HEAL Committee Meeting

STANDING COMMITTEE ON HEALTH

COMITÉ PERMANENT DE LA SANTÉ

EVIDENCE

[Recorded by Electronic Apparatus]

Thursday, February 11, 1999

• 0911

[English]

The Chair (Mr. Joseph Volpe (Eglinton—Lawrence, Lib.)): Thank you, ladies and gentlemen.

Pursuant to Standing Order 108(2), this is a study of the state of organ and tissue donation in Canada. The committee will resume its hearings.

Today we have again two panels. In our first panel we have some witnesses from the various procurement and management organizations around the country.

We have with us Ann Secord, transplant coordinator from the New Brunswick Organ and Tissue Procurement Program. Welcome, Ann Secord.

From the Nova Scotia Multi-Organ Transplant Program, we have Dr. Allan MacDonald, who is the director. Welcome, sir.

From the Newfoundland OPEN Program, we have Mr. Max Bishop, who is the director. Welcome to you as well, sir.

And from MORE Ontario, we have Mr. Graham Scott, who is the chairman. Mr. Scott, welcome as well.

I believe Mr. Scott has to catch a flight, so I'm going to start the process by going to Mr. Scott first.

Mr. Scott, the floor is yours. Our rules are basically as follows: five minutes per presenter and then we'll go to committee members to ask questions in a back-and-forth dialogue. The less time you take, the more time we have for questions and answers. If there are other things you'd like to get into your presentation that might take you beyond the five minutes or even beyond the question-and-answer session, we'll always entertain any other questions or briefs in writing, which will then be distributed to everyone.

Please, sir.

Mr. Graham W.S. Scott (Chair, Multiple Organ Retrieval and Exchange (MORE) Program of Ontario): Thank you, Mr. Chairman. I'm pleased to appear before the committee today. However, I'm not pleased about the state of organ and tissue donation in Canada.

[Translation]

I am President of the Multiple Organ Retrieval and Exchange Program of Ontario, or MORE, which was established in 1988 by the government of Ontario.

[English]

the Ontario Hospital Association, and the Ontario Medical Association

[Translation]

to keep a province-based electronic listing of patients waiting for an organ in Ontario.

[English]

I would particularly like to acknowledge the leadership of one of your members, Elinor Caplan, who, as Minister of Health in Ontario, played the leadership role in the establishment of MORE in 1988.

We have a mandate to create educational and organ donor awareness campaigns for health professionals and the public. Our business is coordination and equity. We're expected to develop and support programs to ensure fairness. We rely, however, primarily on moral suasion.

The work of the committee is pursued by a small staff and directed by a 12-member board of directors, with representatives from the transplant community, the public at large, and the government. We have just completed a thorough update of our operations and computer systems and currently have the potential to accurately track all organ donation and utilization. Indeed we have the capability, and have volunteered it, to operate a national waiting list for Canada.

Despite improved information exchange amongst transplantation centres, there is not a common approach to practice standards, clinical guidelines, or system utilization at either the institutional or the professional level. As sophisticated as our system is, it can only be as good as the input it receives.

• 0915

The emphasis of our board, and its priority, is ensuring that our system can now be most effectively used. With widespread commitment, the potential for improvement is enormous. Government could make the most significant contribution in the areas of national promotion, coordination, awareness, and donor identification.

A perpetual weakness in the current system is the absence of promotion. The lack of available organs for patients in need is currently a crisis in the country. The problem is supply, not demand. There's no shortage of patients seeking life-saving and life-bettering transplantation. But while this list grows, the organ supply is in decline.

It's ironic really. At the heart of the technological wonder that is transplant science lies a very real limitation imposed by under-educated citizens and too many under-committed health and medical professionals. Transplantation may be a marvel, but organ donation, it seems, is a miracle. And the thing is it's not a mystery. So many of the key elements are already in place. We can make it work, and we know what it will take.

Education and awareness amongst health professionals is a major concern. Nurses, physicians, and other staff need more in-depth training and reinforcement on the importance of methods of donor identification and consent. This entails not only understanding organ donation but having the skills necessary to ask for consent in an effective manner. The MORE Program currently has the expertise to carry out training and support, but funding is not available.

Education with our demographically diverse population is always a challenge. Staff must be equipped to deal with a wide variety of ethnic, cultural, and religious factors that may affect one's propensity to donate. Some jurisdictions in the United States and Europe employ full-time experts in organ donor identification and asking, and as a result have significantly better donor rates.

The next topic is hospital development and funding. Transplants' human complications are more easily avoided in an environment where human and financial resources are being stretched to their limits due to a combination of overdue reforms and budgetary restrictions. In these circumstances most hospitals are not ready to commit to the burden of identifying and maintaining a potential organ donor. More must be done in the hospitals, but the issue of supply is paramount. That lack not only robs the system of better responses; it denies citizens a real opportunity, distorts current delivery systems, and threatens the very integrity of those systems.

Provincial coordination—indeed, national cohesiveness and standardization—in organ donation and transplantation is essential if we're to convince the public that this scarce resource is being used in an effective manner.

Currently there are as many approaches to organ allocation and donation as there are transplant centres. While clinical judgment as a rule is not in question, it is vital that allocation and distribution take place in the fairest way possible to serve all waiting patients in a human, health-effective manner and to convince all potential donors that this is so.

There are also many methods of registering and identifying potential donors, with varying degrees of effectiveness. A consistent method is required, with universal promotion and government support, as it could significantly improve awareness amongst the public and increase donation.

Public awareness could also be improved through a more coordinated awareness campaign using resources from a wide variety of government and volunteer agencies currently engaged in such endeavours.

The government is to be commended for establishing National Organ and Tissue Donation Awareness Week. It is a welcome first step in a move towards a more cohesive and therefore more effective public campaign.

Many believe legislation governing donation could benefit from review and enhancement and perhaps national coordination. Currently in Ontario we have legislation that permits organ donation with signed donor support or family consent, and we have a regulation that requires hospitals to have a process in place that would allow for donor identification, but there is no requirement that any action be taken.

[Translation]

In some jurisdictions, the law stipulates that all deaths or imminent deaths in hospitals be declared to an organ procurement organization so that specially-trained personnel can help determine whether the patient is indeed a potential donor, and is available to help ask family members for consent.

• 0920

[English]

Other jurisdictions have presumed consent legislation, where every citizen is assumed to be a potential organ donor unless he or she indicates in advance a decision not to be. In most places where this law applies, health care professionals will ask for family consent.

The MORE Program, however, has no official position on either presumed consent or mandatory death reporting, but recognizes the correlation between such measures and high donor rates and believes that these and other methods of government and public support for organ donation should be discussed openly.

We urge you to recommend strong support for efforts to make Canadian transplantation programs equal to or better than those in the rest of the world. This means improved coordination of and cooperation amongst programs in the provision of essential funding for improvements proven to be effective in saving lives and ultimately overall health care costs. Help us do what we know must be done.

Thank you.

The Chair: Thank you very much, Mr. Scott. I noticed you were trying to observe the rigours of the time constraints. Sometimes we're more successful than others.

Mr. Bishop.

Mr. Max Bishop (Director, Newfoundland Organ Procurement Exchange Network (OPEN) Program): Thank you very much for inviting me to present today.

I agree with Mr. Scott: organ donation in Canada, and especially in the province where I live, has fallen off dramatically.

A formal organ donor and retrieval program has been in existence in Newfoundland and Labrador since 1982. Over the years, continuous awareness efforts have been concentrated on keeping the under-supply in the public view. In addition to public awareness, similar efforts have been taken with health care organizations and also health care professionals so that appropriate policies and education would support the organ procurement process.

As a result of these initiatives, a fair degree of success was achieved in ensuring consistent application of policies throughout the province of Newfoundland and Labrador. However, like elsewhere in Canada, recent health care system restructuring and the subsequent transitional changes have impacted on the Newfoundland organ donor program.

A system of regional governance has seen the emergence of multiple organizations under one board. In many instances staff changes have also resulted, and as a consequence many of the well-trained and supportive supervisory personnel who were well versed in organ donation have changed jobs or are no longer employed. During this transition period, previous hospital practices have become ineffective, and the need for refocusing on a regional-provincial procurement and distribution system is evident.

I'm speaking for Newfoundland, but what you have to remember is that Newfoundland does not have solid organ transplant. All of our solid organs are exported out of the province, and we have an agreement with the transplant centre in Halifax.

A renewed and substantial effort is under way at the present time in Newfoundland and Labrador, and we're looking at building on the successes we had within the province.

The objectives of these efforts are to define the scope of the problem, develop a framework for organ and tissue procurement, seek commitment and support from hospital staffs, and develop appropriate standards and policies to ensure the necessary steps are taken.

We don't have a national standard, so the standards we use are from the different programs in Canada where we send organs. So when we write up our standards, we have to look at just about every transplant program, see what their standards are, and then implement them within our system.

Other objectives are to define continuous awareness strategies to keep the issue in the public's and the health professionals' view, and to discuss methods by which regional awareness of under-supply can be addressed.

To meet these objectives, the Organ Donor Committee of the Newfoundland branch of the Kidney Foundation of Canada partnered with the Health Care Corporation of St. John's to implement the Forum on Organ Donation. The agenda for the forum was dictated by a preformed survey, which was distributed to key individuals within the eight health care regions of the province.

• 0925

The format was twofold. The morning sessions focused on the clinical presentations that were identified and highlighted in a preformed survey. The afternoon sessions consisted of nine working groups, established according to the health care regions and the level of participation they had with the organ donor process.

The forum participants and the people involved in this forum were physicians, nurses, and social workers. These people are going to be key in helping to identify and approach donor families.

The forum participants identified four key strategies needed to increase organ and tissue donation.

Number one was professional education. Education was identified by the forum participants as the key initiative—education of the physicians, the nurses, and the people who are on the front line to make certain they understand the organ donor process.

Health care providers also must be given the expertise to identify and refer all potential donors, as well as the skill to approach the families in times of crisis. With the geography of Newfoundland being what it is, one of the problems we have is that we need people within each jurisdiction to be able to do the approaching. One person in the province cannot do it. We have to have people in each area.

All the health care providers also must be aware that it's the family's right to be asked about organ donation when a family member dies.

The second thing we looked at was the institutional framework. Participants of the forum recommended that an organ donor committee in each of the eight regions be instituted by the end of 1999, and that committee membership should consist of personnel involved in organ and tissue donation, such as physicians, nurses, pastoral care, and social workers.

The purpose of the committee would be to implement the policies and procedures for organ and tissue donation. The extent of each region's implementation would depend on the region's professional resources.

Other roles of the committee would be to increase professional and public awareness of organ and tissue donation; liaise with the provincial coordinator of the organ donor program; monitor the quality assurance through periodic reviews of the process to identify and refer donors, and we could do this by auditing the mortality statistics; and evaluate the outcome of the professional awareness program.

Number three was the establishment of standards. As I said before, we don't have national standards, so the standards we put in are a hodgepodge of all the different programs.

The fourth one was public education. Public education is an ongoing problem, and it should be done within each region. In Newfoundland, because we are such a vast area, for me to travel to all the regions of the province, it's only one and a half positions, and it is hard to do this. We have to get the best bang for our buck, so we have to look at regional areas in which we can have people do the education.

In conclusion, all four strategies—professional education; institutional framework; establishing the standards, policies, and procedures; and public education—are extremely important. However, none of these will be able to be implemented unless we have the resources, both personnel and financial.

