HEAL Committee Meeting

STANDING COMMITTEE ON HEALTH

COMITÉ PERMANENT DE LA SANTÉ

EVIDENCE

[Recorded by Electronic Apparatus]

Wednesday, February 17, 1999

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[English]

The Chair (Mr. Joseph Volpe (Eglinton—Lawrence, Lib.)): Order. Thank you for your attention, ladies and gentlemen, and colleagues.

Pursuant to Standing Order 108(2), a study on the state of organ and issue donation in Canada, session six—you think it's five, but I think it's six—is now in session.

Today we've had a few cancellations.

I propose that we operate in a panel, large as it is, and proceed accordingly. Typically what we do is ask our witnesses to provide us with about a five-minute intervention and then make themselves available for questions and answers from members present.

I hope you're in agreement with that, gentlemen.

Let me just give you a brief introduction.

Dr. Stuart John Smith is medical director of the heart failure clinic at the Canadian Cardiovascular Society.

Dr. Jean Tchervenkov is director of the transplant program at McGill University Health Centre.

Dr. Bill Wall is director of the multi-organ transplantation unit at London Health Sciences Centre.

Dr. Paul Greig is director of liver transplantation at Toronto General Hospital.

It's nice to see a hometown guy here. I know it's a little bit...coming down to Ottawa, but....

Dr. Kevork Peltekian is assistant professor at Dalhousie University, hepatologist at Queen Elizabeth II Health Science Centre, and medical director for the Atlantic Canada liver transplantation program at Victoria General Hospital. Well, that's where he is now.

As well, we have Dr. Wilbert Keon, a colleague from the other place. He is director general at the University of Ottawa Heart Institute.

As per the other sessions we have had, we have a colleague, again from the other place, who is here as an observer, Senator Simard.

Gentlemen, I bid you all welcome, and I look forward, as I know all of my other colleagues do, to your intervention.

Now, I could be parochial and invite the Toronto guy to speak first, but then I'd get slapped silly. Why don't I just start at my left, with Dr. Stuart John Smith.

Dr. Stuart John Smith (Medical Director, Heart Failure Clinic, Canadian Cardiovascular Society): Thank you very much.

I'd like to thank you for my opportunity to speak to you on behalf of the Canadian Cardiovascular Society on issues regarding cardiac transplantation and strategies to improve organ donation.

The Canadian Cardiovascular Society is a non-profit medical society, established in 1947.

You'll be receiving a handout regarding it, with a detailed summary.

More than 2,000 heart transplants have been performed in Canada since 1981. Since 1993 the number of heart transplants performed per year has remained constant—160 to 180 per year.

As well, the number of potential recipients for cardiac transplant has increased steadily. This is as a result of two things—(a) relaxation of recipient criteria, and (b) an increasing incidence and prevalence of end-stage heart failure. However, the number of donors has remained constant over the past decade or slightly decreased. As a result, cardiac transplant programs across the country have adapted over the years to deal with the increasing mismatch of supply and demand.

Reasons for inadequacy of donor organ supply have been reviewed in numerous previous conferences and committee meetings. When one reviews the minutes of these meetings, one is struck that the reasons have not changed over the years.

Reasons for inadequacy of donor organ supply include the following:

(1) ineffective hospital practices with regard to donor identification;

(2) inadequate knowledge on the part of health care personnel regarding suitability for organ donation or referral;

(3) inadequate knowledge on the part of health care personnel regarding issues concerning brain death, diagnosis, ability to explain the issue of brain death to lay persons, etc.;

(4) health care personnel not interested in getting involved in donor identification referral due to the concerns of excessive time issues, conflict of interest, potential for liability, and excessive emotional stress;

(5) inadequate knowledge on the part of health care personnel regarding techniques on how to approach donor families;

(6) inadequate knowledge on the part of health care personnel on donor management prior to organ retrieval;

(7) barriers to and disincentives for hospital and professional involvement in the identification and procurement process;

(8) impact of hospital restructuring, financial issues, and fewer IC beds;

(9) an individual's desire to donate is not known by the members of the family;

(10) a decrease in public education campaigns; and

(11) lack of independent national body to co-ordinate, educate, and make recommendations to the public and to health care personnel regarding organ donation.

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Based on the major problem areas identified, a number of strategies to improve organ donation in Canada are proposed.

The first strategy would be the development of a national organization to oversee all aspects of organ transplantation in Canada. Currently organ procurement is essentially regionalized. Each of these groups has different responsibilities and essentially regional algorithms.

A Canadian national organization, which would oversee all of organ transplantation, would be responsible for the following:

(1) donor identification in secondary and tertiary hospitals, including tracking of potential donors not usually considered for transplant;

(2) a special donor team in secondary and tertiary hospitals trained in techniques for approaching grieving families;

(3) donor management training of health care personnel and development of algorithms for donor management;

(4) development of education programs for health care personnel and the general public regarding organ donation, the donation process, and the outcomes of transplantation;

(5) development of national algorithms for the optimal allocation of organs; and

(6) maintenance of a national recipient list for patients awaiting transplant.

Strategy two would be education of health care workers regarding donor identification, donor management, and the benefits of transplantation.

The third strategy would be education of the general public regarding the importance of organ donation and the benefits of transplantation.

Strategy four would be to revisit the issue of presumed consent. Despite educational programs in such countries as Canada, which has an opting-in system, the number of organs available for transplantation has not kept up with the demand. Many countries have changed from an opting-in to an opting-out policy, with significant increases in organ donation as long as they have applied other initiatives.

Previous concerns about this form of organ donation have not borne out. A variation of a presumed-consent system of organ donation would be the development of a national organ donor registry.

The fifth strategy would be financial support for organ donation initiatives. In order for organ donation to be successful, financial support is required at both the hospital and national levels in order to support national endeavours.

In summary, more than 2,000 heart transplants have been performed in this country since 1981. For years the number of heart transplants performed rose steadily, until the early 1990s, when the rate of cardiac transplantation plateaued at 160 to 180 per year. During the same time period, the number of potential recipients increased steadily while the number of suitable donors declined.

There is no doubt organ donation saves lives. It should also be obvious that there is no single cause that explains the organ donation shortage here in Canada. As a result, no single strategy will be effective in resolving the issue, and no single group or organization will be successful on its own.

Three major problem areas have been identified. The first is the need for intensive education of the public and health care personnel on issues related to organ donation and transplantation.

Second, there is the need for a single national organization to direct all aspects of organ transplantation in Canada, with emphasis on organ donation education.

Finally, there is the need for financial support for educational programs and a national transplant organization.

I would like to finish with the following quotation from testimony before the U.S. Congress in 1990:

What is truly distinctive about transplantation is not technology or costs, but ethics. Transplantation is the only area in all of health care which cannot exist without the participation of the public. It is the individual citizen who while alive, or in the case of vital organs, after death, makes organs and tissues available for transplantation. If there were no gifts of organs or tissues, transplantation would come to a grinding halt.

We should always keep in mind that the donation and transplantation process starts and ends with society, and the citizens are its driving force and its main beneficiaries. Health care professionals are obviously necessary, since donors and recipients cannot come into contact by themselves, but it must not be forgotten that professionals are only there to help and be useful, and will never be the main protagonists.

Our overall aim must be the optimization of the donation and transplantation process in order to alleviate the organ donor shortage. What better way to do this than through the development of a national transplant organization responsible for identification, referral, and equitable distribution of organs throughout this country.

Thank you very much.

The Chair: Thank you, Dr. Smith. I thought for a minute the quote was going to be longer than the presentation.

Dr. Tchervenkov.

Dr. Jean I. Tchervenkov (Director, Transplant Program, McGill University Health Centre): Thank you, distinguished panel, for having me, and for inviting me to speak on behalf of my program at McGill University.

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I am a surgeon, a transplant surgeon, who has been directly involved in organ procurement for the last 10 years. As the surgical director of the McGill University program, I have seen perhaps many of the problems addressed today and over the past few days. I'd like to take the opportunity to discuss these with you.

I will not dwell on some of the issues that were discussed. I think it would be repetitious. They are part of my exposé, and you can read them. I second Dr. Stuart Smith's comments.

I'd like to start by trying to paint a brighter picture than what we all may have espoused. I don't think organ transplantation is that dismal in the country. In fact, I'd like to suggest that as a community, my colleagues throughout the country have done a marvellous job. I think we can proudly say that we have if not the best results in the world, then probably close to the best results in the world, and we should not bow our heads to any other country.

Nonetheless, I think a severe underfunding in the past several years, along with perhaps some of the issues discussed by Dr. Smith, have not allowed us to progress.

It's no secret to all of us that the number of organ donors per million in the country has remained steadily the same for the past decade while the number of recipients who need this life-saving procedure has continued to increase. This honestly does not compare well with other countries. Many countries have doubled the organ donor rate, and some, such as Spain, Belgium, Austria, and the Netherlands, exceed 30 per million.

I have several proposals and comments to try to solve this problem. Several issues must be addressed before we try to find out what the solutions are. Of course, there are potentially many solutions, but primarily we have to know, (a) how the hospital or health care system identifies the potential donor, (b) how we handle it, and (c) how we then procure the organs in order to perform the transplantations.

An organ donor is usually identified as a patient who has been declared brain-dead following either trauma, cerebrovascular accident, asphyxia, and most brain diseases, including brain tumours. While still living, these patients are actively cared for by a team of physicians, neurosurgeons, neurologists, and intensivists, along with many allied health care professionals. We call this the “acute-care team”.

When brain death is imminent, the natural tendency of this acute-care team is to reduce the level of care, which includes not maintaining a patient's blood pressure, disconnecting the patient from mechanical ventilators—with the family's consent—and discontinuing aggressive management of their cardiac, respiratory, and renal functions.

This obviously is in direct conflict with the protocol for managing an organ donor, where good blood pressure and the maintenance of all organ systems must be preserved in order to have good-quality organs for transplantation.

