her that we put her through was an exercise tolerance test - going on a treadmill and watching how quickly the body reacts to that level of exercise.

    Pamela
    The treadmill was probably one of the most devastating. I was fitted up with all the gadgets in the world and you're walking - it's just slightly uphill but you think you're climbing Mount Everest.

    Surgeon
    It's quite a tough test, perhaps one of the best ways to determine is there a weakness in the body somewhere that cannot cope with that level of stress.

    Pamela
    And I must say when I got to the uphill bit I said I can't do this and I kept going and going and panting and breathing and finally they took off all these tid bits off my body and I didn't know whether I had passed the examination or not. And then they put me in to see a psychiatrist and I thought they were all mad, all except me.

    Bakewell
    It so happened Pamela was already part of a separate research study for which she had extra scans of her heart. The transplant team checks with the professor of cardiology to review those scans, and reviews the psychiatric report and other medical results. So finally, does the team think the idea is outlandish or not?

    Surgeon
    Pamela came through all of these tests with flying colours. We found that her kidney function was actually very satisfactory, certainly for an 82 year old and might even have been satisfactory for somebody years younger than that. But nevertheless as the years go by the kidneys, like most other organs in the body, gradually deteriorate in function to some extent and that has concerns both for leaving an 82 year old with only one kidney but also for the recipient. The recipient is getting a kidney which has perhaps seen more miles on the clock and therefore it is less likely that that kidney will last for a very, very long time.

    Bakewell
    So what risk does an 82 year old kidney pose to its recipient?

    Surgeon
    Looking around the world we know that as the age of the donor increases the long-time outcome of transplantation decreases. However, we can't really say how kidneys from people who are in their 80s function because around the world there haven't been that many performed. So to some extent we're entering uncharted territory.

    Pamela
    The surgeon I saw told me about the risks that I was putting before another patient and I said to them well I think if you ask anybody on dialysis would they like to see if the can have any kind of life with a kidney donated by an older person I can't believe that person would say no. It's so awful to be on dialysis, really awful.

    Bakewell
    Time for the panel then to take up then to take up the issues that Pamela's story now raises. Antonia, dialysis, she says it's awful, it's really, really awful, give me some idea what it's like.

    Cronin
    People who have haemodialysis they're attached to a machine, usually three times a week for four hours at a time, and for many people this impacts enormously on the quality of life they're able to live. And there are a number of reports that suggest people think the quality of life doesn't come close to that that they would consider a value of a life worth living. That said there are a good number of individuals who are on dialysis who continue to work full time and have very fulfilled lives.

    Bakewell
    So would an 82 year old kidney be better than dialysis in people's judgement?

    Cronin
    I think that's a really interesting question. I think an 82 year old who's willing to donate a kidney who has remarkably good kidney function, which appears to be the case in this instance, would be very attractive to a number of individuals who are currently receiving treatment for their kidney failure with dialysis.

    Bakewell
    So Chris, how important is the actual age of Pamela's kidney that she's giving?

    Rudge
    Two things matter most: Is it safe for her to have an operation? And secondly, is the kidney working well such that it will provide a satisfactory transplant for somebody else? So in terms of the years of her age I would put that very low down on my list of important things, it's how well it's working that matters.

    Bakewell
    Well we've heard that Pamela had lots of tests of various things, can you give me some idea Antonia what kind of measurements were being taken of her kidney?

    Cronin
    Okay, so first of all a marker of how well overall the kidney functions and what this test estimates is how much blood passes through or filters, if you like, through the kidney to estimate how well overall it works. Now we know that overall there is a predictable reduction in the function of kidneys in normal adults over the age of 40 at a predictable rate and therefore one could say from that that people who are older are more likely to have less good kidney function overall.

    Bakewell
    Age matters in our society doesn't it, should you be preventing someone who's 80 putting themselves at risk for example?

    Radcliffe-Richards
    Well this is where the position of the medical profession is so interesting. The obvious thing that a medical person's expertise prepares them to do is give answers to the kind of question that Antonia was answering and Chris was answering but there's a very interesting question of why once you've got that information it should be the medical profession that makes the decision rather than the person who knows the risks to herself and the potential recipient who knows the prospects for them. Now of course the issue here is that you can't do this yourself, you can't just go along and hand your kidney over to a recipient, the medical profession has to do it for you. And the interesting question is why or how much they should make the moral decision of which risks should be taken.

    Bakewell
    Antonia.

    Cronin
    Janet, I agree with you in many levels but I think in this particular instance what we have to take account of here as well is the fact that the potential kidney is going to go into a transplant recipient and the healthcare professionals, a duty of their care, will be to provide the best they can for that potential recipient. And so if you were able to demonstrate that an individual, regardless of their age, had a level of kidney function that was not compatible with one that would result in a good transplant outcome then I think that's fairly good grounds for making a medically informed decision about whether or not the transplant should go ahead.