Thank you very much.

The Chair: Thank you very much.

Ann Secord.

Ms. Ann Secord (Transplant Coordinator, New Brunswick Organ and Tissue Procurement Program): Mr. Chairman and honourable members of the committee, thank you for giving me the opportunity to speak about the Organ and Tissue Procurement Program in New Brunswick.

• 0930

New Brunswick is one of three Canadian provinces that do not have an organ transplant service. The other two are Newfoundland and Prince Edward Island. New Brunswick does, however, have an organ procurement program, and the four Atlantic provinces function as part of a regional transplant service that is based in Halifax, Nova Scotia.

The New Brunswick program became formalized in 1981 with the appointment of a transplant coordinator. Over the intervening years, the scope of the program has changed from a focus on kidney procurement to the present focus on recovering multiple organs and tissues from each donor. Numbers of organ donors have varied each year, from a high of 21 in 1986 to a low of seven in 1996.

The system of contact when a potential donor is identified in an intensive care unit is the same as in other Canadian programs—that is, a call is initiated to the transplant coordinator and work proceeds from there. However, a few factors are somewhat unique to the New Brunswick situation.

The first is the collaboration with the Halifax program. When a donor is identified, Halifax is contacted first. Kidneys retrieved from all New Brunswick centres, with the exception of Edmundston, go to Halifax. When a donor is identified in Edmundston, the coordination is done with the program in Quebec City, and that is because of geographical proximity. The physicians in Halifax are actively involved in the management of donors from New Brunswick. In many cases, extra-renal organs are placed with the Halifax program as well. This rule applies as long as there aren't high-status recipients in other Canadian centres. If there isn't a suitable recipient in Halifax, then the organs are offered outgoing from east to west.

The second unique factor is that New Brunswick is the only province where the transplant coordinator or organ procurement officer is employed directly by the Department of Health and Community Services. This came about because, again, there is only one position for the province, and the scope of the position is provincial rather than being hospital-oriented. The position was initially attached to the Public Health and Medical Services Branch, but since 1997 has been with Hospital Services.

The third unique factor with the New Brunswick program is that all expenses incurred by a hospital during an organ retrieval procedure are reimbursed to that facility by Hospital Services Branch. This program was started in 1987 in order to remove one perceived barrier to organ procurement—that is, that donor identification and management are costly and ICU budgets cannot handle the additional expenditure.

I would like to take a moment now to highlight two of the initiatives that are currently being investigated by the New Brunswick Department of Health to maximize donor potential within the province.

First, work is ongoing to have the New Brunswick health card reflect each New Brunswick resident's wishes about organ donation. The need for a donor registry was recognized in 1992, and it was felt by the Department of Health and Community Services that the most appropriate association for this donor registry would be with the New Brunswick health card. This is the one identifier that is with a patient at all phases of hospitalization. In order to make the registry useful to and usable by the health care provider in the emergency room and the intensive care unit, that's where the information should be housed.

Two, a plan is being developed that we hope will move responsibility for organ procurement from the Department of Health and Community Services to the regional hospital corporations. The first step in this process was the development and distribution of a manual entitled, Organ and Tissues Donor Manual: Guidelines for New Brunswick Hospital. The next phase will be identifying personnel in the major hospitals who will receive training in donor recognition, management, and coordination. For the referral of donors, there has been a historical dependence upon the two New Brunswick hospitals that have neurosurgery units. This is no longer acceptable if we are going to maximize the donor potential within New Brunswick.

• 0935

I do also want to take this opportunity to express one area of concern, specifically the loss of the national waiting list for patients who are waiting for extra-renal organs. This list has been maintained and circulated on a weekly basis by the MORE Program of Ontario. For various valid reasons, they are no longer able to maintain this service. Until there is an acceptable replacement, the loss of this list, although it was not a perfect system, will mean additional time spent in trying to find suitable recipients for the organs that are being offered. With the current system, at least we have been able to identify which programs have had recipients that could be a possible match to the organs we are offering.

Mr. Chairman, again I thank you for giving me this opportunity, and I'll be pleased to respond to any questions.

The Chair: Thank you.

Now we'll go to the last presenter, Dr. MacDonald.

[Translation]

Dr. Allan S. MacDonald (Nova Scotia Multi-Organ Transplant Program): I appreciate your invitation to come before you and speak on this extremely important problem. If I may, I will continue in English.

[English]

The substance of my remarks is before you in written form, so I'd like to depart from that to make a few points that need to be made, particularly in this forum.

We are an old transplant program, and the director is also old, so I'll take the privilege of my advancing years to say some things that need to be said.

We do the transplants for Atlantic Canada, and our program is a fairly big one. We average around 100 transplants a year in kidneys, and we do livers, pancreases, and hearts, and are embarking on a lung program. From our own perspective, we've spent most of our time making organ transplantation a success—that is, the recipients a success—and that's been the emphasis in the programs across the country.

Organ procurement was initiated when it had to be, in the 1960s, but it hasn't evolved to the same level that organ transplantation has. There are a variety of reasons for that, and let me just reiterate a few of the things that have happened over the years.

Ottawa, the federal government, has sponsored a variety of initiatives, beginning in the early 1980s. You've had, I think, five initiatives, the last one being the Health Protection-sponsored standards committees. None of these have resulted in increased organ donations. In fact the organ donor rate is going down, not up. In large measure that's because the emphasis has been on the wrong syllable.

The point I make in my little submission here is that organ donors don't come into the hospital as organ donors. They come in because they're sick, they've had a stroke, or they've been in a car accident, and they end up in either the emergency or the intensive care unit. And they're looked after by people—intensivists, ICU doctors, emergency room doctors, neurosurgeons, neurologists, and the nurses in those places.

No system that anybody can put in place will make it work if those doctors and nurses don't buy in, and that's where the emphasis has to be. All of the rest of the stuff people have said—the meetings, the standards, the regulations—is all folderol. The only thing that's important is that the people working in the ICUs be given the wherewithal to be able to manage organ donors, speak to the families, talk to them about the brain death process, and actually get the donors.

If you look at systems around the world that are effective—the ones that have a long-term success rate and those that have recently become successful—there is a commonality to them all. The commonality is that somebody in the ICU is responsible for organ donation—not in the administration, not in Toronto or Quebec City or Halifax or Saint John or Fredericton. It has to be in the ICU; that's where the action is.

• 0940

All kinds of things have weighed on that. We have no fewer organ donors than Spain has. They have a lower death rate from automobile accidents; they have a lower murder rate than we have. South Australia has put in a program that achieves the same as Spain, again with lower death rates in almost every category. The donors are there.

What causes the trouble in Canada is the way we've organized, or failed to organize, the system within the hospitals. We have regulations in our own province. We have required consent legislation. We have ineffective regulations. There are no teeth anywhere. So what we need really is a situation where the ICU doctors and nurses have an incentive, a reward, and an obligation—especially an obligation—to identify, manage, request, and achieve organ donation.

Any system that spends all of its time on registries, organ donor cards, and health registries is not where the action is. It may be where you can do something, but it's not going to make the slightest bit of difference. We've had registries for 15 to 20 years in some provinces, at least 10 in virtually every other province. We have two provinces that pay the hospitals for organ donation, and it hasn't made a whit of difference. The problems are in the ICUs.

To give them their due, considering the pressures that ICUs are under these days, they deserve kudos beyond kudos for the fact that we get any at all. But still, that's where the incentives have to be; that's where the effort has to be.

Having said that, organ donation is worth it. We're now at a state in this country—and Canada's really leading the way—where loss of grafts from rejection or for other reasons is becoming less and less of a problem. Probably within the next 12 months, rejection may be eliminated totally or reduced to a level where it's insignificant. The other problems associated with transplantation are slowly coming under control. So we can put an organ in. It will not only work, but it will last. You have to give us the wherewithal to do this.

As a final note, I've been coming to Ottawa hearings and committees since the mid-1970s. I've really had no more faith in this group than I've had in the other ones—that is, it's a great forum for discussion and for talk, but it doesn't result in action. Where the action has to take place is in the provinces. As to whether this group can provide some wherewithal for them to do it, I hope they can, but the action has to take place in the provinces and at the local hospital level. All the organization in the world won't help if the ICU doctors and nurses aren't motivated to encourage organ donation.

Thank you very much.

The Chair: Well, Dr. MacDonald, thank you very much for your frankness, both with respect to the professional component and for the political observation. I just want to ask you one question, though, because I thought I'd heard at least one of the presenters make some reference to the national list that was being made available by MORE. In my readings of briefings that will be presented a little later on, there's another reference to that as well.

It appears that some jurisdictions have a surfeit of solid organs, but if they don't have access to a waiting list or to a list of potential recipients, two things follow. One, the organs will have to be moved outside of Canadian jurisdictions, or two, they will go unutilized. Is that a fair observation?

Dr. Allan MacDonald: No, that's not a fair observation at all. There is some unhappiness, by MORE and some of the other units, about the way the lists are kept. MORE wants to get out of paying for it. They haven't particularly expressed an interest in getting out of it; they just don't want to pay for it any more. They proposed a very elaborate scheme, which wasn't put out to tender and which wasn't reviewed by the other institutions involved. Whether that list goes or not is irrelevant.

• 0945

In the distribution of organs, the only ones that are important at the moment are heart, liver, and lung. That's not going to disappear. It may require a little extra effort on the part of the organ donor coordinators to have to call more than one number; they just have to call one now. But they're not overly occupied. We have so few donors that they're almost unemployed most of the time. So they'll have to work a little hard a few extra times a year.

But that system will still be in place. If we have a status 4 liver failure patient, now we call MORE. At the end of the month, that program goes. Our organ coordinators will have to call five numbers. Well, it takes an extra five minutes per number. That's not a problem.

If we need an organ, we'll list that patient, and the system of sharing won't change. Patients in extremis get the first crack. It doesn't matter whether they're in Vancouver or Halifax. If there's an organ in Vancouver, we'll get it if we need it most. Same with the hearts. That's not going to change. The convenience of it may change a bit, but the system won't change.

I'm really not upset about the loss of the MORE initiative. It will sort itself out, because it has to, but no organs will be thrown away because MORE didn't get its money. They'll still be used.

The Chair: I don't want to monopolize the question-and-answer here, but just before I go to Mr. Elley, does someone want to respond to that?

Mr. Graham Scott: Yes, Mr. Chairman. There are more MOREs than I would like to deal with, but some clarification is required, because the presentations would sound somewhat contradictory.

The Chair: Go ahead.

Mr. Graham Scott: There are in fact two MOREs in Toronto. There is MORE, which I represent, which is the provincial coordinating body, and there was before that an organization called MORE located within the Toronto Hospital Corporation. That's the MORE everyone is referring to at the moment, at least in part.

The Toronto Hospital Corporation voluntarily ran by fax a national waiting list. The Toronto Hospital Corporation decided some months ago that this was becoming too costly and it was very inefficient for them to fund and operate this process on their own. So they announced that they were going to get out of the business.

The issue then arose, would anyone fill the gap? If my memory serves me right, B.C. came to us and asked us if we would be interested in doing it, because we had the new capability with our new systems. At that stage we said we would if everyone would participate. Two transplant centres in Canada said they would not participate, and that was the end of it. As for the cost, the cost was to be shared between all the transplant centres in Canada. I don't think it was excessive, but excessive is in the eyes of the beholder.

