UNEMPLOYMENT AND HEALTH

1344 MARKETS IN KIDNEYS

S;R,—Dr Bach (Nov 10, p 1102) does us a great service in dispassionately exposing the arguments for and against the sale of kidneys by living donors. The potential gains to individuals to the community , and to the advance of transplantation surgery are so great that the subject must be discussed openly and in detail and not dismissed out of hand. Bach’s fundamental point is the utilitarian one-that there must exist a balance between the obvious benefits on the one hand, and on the other, the risks to both individuals and the dangers of profiteering and exploitation and of setting a precedent that might lead medicine further down the road from humanitarian idealism to ethical ruin. Your editorial (Nov 10, p 1081) tips the balance in favour of maintaining the "gift relationship" of Richard Titmuss. Both discussions point separately to the many serious practical difficulties which face any deviation from this standard. Like Bach, I am not drawing any conclusions. My main concern is that the discussion may be deemed to be unnecessary or be endangered by excessive polarisation into idealist and utilitarian camps. These are not opposite ends of any simple spectrum, and the arguments are therefore at risk of being at cross-purposes from the start. It is important to guard against drawing conclusions from ethics alone. Even-the taking of human life has been accepted in war, self-defence, and punitive execution, at least at times, and by the majority. This does not mean that the underlying ethical principle is faulty, unwanted, unacceptable, or inappropriate-only that its application in society requires tempering to make it practicable. The use of the law represents our closest approach to ethic enforcement-as practical a set of rules as possible, based on a generally (but not universally) accepted code of conduct, modified both theoretically and from past experience to be workable and enforceable. This does not make execution ethical, nor does it mean that guilt which cannot be proved in court is blameless-the law is necessarily arbitrary, subject to evolution and to tides of opinion, and is by its very nature only one of the practical tools of society. The highest ethics (such as "Love thy neighbour as thyself) can scarcely be doubted, but are often so vague as to be capable of very varied interpretation and widespread special pleading, and to be quite impractical as guidelines for the government of society. Why, then, should the idealistic extreme view prohibiting the sale of organs by living donors be unthinkingly enforced? Should we not at least admit the possibility of extenuating circumstances? Should even a related donor be prohibited from receiving the expenses and loss of earnings resulting from the donation? Or only the offer of subsequent health insurance for life? Or only the offer of repatriation and resettlement to enable him to receive more readily any necessary future medical care? And if any of these, why not more, given the right circumstances? The circumstances might have to be prohibitively special to permit some transactions-that is not the point. The point is that, in an imperfect world, advantages and disadvantages must be weighed and matched, and matched again in the light of changes in knowledge, experience, attitudes, or circumstances, before decisions are made. To hide behind any extreme view is unfair and unproductive. The most acceptable view in most human affairs is nearly always somewhere between two or more extremes.

Politically, communism theoretically seeks to abolish all heritable advantage-and even preferment by virtue of ability rather than by output. Western socialism waters this down, and purchased advantages are permitted, but are dearly bought, and taxation strives to equalise, but the emphasis is on upgrading mass facilities at the expense of the best, rather than on prohibition of advantage. Given the necessary safeguards-and I do not underestimate or belittle what this implies-does not any scheme for improving the health of some at an agreed and equitable cost to others demand a fair hearing? No-one doubts the superiority of freely donated blood for transfusion

over

its commercial counterpart, and the

agreed, and whether or not in the end any made to initial, preconceived, reactions. changes Please, let discussion continue. can

same must

apply to kidneys and other "spare parts". But let us not throw out the baby with the bathwater. There are still advantages to be had from such an enterprise-as there were from the unorthodox transplantation of a baboon’s heart into an otherwise incurably ill child-that merit discussion, whether or not adequate safeguards

be devised and are

Medical Unit, Eastern General

Hospital, Edinburgh EH6 7LN

N. MCD. DAVIDSON

am alarmed at any utilitarian approach to the serious of kidney brokerage and found your editorial objections weak. This practice must never be allowed-and given the unanimity of scientists against commercial traffic in human organs I am astonished at the use of The Lancet as a forum.