    Bakewell
    Chris?

    Rudge
    I think most people will accept that you can't force doctors to do things that they're uncomfortable with. A number of years ago I was asked to remove the second kidney from a man who'd already donated his first kidney to his first son and he wanted to donate his second kidney to his second son and he would then go on to dialysis. My reason for not doing it was that I, as the surgeon, didn't want to do it and he was very happy to accept that. Whatever I argued about his interests he knew more about his interests than I did but he accepted entirely that clinicians have to be comfortable with what they're doing as well as, of course, as the patient being comfortable with what's being done.

    Bakewell
    Now Chris does it and would it matter to you more that it was a stranger who would be the recipient?

    Rudge
    Donating a kidney to a stranger does raise I think a little question, it's only a little question in my mind, but I think it's a justifiable question, as to whether that is enough of a benefit to balance against the obvious risks that we know about. Now if you're donating a kidney to your child or your spouse or whatever there are very obvious and understandable direct benefits that accrue to you as the donor from that donation.

    Bakewell
    We've spoken of feeling that someone in their 80s could be a donor, Chris, but suppose Pamela was 92?

    Rudge
    I think my answer would be the same - it would depend on her general level of health and fitness and ability to undergo an operation and on the quality of the kidney that's being donated. I think all those things are likely to change the balance of risks and benefits the older somebody becomes, as a generality, but that's only a generality.

    Bakewell
    Now Janet, you've raised an objection to the medical profession making these decisions but to whom would you turn to make these judgements if not the people who are the best informed?

    Radcliffe-Richards
    I'm not saying that the medical profession should not make the decision. The interesting question is what is the moral question that the practitioners are asking? Are they saying is it reasonable for an elderly person to take this risk? Well I don't think they should be asking that question because that's the question the lady herself is answering. But if they're saying I'm reluctant - it's interesting to know exactly what they're reluctant about. Are they reluctant because they're afraid that they will feel terrible if the operation goes wrong and is their feeling terrible a sufficient reason for overriding the strong wish of one person and the potential rescuing from harm of another?

    Bakewell
    Chris.

    Rudge
    I think surgeons always feel awful when things go wrong. I doubt if that's their motivation, I think they're thinking what's a reasonable risk for this lady to take and are we content that the kidney's working well enough to give it to somebody else?

    Radcliffe-Richards
    But in that case if it's about the risks to these two people why shouldn't they be the ones to decide after you've given them the information?

    Bakewell
    Informed consent?

    Rudge
    I think very largely I agree with that, I think there has to be a threshold though. I think it's legitimate for the medical profession to say there's a level of risk that we don't think it's appropriate for us and our patient to take, be that the donor or the recipient.

    Bakewell
    Antonia.

    Cronin
    I think that doctors probably would be thinking about not just of this individual case but also of the living donor kidney transplantation programme in the broader context. Living donation of kidneys to strangers is, as we know, a relatively new thing, the first one took place in the UK in 2007, and we've seen a year on year increase in this to date. And I think there's a really important goodwill to want that success to be propagated and continue and I think that will be part of the consideration.

    Bakewell
    Can I ask you one medical consideration as well, the further one, which of course is that Pamela will be left with only one kidney - how risky is that?

    Cronin
    Well we know from evidence available that there is a predictable decline in kidney function over time from the age of 40 onwards. We also know that when individuals donate a kidney there is a compensatory increase in the remaining kidney's function so that overall it's anticipated that individuals have 75% or so of their overall functions once they've donated a kidney. However, there is less good information available that this compensation happens in the elderly population, being those over 60 years old.

    Bakewell
    Chris.

    Rudge
    It's a rather frivolous way of answering the question which is to say that the person that's been a living donor has a better future than their surgeon because they have had all the tests, they've been shown to be healthy, they've been shown to be fit, their surgeon hasn't. And there's published evidence that living donors have a better future than the general population.

    Bakewell
    Well that's good news for everyone who's thinking about it. But let's go back to Pamela's story now. It may be proving hard for her to become a donor, but it's certainly easier than it would have once have been. Today attitudes are more open to such offers as hers.

    Surgeon
    Ten, fifteen years ago we were less happy to consider people who were on the edge of the capacity to be able to donate. Nowadays because we see the need of people on the waiting list for transplantation living donation in general has become more frequent but also for these more marginal donors, for people who are perhaps more elderly or have some other problem, for instance high blood pressure which causes some problems with the kidney, in these circumstances we are prepared to think about live donation where up until now we would not have done so.