The Chair: Thank you, Mr. Scott.

Mr. Elley.

Mr. Reed Elley (Nanaimo—Cowichan, Ref.): Thank you, Mr. Chairman.

I do want to thank each one of you for coming, in Dr. MacDonald's case probably for the umpteenth time. We need to persevere on this thing if we're going to get anything done. I share Dr. MacDonald's frustration that we have talked this issue to death, and in the meantime people are dying because we've talked it to death.

Dr. MacDonald, you talked about the real problem being in the ICU, and I think many of us recognize that in the ICU is the optimum time when donors can be identified, families persuaded, and that sort of thing. You mentioned a couple of times in your presentation the words, “Give us the wherewithal”. Can you be very specific and tell us, as a committee, what is the “wherewithal”, from your standpoint?

Dr. Allan MacDonald: There are skills involved at every stage of the management and access to donors, and those skills are not uniformly present among all ICU staff or even in all ICUs. So as Mr. Bishop has mentioned, education is important, but not of the public. We keep saying that, but in Nova Scotia the turndown rate is virtually nil. We hardly ever get anybody turn us down. The problem is they're not asked. If they're asked, they almost always say yes.

• 0950

So what we need is an educational program, and what you need is money for that. We have no funds within our program to put in an educational system so that every hospital has it ongoing, in service, on a regular basis. We need that. We need to be able to have the money just to send somebody from our unit around to the various hospitals. There's no budget money for that. You have to do that.

We need at least one, probably two, annual meetings where the ICU staff who are responsible for this can come, and it should be one person from the medical side, one from the nursing side. At this annual meeting, the scientific side of this whole process would be presented by experts so that they could learn from one another and develop the kind of expertise it takes so that their rates are high, particularly in identifying donors.

There are other problems in the ICUs and in the emergency departments. In the old days, patients coming in with a head injury or a stroke would go to the ICU immediately and be worked up there, assessed there, and managed there. But now the ICUs are all so crammed full that priorities have to be established. You have to ask, “How likely is it for this patient to survive our interventions?” So a lot of these people don't ever make it to the ICUs, because we have too few ICU beds for all the people who need them.

As you say, there were headlines in Toronto just recently about somebody not getting a lung transplant because there was no room in the ICU. That's made a headline in Toronto on a single day, but that's happening everywhere, all over all provinces, because we don't have enough ICU beds. We can't get the patients who might become donors into them. The decision is made to treat them on the ward and let nature take its course.

Mr. Reed Elley: Dr. MacDonald, can I follow up on that a bit more? We've known this for a long time. This isn't news, what you're telling us.

Dr. Allan MacDonald: No.

Mr. Reed Elley: Do you mean to say that over 15 years of very public debate on this issue, somewhere along the line someone has not been able to persuade a provincial government to provide the money for this kind of thing? Is money the block?

Dr. Allan MacDonald: As with anything else, money is a block, and it comes right down to the local hospital level. In most provinces there is no reimbursement for the costs and time it takes. I don't think that's a real barrier.

In large measure the problem has been that we've never had either a provincial or a national organization that is devoted to this subject at a clinical level. We've had organizational programs, but we haven't had clinical ones.

There is an international organization on organ donation that meets annually, and the information on what is important and what isn't has taken years to evolve. We all went through this process: “Well, let's just let the public know. We'll get these programs and then everybody will donate.” Then next was, “Let's get registries, and then we'll know that people want to donate.” We put our effort into areas that in the long run turned out not to be particularly important.

Not having a national organization, not having a learning situation, we've been caught out. We used to have the best in the world. Canada was way ahead of everybody else until the mid-1980s, but we didn't have a national organization. UNOS in the U.S., by putting together experts, have gradually developed this kind of experience and knowledge base. We haven't done that.

Quite frankly, there is a shortage of money. If we had a couple of hundred thousand dollars a year in Atlantic Canada, we could put together a program every bit as good as the one in Austria, Belgium, Spain, or wherever, but we don't have the money.

The Chair: I think what Mr. Elley was probably saying is that when a lot of money was flowing to the provinces and when money was coming into the local administrations like water off Niagara Falls, why wasn't this done then?

Dr. Allan MacDonald: Well, it may have been flowing like Niagara Falls in Ontario, but we've always been poor. Everything looks like up to us.

Part of the reason of course was that in the 1970s, when there was money, we were just developing the programs. We did fewer than 50 kidneys a year up until 1979. We had enough donors. As the demand has increased, the money has contracted.

• 0955

Plus the organizational ability is a provincial matter, not a federal matter. We've never had the money to get together to set in place an organization that will set standards, develop protocols, and allow us to learn from each other, so that what we do best in Alberta will become the standard for the whole country and what we do best in Nova Scotia will become the standard for the whole country. We've never had that kind of organization. Whereas countries that have, starting at the same base we did in the mid-1980s, have grown and improved, we've just stayed level.

The Chair: Madame Picard.

[Translation]

Ms. Pauline Picard (Drummond, BQ): Welcome to the committee. Thank you for coming here today, and for making yourself available to answer our questions.

Please forgive my ignorance, however, before I can understand or analyze your needs and your problems, I will first have to ask some concrete and practical questions. First of all, I would like to know what kind of organizations you represent. Are you para- public organizations, are you part of a provincial health department, or are you non-profit organizations? What is your role? What are your goals? Do you have boards of directors and codes of ethics? How are you funded?

Given his broad experience, Mr. MacDonald may be able to answer those questions.

[English]

Dr. Allan MacDonald: If you don't mind, I'll answer in English. My French isn't quite good enough.

Organizations across the country vary. I can only speak in detail about our own. We're a hospital-based program, and for organ retrieval we're also a hospital-based program. We organize it for the whole province of Nova Scotia, and although we do the transplants for the other Atlantic provinces, we do not have any role in their organization or in the systems in their hospitals.

We are not funded. Our hospital has never received any funding for the transplant program, and it's a source of constant concern and a problem for the transplant program, because we're net consumers of resources. There is no extra reimbursement if we call in three sets of nurses to do a heart, a liver, and a couple of kidneys. We spend, spend, spend as far as our hospital administrators are concerned, and they get no money from the province for this, other than what's in the global budget. So the restrictions on us have been quite inhibiting. We are a shoestring organization, and we just barely keep our heads above the water.

At a provincial level, we put on programs and courses, for which we raise our own money. In all the years I've been there, the provincial government has sponsored one meeting, at a cost of $15,000.

To give the devil his due, the recent health minister has taken some initiative in this regard. We've put in a proposal, they've looked upon it favourably, and they say they're going to move with it. But we are just a hospital-based program.

For the other provinces it's quite different. There are provincial organizations, so I'll let them answer for their own provinces.

The Chair: Does any one of you want to try that?

Mr. Max Bishop: I'm sorry; I didn't get the translation and I didn't understand your question.

The Chair: It was on the structure of funding in your province.

Mr. Max Bishop: The structure in Newfoundland is that the money is given from the provincial government to the Health Care Corporation of St. John's, and it's given for one and a half positions. It also gives approximately $10,000 for travel, but it's not very much.

• 1000

If a donor happens in Grand Falls and staff is called in, no reimbursement is done for that hospital. We don't reimburse that hospital. That's part of their global budget. As for the organ donor program, one set fee is given on a yearly basis to the Health Care Corporation.

Mr. Graham Scott: MORE Ontario is funded almost entirely by the Government of Ontario. It has an independent board of directors of 12. The government has one appointee amongst the 12, who is an employee of the Ministry of Health. The rest are transplant centre representatives, a transplant recipient, a transplant donor family representative, a transplant waiting list individual, and so on. So it is meant to be reflective of the problem in the province.

This board structure, however, is new; it's only a year old.

The Chair: Madam Caplan.

Ms. Elinor Caplan (Thornhill, Lib.): Thank you very much, Mr. Chairman.

I'm going to tell you what my question is at the beginning and then speak to it. I'd like to know why there's been no cooperation and why the existing structures haven't worked. I've heard you say there's no incentive, no reward, and no obligation. I want to know if this is a fair portrayal.

There's not a system. We have a lack of clinical asking skills and no education as to how to train in a consistent fashion. All the wrong incentives seem to be in place. There's no accountability and a lot of turf. Is that a fair portrayal of the problem?

Mr. Graham Scott: I would say that's a pretty fair portrayal of the problem, and I would certainly agree with the emphasis Dr. MacDonald placed. There's no sense having a flood of donations if the hospitals aren't prepared to properly deal with them, if they're not prepared to identify the donors. We know that people who've signed donor cards are regularly missed or lost in the system. Training and education are the number one requirement. We would say that's the number one requirement.

Ms. Elinor Caplan: Training and education of...?

Mr. Graham Scott: Of hospital staff—and the ICU is particularly important—but there are other players as well, such as religious players. Certainly in the larger cities in Ontario, we have to deal with a lot of perceived religious barriers. There are some real, but most of them are perceived. We've had some considerable success in getting religious leaders involved, and they can be helpful as support when called upon. But often they're not called upon, because of the very points Dr. MacDonald raised.

While I have some considerable sympathy for some of the funding problems in the hospitals, I also would have to say I can see lots of hospitals introducing new programs within their global funding, and I somehow wonder why their transplant teams don't get the same priority.

Generally speaking, in the transplant centres there is a better awareness and better performance, but I wouldn't give them all “A”s either. Certainly when you get out to the larger community hospitals, I would say we do not get the support generally from them, and they're crucial to making the system work, and they're crucial to Dr. MacDonald's formula.

Certainly what we believe and what we're working on now is trying to push the issue of accountability front and centre. But I also believe that if we had higher public awareness and a little bit more public enthusiasm generated behind a lot of these things, that would also increase the pressure on the hospitals to respond. The idea of accountability or report cards, which has been very much in the news in the last two or three years—not with regard to transplant but with regard to the whole health care system, where it's desperately needed—would make an enormous difference, in my judgment, in helping us with the transplant problem.

Ms. Elinor Caplan: I have one more question, if I may, on the issue of global budgets. Over the years it evolved that hospitals—certainly in Ontario, and I'm assuming that's the way it was across the country—went from line-by-line budgets, where each program was funded by the ministry, to a global budget so that the hospitals could establish priorities. I see some heads nodding.

Now what we're hearing is, “Well, give us specifics line by line for programs that the hospitals are not deeming a priority.” The question is, who has responsibility for ensuring that the priorities are established in a way that will meet the community needs?

• 1005

Ontario as well as the rest of Canada.... For me personally, Graham—and I don't mean this in a personal way; you've been there a couple of years—when I heard talk of two MOREs, certainly that was never envisioned when the original Multiple Organ Retrieval and Exchange was established. I can only look back on it and say here's an example of a really good idea that failed, and I want to know what happened.

Why did it fail, and why aren't you getting the cooperation from the other organizations that can make this work? And the organizations are not only the hospitals. I would imagine it's the same thing in every province across the country. Why isn't this seen as a priority, and why are you not getting cooperation?

The Chair: Do you want to answer that, Mr. Scott, or do you want to let Mr. Bishop do it?

Mr. Graham Scott: I'll answer, but I'll let Mr. Bishop go ahead, because he was trying to say something earlier.

Mr. Max Bishop: As far as cooperation is concerned, I know in my province the cooperation of the hospitals is in the forefront. The only problem we have is the education. We don't have enough money to get out. The hospitals are more than willing.