The transition from giving acute care to a person who was alive to caring for a brain-dead potential organ donor is very difficult for many acute-care teams to handle, and therein lies one of the major conflicts in the organ donation process in Canada and throughout the world.

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Countries that have an exemplary organ donor rate have identified this as their primary problem, and have dealt with it through donor management teams. They have removed from the acute-care team the decision making in terms of asking for organ donation, and have actually managed to create professional teams of doctors, health professionals, and even clergy and ethicists who actively ask the families for organ donation, with success.

I propose that we create such an organization in the country. Often the acute-care team feels awkward about approaching families with respect to organ donation after actively pursuing life. It's a delicate process. It should be left up to the individuals trained in the field of organ donation. Perhaps we need to train such individuals.

In Quebec, as a result of the Gélineau commission report, it was mandated that all major trauma centres must identify such a person or team of people with intensive care experience who will oversee the identification of potential organ donors; approach the families regarding organ donation; and manage the care of potential donors.

We at McGill hired such a person, one with neurosurgical, intensive-care-unit experience, in August of 1998 to manage our hospital organ donation system. It's too early to say, but she's already had a tremendous impact on our organ donation rate. We have gone from 28 to 41 donors identified, and from 8 to 24 donors, in the past year.

We hope this will continue. Currently, very few hospitals in Canada have such a system, including in Quebec.

In order to improve the state of organ donation in Canada, I propose that we institute donor management teams in all major transplant or trauma centres in the country. They should be funded properly.

It also should be made mandatory for any physician faced with a potential brain-dead patient to consult this donor management team, who will then take charge of the case and request family approval for organ donation. It should not be left in the hands of the acute-care team.

This team will probably include some ethicists, perhaps even clergy members, who will then approach the family with tact, compassion, and dignity.

In addition, I second Dr. Smith's call for a national organ-sharing and organ-procurement organization and system where we can gather data and put all our patients on a national list so that we can find recipients within our country and not have to export some of these organs, which has occasionally happened in the past.

I will conclude my remarks by thanking the committee for having me and for allowing me to espouse my views.

I'd like to pass the word to Dr. Wall.

Thank you.

The Chair: Well, you've just been given an introduction, Dr. Wall, so you can't let it slip.

Dr. Bill Wall (Director, Multi-Organ Transplantation Unit, London Health Sciences Centre): Thank you, Mr. Volpe.

I'd like to thank the committee members for the opportunity to address you today on organ transplantation and donation in Canada.

I've had the privilege of being a transplant specialist for 25 years. I feel very fortunate to be part of this wonderful life-saving and life-enhancing treatment for patients with organ failure. I've witnessed first-hand the tremendous improvements we have accomplished over the past 20 years, with better methods to control rejection, which is reflected in the excellent survival rates now achievable in organ transplantation.

Certainly the results are better today than they have ever been. The ability of organ transplants to restore patients, many of whom are close to death, to full and productive lives in the community is one of the greatest achievements of modern medicine. Indeed, we are all proud of what has been accomplished, as Dr. Tchervenkov has stated.

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But these successes have produced a dark side of transplantation—namely, the inability of the current supply of organs to meet the growing number of patients on transplant waiting lists.

Specifically, patients on renal dialysis wait anywhere from two to four years before receiving kidney transplants, if they receive a transplant at all. Approximately 15% to 20% of patients waiting for vital organ grafts, such as the liver and heart, will die on the waiting list.

The problems are going to get worse. Liver disease caused by hepatitis C alone is going to create havoc over the next decade for the vast numbers of patients who are going to need liver transplants.

The number of patients on renal dialysis increases each year in this country by 4% to 6%.

The problems of coronary artery disease in the aging population will demand greater cardiac services, both transplant and non-transplant, to treat them.

The effect is that each year, the disparity between the supply of and demand for organs gets worse.

Canada is, and has been, mediocre in terms of organ donation rates. My personal view is that if a government is going to act in a substantial way to support transplantation in this country, an improvement in Canada's organ donation rate demands attention first and foremost. It would have the most important and the most immediate impact for all those patients awaiting vital organ transplants.

Surveys indicate that although the majority of people favour organ donation, about one in four or five does not. What are the reasons given for this? They are unaware of the need for organs. They are unaware of the success of transplantation. They do not know that transplantation has been transformed from a risky, experimental procedure into one that saves lives.

But even if those individuals who are in favour are asked about signing a donor card, only about half of them respond positively. Many are unsure about the organ donation process. They have many misconceptions about the funeral arrangements, burial arrangements, or even perceived costs to them and their families.

The answer, obviously, is one of education, of informing the public about the need for organs and the benefits of transplantation. Dr. Stuart Smith just provided you with a list of the 11 obstacles that have been identified. Of those, I count seven that rest squarely on the shoulders of lack of education.

Transplantation in Canada is currently a patchwork quilt of organ procurement regions and agencies working with individual transplant centres that do their best to raise the profile of transplantation and speak on behalf of the many patients who are on waiting lists, but there is no national, concerted, co-ordinated, and persistent effort to address the organ shortage in this country.

There needs to be a true partnership between government agencies and specific organizations—for instance, the Canadian Transplantation Society and the Canadian Association of Transplantation—to ensure that this country achieves the highest-possible organ donation rate.

If we compare ourselves with other countries that have the highest rates—Spain, for instance, has already been mentioned—we see that Canada has only 50% in comparison. If we were to double our organ donor rates, it would have an enormous impact on those thousands of patients leading dreary existences on dialysis machines and it would reduce the liver transplant waiting list in this country by two-thirds in a single year.

Transplant centres, which are staffed by the most well-meaning and dedicated of individuals, cannot do this on their own. Resources are needed to co-ordinate an effort by a national body whose prime mandate should be to promote organ donation and transplantation.

There are gaps in professional knowledge, too, and there are professional barriers that need to be addressed. When surveyed, the majority of ICU nurses and doctors were uncomfortable with approaching families about organ donation when organ donors had been identified. Many did not know how to proceed with the organ donation process.

There needs to be a segment of trained health care professionals, beyond what we have at the present time, who are dedicated to organ donation and transplantation. In this regard, Canada has much to learn from other countries that have organ donation rates superior to our own.

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The potential financial obstacle to donor hospitals that do not have transplant programs has to be addressed so that those institutions are not unfairly burdened with the expense of the transplant effort.

I agree with your colleague, Mr. Martin, who has made that an official motion. Those expenses can be a deterrent to institutions becoming involved in organ donation, especially today, with the current financial restraints under which most hospitals are operating.

Over the past 15 years, there have been numerous task forces, advisory committees, panels and so forth that have prepared documents for the government about transplantation in this country. There are issues that have been raised repeatedly—the need for a national public education campaign about the need for organ donors and the successes of transplantation; the need for a national agency that would promote cooperation with all of the various institutions that participate, on a daily basis, in organ donation and transplantation; and even a universal organ donor card that could be promoted throughout the country.

I'd like to conclude by saying that we have a wonderful opportunity at the present time to enhance and save lives through transplantation, which is a health care endeavour founded on generosity, compassion, and altruism. This is something we can and should do for Canadians, as Canadians. It's time now for the government to give this subject the emphasis it needs to improve the lives and save the lives of those thousands of Canadians who are waiting now, and the many thousands who will be waiting in the future, for organ transplants.

Thank you for your attention.

The Chair: Thank you, Dr. Wall.

Dr. Greig.

Dr. Paul D. Greig (Director, Liver Transplantation, Toronto General Hospital): Chairman Volpe, I as well would like to thank the committee for the opportunity to present my views on the state of organ donation in Canada.

I'll pick up where Drs. Smith, Tchervenkov, and Wall have brought us thus far.

I'm a liver transplant surgeon. While I work locally to promote organ donation, let me try to think globally and present a bit of a national perspective from my background as a past president of the Canadian Transplantation Society and a representative to the Canadian Coalition on Organ Donor Awareness at that time; former co-chair of Organ Sharing Canada, in its initiative to increase organ donation in Canada; acting chair of the expert working group advising Health Canada in establishing standards for organ and tissue transplantation; and member of the Links to Success advisory group, a group established by the Kidney Foundation of Canada to promote organ donation in this country.

Let me open by saying that I believe organ donation is the number one priority for transplantation at the present time.

Of the issues the federal-provincial-territorial Advisory Committee on Health Services identified, including that of the waiting list and the standards for organ and tissue transplantation, organ donation is clearly a higher priority.

You've long heard about the low rate of organ donation in Canada. It's particularly low in Toronto. There are many reasons for this. For the purposes of my recommendations, I will break those into two reasons—first, those associated with failure to initiate the organ donation process, such as failure to approach or refer the donor; and second, those associated with failure to obtain consent from the family.

Before I do, I fundamentally believe the poor rates of organ donation in Canada arise from the problem that the entire system is based upon altruism—not just the altruism of the family who consents but even more on the altruism of the intensivist, the nurse in the intensive care unit, and the institution.

While altruism is laudable and very important to organ donation, such a critically important health care activity as life-saving organ transplantation requires more than just goodwill. It requires organization, adequate funding, and accountability at the national, provincial, and local levels.

In considering the barriers to initiation of the organ donor process, my colleagues have identified the fact that within the intensive care unit, there are other demands on the intensivists' and nurses' time, and priorities that conflict with organ donation. There's urgency to clear the backup of patients who need to be admitted to the ICU, and an urgency to discharge the brain-dead individual. There are financial disincentives, with the costs of organ donation having to be absorbed by diminishing ICU resources.

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We've heard quite a bit this afternoon about the potential lack of awareness of the importance of organ donation among many of the ICU staff. Their focus is on these critically ill individuals, not the potential recipients at the transplant hospital. To deal with this issue about the failure to initiate the process, I have four recommendations.