    Bakewell
    Only in 2006 did The Human Tissue Act, passed in 2004, allow people to donate a kidney - not to a friend or relative, but to a complete stranger. To date there have been just over a hundred such altruistic donations, and numbers are increasing year on year. The question arises - if Pamela is allowed to donate who should get her kidney? Altruistic donor kidneys are allocated according to the same strict set of criteria used for deceased donors. The problem in Pamela's case is that the system isn't designed to deal with donors of advanced age.

    Surgeon
    This was slightly difficult because let's say, for instance, we'd gone through the normal allocation system and her 82 year old kidney was allocated to let's say an 18 year old, would we have all been happy with that? Well no we would not. And so we had to think to ourselves are we going to, on this occasion, buck - are we going to change just for one individual the allocation system?

    Bakewell
    While the transplant team wrestles with the problem of allocation Pamela remains resolute in her desire to donate.

    Pamela
    I would have sat on the doorstep for another month and gone on hunger strike and I think they realised that. I probably would have died trying. I think I frightened them to death.

    Surgeon
    It is very difficult to go against a patient's decision when they are as determined as Pamela. But that said we also have a duty of care to protect the individual and I tried to get over to Pamela the wider effect that something that could happen to her might have, both on the staff of the unit but also on other patients if her operation went badly wrong it could have a negative effect on all of them.

    Bakewell
    Right, let's hear from our experts again. Chris Rudge, you actually set up the programme that allows people to give kidneys to a stranger, how's it going?

    Rudge
    It's going far better than I thought it would. The results are good, more and more people are coming forward and I am very encouraged. There are a hundred or so people now in this country who've had a kidney transplant that otherwise might not have done.

    Bakewell
    Antonia, in your experience is it changing the attitude of surgeons, of medical teams?

    Cronin
    I think it's very much evolving, I think the whole landscape of transplantation continues to evolve. However, I still there are a variety of views amongst healthcare professionals. But fair to say that as the programme increases in its activity one would hope that there would be a more permissive attitude to this on the whole.

    Bakewell
    Do you agree with this Janet?

    Radcliffe-Richards
    I think the technology is changing so quickly that people react to new things according to the habits they've developed under quite different circumstances and a lot of radical rethinking is needed. The fact is medical advances keep getting us out of our moral depth and for very understandable reasons the medical profession, who of course have to make the decisions, tend to be very conservative. But this is why bioethics is becoming such an important area because it analyses the questions from a different point of view.

    Bakewell
    Well Chris, can you explain the criteria that have to be passed before a kidney is donated to a particular recipient - who is going to get Pamela's kidney, how are they going to decide?

    Rudge
    When a living donor wants to donate a kidney to a stranger the same complex computer programme that's used for allocating a kidney donated after death is used to identify the recipient of this donation to a stranger. A number of things are taken into account: the age difference between the recipient and the donor, the tissue match, the length of time the person has been waiting for a transplant - the longer they wait the more points they get - and a number of other more subtle biological features. And the computer generates from this list of people that are waiting the person with the most points. And the kidney is offered to whoever comes out top of that list.

    Bakewell
    Who would be the recipient of an 82 year old kidney, would that affect the criteria?

    Rudge
    Part of the allocation process is to try and limit the difference in age between the donor and the recipient. So it's unlikely that the computer program would come up with an 18 year old but it could and I think it would then be for that 18 year old with the advice of the doctors looking after him or her to decide whether this was an appropriate offer of a kidney for them to accept or not. They may be in such circumstances that this is their best chance ever of having a transplant and it might be the right thing to accept it. But there's so little evidence on which that decision can be made with certainty, it's a judgement and I think it's actually quite tricky.

    Bakewell
    We are likely to have more older donors, do you think the system needs to be revised Antonia?

    Cronin
    In recent years we have seen a significant increase in the number of donors who are over the age of 60, this is not just living donors who've come forward but also in the deceased donor population too. And I think in a way it's almost aspect incumbent upon the transplant community to go back and even possibly rethink the allocation system in light of this because as I think the surgeon said earlier on the programme that we have entered into an area of unchartered territory. There is some evidence that has become available to suggest that kidneys donated from the elderly - and I hesitate to say that elderly, the criteria here is over the age of 60 - but these do equally well in those transplant recipients who are themselves over the age of 60 and there has been some concern raised that because they do perfectly well in this age group that kidneys from older donors should be allocated to potential transplant recipients who are a similar age group. Whether or not that's correct or not I think is open for debate and it seems to me in some sense that the age criteria is arbitrary and one might suggest that quite possible actually using kidney function is a better marker of who the kidney should go to.

    Bakewell
    It's interesting because this problem is going to increase isn't it, you've got an ageing population, I mean I'm old and I'm down on the donor list so one day I'll be the problem, what do you think about this Janet?