Hospital education is the key. We saw that in the forum that was held. When you have 87 physicians, nurses, and people from all areas of the province come to a meeting and spend two days discussing it and telling you what their needs are, and when you look at the needs and the priority....

As for bringing patients into the emergency room, when a patient comes into an emergency room and they have a cerebral bleed, yes, they're being worked up in the emergency room in my province, but the families are given the option. If there's nothing medically or surgically that can be done and it's hopeless in this case, they're given the option to go to the ICU for the purpose of organ donation, or they are transferred to the floor for the purpose of letting nature take its course. I just wanted to correct that part.

But as far as the cooperation is concerned, we do get the cooperation, not only from the hospitals, but from the community, the religious groups, and so on. Other than that, you know....

The Chair: Mr. Scott, would you like to add to that briefly?

Mr. Graham Scott: Yes.

In the mid-1990s MORE became somewhat moribund, and that's why we've totally revamped it. I think some of the physicians lost faith in the systems. We fixed that. We've changed the board to make it a dynamic board that really wants to make change. So I would say MORE is a very different organization from the one it was three years ago, and I feel good about that.

On the hospital side, what's happened of course is that after everyone gets the freedom of global budgeting, then it becomes human nature that you want special funding for special tertiary projects. That's how the language and demand have shifted over time. Which is not to say that more money would not be enormously helpful, but the hospitals are hardly faultless when it comes to their level of enthusiasm or drive in making this work.

The Chair: Ms. Lill.

Ms. Wendy Lill (Dartmouth, NDP): Thank you.

Thank you very much for coming before us. I'm not the usual person who sits on the health committee for the New Democrats; it's Judy Wasylycia-Leis. She is now crossing the country on a health tour and talking with all of the players: the doctors, the nurse practitioners, and the patients. So I am having this great pleasure of meeting with you today.

Dr. MacDonald, I want to say I was very personally involved, in the same way that my whole neighbourhood was, just recently in a high-profile transplant in Halifax. My neighbour donated his kidney to his step-daughter. He's a radio announcer, and he was very public about it. The whole community in fact became emotionally involved in the process. That was a tremendous education for us all in terms of what a family goes through on that issue.

What I'm hearing from all of you is that when it comes right down to it, somebody comes in, they're at death's door, a family is coming with them, and we have enormously stressful situations made definitely more stressful by the fact that there aren't enough ICU beds.

The fact that we apparently had money flowing over into our health care system like water over Niagara Falls certainly didn't appear to me either in Nova Scotia. We have now had $3 billion removed from our health care system by the federal government.

• 1010

I see a situation where we have chaos in ICU wards and we have very stressed-out medical professionals who are working overtime and trying to just keep a lid on things, basically to do what is necessary. Yet in the midst of all of that, they are supposed to sit down with family members and have a sensitive interaction about whether or not they want to get involved in an organ transplant. It just seems the most contradictory kind of environment that could exist in the world.

Where do we go from here? You're sitting here at a committee talking to all of us, but in fact the reality of the situation is what you're dealing with, which is that on the ground, it's a pressure cooker.

Dr. Allan MacDonald: May I address that?

The Chair: Go ahead, Dr. MacDonald.

Dr. Allan MacDonald: Our approach is to try to do something about the issue you've just identified, and that is the ICUs. The way we've gone about it is to ask the senior intensivists in our province to set up their own organization.

We're really in a bit of a conflict of interest, as transplant surgeons and physicians, and even our organ donor program people, to be asking for organ donors. In fact it's been recognized pretty well that we have to stay out of it. We can't be seen to be going after people for donations, because it really is a conflict. It's really up to the people who are not involved with transplantation, who are dealing with people who might be donors, to do this sort of thing.

So we've asked our intensivists to set up an organization, initially in Nova Scotia, because they all have ICUs and they all have professionals in them and they all meet on an annual basis, and then to ultimately incorporate those in the other Atlantic provinces. We've asked them to set up the kind of schema that will in fact improve the level of comfort about asking and improve the skills with which the donors are managed, since we still lose a substantial fraction of donors because the skill of managing donors isn't uniform across the ICUs. We want to correct that by having those people who actually do that correct it.

Even if we left everything else out and didn't get a nickel for all the other things we've mentioned here, I suspect that single initiative will result in organ donor rates equal to those everywhere else. The other stuff is all necessary, because you have to have infrastructure to retrieve and distribute and so on. And we have to do our own homework with our surgeons, particularly in the other hospitals, so that they'll be available on an instant's notice to take organs, etc. All that's the kind of thing you have to put in place.

We just want to get the thing out of the hands of the people who really ethically have a conflict here and into the hands of those people who really manage patients. Whether the patients become donors or not, these people still have to manage patients at the end of life and make decisions about discontinuation of life support. That's where the emphasis should be; that's where the support needs to be; that's where the organizational effort should be concentrated.

The Chair: Thank you.

Ms. Minna.

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

I first want to make an observation. From the presentation this morning, I get the impression that the poorer provinces, or the smaller provinces, are doing better than the larger ones in this field, in terms of at least identifying and beginning to have a structure of some kind. That may be a wrong impression, but it seemed to be what I was hearing, and I wonder why that is.

The thing I heard most was that there isn't cooperation amongst provinces. Mr. Scott said he tried to get a national list going under MORE, but there were, I think, two provinces that were not going to be signing on, so that canned it.

I want to ask Mr. MacDonald, Mr. Scott, and anyone else, is there a need for a national list? Would it do any good to have one?

• 1015

Mr. MacDonald, I think you said you didn't think it made any difference one way or the other whether we had one or not. Does everybody feel that way, or am I just misinterpreting this?

Mr. Graham Scott: It depends to some degree on the weight you put on the issue of equity and ensuring that those most in need do in fact get the first shot at available organs. You see, I can't look you straight in the eye and say I believe that happens at the moment. I'm not questioning day-to-day medical judgment. There's no question in my mind that in every transplant centre, the people who are most deserving get it. The question is whether the application of that on a wider base is properly carried out.

I can only speak for Ontario, but certainly in Ontario, that has been a huge public issue. Donors in particular have wanted to know that they had the maximum result from the donation, or their families would want to know that. That has been an issue, and because of different standards and different approaches in the different transplant centres, I'm not satisfied that we're getting that outcome.

That's a very important thing to us, and therefore the integrity of the list is a very important issue for us, though not because it will solve everything. Dr. MacDonald is right: that in itself won't solve the problem. But if indeed we get the success at the key end that Dr. MacDonald is talking about, then the program runs the risk of becoming a little bit in disrepute if there's a feeling in the public that those most in need aren't getting the first shot.

The Chair: Mr. Bishop.

Mr. Max Bishop: The national list is fine. I look for the national list, because of the distance people have to come to retrieve the organs. If all of the organs are going to Halifax, then that's not a problem, but if people are coming in from Ontario or farther west, then there is a problem. If we can cut down on the timeframe, it's very important.

As far as cooperation is concerned, I've been working with the organ donor program for 11 years, and in that period of time, when there's a patient in need, regardless of whether it's in Edmonton or wherever, and that person is the most urgent with the sharing criteria we have, they get it. I just wanted to make that point. The cooperation is there.

The Chair: Ms. Secord.

Ms. Ann Secord: When I raised the issue of the waiting list, that was my concern: the time factor that now is going to be involved in placing the organs, because instead of having the list available, you are making multiple calls in order to see if there's—

Ms. Maria Minna: So you see a use for it.

Ms. Ann Secord: Absolutely. But I also want to indicate that cooperation certainly has been there and will continue to be there. It's just going to take more time.

The Chair: Dr. MacDonald.

Dr. Allan MacDonald: Could I tell you how the things works, say for liver? There is a national committee, a subcommittee of the Canadian Transplantation Society, that's a liver committee. We meet annually. The rules are established. They're debated every year, as indications and results warrant, but the rules are there. I have absolute and utter confidence that my colleagues in the other liver programs are in fact observing the rules. I know they are.

The rules have to do with the mandatory distribution of a liver to the recipient who's at the top of the urgent list, regardless of where that particular recipient is. We don't always have people in the country on the urgent list, but if they are on the urgent list—and the rules are quite specific about who is urgent—then they get the organ. The same is true for heart.

The only programs where we don't distribute organs are kidney programs. These people are rarely on an urgent list. They're on dialysis and they can be maintained, so we don't distribute kidneys. There are a lot of reasons for not distributing kidneys that have to do with preservation and damage being as important as matching, etc.

I don't think that because the MORE Program's proposal has fallen, this list is going to just disappear.

The Chair: Excuse me a second. Dr. MacDonald, I wonder if you'd make a list of those rules to which you've just referred available to the committee. Is that possible?

Dr. Allan MacDonald: Sure, I'd be pleased to do that.

The Chair: Thank you very much.

• 1020

Ms. Maria Minna: Is there an accountability of some kind under those rules?

Dr. Allan MacDonald: Well, that's part of the problem with the MORE proposal. We thought it was excessive in terms of the amounts of money they wanted. We feel we could do the same thing virtually for free using the Internet, but they want not just the list; they want to be able to produce statistics every year, accountability, and so on.

Ms. Maria Minna: [Inaudible—Editor].

Dr. Allan MacDonald: Well, it's expensive.

Ms. Maria Minna: Yes, but it also gives you a great deal more information.

I would also like to know from—

The Chair: Thank you, Ms. Minna. You'll have to come back on one of them.

Madam Redman.

Ms. Maria Minna: I have just a little one, to get a list. I'll come back if I can.

The Chair: Thanks.

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

I appreciate all of you coming and bringing your particular perspectives.

From what I've learned about organ and tissue transplant, it seems to me there is no silver bullet; it has to be a multi-pronged approach. Dr. MacDonald, I do appreciate your candour in what you've said.

Have any of you or all of you looked at the Spanish model? It's one of the things that's been held out by previous witnesses as perhaps the gold standard that we could look at. Can I just see a nod or a shake? Have any or all of you looked at that model?

Dr. Allan MacDonald: I've visited Spain and I've gone to other countries, such as Belgium and the Netherlands. I've been intimately involved with the U.K. transplant. I've interviewed the people from South Australia.

Actually the best programs in the world are not the ones you've heard about. The ones with the highest donation rates are in Texas, Florida, Wisconsin, and Michigan. Most of what the Spaniards do is actually a direct copy of the Wisconsin program. If you look at the Spanish results, in some areas they have 40% refusal rates, which is not a problem in this country.

The things they took from the programs that they themselves trained in have a recurring theme in all of the successful programs. The major recurring theme is the one I've emphasized—that is, they have somebody in the hospital who has a jurisdiction in the intensive care unit, whose job it is. In Spain they pay them, and we may have to come up with a scheme like that. It's the same everywhere else where it works: there's a system of incentives, there's a system of carrots, but largely there's a system of obligation.

It's quite astonishing, and I'm sure most people here probably don't believe it, but most doctors, told what they should do, actually do it.

The Chair: Some of us are astonished.

Dr. Allan MacDonald: If the ICU doctors are told that this is what they have to do, I have confidence that the vast majority, 95% of the time, will do it.

Mrs. Karen Redman: Mr. Scott, you also indicated you looked at the Spanish model. Would you care to comment on the application you see for Canada?

Mr. Graham Scott: I don't disagree with Dr. MacDonald's assessment. I'm quite comfortable with it.