One, I believe we must have an automatic process of referral. This country requires a policy of required referral of all deaths or impending deaths to the local organ procurement agency, similar to what was recently enacted in Pennsylvania. I believe this needs to be enacted through enforceable national legislation. It should produce an audit of organ and tissue donor activity for which each OPO and institution is accountable. I believe it requires financial penalties for non-compliance, but it will require local support and the accountability of a national organization for transplantation.

Two, I believe we must remove financial disincentives to both institutions and the physicians at the bedside.

Three, I believe we must relieve the pressure on ICU beds and OR resources by specifically funding ICU beds for an organ donor above the cap that most ICUs have and funding for ORs so that in the emergency cases of transplantation we don't interfere with other essential surgery.

Finally, to ensure adequate ICU staff awareness, we need Canada's version of the Spanish model—that is, an individual in the ICU who is responsible and accountable for not only local education but also facilitation of the organ donor process.

Regarding the issue of the failure to obtain consent from the family, we've heard how important it is to have an individual who's skilled and compassionate and knowledgeable to approach the family. While many of our intensivists have these skills, they may not have the knowledge, and data would indicate that a transplant professional, when approaching the family, will improve organ donor rates.

I also believe the lack of a directive from the deceased to the family is an important barrier. Many people do not indicate their wishes to their family, and at the time of death, within the family setting, each member has a veto. If there's any insecurity by each member of the family, there's often a veto, and the family will refuse.

Finally, there may be cultural issues that need to be dealt with on a local basis. I have three recommendations with regard to these.

First of all, I believe Canada needs a national organ donor registry similar to that established in British Columbia. I would recommend that it be affiliated with the provincial health care card, and that it result in a database that is accessible to hospital staff whereby we can provide the information to the donor families and let them know what their loved one's wishes were.

Second, we must have organ donation specialists, individuals skilled in and knowledgeable about approaching and helping families during this difficult time. These may or may not be individuals associated with the local OPO or the intensive care unit.

Finally, we must have standards for organ donation in this country similar to the standards that are being established for organ and tissue transplantation.

I will summarize five areas in which the federal and provincial governments can help us.

First of all, I believe we need federal legislation to establish required referral at the time of death. This should be enforceable and financially supported by local and provincial initiatives to facilitate success and generate an audit for which we are accountable.

Second, there must be adequate reimbursement for organ donation activities; provincial funding required for hospitals and intensivists; and provincial funding required for ICU staff who are responsible and accountable for organ donation and approaching families.

Four, there must be federal funding for a national registry for organ donors.

Finally, as each of my colleagues has alluded, Canada requires a national organization for transplantation that's accountable for organ donation, organ allocation, and the maintenance and enforcement of standards. Such an organization must have federal, provincial, and territorial mandates for these activities and be accountable for their outcomes. Without such a body, we cannot have enforceable standards or activity and accountability for this essential health care system. I do not believe organ and tissue transplantation can remain dependent simply on altruism.

Thank you for the opportunity to present.

The Chair: Thank you, Dr. Greig.

Gentlemen, I don't want to give you an indication that there will be a lot of interruptions, but in the event that members get up and move around here, please don't be too concerned and distracted. It will happen.

Having said that, goodbye, Madam Redman.

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Dr. Peltekian, I'm advised that this is in both languages.

Dr. Kevork M. Peltekian (Medical Director, Atlantic Canada Liver Transplantation Program): Yes. I worked on this two nights ago.

The Chair: So you're bilingual.

[Translation]

Dr. Kevork Peltekian: Yes. Very well; I do not speak French very well but I understand it well.

[English]

The Chair: Then you have a head start on the rest of us.

Dr. Kevork Peltekian: My name is Kevork Peltekian, and I'm a liver specialist from Halifax, Nova Scotia. You can quickly see why I don't mention my first name to my patients any more.

Voices: Oh, oh.

Dr. Kevork Peltekian: It's the Kevorkian thing; it's his last name and my first name. In fact, I was surprised when I got the call to talk about organ donation. I didn't think it was what this committee wanted to hear.

But let's get to some serious stuff. I deal with serious stuff all the time, being medical director of the Atlantic Canada Liver Transplantation Program. This issue is not going to get better; it's going to get worse. Dr. Wall already alluded to the issue of hepatitis C, which is an important thing in terms of liver transplantation.

Over the next few minutes, my task is going to be to convince you that we need a national organization for not just donation but also management of organ and tissue donation in Canada. Let me go over a few things.

First, when a person is going to go through organ donation, they go through different stages. The first stage is the red light coming up, saying “stop”. Life is going to stop. That's what happens. Brain death is suggested. What happens next is the consent forms, and making sure the organs that are supposed to be donated are all functioning well.

An important aspect of this is the safety of those organs. You can't be putting organs that are not safe into recipients. So there's that whole process that occurs when the light is orange.

Only after all these things are gone by does the green light come up, and it's a go for donation. That's when the transplant surgeon gets in, takes the organs out, and suddenly a life is finished and at least three or four lives start getting better after that process.

It's important to identify that these are three different phases and three different stages of the process. These three processes cannot be done by one person. You cannot expect an intensivist to do all these things. In fact, you don't expect the intensivist to do the first two, either. The intensivist's job is take care of your loved ones.

I mean, imagine being in a side room, with a loved one in an intensive care unit. Everybody is working hard to keep that person alive. Suddenly, the person changes hats and says, okay, now your loved one is going to be an organ donor.

It cannot work that way. It's absolutely important to get a middle person.

Now, the middle person is what the Spanish model is all about. I think this committee has heard all about that. In fact, the way they've done it is that every hospital that has more than 150 beds has to have one of those folks who organizes that middle part.

Now, the other part of this red, orange, and green issue is that you cannot expect the transplant surgeon at the green light to do the work for the middle person. These are two different functions. This therefore requires two different organizations. You cannot get the transplant organization in Atlantic Canada looking after donors.

We don't do this thing in blood. If we need to get blood, the surgeon does not go around looking for blood donors. There's another group that works on that and that provides you with safe blood to do your surgery.

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That brings us to this other thing. Now, you've been saying, geez, what's he talking about? Why is he talking about blood, anyway?

This is important. Look at this logo. If you show that logo outside of Quebec, most people would know what this stands for. It stands for blood donation. This is something you folks started in the fall of 1998. You tabled the legislation and initiated this process.

Do you know what I want you to do? Cross out the word “blood”, and think of organ and tissue now.

In your handouts are pages I took out from the web site of the CBS, or Société canadienne du sang. There's a mission and values statement. This is public information, so I copied and distributed it in both languages, English and French. Just read through it.

Can I have a copy of it myself? I don't have that kind of memory yet.

So read through it, and look at the mission. This is what I want you think about—that this organization will provide, “a safe, secure, reliable and cost-effective supply” of organs, tissues, and alternatives, including xenotransplantation. I'm sure this committee has heard about that.

If you continue on in that mission sentence, it would say that this independent national organ and tissue supply system will do the job, “in a manner that nurtures the trust, commitment and confidence of all Canadians”, including the donor himself or herself, the families of the donors, and the recipients and their families.

So this becomes important; suddenly you can visualize this whole organization with a mandate such as you have done in the past with blood.

Having said that, let me move along to your task. You've heard a lot of things today and in the last few weeks. There's a list of things there.

Of course, everybody has the budget on their minds from yesterday, but there's talk about a national organ registry. I haven't heard anything about the health card. The health card report is something that the Honourable Minister of Health has mentioned. I think it's important to allocate a line there saying organ donation rates should be part of that report.

But this is a long list, and I'm not sure you will be able to do all these things at this point. Especially at the end, you have to come up with something to gain the trust of Canadians. It's very important.

My suggestion, therefore, is that we come up with a national organization for the management of organ and tissue donation. This is absolutely important if we are to give Canadians the best possibility to improve rates in organ donations and to reduce the numbers of deaths on transplant lists.

I thank you very much for this opportunity. I hope I didn't cause too much fuss with all of the technology I had to utilize in this committee's work.

The Chair: I'm happy you used it, thank you.

I'm going to ask Dr. Wilbert Keon, a colleague from the other place, to proceed.

Dr. Wilbert J. Keon (Director General, University of Ottawa Heart Institute): Thank you, Mr. Chairman, and thank you for the invitation to be here for this very important hearing.

I would like to begin by commending Dr. Keith Martin for focusing on this subject in the other place, and gaining the attention of everyone there. I would also like to compliment Minister Rock for establishing the committee with the mandate to address this important issue. I'm sure something useful will come out of it.

The Chair: Just for those who don't know, “this place” is the House of Commons, and “the other place” is the Senate. That's the way the Senate refers to the House of Commons—“the other place”.

Ms. Elinor Caplan (Thornhill, Lib.): So is it Dr. Senator or Senator Dr.?

Some hon. members: Oh, oh.

The Chair: A little bit like being a judge.

As well, the committee sets its own agenda. Sometimes it's at the request of the minister but more often than not it's at its own request.

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This is one of those occasions when the committee's intentions and the minister's request coincided very nicely, so your comments regarding both his initiatives and those of the committee are absolutely apropos.

I said that for the opposition's sake.

Some hon. members: Oh, oh.

The Chair: Go ahead, Dr. Keon.

Ms. Judy Wasylycia-Leis (Winnipeg North Centre, NDP): Do I get equal time?

The Chair: No. You monopolize too much of it as it is.

Dr. Wilbert Keon: It's also interesting to be here today after the announcement of the health budget yesterday. I had the privilege of serving on a couple of advisory committees to the minister for the past couple of years. One of them was on health information systems, and the other, of course, was the health advisory committee on science. It was very encouraging to see a lot of the recommendations and deliberations of those committees coming forth in the budget yesterday.

I think what transpired yesterday really is a giant step forward for Canadian health, science, and medicine. I think there's an opportunity now, with the framework that's going to come out of this budget, for us to do something very positive as it relates to the presentations you've just heard from all of these transplant specialists. We will have a structural framework that we can work with now and that will help us pull together federal-provincial resources in a way in which we haven't been able to in the past.

