Dr. David Hickey:

It is nice. I do appreciate it.

I am the director of the national kidney and pancreas transplant programme. This programme is also responsible for organ procurement which is the main topic of discussion today. I have been committed to this programme for 30 years, having personally performed over 1,500 kidney and pancreas transplants and 300 organ procurements. I feel I am in a position to comment at least on my own area which is organ procurement, kidney and pancreas transplant.

The programme started in Jervis Street in 1964 and this year we will complete our 4,000th transplant. This puts the national kidney transplant programme in the top 20 in the world in terms of numbers done. We started only six years after the first successful transplant was done in Boston. We have been at this a long time and I have seen many things happen. Every initiative and advance in this area has been made through the hard work of a few committed individuals. There has never been a national approach to the concept and problems associated with organ donation and kidney transplantation. For example, when we moved to Beaumont in 1987 they forgot that there was a transplant programme moving from Jervis Street and we had to re-jig the urology ward. Essentially that ad hoc concept is how transplantation has been dealt with since.

The main subject of the discussion today is organ procurement. While we need more organ donors I want to emphasise the impact of that on a service that is already stretched beyond its limits in which we are already failing our patients. The numbers waiting are increasing but the numbers being transplanted are not. I will talk about the lack of organ donors, the poor infrastructure in which transplant patients are housed, the shortage of transplant surgeons which is reaching crisis and what I think the ideal for the country should be.

The more donors we have the more organs are available for our patients with end organ failure - liver, kidney, pancreas, heart and lung. There is a global shortage of organs for transplantation, particularly kidneys. It is generally accepted around the world, particularly the western world where this is taken very seriously, that renal failure management is going to bankrupt health services in the next 20 years. I do not know the figures here but in the United States already something like 15% of the health care budget goes on less than 1% of the renal failure patients. With diabetes and end-stage renal failure increasing this will get worse. We need to address this because if we do not we will be talking about rationing dialysis in the not too distant future. That means that there will be no dialysis for people like me or anyone over 60. If one is under a certain age there will be no dialysis. If perhaps one is mentally retarded, or if one is not a valuable member of society, there will be no dialysis and so on. This is a slippery slope and it happens in countries that cannot sustain themselves with transplantation, such as India, Pakistan and Israel, where people go abroad and buy kidneys because there is no alternative apart from dying. While one can have ethical concerns about that, if one has to choose between dying and buying a kidney most people eventually will buy the kidney. That is a slippery slope that is at the end of failure to address this problem while we can still do something.

We have reached a plateau in transplantation in Ireland. We have approximately 18-20 donors per 1 million of the population which up to ten years ago was one of the best rates in Europe. Seeing the coming storm, most European countries have adopted a process of investing in organ donation. It has been done under the concept of presumed consent, the soft opt-out.

The legislation had certain achievements, including bringing transplantation into mainstream discussion at government level in these countries. Most people involved in transplantation travel and know the real advantage is the huge investment in infrastructure at local donating hospital level.

I am sure everyone here knows that presumed consent does not mean a thing. Nobody anywhere in the world takes organs from a child or a person's loved one without seeking the permission of the family. This just does not happen. One can call it what one likes. The presumed consent concept should mean it is presumed anyone looking after a patient who has died offers the family the opportunity to donate. This is an immense consolation to the family. It is a service to a family who has lost a loved one and is not just an organ procurement agency looking to do more business. It offers immense consolation down the line that a young person's family knows that at least, out of a hopeless situation, five people had their lives saved and significantly improved. The other side of the coin is that occasionally we receive letters from families who were not offered this consolation and not asked about organ donation. It is usually out of a perceived kindness as medical personnel wonder how can they possibly bring up this topic at such a time. It is a very delicate area which needs to be examined. The kernel of the problem is that people do not ask because they feel, and justifiably so, that as they have been looking after someone for a while they cannot possibly turn around and ask. I support the concept of soft opt-out presumed consent, but only if it brings organ donation into the main arena and introduces a presumption that everyone wants to do it, and the infrastructure must go in at ground level, which has been the message throughout Europe.

We must address the issue of infrastructure. Hospitals are generally accepted as the location of some of the saddest and happiest moments of our lives. Internationally it is recognised that when it comes to architecture, hospitals should be among the most inspiring public buildings. Every one of us has horror stories and happy stories from hospitals and can empathise with this. The situation in most hospitals is unacceptable for 2013 living. We should examine having something similar to the situation in Norway, a country of 4.6 million people. It has one transplant centre which does six times as many lungs and twice as many kidneys as we do. We must look at this.

The next problem in transplantation is transplant surgeons. No transplant surgeons means no transplant. This is a bigger crisis than the lack of donors for the continuation of transplantation in Ireland. Transplantation surgery cannot recruit young people into training. Anyone we do train goes to the United States the minute he or she can tie a knot because of the opportunities there. It involves night work and weekend work and is not what we call a lifestyle-friendly medical career, which is what many graduates seek nowadays. I will give an example of the impact. Transplant surgeons have the second highest divorce rate among surgeons in the world. Neurosurgeons have a higher rate, mainly because they are neurosurgeons. With transplant surgeons it is because of the lifestyle - they are never there.