Mrs. Karen Redman: In addition to that, one of the topics that keeps recurring is the fact that there's a lack of funding. I heard Dr. MacDonald in his presentation talk about, I believe the figure was $200,000, and I'm just wondering if the other three presenters feel that funding is a problem. And if it is, can we quantify what we need to look at to invest in this?

Ms. Ann Secord: Certainly funding is a problem as far as education goes—education of health care professionals in the ICUs. I'm not able to quantify that, though, from a New Brunswick perspective, because it's not anything we have put a number on.

Mr. Max Bishop: I agree. If we had more money, the education would be the key thing we would look at with the people within the ICUs and in the regional hospitals. But as for a dollar figure or a quantity, no.

Mr. Graham Scott: The Ontario government and the Ontario Hospital Association put together a committee that recommended that funding in the amount of $6,800 be available to hospitals for each organ donor, on the belief that this would make a substantial difference. That's a recent report. I've no idea what the government's intentions are in relation to it.

The Chair: Do you think we could have a copy of that study as well?

Mr. Graham Scott: I'm sure we can get you one.

The Chair: Please. Just make it available to the clerk; that way committee members can have access to it.

Are you going to finish off with this one?

Mrs. Karen Redman: Just to go back to the multi-pronged approach, I believe most people in health care are there because they are humane people who want to make the world a better place and stop suffering or ameliorate it.

• 1025

What really came home to me was when this committee met with the parents of youngsters who were looking for donors or youngsters who hadn't survived waiting for donors. Despite the fact that I've heard some comments today that maybe we don't need that public education process, it puts all of this in context. For me it's a very necessary part of a much bigger picture. It may not be job one that we need to do to get from where we are to where we need to go, but that kind of background context for society and the community is absolutely essential.

The Chair: Mr. Bishop, do you want to comment briefly?

Mr. Max Bishop: I have one question.

I agree with you about looking at a child who has died for want of an organ, but you also should look at the other benefit, the benefit that is accrued to a family who donates. Sitting across from a woman whose nine-year-old son has died, we should not be able to take away from that individual the benefits it gives to her. If we don't ask them, then we're doing that.

The Chair: Thank you, Mr. Bishop.

I have time for one very brief question from Mr. Jackson.

Mr. Ovid L. Jackson (Bruce—Grey, Lib.): I have just a quick comment.

Guests, you've said we need some way of having awards and giving recognition to those people who donate the organs, and some way of educating them. You've indicated that some incentives are needed for hospital staff.

There has to be some kind of triage system. We had a situation recently that everybody talks about with regard to the lungs that had to go back to the donor. These things have to be done in a timely fashion, it would appear to me. I'm not a doctor on the front line, but it would appear to me you have some kind of triage system.

Obviously in the hospitals—maybe it would come to the ICUs—you have a system of sorting people out. Is there not one with regard to transplantations? Because it doesn't happen every day that suddenly the organ becomes available. How is this managed in the current system?

Dr. Allan MacDonald: That's not really a problem. Once an organ donor is identified as an organ donor, the local transplant team is notified, and then an algorithm is followed and a system kicks in. From there on in, things get done.

Each program has a fairly effective set-up for managing the recipient side and getting the recipients in from, in our place, Labrador, Newfoundland, New Brunswick, P.E.I., and Nova Scotia. So some are coming a thousand miles as a recipient.

All of that works. All of those systems, while all of them could be improved, are pretty good. The real problems are in getting the organ donors identified in the local hospitals.

You're quite right; for some units in small regional hospitals, it may come up only once every two, three, or four years. We've looked at our own system. If we had three donors per 100,000 population, which is the optimum, for some hospitals it would be once every four years. But if we don't get those, then our system ticks along at half of what it should do. We really need that one donor every two or three years from these hospitals in order to keep the system functioning properly.

Mr. Ovid Jackson: The point I wanted to make, though, is that I've built a hospital and I've sat on hospital boards, and there's quite a bit of politics with you doctors when it comes to the use of the emergency room and whether or not your egos get in the way of getting your job done. Does that get in the way when a person...?

To me, the transplant should be in this triage and it should bump right up to the top, so if a surgeon has to operate, he gets bumped out of that spot and it gets right in there. That's the question I'm trying to ask. How is this managed?

Dr. Allan MacDonald: It's a problem. There's no question that my priority is not your priority, and we do end up as tail-end Charlies on a lot of lists, because it's all done out of hours.

You must put it in context. Last year we did about 200 transplants, all organs, but we operated on 28,000 people, so we're pretty small potatoes when it comes to.... The fellow who needs his heart valve replaced and his doctor probably feel he's just as much a priority as my patient who needs a new liver.

• 1030

So those are problems, but they get sorted out at a hospital level. While that's the fight the transplant units have to take up and win, we really shouldn't hand that over to... We'd like all the help we can get, but that's an internal battle that we in various places have won more or less successfully.

I don't think that's a real limitation. If the organs are there, they get transplanted. We haven't thrown any away, that I can think of, in the last 10 years or so.

The Chair: Okay, Dr. MacDonald, I'm afraid we're going to end this particular panel with that last statement.

I want to thank Dr. MacDonald, Ann Secord, Max Bishop, and Graham Scott for their presentations and their willingness to engage in this very lively back-and-forth.

I'm going to take a one-minute recess while we bring in the next panel. Thank you.

Ms. Elinor Caplan: I know there isn't time for a question to be answered by the panellists, but I'd appreciate it if they would do something to help this committee. There was a suggestion that we establish a national organization. I'd like from each of them an idea of what they feel the mandate of that organization should be, what the appropriate federal role would be, what sort of accountability that organization should appropriately request, and how in fact it would work. I'd also appreciate in writing the names of the transplant centres that did not want to cooperate in a national patient registry.

The Chair: What we'll do, Madam Caplan, is have our clerk submit that request to each of the presenters in writing. Can I ask the presenters to respond back to the committee through the clerk at their earliest convenience, keeping in mind that we want to complete this study in short order?

I thank you once again.

• 1032

• 1036

The Chair: Colleagues, we'll reconvene. In this second panel we have the organ procurement and management agencies from other provinces. In the last session we had those from eastern Atlantic Canada.

On this panel we have Dr. Kneteman from the HOPE Program in Alberta; Mr. Donald Langlais, who is director of Quebec Transplant; Bette Boechler, program manager from the Saskatchewan Transplant Program; and Dr. John Jeffery, who's the head of the nephrology section, Manitoba Transplant Program.

Welcome to each and every one of you. I noted that some of you were in the audience over the last presentation, so I think you're more or less familiar with the rules. We'll try to hold you to a five-minute presentation and then questions and answers.

Why don't we start with Dr. Kneteman?

Dr. Norman M. Kneteman (Director, Liver Transplantation, Human Organ Procurement Exchange (HOPE) Program, Alberta): Thank you very much, Mr. Chairman. I'd like to start off by thanking the standing committee for giving us the opportunity to address this important issue in a public consultation.

The critical issue that we need to focus on this morning is that of the shortage of organ donors. We've had discussion of many other areas, including the allocation and distribution system, national lists, etc., which are in their own right issues that need to be addressed, but in all honesty, they are not the critical issue this committee needs to focus on.

The performance of Canada as a nation and the regions within it in organ donation has not met the standards we would expect. We've heard of the success of different jurisdictions in the United States and Europe, and specifically the Spanish model, and that is what we need to concentrate on: How can we take our own performance to that level? It would both dramatically improve the number of people who could benefit from transplantation and potentially also achieve a very significant cost saving by decreasing the amount of money we spend on hemodialysis, which is rising at a rate of 10% to 12% every year.

The issue of public support is a critical one in this area, but it is one in fact that is reasonably well established. Gallup polls and other such polls across Canada routinely reveal support from the public for the idea of organ donation to be between 80% and 90%. Maintenance of that support is essential, so public education is important, but in fact I do not believe that is our major block at this time.

When we look at the actual rate of donation from potential donors in Canada, however, we find that rather than seeing that 80% or 90%, it's 40% or 50%. The important question is, why that big discrepancy?

• 1040

The rate of donation in Canada has been stagnant now for almost 10 years, at around 13 to 14 per million population. In my written submission I have a graph that demonstrates those numbers in Canada. In addition, those numbers are compared with numbers from the United States, where there has been a slow but steady improvement in rates of organ donation up to the range of now over 20 to 21 per million population per year; and in stark contrast, the results in Spain, where the numbers 10 years ago were virtually identical to Canada's, and by institution of a system nationally, those numbers are now double what Canada's are, at 29 per million.

I've also outlined in this submission the impact that has. We do see decreased numbers of organ donors, we frequently hear about lengthy times on waiting lists, and we frequently about people dying awaiting organ transplants, but that does not even necessarily capture the whole problem.

The Chair: I'm going to interrupt for a quick second, because I see some members looking for your brief. We received it just the other night, so we don't have it in the distribution system just yet. I just want to advise members that your brief will be available to them probably before the end of the day, regrettably, but they'll at least be able to refer back to it. So if they'll just listen to you, they can make reference to the brief a little later. I'm sorry.

Dr. Norman Kneteman: What I will do then is actually highlight some numbers so that it puts a little more meaning in my comments.

As I mentioned, the rate of donation in Canada is about 14 per million per year. Other jurisdictions that started at virtually the same rate 10 years ago have now doubled those numbers to 29 per million per year.

When we look at the outcomes of that, as I mentioned, they include longer times on waiting lists and people dying awaiting organs. I know one of the presentations last week told you that about 160 or so Canadians died awaiting organs last year.

What we have to realize is that when there are not enough organs—and we certainly have an important priority to maximize the benefits achieved from the organs available—what that means is the criteria to actually get listed for a transplant have to be fairly tight, fairly rigorous. Therefore a very significant number of people for whom a transplant may be the best care available may never actually make it onto a waiting list. Because of that, what we really have to look at is how many vital organs might be available in Canada and how many people we might be able to help if the system actually functioned.

In the information you will receive, it says if we double the rate of organ donation in Canada—which Spain has accomplished over the last 10 years—that translates into something like 660 vital organs and 660 people who would in fact have the opportunity for another chance at life. That's several-fold greater than the number of people who make the statistics of dying on a waiting list.

In addition, the rate of use of cadaveric kidneys means that some 700 people could potentially be removed from dialysis lists. When you look at the cost of dialysis, which has been compared many times to the cost of kidney transplantation, transplantation is much more cost-effective, largely because the patient is removed from the need for chronic, ongoing maintenance. Because of that, the potential saving from an effective donor system is probably in the hundreds of millions of dollars and likely would not only pay for the donor system but would pay for much of the transplant activity in the country.

We had discussions earlier this morning that were very useful. What I would like to do to highlight that is give some of our own experience in Alberta in terms of some of the problems with the organ donor system we have.

In the mid-1990s, regionalization and health care restructuring hit Alberta very hard. There was a dramatic impact on the staff within hospitals and the system itself in trying to find a way to work with the dramatic decrease in budgets.

The organ donor system in Canada is critically dependent upon voluntary effort of the nurses and physicians in emergency departments and critical care units to identify potential organ donors and to take the time, in the middle of the night, when they're overworked, to have a meaningful discussion with the family, which is essential if you're going to have a high rate of success in achieving consent for donation.