I think the barriers to some of the problems we have seen in transplantation have arisen out of the Canadian tradition, when we go to do things, of a little bit of awkwardness in terms of defining what the federal and provincial roles are in some of this. I think much of that awkwardness is disappearing.

I am not going to read my brief, because it's all been presented to you by the previous presenters, but I will make a few points to reinforce some of the things they had to say.

I think we need both short- and long-term solutions to this problem. I'm a transplant surgeon, and I'm very alarmed at the decline in donor organs. I think we have to come out with a short-term solution—education, advertising, and awareness—and then we have to come to a long-term solution, which has already been presented to you, I believe, by every witness before me. That long-term solution is to find a national organization to deal with the promotion of organ donation and a national organization that can co-ordinate the excellent provincial organizations we have in place, such as MORE in Ontario and the organizations in Quebec and B.C. and so forth.

We have to come together to do the following: establish and maintain standards of practice or standards for registering or identifying potential donors, and enforce these standards; ensure equitable organ allocation through sharing; audit and report the results of transplantation; investigate and manage transplant-related problems; and ensure that transplantation is performed to the highest technical and ethical standards.

As well, we really must find a way to establishing a universal organ donor card. There have been some good suggestions made here. We really must find, through this national organization, a universal organ donor card that will be simple, understandable, and universal, across the country, so that everybody will be aware of the need for this.

We have very good models in place in Canada. We sometimes get a little discouraged with some components of our health system, but we shouldn't. We have some very good models we can look at inside Canada, although it's been suggested that we look at some outside Canada.

• 1630

For example, the B.C. Transplant Society, established in 1985, if looked at as a little module is I think a very effective working module. I think my colleagues would agree. Perhaps some of the ideas out of that could be raised to the national level.

It's also mandatory that we come to an understanding with the provinces that they would accept the recommendations of the national organization to compensate particularly the little hospitals that have to deal with this situation of organ donation, which is so disruptive to them. It occurs on only very rare occasions. They don't know how to deal with it. They don't have the organization in place to deal with it. They need the expertise of a national-provincial resource that can be in touch with them very quickly.

With advancing technology, this is very possible now. It could help lead them through this difficult time and would also see that they were appropriately compensated, at the end of the day, for the services they rendered and the services that were interfered with while rendering this service.

I will come back and focus my presentation on a very simple recommendation to you. You've had a number of excellent recommendations, but I think we really should focus on how we're going to establish a national organization. This can be a cooperative national-provincial organization for organ donation, monitoring quality control, organ sharing and so forth, and inventing an appropriate universal organ donor card.

That's not a Herculean task. It's a matter of commitment, and a matter of getting on with it.

As I mentioned earlier, the framework is there now. We can work within the framework of some of the other things that are coming forth in this very encouraging time, I must say, of national-provincial relations.

Thank you.

The Chair: Thank you, Dr. Keon.

We'll go to colleagues around the table. I thank everyone for their patience, especially the witnesses, because they've sat through each others' presentations.

I hope you're still with us.

Mr. Vellacott.

Mr. Maurice Vellacott (Wanuskewin, Ref.): Thank you very much.

I want to direct some specific, rapid-fire questions here. I want to open by referring to an e-mail I received, as others here would also have received, from a B.C. couple.

They talk about their feeling of uneasiness—their son was an organ donor in Alberta in 1994—and offer some recommendations. One was not to ask, prior to death, for commitment, even verbally, for transplantation.

They said:

This happened to us. We later felt that our son had been treated more as a potential donor than our son before the declaration of brain death. We had confirmation from others that this impression was shared.

They go on talk about the whole situation it created for them when he was “still on the respirator, with a beating heart, though anesthetized”, and so on.

I could go on from there, but I just wanted to highlight the fact that these people are not opposed to organ donation, but they have some very specific concerns.

Somebody might want to respond to that. Their suggestion is not to have any requests made, by whatever team you're going to have in place for this, prior to brain death. It does create some problems, I suppose.

I would be interested to address to Dr. Tchervenkov...even to remove the acute-care team, whose role is to do its very best to restore that person to health. Then you take them out so that it's not as awkward for them, and you have this management team come in to take it the next step, if you will.

I would think, as I understand it from talking to people, there are deeply held religious and ethical issues—I think we've kind of acknowledged that—around this whole issue of transplantation. I'm wondering if simply by saying we're taking it out of the hands of those acute-care specialists to the management team that all of a sudden this would dissipate overnight. That would be my question to you.

• 1635

I get a sense from you, Dr. Wall, or from your presentation, that knowledge itself will kind of take care of all that, and that if people just knew and understood what doctors and the medical specialists understood, there'd be no more problems.

I'm not as optimistic, frankly, but I'd appreciate a response to that, because you seem very optimistic that if the knowledge were there, then these religious or ethical types of issues would go away. I don't know if I'd want to say it, but if we somehow got people out of the dark ages into the present in terms of their knowledge, then there'd no longer be an issue around this thing.

Admittedly, this is different from donating blood or a kidney, because there you go on living afterwards.

I have one quick follow-up question, but I'd appreciate a couple of quick responses on that—the whole thing about the management team, and whether you think that would remove any angst or uneasiness or awkwardness.

Dr. Jean Tchervenkov: It's a step in the right direction, of course. I believe it will actually remove some of these awkward manoeuvrings that can happen, as in the case of this family, where the treating acute-care team may see that the patient is slipping away, going into a state of imminent brain death, and they may trigger the ventilator once or twice a minute. These are medical terms that suggest, perhaps from a scan of the head, etc., that this is happening.

If they're not mandated—because right now, nobody really knows what to do and when to intervene—some of these acute-care teams may be faced with this issue once a year, or maybe once every two or three years. So it's something they're not always dealing with.

If these donor management teams include, as you say, perhaps some members of the ethnic communities throughout Canada, where there may be much more of a problem with donating organs—and we need to meet with these groups representing these ethnic communities; obviously, many of them do benefit, actually, from organ transplantation, just the same as any other Canadian—then perhaps we can work toward improving this eventually.

Mr. Maurice Vellacott: I expect, then, we would be respectful of their ethnic, religious, or cultural misgivings, and we would not try to say, hey, you're wrong, you have to accept this western mindset.

Dr. Jean Tchervenkov: It's not a matter of imposing things; it's a matter of education, really.

Mr. Maurice Vellacott: Okay.

Dr. Wall.

Dr. Bill Wall: I think this is one of the most sensitive, and potentially most awkward, areas we deal with in medicine—the pronouncement of death, the withdrawal of support, and then the asking for a donation of organs from a family at a time of maximum grief over the loss of a loved one. It's at the most difficult time in their lives.

That's why trained professionals, who know how to do this, who are compassionate, who are sensitive, who've done it before, and who've been educated on how this is done, are needed. That's why so many of our health care professionals do not feel comfortable with it. They haven't had any training on how this is to be done.

In Spain this is routine now. The organ procurement officer or organ donor officer, whatever term you'd like to use, has gone through a training program specifically to deal with all of these awkward situations, to be sensitive about cultural differences, ethnic differences, religious differences. That's the solution to this—to have the right people doing and saying the right things at the right time.

The background to this, of course, is a fundamental understanding that the transplantation team has nothing whatsoever to do with the pronouncement of death and how that person is managed before they are identified as a donor. These two processes are absolutely, completely separate.

Therein lies some of this distrust that the public has about some of these processes. You'll understand that some people use that as an excuse not to sign the card. They feel that if they sign that card, and happen to find themselves critically ill in an intensive care unit, somehow the physician, surgeon, doctor, or nurses won't do everything possible to remedy the situation, to save their life.

Of course, that's utter foolishness. We can't imagine something like that happening in this country.

• 1640

That's why the national organizations and everything we've talked about would ensure that there is confidence among the public that what we are doing is accountable and it's transparent, with ethical input from all the aspects of health care professionals whose value is very important to us.

So it's that kind of education I was referring to earlier. When I said education was the solution, I didn't mean to be glib in that way at all.

Mr. Maurice Vellacott: No, I understand.

Dr. Bill Wall: This is a very extensive education at both the public and professional level, and that, I believe, is what is lacking.

Mr. Maurice Vellacott: Right.

The Chair: Just a moment, Mr. Vellacott.

Dr. Wall, surely the fact that so many witnesses, including some today, have focused on the importance of separating the ICU component from the transplant component suggests, at least to the untrained, that this is not always the rule.

Dr. Bill Wall: I guess without specific examples, I couldn't say yes or no, but it certainly is the rule in our institution, and we've been in this process for a long time.

I think awkward situations get reported now and then. We all feel bad when we hear about an awkward situation with respect to organ donation and transplantation. It should be altruistic and it should be compassionate. It's a noble act. If it comes out in any way different from that, then there has been a problem somewhere.

The Chair: I think Dr. Greig wanted to respond to your initial question, Maurice.

Mr. Maurice Vellacott: I guess I was going to say—

The Chair: No, let him do it, please. I'll come back to you anyway, Mr. Vellacott.

Dr. Paul Greig: I couldn't say it more elegantly than Dr. Wall has, but I would say that this has been studied. The principle here is called “decoupling”, separating, in a family's perception, the care of their loved one, and the fact that absolutely everything was done, from the approach for organ and tissue donation.

It is not necessarily the rule. There are many intensive care units across the country where the intensivist believes continuity is important in dealing with this grieving family, and feels very strongly that they should be the individual to initiate organ donation discussions. It's not unreasonable to have them part of the approaching team, but there are very good data, particularly from the coalition on organ donation, the Partnership for Organ Donation, that would indicate that families approached by trained professionals who are appropriately compassionate and knowledgeable in this setting will understand and consent to organ donation more readily.

The Chair: Dr. Smith.