SIR,-I

matter

Laboratory of Experimental Medicine, Collège de France, 75231

Paris, France

JEAN DAUSSET

*0n Oct 26, 1983, three Nobel laureates (Sir Peter Medawar, FRS, Jean Dausset, and George Snell) wrote to President Reagan in an attempt at commercial kidney brokerage-namely, the establishment of International Kidney Exchange Ltd by a doctor in Virginia. Part of that letter is reproduced below.-ED. L.

response to

"While the donation of an organ after death is a noble and moving gesture of human solidarity, and while the voluntary donation of a mother to her child or between brothers and sisters is acceptable when strongly motivated by powerful sentimental links, the selling or buying of an organ of non-related individual is, in contrast, shocking and could lead to abuse ... It opens the door to every kind of extortion to which all those who are dependent on others in a society would be submitted, those who belong to the inferior layer of society or to a despised and ...

oppressed minority ... Equally, it opens the door to all types of hypocrisy, as a sale can be thickly camouflaged as a disinterested so-called gesture or as a so-called ’gift’. Multiple compensations, under the table, and blackmail would then be practised. The rule, therefore, is simple and clear: double organ grafts (such as kidney grafts) should not under any circumstances be practised using organs from living non-related donors." UNEMPLOYMENT AND HEALTH on unemployment and health circumstances correctly places "today’s beyond all previous experience". It comments critically on studies of the psychological consequences of unemployment and concludes that "more work is needed", but not more research work. Given that current levels of unemployment constitute a major socioeconomic and political issue, it seems hard to accept that to conduct research in this area is to "connive at Government inaction". Firm evidence on the relation between unemployment and health is of fundamental importance and may benefit the unemployed or the unwell by demonstrating to those in authority the high costs of both unemployment and ill-health. You did not mention the high parasuicide rate amongst the unemployed in Edinburgh and other centres. 1,2 While providing a timely if selective review of the methodological difficulties encountered in studies of unemployment and psychological illness, you made no comment on health, an equally difficult area in unemployment and physical 3 terms of methodology. The editorial correctly states that longitudinal studies are most likely to yield valid results, but that they are expensive, timeconsuming, and few in number. The major advantage of such longitudinal (prospective) studies is that both health and employment status are determined at the initial examination and the individuals are then followed up to determine the relations between these two variables over time. They permit an inquiry into whether unemployment is associated with the development of ill-health and the extent to which varying degrees of chronic ill-health influence future employment. The British Regional Heart Study is a longitudinal investigation into the factors concerned with cardiovascular disease (coronary heart disease in particular) in 7735 middle aged men drawn at

SIR,-Your Nov 3 editorial

1345 random from general practices in 24 towns in England, Wales, and Scotland.4 All these men were examined in detail in 1978-80, at a time when unemployment had just begun to rise and are being followed up for a period of 8 years, to 1986-88. Those men unemployed at the initial examination fell into two groups-those who considered that their unemployment was associated with illhealth and those who considered themselves to be well. Both of these groups showed evidence of an excess of chronic respiratory disease and of ischaemic heart disease compared with rates in employed men.Clearly, even those unemployed men who thought they were well, had more disease than the employed men. The suggestion arising from this study is that those men who have early evidence of disease, may become unemployed more readily and remain unemployed for longer than men who are healthy. This possibility cannot be confirmed from the preliminary crosssectional analysis; a more dynamic view of the unemploymenthealth relation is needed. To obtain this dynamic view, we are using information from a postal questionnaire to all men at 5 years after entry into the study. The questionnaire asks about employment status before and after entry into the study, and also into changes in health (recall of doctor diagnosis) and in risk factors (smoking, drinking, weight). The illness data are validated by the follow-up procedures linking each man’s general practice with the Regional Heart Study, and despite movement between practices, we have maintained contact with 99% of the men. The questionnaire has achieved a very high response rate (98%) and, in conjunction with the measurements made at initial examination, should enable us to examine the extent to which men have been selectively forced out or kept out of the work force because of ill-health. Such individuals may become registered as sick, since it has financial advantages, or they may be compelled or encouraged into early retirement. Since the sick and the retired are no longer "actively seeking work" they constitute a potentially large source of bias in official unemployment statistics. A further source of bias is that studies of the unemployed actively seeking work are confined to a selected healthy group. The Regional Heart Study should be able to provide detailed information on the dynamics of the unemployment and health interrelation and to quantify this "selection of the fittest". of Clinical Epidemiology and General Practice,

Department

A. G. SHAPER D. G. COOK

Royal Free Hospital School of Medicine, London NW3 2PF 1. Platt S. Unemployment Bull 1983; 10: 4-5

and parasuicide in Edinburgh 1968-1982. Unemployment Unit

S, Kreitman N. Trends in parasuicide and unemployment among men in Edinburgh 1968-82. Br Med J 1984; 289: 1029-32. Cook DG, Shaper AG Unemployment and health. In: Harrington JM, ed. Recent advances in occupational health Vol II Edinburgh: Churchill Livingstone, 1984:

2. Platt 3

233-49 4 5.