What we saw in the midst of those pressures on the organ donor system in Alberta was a 40% decline in organ donation in one year. That highlights how fragile the system can be. We made major efforts to address that over the next two years, and utilizing what we felt were the successful components of models in Spain and other areas in the world, such as Austria, Belgium, and parts of the U.S., we were able to substantially turn that around. In fact in 1997 we had an organ donor rate in northern Alberta of 29 per million per year, which equalled the Spanish results.

• 1045

We have not been able to maintain that, and that's been a problem in Canada from jurisdiction to jurisdiction. An incredible effort goes in on the part of organ procurement organizations and transplant professionals. The results come up. Without a system in place that is well supported, that almost always has proven to be non-sustainable in Canada.

So what I'd like to do next is run through and actually outline where we see the major problem in the system: why it is that donors are lost.

The first is that the potential for donation is not recognized by the people in the emergency departments or in the intensive care units. The second is that the people who are working in those areas are overtaxed, run off their feet, and do not feel they have the time to approach the families on this issue. The individual who is critically ill may not in fact be suitably resuscitated, because the prognosis is grim, and therefore the system in fact makes the decision on organ donation; the system decides there aren't enough resources to go ahead. That may be compounded if there are not enough critical care units for that donor, and as a result, the family is not given the opportunity to make the decision, but the shortages in the health care system make it for them.

Additionally, if the discussion on donation is carried out inappropriately or by poorly informed health care personnel in a hurried situation in a hospital corridor, the outcome clearly is not likely to be a positive one. And if we have difficulties with access to operating rooms in a timely fashion, or problems with enough personnel in the intensive care unit, we may then have the problem compounded by deterioration of the donor so that we are unable to recover as many organs as possible.

There are models we can look to for some solutions to these problems, and I'd like to focus on just a few points that may be very helpful.

The Chair: Could I ask you try to tighten it up?

Dr. Norman Kneteman: It will be.

First of all, I would agree strongly with Dr. MacDonald that we need to focus our efforts where donation actually occurs, and that's the emergency departments and the critical care units. That is where we're likely to get the biggest impact for what we are doing.

Secondly, in order to try to avoid missing donors, we need to have a system where there is some mandatory reporting of people in coma so that there is someone with the knowledge to screen them quickly and effectively.

Thirdly, we need to have a system where the family is given the opportunity in all cases to decide about organ donation, with a careful explanation of what has actually happened to their loved one and then a discussion of potential donation. In order for that to happen well, we need to provide people in the emergency departments and critical care units who actually carry out that discussion well.

We need to be sure there's an auditing of what goes on in the hospitals and in each unit, and the accountability for that must be with the hospital executives and the medical leadership in those areas.

There needs to be funding for this system, and we need to be sure the funds actually go where they're intended.

And finally, there needs to be, in all honesty, the stick along with the carrot, and that is financial penalties when there's underperformance. That means clearly that if the system is not working, the funds that are to support the system should be withheld.

Thank you for the opportunity to make the comments.

The Chair: Thank you, Dr. Kneteman.

[Translation]

Mr. Donald Langlais.

Mr. Donald Langlais (Director, Québec Transplant): Good morning, and thank you for your invitation to appear here today.

I left some notes with the interpreters so that they can follow my presentation.

Québec Transplant is the single organization in Quebec responsible for managing the organ donation process as a whole. I will try to touch on all the points you said you would like to hear us speak on. Among other things, you talked about awareness-raising among the public. This is something Québec Transplant did do in the past. In 1997, for example, a committee established by the Quebec Health and Social Sciences Department, and chaired by Mr. Gélineau, submitted a report that gave our organization a different thrust. I have tabled the report in both French and English for committee members. Whenever I talk about the Gélineau committee, I will be referring to that report.

The report recommended that Québec Transplant be asked to withdraw from awareness-raising activities, and to leave such activities to organizations and associations both interested and dedicated to that end, such as the Kidney Foundation of Canada, the Diane-Hébert Foundation, the Canadian Cystic Fibrosis Foundation, and others. However, Québec Transplant maintains close contact with those organizations to provide assistance and support with the scientific and technical aspects of organ transplant.

• 1050

With respect to organ donations, we believe that there is a lot of room for improvement. Mr. Kneteman stated that surveys show over 80% of people are in favour of organ donation. Perhaps this should be verified.

In Quebec, however, many people have a problem with the notion of brain death. The topic of brain death is always brought up whenever we speak with groups. Specific programs should therefore be set up to help people understand many fundamental aspects of the organ donation and transplant process.

A few moments ago, we were talking about awareness-raising and education of health care professionals. In Quebec, in co-operation with an organization called Partnership for Organ Donation, we have conducted studies in at least two major hospitals. We observed that 50% of patients who would be potential donors were completely overlooked in the identification process. The Gélineau report made a very important recommendation in this regard: That each hospital have specially trained people to approach potential donors or their families for organ and tissue donations.

At present, such people are appointed in 90% of Quebec hospitals. They also provide training support. One of Québec Transplant's roles is to provide these people—let's call them coordinators—with training that they can then use in their turn to train others in the system.

We are losing donors in hospitals. That is because we always do things after the fact. Only at the end of the year do we find out how many of the patients who died during that year could have been potential donors; then we compare that number with the number of donors we did have.

In Quebec, we want to do researching to determine what percentage of patients who died during a given year could have been potential donors. This would help hospitals establish annual objectives from year to year. Let's see how this works. We could say: There were 1,000 deaths in last year. If we know that 2.5% of those patients could have been potential donors, I should have had 25 potential donors. But I had only 12—what happened to the other 13? That's when we could start taking remedial measures within the system.

Let's come back to training and education of hospital staff. Québec Transplant has a very clear mandate there—to train hospital staff through special coordinators.

You also mentioned national standards on safety, and policies governing transplant activity. These are all very important aspects. Let's not forget the background of the blood commission. In Quebec, Québec Transplant keeps in close touch with the Public Health Directorate to ensure it remains abreast of epidemiological monitoring. If we were to discover that a given transplanted organ was taken from a patient who had a communicable disease, we could very accurately monitor everyone who had been contaminated by the person involved. I believe that this assures the safety of organ recipients.

As for protection, important standards applying to donors are complied with. There is a national committee dealing with this issue, but the name of the committee escapes me. The committee is on its fourth edition, though it has not yet published any findings. Participants were saying a few moments ago that it was time to act. Yes—at some point we do have to act.

• 1055

As medical technologies continue to advance, our waiting lists will get longer. In general, people seem to agree that transplantation of safe, healthy organs is important and necessary. But the hospitals are where the action is. We have to continue making every effort to ensure donors are identified. We try to do this by monitoring them closely and by appointing special coordinators in hospitals.

Our province does reimburse hospitals, particularly for some aspects of harvesting. Does this have an impact? It is difficult to say exactly. Only time will tell whether such considerations have a positive impact.

Thank you.

The Chair: Thank you, Mr. Langlais.

[English]

Bette Boechler.

Ms. Bette Boechler (Program Manager, Saskatchewan Transplant Program): Thank you.

I would like to thank the committee for inviting me to speak regarding the state of organ and tissue donation in Saskatchewan. The issue I will speak about has already been mentioned, so I will be brief.

In Saskatchewan the only solid organs that are transplanted are kidneys. This makes Saskatchewan one of the few provinces that exports all extra-renal organs, which include heart, liver, and lung. The Saskatchewan Transplant Program has always offered these organs to other Canadian programs based on national sharing guidelines and the national recipient waiting list. Only when we are unable to place these organs in Canada do we offer the organs to the United States through an organization called UNOS.

It's important to note that in 1998 Saskatchewan had 22 cadaveric donors, which gives us one of the higher, if not the highest, cadaveric donor rate in Canada per million.

Due to resource constraints, the MORE Program in Canada is no longer able to produce the national waiting list, and as of January 1999 the proposed computerized list project has been cancelled. This leaves Saskatchewan in a difficult position, because we rely on the national recipient list to determine where we should offer extra-renal organs. We work within tight timelines when maintaining a multi-organ donor, and we do not have the time to phone every program in Canada and offer our organs.

After speaking to the medical director in our program about this issue, we have decided we will place organs regionally, and after that, we will go to UNOS and place them in the States. In terms of the organ shortage in Canada, this does not in any way help Canadians who are waiting for transplantation. However, given the fact that we don't have a clear idea of who the best recipient matches are without a national waiting list, we feel we have no option.

The Saskatchewan Transplant Program would like to recommend that federal funding be provided to produce a national waiting list, whether it be computerized or manual. This is the best way to ensure organs are only sent to the United States when there is no appropriate recipient in Canada.

Thank you.

The Chair: Thank you very much.

Now we'll go to Dr. John Jeffery from Manitoba.

Dr. John Jeffery (Head, Section of Nephrology, Manitoba Transplant Program): Mr. Chairman, ladies and gentlemen, thank you for the opportunity of being here.

I'm not going to reiterate what a lot of the previous speakers have said, other than to make an editorial comment that what are issues in one province or one particular program may not be necessarily the issues in another program. We all have the same goal of promoting organ donation, but I want to take a more global point of view beyond that.

Once we have those organs, we have to do with them what is proper. When you look at what has happened in Canada, we have not had a coordinated approach to transplantation, and as a result our organ donor numbers are inadequate. Our human tissue acts differ from province to province, and they're not enforced within the province—for example, mandatory consideration. Our standards for testing for transmittable diseases have not been established; they're being written and being put in process at this time. Standards for organ and tissue retrieval are just being written and again have yet to be implemented.

Standards for our transplant labs, which are responsible for the matching of donor to recipient, have not been established. We've heard a lot about the waiting list. Manitoba agrees we need one. Organ-sharing and allocation rules and guidelines have not been established for all organs. They're very successful for liver transplants; they're a miserable failure when it comes to heart transplants.

• 1100

There's no forum at this time in which lay people—ethicists, patients, clergy, etc.—can express their issues with respect to transplantation. We also don't have an adequate data system to allow us to know what we're doing and the results of what we are doing.

Recommendations from my program—and I've been involved, as Allan has, for 20-some years in these issues—are as follows.

The federal and provincial governments should establish a national transplant organization. We're one of the few countries that doesn't have that. This has to be appropriately funded, and its mandate for the future should be to ensure that all of the issues we've heard about over the last two hours are addressed and attended.

I do not think this has to be a large, expensive organization. We have in this country a lot of expertise and a lot of resources at the local, provincial, and national levels and within the health care profession organizations. What has been lacking to date is the funding for those organizations to take on these issues, make recommendations, and address the concerns you've all listened to this morning.

Thank you.

The Chair: Thank you very much, Dr. Jeffery.

I'm going to go immediately to our questioners list. I have Mr. Grewal, who is not a usual member of the committee, but he's joined us in place of Mr. Reed Elley.

So Mr. Grewal, to you the first question.

Mr. Gurmant Grewal (Surrey Central, Ref.): Thank you very much, Mr. Chairman. Through you, I would like to thank the panel for giving their very eloquent presentations.

I would like to remind the members, and particularly point out to the panel members, that there was a motion in the House by Dr. Keith Martin of the official opposition with respect to what we are talking about today, and this motion was passed in the House a few weeks ago.

Organ and tissue donation is an important concept. We very well understand that. I also acknowledge that we are not only talking about saving hundreds and thousands of dollars cost-wise, but we are also talking about saving someone's life.