Dr. Stuart John Smith: I think most of the points have been made, but I would just reiterate a few.

I think this is a good example, based on what you described with regard to this family, of a lot of things that went wrong. From what you described, for example, there's the suggestion that they were approached before he was brain-dead.

We would emphasize that this is an independent process, and that an outside group is doing it—again, someone from the transplant group. So there's problem one—the approach.

The second problem you brought up in your description was the whole issue whether it implies this was an issue of ethnic concerns or—

Mr. Maurice Vellacott: “Ethic” was what I actually said.

Dr. Stuart John Smith: Religious concerns.

Mr. Maurice Vellacott: Yes.

Dr. Stuart John Smith: Again, if we actually brought it on the table, I think most religious leaders—and there are a few exceptions—including Muslim, Jewish, or whatever, would say to you that those are not concerns from their point of view. The concern is that you do what's best to preserve life on all counts. Certainly organ donation is not something they are against.

Three was the issue about the patient not being brain-dead, etc. Again, reading between the lines, it sounds to me like a lack of understanding around the issue of what is brain death and what's involved, etc.

So I think it's a good example of what happens, and reinforces that when you get an expert procurement or organ donation team in there, it would be done properly.

Everything about this was wrong, and this is why you're hearing about it.

The Chair: Elinor Caplan.

Ms. Elinor Caplan: Thank you very much, Mr. Chair.

I'd like to start by saying how pleased I was that the minister gave the committee this mandate. I very much support the goals of the mandate, which is to see what the federal role might be in supporting not only organ donation but also transplantation programs across this country. So I appreciate all of you coming today.

It's in that spirit that I ask the next questions, about some of the difficulties that exist.

• 1645

The first question I would have relates to some experiences I had in a previous life, in Ontario. When Graham Scott, chair of the Multiple Organ Retrieval and Exchange program in Ontario, was here, he said there were two MOREs. I was curious as to how that happened.

Dr. Greig, it appears you're with both.

Dr. Paul Greig: If I may, MORE Ontario is the umbrella organization overseeing the five regions of Ontario, and within each region there are co-ordinators, who refer to themselves as MORE London, MORE Hamilton, MORE Toronto, MORE Ottawa, and MORE Kingston. These individuals work locally, promoting organ donation and actually co-ordinating the organ donors, working with the umbrella organization that we refer to as MORE Ontario.

Ms. Elinor Caplan: So two MOREs do not exist. There's not a separate one at the Toronto Hospital.

Dr. Paul Greig: No. The co-ordinators who are responsible for organ donation in the Toronto region, including St. Michael's Hospital, the Hospital for Sick Children, and the outlying hospitals, work through MORE Toronto, liaising with their colleagues in London and Ottawa within the auspices of MORE Ontario.

Ms. Elinor Caplan: It was my understanding from his testimony before committee, when we were talking about a national registry for donors and those who are waiting, that there is one that today is housed at MORE Toronto Hospital. The goal was to have MORE Ontario co-ordinate this on behalf of all of the transplant centres across the country.

Dr. Paul Greig: This is the national waiting list for recipients to which you're referring, I believe, Madam Caplan.

Ms. Elinor Caplan: Right.

Dr. Paul Greig: Toronto has maintained a quasi-national list. It's updated every Friday afternoon and mailed out, and by the next Thursday it's a week out of date, but it's the best we have.

We have been working on the development of an Internet-based national waiting list and have struggled with many aspects of it because of, one, the lack of a national organization for transplantation; two, no mandate; three, no security, frankly, and confidentiality issues; and four, no one to whom to report—all very important issues.

The issue about where that will go I believe has been resolved now that London, Ontario, has volunteered to take on this initiative until such a real-time waiting list can be established. But we still lack there.

Ms. Elinor Caplan: I appreciate that. I received copies of some of the communications Dr. Wall had sent to the transplant centres on that, and I appreciate everyone's efforts in trying to pull this together. What we're trying to explore here are some of the barriers to making that happen and the potential role for a national agency.

While I think we all respect the need for each province to do their own thing, there is a goal to have everyone working together. I think that's what you said when you talked about the need for national coordination.

Dr. Paul Greig: Transplantation is different from just about every aspect of health care delivery. You can do aortic coronary bypass as well in every city across the country, but we share organs between and amongst each other, so we have to have similar listing criteria. After all, when a liver leaves the Toronto area, it's reassuring to know that it's being transplanted into someone who would be transplanted in Toronto.

So we have to have similar listing criteria, and we have to have equity of these organs that are being allocated across the country and within provinces. It's really a national thing that is very different from just about every other aspect of health care delivery.

Ms. Elinor Caplan: You stress the need for audit and accountability. Actually, I've had that discussion, and I know where Senator Keon is on that one—strongly supportive.

I just wanted to hear from each one of you on whether you believe a very important part of the development of a national agency is to have the audit and accountability function as part of the national role.

Dr. Paul Greig: Well, I obviously feel strongly about it.

Ms. Elinor Caplan: Does anyone disagree?

Voices: No.

Dr. Kevork Peltekian: It's in that mission and values statement of the CBS. It says that. That's the fun thing about this; you can just pick it up and read all the things we said with regard to the safety of the organ, the issue about the auditing, and the quality assurance. It's all in there.

Ms. Elinor Caplan: So if you all agree, why hasn't it happened?

Dr. Kevork Peltekian: The infrastructure is lacking, and infrastructures need funds. That's the simple answer to that.

• 1650

We do this thing in patchwork, I think. In all of Atlantic Canada, do you know how many people run the show? Three people. Three people run the show in all of Atlantic Canada. It's an office in a hospital. That's all. They do a marvellous job, but we can improve that if the infrastructure is there and the funds are there.

Dr. Stuart John Smith: You tend to run the programs out of your offices, and it's the commitment of those offices to do it. Now, clearly there are local arrangements and procurement groups in Atlantic Canada, Ontario, and B.C., but again, I think the reason that all the things you've asked about haven't happened is that you need to have algorithms for allocation. We are not necessarily identical.

Right now, at times, we'll get a call one night, one moment, from Winnipeg, saying, “Here's an organ”, and yet we know that last night we did two transplants and that there are status fours, the worst possible status in Canada when you're waiting for transplants. We get two calls, from two different parts of the country, saying they have organs. When we ask them what about our guys who are status fours—we're calling them from home, “What's wrong, why aren't you using them?”—we're told, “Oh; we didn't know about that.”

There's no communication between these other regional algorithms. We try—we do try—but again, most of our discussions occur in the middle of the night.

The Chair: Dr. Greig.

Dr. Paul Greig: If I may, we are doing some of that. The liver transplant community, as you know, meets yearly, because we think it's important to do that. The directors of the programs review the listing criteria. We review the algorithm. We have one of our co-ordinators do the stats to determine wait times and deaths waiting.

I'll be honest; we have no mandate to do this. We are not empowered to do this. Frankly, we do this scratching up of funding, with our own personal time away from our busy practices and research activities, because it's the right thing to do.

Ms. Elinor Caplan: Wasn't it the mandate of MORE Ontario to do that? Each province funded their own, but wasn't the structure put in place back when MORE Ontario was given the mandate in, I think, 1988?

Dr. Paul Greig: MORE effects that within Ontario, but at the national level it only occurs through...well, frankly because the physicians and transplant co-ordinators think it has to be done. They are doing it, at least with liver transplantation.

This year, in conjunction with the CAT/CTS annual meeting, each of the major four refusable organ groups will be meeting and working out national sharing algorithms.

Once again, we have no mandate to do this. There is no federal mandate to do this. We have no legal basis upon which to do this. We think we're doing the best things. We have ethical backgrounds and all. We're doing the good deed.

So you walk away from it saying, “This is the right thing to be doing”, but it would be more than proper, far more than proper, to have a federal-provincial-territorial mandate to be doing this.

The Chair: Before we go to the next questioner, Dr. Keon, you wanted to comment.

Dr. Wilbert Keon: Yes.

Mrs. Caplan, you asked a very good question—namely, if everybody agrees, why isn't this happening? The reason it's not happening is that the milieu just isn't there for it to happen.

MORE Ontario functioned very well after its inception, for a few years. Then what happened is what Dr. Smith described as happening the other night out of the Heart Institute, being offered two hearts at once. A number of people started connecting by telephone across the country, setting up informal connections.

There are no bad intentions, but you're getting independent operations that are operating outside the system.

Ms. Elinor Caplan: It that because of a lack of accountability, a lack of audit?

Dr. Wilbert Keon: Yes. It's because of a lack of accountability. It's because of a lack of leadership. It's because of a lack of centralization, accountability, audit—the whole thing.

If you had a central system—and it could be brought up quite easily, because there are good systems in the provinces—that brought them together through networking, then you would have accountability and everything, I think.

The Chair: Madam Wasylycia-Leis.

Ms. Judy Wasylycia-Leis: Thank you, Mr. Chairperson.

I have several questions. I think I'll start by asking Dr. Wall a question based on a comment he made.

I think many in this committee share your view that we have stacks of studies, and lots of investigation into this issue, but we still haven't been able to get it to the top of the political agenda, partly because it's a funding issue, I think, and partly because it requires that federal-provincial cooperation to make it work.

• 1655

What can we do this time to make sure all of this doesn't end up as just another study on top of all the other ones?

Dr. Bill Wall: As has been mentioned, we're delighted that the Minister of Health, Allan Rock, has called this important issue to the attention of Canadians. Now that it has squarely the attention of Canadians, and you, I think the buck stops here.

As health care professionals and people who are privileged to be involved in these activities, we want you to sponsor this, to endorse it, to make it happen, to provide the resources for it. The people sitting at this table and many of our colleagues would be happy, and are prepared, to sit on the national transplant committee of Canada—if that's what you care to name it—

The Chair: You didn't consult amongst each other before you said this, right?

Voices: Oh, oh.

