Sergey Gauthier: "Black transplantation is impossible in Russia"
Andrey Samokhin, Kultura newspaper
This year is rich in anniversaries and events in the domestic transplantology. Half a century – the first kidney transplant, 25 years – a similar operation with the liver. In the summer, parliamentarians adopted and then signed by the president amendments to the law "On the basics of public health protection in the Russian Federation", opening a new page in posthumous, including children's, donation. Even during the discussion, the amendments caused protests from a part of society.
We are talking about fictional and real pain points of the industry with the director of the Academician V.I. Shumakov Federal Research Center for Transplantation and Artificial Organs, chief transplant specialist of the Ministry of Health of the Russian Federation Sergey Gauthier.
Culture: The expert of the State Duma Committee on Family, Women and Children, Hieromonk Dimitri (Pershin) proposed to introduce a voluntary "posthumous donor card" in the country – as an insert in the passport. In his opinion, such a form would be a reasonable compromise between the presumptions of "disagreement" and "consent" to posthumous organ removal. It is the latter, it seems, that causes the most fierce disputes in society?
Gauthier: Now in the Russian Federation there are several acts concerning the statement of death, the will of the deceased about donation and the proper attitude to the body of the deceased. The 1992 law on transplantation confirmed the presumption of consent that worked in the USSR. That is, if there is no explicit prohibition of a person or his relatives, then the organs can be removed after death. It has been preserved even after the current amendments. All my colleagues, who have to look into the eyes of people whose lives depend on donated organs every day, are convinced that this is the right thing to do.
As for Father Dimitri's "consent card", it is ideologically a useful step, but it must be registered somewhere. We need an official register where voluntary potential donors will be marked, which will make the process of voluntary post-mortem organ removal work effectively nationwide. In the meantime, voluntary donation has not become widespread, it is necessary to improve the existing system. Thank God, the ice broke in the summer: the long-awaited amendments to the law "On the basics of health protection ..." were adopted, budget funds were allocated that will allow medical institutions to financially motivate to preserve organs after a person's death. It is important that, thanks to the approved instructions for the diagnosis of brain death, from January 1, 2016, we will theoretically be able to work with children's organs, of course, with the consent of parents.
Culture: Is there an alternative to transplantation as such?
Gauthier: Recently, hepatitis C, which was considered incurable, was medically defeated. Leading very often to cirrhosis and liver cancer, this ailment gives a huge number of "waiting lists" for a transplant. After some time, the number of such will decrease worldwide. If we take the heart, then in many countries and in our country, among others, they are actively engaged in the creation of artificial devices that replace it in heart failure. There are intermediate results on growing mouse hearts from stem cells. With all the current imperfection of these paths, I think in 10-20 years they can lead to a full-fledged alternative to transplantation. By the way, our center has become the developer of the first artificial left ventricle of the heart in Russia. Now it is already beginning to be put to patients in some cities. To summarize: transplantology will gradually be replaced by other methods, but today for hundreds of thousands of earthlings this is the only hope for life extension.
Culture: Your opponents, especially in the context of the latest amendments, claim that motivated resuscitators may deliberately "not be zealous" in bringing a "valuable" donor back to life...
Gauthier: The argument is completely illiterate. To get a normal organ, the patient needs to be treated very well, even with an overwhelming probability of death. The donor material should maintain full blood circulation even after the diagnosis of brain death. This simply excludes intentional "undertreatment" in the intensive care unit. There is even such a paradox for non-specialists: the brain is no longer working, but the body is still being treated...
I think an epoch–making event took place in the country this year - the maintenance of some body functions, despite the diagnosed clinical death, is recognized as a medical activity. Accordingly, the hardest work of doctors who were engaged in this on pure enthusiasm will finally be paid. By the way, about children's posthumous donation: the obligation of the requested parental consent is established by law. Thus, the topic of the possibility of "parsing for organs" of deceased orphans from orphanages is completely removed.
Culture: Recently, a scandal surfaced in the press with the "unauthorized" removal of organs of 19-year-old student Alina Sablina, who died in hospital after an accident...
Gauthier: The scandal was inflated due to elementary ignorance of the law. After all, it does not prescribe that doctors are obliged to inform the relatives of the deceased about the removal of organs after the death is confirmed. That is why they were denied the initiation of a criminal case. But, on the other hand, judge for yourself: a loved one has died, and the doctor, reporting the tragedy, offers the crushed relatives to decide right now whether to remove organs from the corpse. Yes, can a person in such a state decide something? In addition, in most cases, finding relatives and taking their written consent is not a matter of one day, and sometimes it is impossible at all.