** an

Great Britain. Lancet

article

on

this theme

1982;

i:

1290-94.

begins on

p 1324.-ED. L.

STABILISING EFFECT OF AMINOACIDS ON FACTOR VIII IN LYOPHILISED CRYOPRECIPITATE

SIR,-Cryoprecipitate lyophilised in the original bags as single was previously shown to be suitable for treatment of haemophiliacs. The method is now being modified for large-scale production, and during this work the effect of synthetic aminoacids was investigated, after earlier studies had demonstrated their stabilising effect on purified factor VIII concentrate.2 ’Synthamin 17’ (Travenol), a 10% mixture of fourteen synthetic aminoacids, donor units

added in amounts up to 4 mg per unit of factor VIII to concentrated cryoprecipitate prepared and assayed as previously described. 1,2 For clinical use ten individual bags were kept in moisture-proof packs. For stability studies, pools of up to 10 donor units of concentrated cryoprecipitate (35-40 units/ml) were sampled into clean bags or glass vials with or without synthamin, freeze dried, and sealed in a nitrogen atmosphere. was

TABLE II-RESIDUAL FACTOR VIII PROCOAGULANT AFTER GAMMA IRRADIATION

The most striking effect was a much better solubility (less than 5 min compared with 15-30 min in controls). Stability on storage was also greatly improved. In an accelerated ageing test at 37°C there was an almost 4007o per week loss of activity, the material becoming practically insoluble after 3 weeks. As shown in table I this was completely prevented by the added aminoacids. Similarly, after heating at 70°C for 16 h without, or with a lesser amount of synthamin (0’3/unit of factor VIII) the cryoprecipitate became practically insoluble. With 1 mg per unit, full solubility and activity was preserved. Table I also shows that for prolonged heating 70-75 °C is a critical temperature. The effect of gamma irradiation from a cobalt source was tested in the range of 1-4 Mrad (ie, potentially sterilising dosage). Table 11 shows that the damage to factor VIII is dose-dependent and is partly offset by aminoacids, without which all the samples exposed became insoluble. Since the mechanism of protein denaturation is not at all well established3it is premature to speculate on the general significance of the above findings. An obvious step will be to examine aminoacids individually and in simple combinations. Of more immediate practical importance is the question whether heating (or gamma-ray treatment) of dry factor VIII preparations is likely to inactivate any potential pathogens, in particular human lymphotropic virus type 1114 with the reservation that a virus may be also protected by the additives which so markedly stabilise a protein as labile as factor VIII. -

Shaper AG, Pocock SJ, Walker M, et al. British Regional Heart Study: Cardiovascular risk factors in middle aged men in 24 towns. Br Med J 1981; 283: 179-86. Cook DG, Cummins RO, Bartley MJ, Shaper AG. Health of unemployed middle aged men in

TABLE I-HEAT STABILITY OF LYOPHILISED CRYOPRECIPITATE WITH AMINOACIDS

We thank Dr P. Wills of the Australian Atomic gamma-ray facilities.

Energy Commission for the MARGOLIS MICHAEL EISEN

JOEL

NSW Red Cross Blood Transfusion Service, Sydney, NSW 2000, Australia

Margolis J, Rhoades P. Cryoprecipitate lyophilised in single donor units for treatment of haemophiliacs. Med J Aust 1979; i: 523-24. 2. Margolis J, Gallovich CM, Rhoades P. A process for preparation of "high purity" factor VIII by controlled pore glass treatment Vox Sang 1984; 46: 341-48. 3 Lapanje S. Physicochemical aspects of protein denaturation. New York: John Wiley, 1

1978. 4. Gallo

RC, Salahuddin SZ, Popovic M,

cytopathic 506-08

retroviruses

(HTLV-III)

et

from

Frequent detection and isolation of patients with AIDS. Science 1984; 221:

al.