Dr. Bill Wall: —to ensure that the terms of reference are agreeable to you, and to ensure that there's accountability and credibility. Because if we are asking all of the nation to participate in this and to embrace it the way we would like to see it embraced, we have to be accountable to them.

We must be very cognizant of the future of transplantation as well. As we're speaking now, it may be that in the future, which might be closer than we think, xenotransplantation, the use of animal organs for human needs, will be possible. That is the solution to many of the problems we've just addressed.

At that particular time, it's going to be tremendously important for all of us in this nation to have complete confidence in the process of xenotransplantation, to be sure that it is safe, that there are safeguards built in. There'll be no more important time in the history of transplantation in this country than if and when that is possible.

We hope, as transplant specialists, to see it happen, and when it does happen, if it can happen, it will be the most wonderful time to practice transplantation surgery. However, it will also bring on the most serious societal, ethical, moral, and legal issues we have ever faced in all of transplantation.

We have to be seen as being accountable for this. There should be a national body—not federal or provincial or interprovincial, but national—that embraces all aspects of these interprovincial arrangements that exist in health care.

I think it's true to say that a small brewery today in Fernie, B.C., that makes an excellent beer cannot sell a single bottle of their beer in the province of Ontario today. Legislation won't permit that, because they don't happen to have a counterpart here in Ontario.

Well, tonight, if a desperately ill child in Montreal is dying of liver disease, and there happens to be a donor in Vancouver, one or two phone calls can make the arrangements to have that liver removed in Vancouver and sent to Quebec to save the life of a dying child. We have to go through no legislative process whatsoever to do that, and I think it's wonderful we can accomplish that in this country.

Transplantation has grown up in little pockets of activity, little areas of excellence, and we are forced to come together now in a greater sphere because of organ sharing, because of all of the guidelines we have to satisfy. We would like a national mandate to do that, the national organization Dr. Keon has referred to, to oversee all of the aspects of transplantation—the safety issues and the guideline issues to ensure that we are meeting the highest possible ethical standards. Canada, we hope, will be a world leader in transplantation in the future.

The Chair: Madam Wasylycia-Leis.

Ms. Judy Wasylycia-Leis: Another question, although my time might be short.

I sensed a difference between what Dr. Greig was saying and what I think everybody else was saying around bringing down the force of the law to move in this direction. I think Dr. Greig is talking about mandated choices, about legislation requiring referrals. I didn't hear that from the others.

I'm wondering if there is a difference, and what the rest of the panel feels about Dr. Greig's suggestion.

Dr. Jean Tchervenkov: Actually, I did say it. It's in my exposé that there should be a mandated consultation with the team that is going to be in charge of asking for organ donation, which is very similar to what Dr. Greig said.

• 1700

It's time to go from the purely altruistic, not from the point of view of the patients' families—I think that's still required—but from the point of view of the commitment from physicians who are not dealing with transplantations, to a form mandating that every potential donor becomes one, if possible.

The Chair: Dr. Peltekian.

Dr. Kevork Peltekian: Actually, I've given the name of an article, to be distributed to members, that talks about all these different types of consent, and how to take it and so on and so forth.

At the end of the day, you can't ask the transplant surgeon what should be done. You should ask society what they want to do. This is a societal decision. These are life and death matters. There are feelings involved.

I mean, we all like the concept. We all like to get those numbers up there. But it's your job to go out and ask society what they want, to give them the right information.

We like the idea that consent would be presumed, but if Canadians don't want that, you can't ask them to do it. That's your part, to go and ask society. I mean, we will suggest that, but—

Dr. Jean Tchervenkov: But, Kevork, I think there are different issues here—presuming consent from the family and mandating that physicians and intensivists do their duty in the sense of allowing a body or an organization to request donation. I think those are two different issues.

Dr. Kevork Peltekian: And I agree with that part of it.

The Chair: Dr. Wall.

Dr. Bill Wall: I'm not enthusiastic about legislating people to do things. Surveys have been carried out, asking opinions about presumed consent, recorded consideration, and so forth, and the general public is not in favour of that. Most of us have feel we have certain rights that are undeniable. One is our bodies and what's done with our bodies.

Now, if you look at the areas in this country that have the highest donation rates, or at superb areas for it in America—Lifelink in Florida, for instance—or at countries that have the highest organ donation rates, they do not have legislation of this nature, and have not needed it, to accomplish what they have accomplished.

We pride ourselves in southwestern Ontario on an organ donation rate of around 22% to 26% from year to year, which is way above the Canadian average. There's no legislation in southwestern Ontario. There's a profile for transplantation, an awareness, an exposure. It's in the public eye.

That's what Dr. Keon has accomplished at the Ottawa Heart Institute with the organ donation rate in Ottawa. It's because people understand this. They have faith in it. They see the effect of it.

So my view would be that trying to force people to do things in this area is not necessary. That's number one. Two, I think there are far better ways, such as educating the right people about the process so that you take away fears and anxieties and so forth.

I wouldn't say I'm against legislation but I'm not enthusiastic about it. I think there are much better approaches that have been proven to be effective.

The Chair: Thank you, Dr. Wall.

Madam Ur.

Mrs. Rose-Marie Ur (Lambton—Kent—Middlesex, Lib.): Thank you, Mr. Chair.

I'm pleased to hear all the presenters today, especially—and I guess I'm a little bit biased—Dr. Wall, from southwestern Ontario.

Your dear friend, Dr. Cal Stiller, is on the team as well, I believe.

Did MORE start with the team that was originally set up in southwestern Ontario? I know there were some participants in the Strathroy area who were organizing a group. They had all the bishops and church people and everyone all organized, and then London came on board.

Dr. Bill Wall: No. There was something called the Multiple Organ Retrieval and Exchange Program of Toronto. That existed before Ontario MORE, with “MORE” standing for the same thing.

About 11 years ago the provincial organization was formed with the mandate of ensuring fair and equitable access of organs in the province and helping to promote organ donation. That was independent.

London became involved, like Hamilton and Kingston, because we were within one of five geographic regions within the province. Automatically we embraced the Ontario MORE, as it were, because we were a region within that.

• 1705

You give credit to Cal Stiller. Like Dr. Keon, he doesn't get enough credit for what he's done. They're the pioneers in transplantation in this country.

I'm glad you mentioned his name, because his name deserves to be mentioned. The effects of transplantation in southwestern Ontario are seen in large part because of his vision and his commitment 30 years ago to the whole process of organ donation and transplantation.

Mrs. Rose-Marie Ur: I don't know whether this is the perception out there, but are all doctors out there in favour of transplant? Is that perhaps a problem with some patients who don't feel quite as comfortable regarding organ donors? There are some doctors who aren't quite as enthusiastic as are you gentlemen sitting here today. Is that inhibiting some of the numbers we could be accessing, the less-than-positive attitude of some physicians?

Dr. Stuart John Smith: I think your point's well taken. If you ask society and you ask physicians, their support for transplantation is the same, around 90%. When you ask the same physicians if they are then willing to approach families, the number drops significantly, down to around 55% or so.

The reasons are some of the ones I brought up. It is one thing to support organ transplantation but it's another thing to say they have to approach donor families. So there are lots of different reasons for that.

The other thing is that you should be aware that one issue is education. Very little is taught to physicians or nurses in their training programs, so most physicians are only marginally more aware than the general public about the successes of transplant.

I'm amazed, when I go around to my cardiology colleagues, at how many people, when asked what is the one-year survival of a cardiac transplant, quote numbers like 60%. They spew it off as though it's the law, when it's clearly not the case. It's 92%, in fact.

I think most physicians are ill-informed, and if they're ill-informed, of course, they pass it on to their colleagues, to the public, and it spreads on. So I think an educational program for health personnel is very important at all levels.

As I said, in theory I think they support it, but in their own understanding of brain death, how to approach families, successes of transplant, and all these other aspects, they're only marginally better than the general public.

Mrs. Rose-Marie Ur: I strongly endorse the acute-care team and the donor team. The donor procurement team should be made up of medical people, of course, but I think we strongly need, as Dr. Wall and Dr. Greig said, caring and compassionate people, not necessarily doctors, who are gifted in that field. I think that's the way we'll win respect for this great project. We certainly have to endorse it.

Dr. Greig, I believe you said the United States has great statistics on the number of people who donate organs. How do they sell it down there in a way that we could use up here?

Dr. Paul Greig: The Partnership for Organ Donation has been very involved in looking at many of the jurisdictions within the United States, some of which have excellent organ donor rates and some of which have very mediocre donation rates. They've helped some of us in Canada, as well. I know they were active in British Columbia. They've been working in Toronto as well.

Dr. Wall's right that some regions have traditionally always had very good organ donation rates, and those of us with very poor organ donation rates are desperate, frankly, to find out what they do and how they do it. Clearly, you've heard today that it isn't that simple.

We all recognize that a well-meaning, well-placed individual in a hospital can be the single reason for that hospital to have an outstanding organ donor rate, or else a high-profile program, of which the entire committee is extremely proud, can very much affect an area.

I don't use those as excuses. Some of the recommendations I've made today stem from what the Partnership in Organ Donation has recognized, that the decoupling of the process is important.

I personally don't believe we can rely on the education of individuals, medical care staff in the ICU, to initiate the process. Clearly, within the family there are differences of opinion regarding that issue.

I wish I could say, okay, here it is; we've learned from the United States. The Spanish have a different model.

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Mrs. Rose-Marie Ur: Maybe we should clone Dr. Cal Stiller in that, and move it around the countryside.

Dr. Paul Greig: That would be fine.

Dr. Bill Wall: That would work.

The Chair: Dr. Smith.

Dr. Stuart John Smith: In answer to your question, though, the United States has a case of mandatory reporting in some of the bigger jurisdictions, correct? That's maybe not in all the jurisdictions, but mandatory reporting means when a potential donor comes in, at least you're required to report it. Maybe nothing comes of it, but at least we've identified a potential donor.