    Radcliffe-Richards
    I think it's totally open to debate. One of the - I said that many new issues keep arising - one of the interesting ones here is that doctors have traditionally asked simply should I give this patient this treatment where they take the drug off the shelf or whatever and here we have potential treatments that are of a whole variable range of quality and we have to try to work out how to allocate the different qualities to different people. And the other thing that's interesting is that if you talk to transplant surgeons now they say that a lot of their experimental procedures would simply not have - would not be allowed now, the kinds of pioneering procedures they did, because there were so many risks to the patients and the donors. And we simply have to work out how many risks we're allowed to take and not be too risk adverse.

    Bakewell
    Okay, well we know Pamela's story so far and I want to ask each of you what would you advise knowing what you know now of the story. Antonia Cronin.

    Cronin
    I think this is a very difficult question to answer and I think the position of the transplant team is difficult and given that there isn't a consensus of information available but there is some evidence to support the view that kidney transplants from older donors do perfectly well in older age recipients then I don't think I would think it unreasonable of the transplant team to support that type of decision.

    Bakewell
    Chris Rudge.

    Rudge
    Well I think I probably still think like a surgeon, so I think Pamela should donate, I think the allocation system should be changed in two ways: one is the kidney should preferentially go to an older recipient rather than a younger recipient and secondly, I think it should be transplanted as quickly as possible after it's been removed and if that means it has to be transplanted in the hospital close to wherever she has it removed rather than into a patient at the other end of the country well so be it.

    Bakewell
    Janet Radcliffe-Richards.

    Radcliffe-Richards
    That sounds absolutely right, I think this woman is splendid and I think she should certainly go ahead and if one surgeon doesn't want to do it find another one that will. And if - the important question is here is about whether there's a threat to the programme if anything went wrong, now when you have a problem like that you've got two risks balanced against each other. What you try to do is find a way to lessen one of the risks. I would have got this woman on television so that everyone could see her saying I'm taking the risk, it's not the transplant team's fault if it goes wrong, it would give wonderful publicity to the transplant programme, I think you could get round it that way.

    Bakewell
    Well we have got her on radio Janet. Let's now hear how Pamela's story worked out: what decision did her transplant team come to?

    Pamela
    I was called back to see the surgeon I had seen originally and I was told that I had passed all the exams and that they were going to put me on the waiting list and I had jumped over the moon. I can't tell you how happy I was.

    Bakewell
    The team decide to buck the allocation system. Acting within the rules, they pinpoint the top five most suitable candidates - and then they give the kidney to the oldest.

    Now Pamela has jumped through the hurdles it's time to tell her son and daughter of her plans.

    Pamela
    I told them that I was going in for surgery and they said - What made you do it? And then I said - You've forgotten about what your father went through. And they said no they hadn't but they thought it was wonderful and they said good for you mum, that's what I wanted them to say. And then the time came when I got a little telephone call saying could you come to the hospital. I couldn't believe it.

    Bakewell
    Pamela can't wait to donate, but the transplant team are still concerned, for them this is uncharted territory.

    Surgeon
    I guess I picked up from perhaps colleagues in the rest of the hospital who were slightly wondering what we were doing operating on an 82 year old to remove a kidney and there was a certain amount of anxiety in the team I think that although we'd thought this through very carefully, we'd thought through the allocation carefully, that actually something bad might happen to Pamela.

    Bakewell
    In the event Pamela's operation went smoothly. Her left kidney was removed by keyhole surgery and after four days in hospital she was discharged back home.

    Pamela
    It's given me sheer happiness because I had just felt that there was something I could do that would relieve me of the pain of my husband's death, which it did. I really feel I've done what I wanted to do in this world and then I will depart very happily. I'd like to give a piece of my liver but I haven't been able to convince anybody yet - yet. (Laughs)

    Bakewell
    And the donor? Pamela donated anonymously so she and the recipient of her kidney have never met so she's now hearing his voice for the first time.

    At the age of 69, Paul's kidney had been failing for 10 years, then at the stage when he would have to go on dialysis he was offered Pamela's kidney. He was told his donor was 82 years old.

    Paul
    I sort of wasn't concerned at all, I'm no spring chicken meself. The thing that's amazed me really that a person could have the sort of courage and the generosity to do something like this. So I sort of wrote the letter and I think I just wrote Dear Friend. I'm sorry, she's been to me a really good friend.

    Pamela
    That letter really sent me soaring, it was wonderful. He said he'd been out for the first time in three years to take his grandchildren for a walk and that was - oh you know that was really when I knew I'd done the right thing and I wish I could give the other one.

    Paul
    The difference it's made to us, it's just - it's like giving me a new life. I wake up now and I'm not tired, we're able to play with the grandchildren now and take them out, I just couldn't have done it previously, it was really difficult and I'm sort of not tired doing it, well I am tired a bit. (Laughs)

    ENDS

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