The point was made here that the criteria are very tight for organ donation, particularly with reference to the situation in Spain, which has doubled its organ donors in the same period as we are talking about. I don't know what is meant by “criteria are tight”. I think Dr. Kneteman mentioned that. I would like to know that.

Second, we know that 90% of the people in Canada have a positive opinion about organ donation. So where is the lack in the whole system? Where is the crack, if there is high interest from the public in organ donation, but actually the donation is so low?

I cite one brief example here. When I got my driver's licence in British Columbia, I was given three stickers for organ donation. If I wanted to be an organ donor, I should take the sticker, peel it off, and put it on my driver's licence. I didn't see anything whereby someone somewhere would know I am an organ donor, except the cashier in the bank; when I go to show her my ID to cash a cheque, she will know, yes, I'm an organ donor. But I don't understand who in the Ministry of Finance or in a hospital practically will know I'm an organ donor.

What also bothers me is that in Canada, the relatives, the surviving members of the family, have veto power against organ donation. I would like to get comments from the panel on whether that should be there or whether we should do something so that veto power is taken into consideration when someone is already authorizing or offering herself or himself to be an organ donor.

Finally—

The Chair: Mr. Grewal, do you want to leave any time at all for them to answer?

Mr. Gurmant Grewal: Yes, I will finish in 15 seconds.

Finally, when you were saying more funding should be there, do you mean at the provincial level or the federal level?

Mr. Chairman, I leave it there.

The Chair: All right. You've exhausted all of their time.

Mr. Gurmant Grewal: I took only one and a half minutes.

The Chair: Before I give them an opportunity to answer, just for your information and for that of the rest of the committee members, the only people who haven't shown up today are the people from B.C., but we have them scheduled for our first or second session in March—March 11.

Mr. Gurmant Grewal: Thank you.

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The Chair: They'll be here, and they'll be able to address your specific question in that regard. So if the panel wants to steer clear of that one, it's okay; it's going to be answered.

Otherwise,

[Translation]

Mr. Langlais, we'll hear you first.

Mr. Donald Langlais: With respect to identification, both Quebec and British Columbia had a system whereby on the back of the driver's licence, there was a space where the licence holder could identify himself as an organ donor in case of death. But the Quebec system has changed since the Gélineau report was published. We now put a self-adhesive sticker on the back of the health insurance card, since that is the card used in hospitals.

When a patient is taken to emergency, his health insurance card is checked to help identify him and determine which treatment is required. When brain death is imminent, the back of the card can be checked. The card is there. This makes more sense than identifying yourself as an organ donor on your driver's licence, which is not used in the provincial health care system.

If I remember correctly, there was also a question on funding—whether funding should be provincial or federal. I would agree with Mr. Jeffery, who said that there should be a national umbrella organization. However, there should be funding earmarked in each province for education and information, particularly for people who identify potential donors, in other words, health care professionals.

That is where the action is. It doesn't matter what procedures you implement to identify potential organ donors. If nothing is done within hospitals, things will not improve.

That is all I wanted to say.

[English]

The Chair: Bette Boechler.

Ms. Bette Boechler: I would like to respond to the question regarding the family's right to veto a potential donor's wishes. I've dealt with many donor families, and if a donor family says they do not want retrieval to take place or they do not want one or more organs retrieved, I personally, for one, am not prepared to go against their wishes.

I believe that because the families are the people left to grieve, and everyone does their grieving in their own way. As a health care professional, I'm not prepared to interfere with that process. I've had families who've said, “Please don't take the heart” when another family member has given open consent, and I will not retrieve the heart. That's my personal opinion, as a nurse and as an organ procurement coordinator.

The Chair: Dr. Jeffery.

Dr. John Jeffery: We're actively discussing this specific issue in Manitoba at the moment. The human tissue acts in Manitoba and Ontario, and probably in most of the other provinces, quite clearly states that a valid donor card is full and binding. That means the health care professional should act on the basis of that donor card, no matter what the family's wishes are. Programs right across the country, including our own at the moment, fail to follow the intent of the law, because of concerns about anguish to the family and also adverse publicity.

From an ethical point of view, this is an issue we need to overcome. I as an individual, and the majority of our society, I think, believe in self-determination: we decide whether we want to be resuscitated, we decide what we want to have done with our organs after death, and the family should not have the right to overcome that.

This is part of the public education that is needed on both national and provincial levels. We need a forum for this kind of ethical discussion to take place so that these matters can be clarified and the positions of the transplant programs with respect to organ donation can be made more certain.

The Chair: Thank you.

Dr. Kneteman.

Dr. Norman Kneteman: On the issue of family refusal, certainly there are ethical issues involved. On a practical basis, in our own experience in the HOPE Program in Alberta, when someone has a signed donor card in their wallet, be that on a driver's licence or health card or whatever, it is very unusual for the family to counteract their wishes. Occasionally some specific organ may mean something to someone, but in the vast majority of cases, our experience shows that the family goes along with the wishes of their loved one. So it's an important issue, but one that, practically speaking, doesn't tend to hit us very often as a big problem.

• 1110

On the question of criteria for transplantation, there are criteria for the provision of any kind of medical care, which are more or less rigorously applied. In most cases it's: How much can we afford, as a society, to provide? We don't necessarily do a coronary artery bypass graft on everyone who has a little blockage. There are criteria in terms of when you will achieve a significant benefit that balances the risk. And it has to be done in the context of how much money the health care system has. In transplantation it is also done in the context of how many organs you have to provide. It's not a financial decision; it's how many people you can help.

Because the donors and the donor families have provided that resource, realistically it's our responsibility to do as much good as we possibly can with the organs that are made available. Say, for example, we have a broad range of potential recipients, and at one end are people with a problem that has only a 20% chance of being helped by the transplant, and at the other end is someone who has a 90% chance of being helped by the transplant. On a social basis, as a society, and in terms of our responsibility to the donor family, people who are at the end who have the greatest chance of benefit from a transplant will be those who are listed for transplantation.

[Translation]

The Chair: Ms. Picard.

Ms. Pauline Picard: Good morning. I wanted to tell you how much I admire the excellent work you do and your respect for human life—for the families waiting for transplants and those who contribute with a gift of life. I admire you enormously, and I wanted you to know that.

My question is for Mr. Langlais. First of all, allow me to thank you for your testimony. A few moments ago, I think that members of the Standing Committee on Health believed the smaller provinces were better organized than the larger ones. But now they know that Quebec—through Québec Transplant—is recognized for its efforts across Canada.

You said that you provide training and education for health care professionals in hospitals. I would like to know how those activities are received. Are health care professionals open to your efforts?

I have three questions in all, so I will put the other two quickly. How do you cooperate with other provinces, and what funding do you receive from such organizations as the Kidney Foundation of Canada? Is it enough? Is there harmonious co- operation with organizations?

Mr. Donald Langlais: I'll start by answering the easiest question—the one on funding from organizations like the Kidney Foundation of Canada and others. We don't get any at all. We are funded directly by the Department of Health, but we are not governed by the Health and Social Services Act.

If you look at the health care system as a bubble, Québec Transplant is a satellite that revolves around it, though it is still funded by the department. However, we receive no funding from groups at all. However, we do maintain close relations with the groups to ensure they remain in touch with their members and other individuals, and talk about organ donation.

All organizations recognize Québec Transplant's scientific and technical expertise. So we do work with these organizations. Since the Gélineau report was published in Quebec, the organizations have focussed on establishing a group called Info dons d'organes, which includes the Kidney Foundation of Canada, the Diane-Hébert Foundation, Canadian Cystic Fibrosis Foundation—in other words, all organizations involved in organ donation. They do not fund us, however.

Your other question was on the training of health care personnel. After the report was published just over a year ago, we began to appoint coordinators within hospitals. To date, we have met with them three times. We have provided information and training to them.

• 1115

I was talking about brain death earlier. Brain death can be a sensitive issue even for people working in hospitals. It is an easy concept to deal with. We will therefore be targeting it specifically in the next year with some of our activities.

Of course, these people also help us gain access to ICU personnel. A few moments ago, we talked about the ongoing monitoring that we want to institute in hospitals. We know that a coordinator cannot be there 24 hours a day, 365 days a year. He has to have support. We believe that the ongoing monitoring should be ensured by ICU personnel. Whenever there is a shift change—in general, every eight hours—there should be a notice indicating that the patient is in a coma, and that brain death is imminent. That would trigger a sort of red light at the ICU, and a process involving the coordinator, in co-operation with Québec Transplant. If we could monitor potential donors 24 hours a day, not too many of them would slip through the net. We have to get this moving. We started appointing coordinators about six months ago, and we will review the program's effectiveness after it has been in place for about a year.

Ms. Pauline Picard: What sort of co-operation do you have with other provinces? Someone talked about a national committee earlier. Do you follow the national committee?

Mr. Donald Langlais: Employees have a national organization called CAT. Québec Transplant coordinators are part of the national group. Québec Transplant has always participated transparently in any national efforts undertaken to establish standards for procurement and histocompatibility. We have done everything we could to make sure that safety criteria are complied with. Both in Quebec and elsewhere—let's not forget that organs are exchanged across Canada.

A few moments ago, the Saskatchewan representative said that Saskatchewan transported organs to other provinces. We do that too. When someone in Ontario has reached the acute phase and needs an organ, we transport an organ to Ontario as soon as it becomes available in Quebec, and vice versa. Co-operation is excellent.

Ms. Pauline Picard: So no problems there?

Mr. Donald Langlais: No, none at all.

Ms. Pauline Picard: Thank you.

[English]

The Chair: Dr. Jeffery, you wanted to add something there?

Dr. John Jeffery: Yes, I'd like to make two points.

One I alluded to earlier was on the differences between provinces. For our own province, brain death is not an issue. We haven't had to discuss that for at least 10 years. The consent rate, with the exception of the first nations people, is not an issue. The consent rate is 80%. Education of professionals is not currently an issue. I have the staff to do that, and we do that.

The issue for us in terms of donor numbers at the moment is simply that our emergency rooms are jammed up, with eight to 10 patients at any one time waiting for admission to hospital, over-utilization, and no ICU beds. So when there is a potential donor, they're often allowed to die in the emergency room instead of being carried forward, which is a big change.

Three years ago, for three consecutive years, Manitoba was either first or second in the country in organ donor rates, and we matched those of other countries. In the last two years our organ donor rate has dropped down to close to the national average. This is in parallel with the financial crunch our hospitals have suffered.

The second issue is slightly different. We have two major transplant organizations in this country. One is CAT, which is made up mainly of the transplant coordinators and nurses, and the other is the Canadian Society of Transplantation, which is made up of physicians and scientists. These two organizations are funded out of membership dues, which are obviously very limited.

There are a number of committees within both of those societies and there's certain collaboration between the two societies, but neither of those societies has ever had the mandate or the funding to conduct the business of transplantation in this country. That has been sorely lacking.

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In 1992, funded by the Advisory Committee on Health Services, formerly ACIMS, we actually had a national meeting where we agreed that there should be some kind of national organization. Unfortunately funding was withdrawn about two months after that meeting was held.

That's part of the history. We're going through that cycle again right now. The provincial issues need the authority of some kind of national body so that provincial programs can go to government and say, “This is what happens in the other provinces. This is what we should be doing. You have to fund it.”

The needs in Quebec are different from ours, and our needs will not be the same tomorrow as they are today, but we have to have the resources to do the job that's been given to us.

The Chair: I hope the budgets of the provinces as well as the federal government will bring you some cheer.