A normal approach to the problem of donation in the United States: when you get a driver's license (and they get almost universally there), a permit or a ban on posthumous donation of your own organs is marked with a special icon. I do not agree with everything that happens across the ocean, and the further – the more. But it is precisely this tradition that gives them 26 cases of posthumous organ removal per million of the population every year. Which provides approximately 20,000 transplants per year. Compare: we have one and a half thousand such operations a year, with the corresponding figures of organ removal slightly more than three per million. And this is with the current presumption of consent! Even in neighboring Belarus, the same indicator is 18. It turns out that people there treat each other more... brotherly, or something.
Culture: And the Russians?
Gauthier: And Russians, sorry for the truth, – in most cases negatively, sometimes even in a slob-like way. This is the main problem of the development of transplantology in our country. Compatriots simply do not want to understand that by refusing, they deprive several fellow citizens of hope for life. In a Christian way, and simply – is it human? I don't think. Unfortunately, neither the state nor the Church, with the exception of some of its representatives, have until recently been engaged in explaining the ethical meaning of donation. But you have to start doing this, almost from kindergarten, as in European countries.
Culture: Well, in Europe they teach a lot of things from kindergarten...
Gauthier: I agree, not everything needs to be adopted, and for donation it is necessary to find words and concepts not "borrowed", but rooted in national meanings. And there are such. This year, the state seems to have turned its face to the problem of public propaganda of donation. And our Church is finally beginning to speak out more definitely on this topic.
Culture: Actually, it has long been written in the "Fundamentals of the Social Concept of the Russian Orthodox Church" that organ transplantation based on the will of a person is a manifestation of Christian love....
Gauthier: Of course, I know about this and I consider the Russian Orthodox Church, as well as other traditional confessions, allies. But, unfortunately, some media outlets, as if on behalf of believers, still broadcast a lot of harmful fictions about our work. There are so many horror stories that you don't have time to react to them.
Some of the terrible scenarios expressed by "experts" who do not know the essence of the matter, causes persistent grudge among professionals. Because it contradicts simple realities. For example, the "cultivation" of future organ donors by rich villains "for themselves". The donor and recipient should have a lot of indicators. There is a pattern: out of 17,000 earthlings, only one pair is fully compatible for transplantation. In practice, an organ is not selected for the patient, but a suitable recipient is being sought for the already withdrawn organ. This is done by the Moscow Coordination Center for Organ Donation with a single automated online database of seized organs and people waiting for a transplant. It was created thanks to the Moscow Department of Health; there is nothing like it in the rest of Russia yet.
Culture: But after all, international "black transplantologists" are not stories!
Gauthier: In Kosovo, during the confrontation with the Serbs, human organs were indeed criminally seized, as the UN investigation showed. There is indirect information that similar barbarism was committed last year in the Donbas. But in both cases there was war and state chaos. In Russia, today, every seizure is recorded and logged multiple times: there are simply no private clinics, cryophages, ways of selecting recipients and transporting them. In our country, it is simply unrealistic to carry out such activities secretly. By the way, at one time in the USSR there was an agreement with the COMECON countries on the exchange of organs. But these flows were so minimal that the project burst on its own. Can such an agreement arise within the framework of the EAEU or BRICS? Theoretically, yes, but this is not tomorrow's case at all.
Culture: Is the creeping commercialization of medicine the reason for distrust of transplantology? Thus, sharp criticism in the media was caused by the accreditation in May by the Ministry of Health of the Russian Federation of the Fortis network of commercial Indian clinics specializing in organ transplants as an official partner of the Russian state. What is this – a sanction for transplant tourism?
Gauthier: Commercialization in this area should by no means be allowed – neither legally (as it is now), nor even at the level of discussions. In 2008, the majority of countries developing transplantology adopted the "Istanbul Declaration", one of the main principles of which was the development of organ self-sufficiency. That is, in order not to expose citizens to the temptation to sell abroad, for example, their kidney. Or vice versa, to go to a foreign commercial clinic based on someone else's organ, which is called transplant tourism.
Russia was not officially invited to that meeting, but our professional community voluntarily follows the adopted declaration. For example, no domestic clinic performs commercial organ transplants to foreigners. Although the law does not prohibit this. This is an ethical axiom! If about 17,000 of our fellow citizens are waiting for a donor "Russian" kidney in Russia, then why should a rich "foreigner" get priority? As long as I hold my position, this will not happen.
As for Indian clinics, the situation is as follows. Russians have every right to go abroad for medical care that cannot be provided to them at home. For example, until today – heart transplantation for children. Moreover, the state is even obliged to send them there. Why India? Yes it's very simple: there are qualified doctors, high-quality clinics and... high infant mortality. I hope that with the development of Russian transplantology, including its "children's" direction, the necessity of such partnerships will disappear.
An "organ resource" is a national wealth, and one that is not traded under any circumstances. This is definitely the area of responsibility of the state. In this sense, the new law adopted in the summer, as well as the State Program for the Development of Healthcare until 2020, are long–awaited steps towards the transplantation sovereignty of Russia.
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18.09.2015