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King's College London - Health: More than a medical matter






Report Review: Human Bodies - Donation for Medicine and Research

24 October 2011

By Antony Blackburn-Starza

Appeared in BioNews 630

It was the recommendations to pay for the funeral expenses of organ donors and to remove the cap on compensation for gamete donors that made the headlines. But it is not the specific recommendations of the Nuffield Council on Bioethics' report 'Human bodies: donation for medicine and research' that it will be remembered for.

What will remain in the memory is the way in which the Council went about its deliberations, which this review focuses on. It may be some time, therefore, before the true value of the report becomes apparent, but a few significant points are immediately worth comment.

First, the report seeks to establish a common framework or 'shared consensus' for policy makers within the wider and fragmented sphere of donation. The scope of the report is ambitious. It covers a wide range of human bodily material including blood and blood products, organs, tissue, gametes, embryos, fetal and embryonic stem cells and the living or whole body after death. Furthermore, it recognises the 'pluralism that characterises people's values, attitudes, beliefs and behaviours' in relation to the human body. But the report finds central ground upon which it establishes an overarching framework to implement policy. This is commendable.

Common to all is the crucial role played by the 'transaction' of donation and the 'intermediaries' involved, it says. This immediately dislocates the goal-orientated agenda of the state from the irreconcilable (moral) attitudes of individual people – allowing a common policy to take hold. If we focus not on the views of individuals, but the interests of society generally then certain conflicts or tensions in foundational ethics can be seemingly avoided.

Second, the report represents a descriptive analysis of the social, legal and political context of donation which makes it the latest authority in this area and very useful reading. It acknowledges that bodily material circulates within a global market place and recognises the pressure within the UK to meet often results in fertility clinics not being able to meet requests for IVF treatment. More specifically, the rate of egg donation has declined and the numbers of eggs available does not meet the demand from researchers and people seeking IVF.

Third, and perhaps significantly in years to come, is the Council's 'solution' to the above problem is framed in a symbiotic ethical framework between a state that actively promotes measures that improve general health, on one hand, and the notion of altruism as the basis for donation. This is advantageous in two ways. Its emphasis on the role of the 'state' allows for practical recommendations that bypass a potentially stifling ethical debate on the foundational ethical questions over the moral basis of donation, as above.

Further, by advocating 'altruism' as its favoured principle, the Council manages to a certain extent to avoid the problem of mutual exclusivity that other principles, such as autonomy, appear to attract. Yet it does not 'exclude' other approaches and invites principles such as welfare of the donor and the potential of harm and exploitation in 'non-altruistic focused' interventions, discussed below. Neither does its ethical framework become amoral. The Council affirms its previous position against the concept of purchase of bodily material.

Crucially though, the Council gives the framework some direction to determine in what ways it is ethically acceptable to 'encourage' individuals to donate their bodily material. It takes the standpoint that policies that aim to increase supply or reduce demand for blood and organs are justified by the broader context of public health. Thus its framework is goal-orientated, making for a workable overarching methodology – the details of which are discussed next.

Fourth, the language the Council adopts to determine the acceptability of public health policies provides clear and practical guidance to the healthcare professionals involved. It sets out an 'Intervention Ladder' – developed from an earlier report - where each 'rung' (six in total) takes the form of a type of intervention or 'input'. It surmises: 'The more intrusive and restrictive the policy on individual choice and liberty, the greater the justification required from the public health policy'.

The rungs range from actions which are seen as 'ethically straightforward', in the lower rungs, to those which are ethically more complex – rather than ethical or unethical, as such.

Rung 1: information about the need for donation

Rung 2: recognition for altruistic donation

Rung 3: removal of barriers and disincentives to donate

Rung 4: extra prompt or encouragement to donate

Rung 5: offering associated benefits in kind to encourage donation

Rung 6: offering financial incentives that leave the donor in a better financial position

The first four rungs are termed 'altruist focused' and the rungs five and six are said to be 'non-altruistic focused'. 'Non-altruistic focused' interventions must be closely scrutinised, it says, to ascertain whether it might be 'harmful'. Yet it emphasises that a departure from the altruistic model would be 'reckless' and could 'run the risk of irreversible damage to important communal virtues'.

Thus the report distinguishes between different types of donation – donating for research or donating for oneself or specified individuals – allowing for more restrictive approaches were necessary. In this two-tiered approach, the report acknowledges that there is something 'special' about donating ones' bodily material – be it an organ or gametes – and the value of this should be reflected in policies designed to promote donation to a burgeoning demand in healthcare and research. But likewise this may require greater justification for non-altruistic interventions.

For me, it is not only the specific recommendations and the broader ethical framework that strikes me as the most significant contribution the report makes in the area, but the simple point that it moves the debate over incentivising donation forward. In short, it provides a brave a pragmatic step forward and towards facilitation. The report reads very much as a 'tool' for healthcare professionals.

However, avoiding the central question of whether one is morally required to donate may be a fundamental weakness that may impede future progress.

This is important, as vast improvements can be made in bridging the gap between the initial decision to donate and the physical act of donation, whatever the reasons are to donate.

Furthermore, and to end on a cautionary note, an emphasis on procedure for donation could make it more difficult to formulate substantive criticisms of one's reason for donation. This may leave us without a mechanism to regulate the area.

 

SOURCES & REFERENCES
Nuffield Council on Bioethics | 11 October 2011
 
Progress Educational Trust | 13 July 2011
 

RELATED ARTICLES FROM THE BIONEWS ARCHIVE

28 August 2012 - by Daniel Malynn 
In this documentary of extremes, freelance journalist and documentary producer Storm Theunissen finds out how cash-strapped Britons can make money using their bodies. On one side, you have Storm's outlandish plans to make money by selling urine and earwax for medical testing. On the other, there is an altogether more interesting and insightful look at egg donation in both the UK and USA.... [Read More]
23 July 2012 - by Dr Marilyn Crawshaw and Jennie Hunt 
The Human Fertilisation and Embryology Authority (HFEA) recently announced membership of its newly formed National Donation Strategy Group, set up in response to the findings of its earlier Donation Review, which, it says, uncovered numerous barriers to gamete donation.... [Read More]

24 October 2011 - by Professor Dame Marilyn Strathern 
'How far should society go in encouraging people to donate their bodily material?' is the question at the heart of the Nuffield Council on Bioethics' report on the ethics of donation for medicine and research, which was published earlier this month... [Read More]
17 October 2011 - by Professor Eric Blyth, Jennie Hunt and Professor Olga van den Akker 
We welcome much of what Kamal Ahuja wrote in his recent BioNews Commentary 'If it ain't broke don't fix it'. Like him, we believe there is no good evidence to demonstrate that paying 'donors' would increase the supply of donated sperm or oocytes. On the contrary, there is evidence to suggest that properly constructed donor recruitment programmes – such as the one pioneered at the London Women's Clinic – are capable of recruiting a good supply of altruistic donors... [Read More]
17 October 2011 - by Antony Blackburn-Starza 
A report on the donation of human bodily material for medicine and research has made several recommendations including removing the current cap on egg and sperm donor expenses in the UK... [Read More]
30 September 2011 - by Dr Kamal Ahuja 
The Human Fertilisation and Embryology Authority (HFEA) has already made two decisions following its public consultation and review of gamete donation policies in the UK: first, intra-familial gamete donation can continue as before (subject to certain provisions); and second, the number of families which a single donor might help create remains limited to ten. The bigger question on compensation and benefit in kind to donors will not be answered until later this year... [Read More]

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