Then there's the presumed-consent model, such as in the Spanish model, and then our opting-in type of model.

The Chair: Dr. Greig, this is a little parochial, but I thought I heard you at the beginning say that donor rates have actually been dropping in Toronto. Why is that? If I didn't hear you correctly, then what I heard is that you have a very low rate of donations.

Dr. Paul Greig: They're very low. I've not seen the 1998 numbers, but I understand numerically it's less than in 1996-97.

If you look at the data from the past five to ten years—it's public knowledge from CORR and MORE—we're stuck at 12.4%, 12.6%, or 12.2%. It's all the same number. If last year was 11.9%, then we broke the 12% barrier.

This is all the same number, the same poor number. I don't see any change despite all the good work, all the education we're doing locally, and the changes we've made in MORE Ontario, with the MORE Toronto co-ordinators, who we now call “organ donor specialists”, and their activity in the local ICUs. None of that has budged it, frankly.

The Chair: Okay.

I'm sorry; I interrupted you, Dr. Tchervenkov, when you wanted to say something. I know it's not related to the question I just asked, but please go ahead.

Dr. Jean Tchervenkov: I just wanted to reiterate what Dr. Smith said on mandatory reporting. What I'm saying is basically the same thing, in a way—that is, mandatory consultation with a proper, established, well-formed team for organ donor request and donor management.

So I cannot stress enough that this is probably going to be an important reason in terms of improving donation rates, along with educating the public and educating the medical profession.

The Chair: Thank you.

Madam Minna.

Ms. Maria Minna (Beaches—East York, Lib.): Thank you, Mr. Chairman.

I guess everything we've heard so far, from both today's presentation and other days', points to some obvious things—some type of national structure as well as expertise at the hospital; compensation or non-compensation, depending on who's presenting; and education overall, including the medical profession.

I wanted to go back for a moment to you, Dr. Greig. Earlier you were talking about a financial penalty for non-compliance. Were you referring to hospitals or to...? I wanted to clarify that. I wasn't sure what you meant by it, or how it would be done.

Dr. Paul Greig: I don't believe we can have a toothless tiger. Pennsylvania's legislation, which has been particularly effective in the Philadelphia area—probably because of the infrastructure they've built within the hospitals in addition to the legislation—does indeed have a penalty for non-compliance. To date it has not been invoked, and I would argue it should not be invoked for a good long time.

I would like to live in a society in which, when we die, it's just presumed that the intention is to pass on the organs. I believe it will take a generation or two before that occurs, before that becomes the norm. Until that time, the presence of mind has to be instilled and developed in people, and phoning them at the time of death would be the time to get the health care personnel, those people on the front lines, in that habit. That's my motivation behind required referral.

I think you have to build into the legislation a penalty, because if it's not there.... Lots of legislation has required consideration, and recorded this. When it's not enforced, we once again rely upon the goodwill of the doctor or the nurse at the bedside.

If it's not enforced, if it's not audited, and if there isn't someone accountable for it, then we're back to a goodwill system. That doesn't seem to work, in my estimation.

Ms. Maria Minna: That piggy-backs onto what you said earlier with respect to federal legislation requiring referral, or mandatory reporting, as you were referring to earlier. These two are kind of one and the same thing.

Given that we have a health system administered by the provinces, although funded by the federal government, I'm not sure how the federal government could pass legislation that would require these things. How would we implement it in practical terms?

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Do you see what I'm saying? For the federal government to introduce a federal piece of legislation that included, in essence, coming down to impose certain behaviour on hospitals, in our structure of government, would be rather difficult.

Do you have a suggestion?

Dr. Paul Greig: Yes, I think I do. The mechanism for establishing and maintaining standards for organ and tissue transplantation in Canada, or the technique being used, is that the standards will be referred to in legislation but the standards will be maintained separately from this. So if you want to change the standards, you don't have to change the legislation.

If standards for organ and tissue transplantation that were established at the federal level required within those standards the mechanism for required referral, then each province might be—forgive me—obliged to pass their own legislation, in parallel with their own version of a human tissues gift act, to have their own version of a required-referral type of legislation.

That would be my guess at the mechanics, but I'm not—

Ms. Maria Minna: It was just an interesting paradox there.

Sorry; I'm not chairing here.

Dr. Jean Tchervenkov: If I may interject, I believe we should not penalize people for just not doing something. I think many times a hospital or intensivist may not refer because of the financial penalties if they do. It's inherent in our medical system.

If we're going to enforce the law, I believe there should be a system of both rewards and penalties. I think you're probably going to have people act much more on having rewards as well.

The Chair: Dr. Smith.

Dr. Stuart John Smith: I think there are two other alternatives to your approach. It comes back to the issue of a national organization, and again identifying organ donor teams. One of the roles of that organ donor team would be to identify potential donors that may be coming into the hospital or at other sites. Again, that would take it out of provincial or legislative types of issues.

The second issue is the option of presumed consent. It's not presumed consent from the point of view of the family; the issue is that people could report it as part of their income tax, with changes on an annual basis—that type of presumed consent. Again, that could come under the idea of a national organization.

The Chair: Thank you, Dr. Smith.

I have two more questioners, but I know some of you have to catch a flight. I plan to bring things to a close at about 5.30 p.m. If that's too late for you and you have to leave, please accept my thanks for coming on behalf of the committee, and you can exit.

Dr. Kevork Peltekian: Thank you very much. I appreciate this, from the group.

The Chair: Thank you, Dr. Peltekian.

I'm going to go back to Mr. Vellacott.

Mr. Maurice Vellacott: Just to follow up on my line of questioning from before, I'll sketch something here. Perhaps you could listen patiently to this first part of it, because I think it's something, whether you choose to or not, you're going to have to deal with. I had started into it a little bit earlier.

I'm referring to the milieu in which...and the whole comment about information and so on. I appreciate the remarks that were made there.

There was an article in the Globe and Mail on Saturday with respect to a Dutch report on the euthanasia experience. I take it you've seen it. Guidelines are not being followed there, and there are more problems, and more non-voluntary euthanasia, than at first thought. They're acknowledging this. This is their own system there.

As well, it's been reported in recent weeks, throughout the country, that two brothers are in a particular court case where their father, who had a DNR on the record...against the sons' consent, and this type of stuff. There's also the Sawatzky case in Winnipeg, and we can go on.

I'd like to think that would go away, but frankly, with the edge of the baby boom coming up here, and an aging population, realistically speaking I don't think there's going to be any less of that. We'll possibly see more of those cases in the media. You may or may not agree with that.

With that as the backdrop, then, is this what you're going to be facing and fighting almost in terms of public trust for hospitals—particularly, I would suggest, organ transplant? How would you figure to counter that?

I appreciate, Dr. Greig, your passionate sharing of the sense of ministry and mission in what you do, but when we talk in terms of how it can't be done through altruism any more, and we need very strong enforcement—and this was referred to by others here—with the use of legal hammers and that type of thing, I'm just wondering, how do you figure to respond to that?

• 1720

I'm not trying to be personal about this; I'm just saying that's what I think you're going to be facing in the days ahead. I'm not thinking it's going to go away; I'm thinking you'll have to deal with more of that type of stuff as we deal with limited health resources and so on in the days ahead.

Perhaps you could respond quickly to that, and then I have another specific question.

The Chair: Mr. Vellacott, you might want to ask that question as well, really quickly, because we're running out of time.

Mr. Maurice Vellacott: Okay, I'll ask the other question, although it's been commented on to some degree.

One of the points of the motion, although not the terms of reference, that put this committee into action, I guess, was the whole issue of presumed consent—that is, you cannot override the wishes of a loved one if they've previously stated those wishes. The other issue was that of the national database by way of census or tax return or whatever.

With respect to both of those subpoints of the original motion that got this whole thing going, first off, how do you respond? You may even want to say you disagree with me, and you think it's going to be not an issue, with scarce resources and so on, and the Dutch euthanasia experience, and so on.

The Chair: Dr. Smith.

Dr. Stuart John Smith: First off, you always hear about those types of cases in the newspaper and not about all the other cases. I think these are very few and far between. Many of these cases—

Mr. Maurice Vellacott: But I guess my point is that they are in the media.

Dr. Stuart John Smith: I understand that, but in reality, though, there are many, many more patients who are much more thankful, and you never hear about them. You hear only about the bad things.

So in terms of those cases, again, many of them involve the approach issue, with the approach being improperly made. I think the way in which it was done probably led to the response of the newspapers.

If you look at the literature, and at the experience, you will see that people who donate do so for a reason. They donate because they want to see something good come out of something bad. People who don't donate don't understand the concept of brain death, or don't have trust in their physicians or health care team.

Again, it comes down to how the health care team is presented to the patient. For most patients who leave hospitals, I think there is a great deal of trust. It's the few patients...and we'll never be able to deal with those individuals.

So I don't think it's as big an issue as you make it out to be, or have suggested it might be, but it certainly will be an issue.

The second point is around the issue of presumed consent. Presumed consent doesn't necessarily mean you override anything. You can always opt out. That was one form of presumed consent.

So if you look at some centres—

Mr. Maurice Vellacott: Maybe I used the wrong term. Where, in fact, a donor has said, in his life, that he wants to give organs, and then the family overrides later—

Dr. Stuart John Smith: Exactly.

Mr. Maurice Vellacott: —then part of the motion was to say, well, no, they can't override it; he said this, and it's settled.

Dr. Stuart John Smith: That has been considered, again in other countries. In fact, it rarely has had to be used. In factoring in the numbers, in well less than 10% do they ever come to even any issues in terms of presumed consent.

So I think we have to look at experiences in other countries that have used this—

Mr. Maurice Vellacott: I'm using probably the wrong word, sorry.

The Chair: Do any others want to comment? Dr. Greig.

Dr. Paul Greig: I think Canadian citizens must absolutely have confidence in their organ donation and transplantation system and have confidence in the system, when in general we're not used to having confidence in “the system”.

I've become a believer in the value of standards, and establishing standards for organ and tissue transplantation in this country. Health Canada is still working to implement them through CSA, the Canadian Standards Association.

Once they're up and running, I think that will go a long way toward assuring the Canadian population that indeed standards exist and are being adhered to by means of inspection, accreditation, and licensing within transplantation. Frankly, I think it's going to be a model for other aspects of health care.

So I've become a believer in standards. I think that will help that problem.

The Chair: Madam Redman.

Mrs. Karen Redman (Kitchener Centre, Lib.): Thank you, Mr. Chairperson.

My question is two-pronged, so I'll give it all at once.

We've had a lot of consensus from all the groups of witnesses. I would tell you that you are probably largely talking to the converted. You probably sense that.

The issue of a registry for donors, and standards, and some type of uniformity across the nation has come through loud and clear. My interest in this question is how we move this forward.

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I mean, people talk—obviously, there are dollars attached—but have any of you seen costing, or could you attach a dollar figure as to what the government would be looking at investing in order to have that happen?

Second, we've heard from the liver and kidney associations that they've been probably the most successful at attracting donors and leading this whole issue forward. What's the best balance between the non-governmental agencies and associations that are already in the communities doing this work and whatever kind of government initiative that would go forward?

The Chair: Dr. Keon.

Dr. Wilbert Keon: Go ahead, Bill.

The Chair: Everyone's so gentlemanly. I don't understand this.

Go ahead, Dr. Wall.

Dr. Bill Wall: I don't know if I can answer the latter question. Certainly, such organizations as the Heart and Stroke Foundation of Canada, Canadian Kidney Foundation, and Canadian Liver Foundation, made up largely of volunteers, do a wonderful job for the groups they represent. On many occasions they've worked very closely with the transplant groups, because transplant is the only solution to some of the diseases that afflict those patient populations.

Perhaps I could just say one thing about my reservation about a donor registry for the nation. You're asking basically for a computer network that's going to record something about 30 million people, because even a two-year-old child can give consent, through the father of that child, who might want to express the wish for that child to be a donor until he reached the age of consent. So you're talking about something that is extremely extensive for this nation.

As I said in my remarks about areas and groups and countries that have the best donation rates, they do not have donor registries. They don't exist in those countries that have the best organ donor rates. It is not necessary.

That's my view about that. It may seem like a good idea, but if you are forcing people who may not know enough about transplantation to make the right decision or a wise decision about organ donation.... Of course, if you give them the option of opting out, they will opt out. So when I said one out of four or five people isn't in favour, and you make them record their wish somehow, they're going to decline. Automatically you've excluded 25% of the population from ever being an organ donor because you haven't educated them about the donation process and the reasons, and the right answer that they should come to.

In terms of the other situation—and I apologize for expanding on this, but Mr. Vellacott said something very important—I think it's true that the legal opinion would be that if an individual had signed a donor card and that was an express wish, we, as transplant specialists, would have the legal right, defensible in court, to take those organs, regardless of what any next of kin said. I think that's true, and I think that would be the legal opinion. However, we would never do that. No transplant program would violate the wishes of the next of kin, because it speaks to everything we've talked about here, about credibility, and the sense of nobility and everything that's related to transplantation.

The solution to the problem you have raised again goes back to these surveys that tell us half of the people, when asked if they knew the wishes of their next of kin, if they should die, say they do not know; 63% of families have never discussed this with other family members.

Now, if they had, and they knew their father had wanted to donate his organs, I feel any reasonable person would respect the wishes of his or her father and say, yes, that's what they wanted, and I want you to do it. It arises because they didn't know it. They might have their own views about transplantation, and then it brings an awkward situation.

So there's an easy solution to the situation you have brought up. I feel very uncomfortable about doing something in the legislature that would tell doctors to go ahead and take these organs against the wishes of the next of kin. I would advise against that. It doesn't give me a good feeling.

I'm sorry, Dr. Keon; I interrupted and went on too long.

Dr. Wilbert Keon: I was probably just going to say the same thing.

I don't think we need legislation at this point in time. What we need is a national organization that can coordinate the provincial resources.

• 1730

You were talking about the cost of this. I don't think cost would be prohibitive with the resources at Health Canada. With the resources coming up in the health information system, I think they could be wedded to put this in place without a great deal of cost. I won't throw out a figure, but I don't think you're looking at tens of millions here.

Again, if you avoid legislation, it makes it simple to go back to the provinces for implementation, which comes over to the other question of this overlap between euthanasia and brain death. Euthanasia is very clearly defined in the Criminal Code. It's a total no-no in Canada. It's a criminal offence.

So that's an open-and-shut issue, one I don't think we have to worry about. I don't think the Canadian public has to worry about that.

I think what has to come out of this deliberation is the promotion of a national co-ordinating organization that is very similar—and I throw it out for the third or fourth time—to the health infrastructure, which can work with the provinces, work with the local organizations, pull what we have together, and provide a universal organ donor card, as Bill has suggested, rather than putting the name of everybody in the country on a computer in terms of whether or not they're a donor. That would be a horrendous undertaking.

The Chair: Dr. Tchervenkov, do you want the last word on this topic?

Dr. Jean Tchervenkov: If I had $10 million or $15 million, and I would like to spend it wisely on promoting organ donation, I would set up a donor management team, pay for it, and maybe institute it in hospitals where numbers warranted. I would spend it also on a national organization to promote transparency and to look at our data and our outcomes.

I would also second Dr. Paul Greig's suggestion. I do think transplant centres need some funds to open up operating rooms and beds in intensive care units to take organ transplantation away from the general, regular operating room schedules and ICU demands. These would be mandated specifically for that type of activity.

That's it.

The Chair: Thank you, Dr. Tchervenkov.

Before we wrap up, I wonder if I can ask a question. If you think it's a brilliant question, I'll take all the credit for it. If you don't think very much of it, I'll lay the blame on our research department.

Dr. Peltekian, in his presentation, you will recall, asked us to consider Canadian Blood Services. He said to take that structure and replace the word “blood” with “organs”. Nobody commented on that, and I'm wondering whether collectively or individually you've thought about that “national agency”—quote, unquote—as a model for what you talked about when you suggested a national organization.

Dr. Bill Wall: I can't comment, because I'm not that familiar, I'm embarrassed to say, with Canadian Blood Services.

The Chair: That's fair. It's a new organization.

Dr. Bill Wall: However, if Dr. Peltekian was recommending it, I suspect it was a good recommendation.

The Chair: Okay.

Dr. Paul Greig: I've been working with Health Canada to develop the standards for organ and tissue donation, and one of the first things suggested was that they be lumped together with the standards for blood donation. Because of the bad name blood has gotten in the past five years, we'd prefer that organ and tissues be considered somewhat separate from blood donation. After all, blood donation is a renewable resource, etc.

• 1735

Like Dr. Wall, I plead ignorance, somewhat, in terms of the structure of Canadian Blood Services. I have my own personal vision of what would be necessary for a national organization for transplantation. I suspect there'd be some very similar aspects to the national issues CBS has.

So I would think the model would be a reasonable one, with the caveat of, “Let's see the deals”.

The Chair: Okay. Fair enough.

Dr. Wall, you have with you a medallion of sorts. I think you wanted to give some indication of how it fits into the general discussion. I'm sorry I didn't give you an opportunity to introduce it before.

Dr. Bill Wall: I do have it, Mr. Volpe, and thanks for mentioning it. I thought this was presented to you in a formal way by my colleague, Jane Drew, the transplant coordinator from London.

We had this medal struck a little more than one year ago. It was designed by an artist, Mr. Bill Johnson, who gave of his time voluntarily.

For a long time we have believed strongly that organ donors and their families have not received the recognition they should have received over the years for giving this gift of life to other individuals, and we wanted to recognize them in a tangible way.

So we had this medal struck, and gave a great deal of thought to its design. On the front is an embossed maple leaf and a silhouette in the background, leading to different interpretations—the passage of life, one in the background, one in the foreground, and so forth. We wanted it that way.

It has the maple leaf because we think that's a Canadian distinction. We view everything we talked about today as something Canadian, done by Canadians for Canadians, usually for Canadian strangers. It's a noble act that deserves recognition. It says, Le don de la vie en reconnaissance, and then there's a space on the back for the family to inscribe whatever they would like to inscribe.

We had a session last April during Organ Donor Awareness Week, where we gave this medal out to donor families. It was a sensitive evening. It brought out many emotions, as you might expect.

We'd like to see the government, the nation, accept this and endorse it as the donor medal that can be promoted in much the same way a war medal is given for an act of bravery. This is a noble act that we think deserves the attention and recognition of the government.

If the government was prepared to do this, it would fill that need, we think. As well, doing that will in itself raise tremendously the level of awareness about organ donation in this country. To have our Governor General give out a handful of these in a ceremony once a year during Donor Organ Awareness Week I think would be something we would be delighted to have.

A number of procurement and transplant programs did this last year. I know Dr. Keon did it in Ottawa. That was a very worthwhile endeavour, and I think they plan to do it again this year. Edmonton will, and Vancouver, and groups in Toronto. Montreal is interested.

So we'd like this to be promoted as a Canadian medal that would have the support of the federal government and be recognized nationally for what we hope it will be.

Thank you for permitting me to say that.

The Chair: Okay.

To Dr. Wall, Dr. Greig, Dr. Keon, Dr. Tchervenkov, Dr. Smith, and, of course, Dr. Peltekian, I think I speak for all members of the committee when I say this has been a most instructive exchange. We thank you for taking the time out of your schedules to share your experiences with us. It will all come out, I think, when the committee makes its recommendations.

What you've witnessed is that there seems to be developing a political will to do something. As to what will happen, of course, only time can tell.

Thank you very much.

The committee is adjourned to the call of the chair.