Madam Caplan.

Ms. Elinor Caplan: Thank you very much.

I'm interested in the situation in Quebec with the rates of available donations. Would you say you're higher than the national average as a result of the system you have?

[Translation]

Mr. Donald Langlais: On the basis of data I have identified for 1998, the figure was 14.2 for Canada and 16.2 for Quebec. So we are above the national figure. This is an important increase over last year for Quebec.

[English]

Ms. Elinor Caplan: Do you feel it's possible to achieve the rates of some of the world leaders with the situation you have now and the modification you've suggested? Or do you think other things need to be done in order to be able to achieve the benchmark that has been set by Spain and some jurisdictions?

[Translation]

Mr. Donald Langlais: Well, with the appointment of coordinators and the development of monitoring instruments, that figure should rise significantly.

I would also like to find some way of challenging hospitals by giving them an objective. At present, we still talk in the past tense, telling hospitals how many donors they had the previous year. But what is any given hospital's objective? That is why I feel there should be some approach, statistical or otherwise, to establish objectives. What is the number of potential donors per year in Quebec? How are these donors distributed among hospitals? When we know that, we can tell any given hospital what its objective should be in terms of approximate number of donors. I'm sure the hospitals would then be in a position to try to achieve the objective. This would be a significant improvement.

[English]

Ms. Elinor Caplan: The question I have for everyone follows on that. When you talk about the challenge, the issue would then be the accountability and the reporting. What mechanisms are in place right now in the area of reporting and accountability in your provinces?

Dr. Norman Kneteman: There's a national registry, the Canadian Organ Replacement Registry, which does collect donor numbers. The difficulty is that there is no real oversight committee empowered to look at and act on those numbers.

That's where I would agree strongly with what Dr. Jeffery and others have said. Although the mechanisms to make donation work are likely going to have to go through the provinces, because they fund the hospitals, it is still essential to have a national structure that can look at what actually goes on and find out what works in Quebec and what works in Alberta, so that we can build a system that's going to work as it has in other countries. There is collection of information, but there is actually no one empowered to do anything with it.

Further, earlier there were questions about guidelines and such. Over the last few years, under the leadership of Health Canada's Bureau of Biologics, the Canadian general standards on organ and tissue donation and specific subset standards for solid organs and other areas have been written. They are in the process of working their way through the system, and I understand that at least the general standards are very close to being placed with the Canadian Standards Association.

But again, at least from my reading of it, we will have no mechanism to actually monitor the accreditation process and do something about the numbers we see. We will have some good guidelines that have been written by well-meaning people, but as for what we actually accomplish with them, it's going to be hard to understand what you're going to do without some kind of overall structure to monitor donation and transplantation in the country, and thereby feed back to the provinces.

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Ms. Elinor Caplan: That would be the reporting mechanism.

Dr. Norman Kneteman: Well, a reporting mechanism, but also a mechanism to actually look at the outcomes, the numbers, the responses, and be able to have some mandate to interact with people. Now, as Dr. Jeffery said, we have national organizations, but they're professional organizations whose responsibility is to try to make sure the professional standards are upheld and education occurs. They have no mandate to tell the British Columbia transplant system whether or not they are doing an appropriate job, or even to benefit from what the B.C. transplant system has accomplished.

Ms. Elinor Caplan: Are you talking of a national system of accreditation?

Dr. Norman Kneteman: I'm talking about a national system that would have multiple jobs, much like UNOS does in the U.S., like the ONT does in Spain, like Eurotransplant does in Germany and Austria, etc.—a system that is mandated to collect information and look at the guidelines established and be sure the programs actually follow them.

There are some of those guidelines in Canada. Dr. MacDonald made reference to the national sharing structure that exists in liver transplantation. We've worked on that on an annual basis for eight years now. It is in place. It makes sure that if there is an acute need anywhere in Canada, that person gets the liver. The cooperation from Quebec has been excellent in that system, as has that of all the other provinces across the country.

The bottom line is, though, there's actually no one empowered to then gather and act upon the information. That's the kind of structure we really need.

The Chair: Dr. Jeffery.

Dr. John Jeffery: We have no accounting and reporting system of a formal nature. I report to myself for the activities of the program.

Ms. Elinor Caplan: That's a unique accountability structure.

Dr. John Jeffery: Yes.

Ms. Elinor Caplan: You look in the mirror every morning and say, “This is how I'm doing.”

Dr. John Jeffery: There are a lot of concerns. I have seen concrete examples of disease transmitted by tissues, which I have no responsibility for. I've seen organs go to the wrong recipient—not in the sense of a mistake, but not going to the most urgent recipient—because we don't have good listing systems.

We did a survey of the transplant labs across the country. The methodologies used in cross-matching, which determines which organ can go into a person, differ from laboratory to laboratory, and some of them are quite antiquated, outdated. We have no process in place to look at the issues and say this is what we should do today, to look at what effect that has, and then, as science progresses, to incorporate new ideas, new thinking.

Ms. Elinor Caplan: You feel that should be part of the mandate of a national organization?

Dr. John Jeffery: Very definitely.

The Chair: Thank you.

Mr. Vellacott.

Mr. Maurice Vellacott (Wanuskewin, Ref.): My comments will centre on the term “brain death”, which was brought up first by Don Langlais, but I want input from others as well. I hear of people who had in fact been declared “brain dead” but then later recovered, and I want some responses on that.

I found your acknowledgement in this area very frank, Mr. Langlais, when you admitted it is not an easy concept to deal with, and that even personnel in the hospital did not necessarily grasp it, or there was some uneasiness to some degree. I would have to say I appreciate what I perceive to be some humility and honesty on that issue, because frankly some medical people are very dismissive about that, and maybe that's part of the problem. If there's no reason to be concerned, then maybe there needs to be a respectful communicating of that to the public in ways they understand, from a lay point of view.

Are you a medical doctor? Oh, you're a layperson, with special expertise in the area of health of course. I'd like to hear from the lay people and then from the medical doctors and from Bette, as a health professional as well.

I recount this because I was in conversation just in recent days with a medical doctor who had been declared “brain dead”, and she recovered and then went on to do a psychiatry specialty. It was a very interesting story, and not the only conversation I'd ever had along these lines. She said to me, “Had there been someone in the next bed who needed a heart, and had they harvested my organs prematurely, I'd not be alive today. I would not have gone on to do a psychiatry specialty hereafter, had they moved in on me, `brain dead', and harvested organs.”

So first off, can you give me a definition in lay terms of what you understand or perceive brain death to be, communicable to me? Then secondly, how do you explain this kind of situation, with a diagnosis of “brain death” and recovery later?

The Chair: Who wants to go first?

Mr. Maurice Vellacott: I'd like to hear from Donald Langlais first, and then I'd like to hear from the others as well.

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[Translation]

Mr. Donald Langlais: You know I am not a physician. So I will let my two colleagues tell you about scientific aspect of brain death.

You said that someone had been declared brain dead, but then came back to life. This year, I was asked to speak on a Quebec television broadcast, and then went back to study the issue. When someone is declared brain dead, he is taken to a harvesting centre. That is where the question of caution comes in. In Quebec, as in other provinces, I believe that death must be certified by two independent persons who do not communicate with each other. This is to ensure that the patient is in fact brain dead, and that organs are not harvested from anyone demonstrating brain activity of any kind. The procedures to determine brain death are very specific. I think our physicians are well able to certify brain death.

There could have been a situation where someone was believed brain dead while just being in a coma, but it certainly wasn't absolute brain death. At this point, to avoid that danger, we require two statements of absolute brain death before intervening and taking any organ whatsoever.

I'll let the doctors tell you about it, but I'd be surprised to hear that anyone being declared absolutely brain dead by two experts ever came back to life.

[English]

Dr. Norman Kneteman: “Brain death” perhaps is a phrase we shouldn't use too much any more, because in fact in Canada and in virtually all of the western developed world, brain death is death. It is our definition of death. That is, if your brain no longer functions, irreversibly you are dead.

We don't define death by your heart stopping or anything else, because as you well know, people's hearts stop, they get resuscitated, and they do fine. Brain death really occurs when there is some insult that means all of the blood supply to the brain is cut off. When that happens, it's an irreversible situation.

The question is, how can you be 100% sure that your medical diagnosis of brain death is true? That's the issue you really address. There are anecdotal situations where someone has supposedly come back from brain death. There are none that are well documented, where the person actually accomplished what was related—that is, two independent physicians went through all of the required tests necessary to make a diagnosis of brain death.

Someone may be in a deep coma, and yes, they may recover from that, but that's a different situation from brain death. A deep coma is simply cessation of function of the brain. Brain death means the blood supply to the brain is irreversibly lost. That is confirmed by a whole series of tests and sometimes also by radiological X-ray imaging studies that show no blood flow to the brain. It is important that the idea is transmitted to the public that in those situations, a very careful diagnosis is made independently on two occasions, and it is an extremely careful process. We are unaware of anyone in that situation recovering.

Mr. Maurice Vellacott: So that's uniform across the province, across the western world, the fact of two of them? Nobody is moving in before two? That's in every province across the country and in the western world, to your knowledge?

Dr. Norman Kneteman: That's my understanding for across Canada.

Dr. John Jeffery: The medical criteria are quite explicit and have to be followed by two members who are experienced in that process, and the word “experienced” is very important there.

I've been doing transplantation for 28 years now, and over the years I have seen a number of people called down to the emergency room, where there is a brain-dead individual, and they go and stand at the bedside and in 30 seconds say, “That person is not brain-dead.” They haven't even done any formal testing. It's done by inexperienced people who are not qualified to do that.

Transplant programs are exceedingly careful to make sure that anybody who declares brain death is well qualified. We make sure doubly.

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Dr. Norman Kneteman: I have one quick additional comment. The law in Alberta, and I think everywhere else in the country, is also very explicit that no one involved in the transplant program can in any way be involved in the diagnosis of brain death, because clearly there would be the potential of conflict. That's uniform, and that's an important consideration as well.

Mr. Maurice Vellacott: Right.

Bette, did you have a comment?

Ms. Bette Boechler: No, I don't.

Mr. Maurice Vellacott: To follow up on that then, again I have two quick questions.

Going back several decades now of course, would it be fair to say that if we had not moved and shifted to accept the theory coming up from the States, as I understand it, that brain death was synonymous with death—if we had stayed with the earlier definition of all the body systems shutting down—would there be such a thing as organ transplantation? I guess I'm asking a very rhetorical set-up kind of question. Had we not moved to the “brain death” definition being synonymous with death, would we even have the possibility of organ transplantation?

Dr. Norman Kneteman: That's the situation in some countries, such as Japan, which only adopted brain death last year. Donation there occurs from living donors when possible.

Mr. Maurice Vellacott: So they're just doing kidneys and other things like that.

Dr. Norman Kneteman: And occasionally segments of livers.

But we also have to understand that brain death was not developed for transplantation. Brain death was developed by neuroscience experts, because they had people in comas, and the question came up in terms of the family's interests and the medical care system's interests: When is that an irreversible process? No one wants their family member supported forever.

So the criteria to diagnose irreversible brain death were developed by neuroscience experts for that reason. They were then applied in transplantation as a very effective safety valve.

Mr. Maurice Vellacott: But I am correct to assume then that had there not been this, and I wasn't—

Dr. Norman Kneteman: Cadaveric organ donation would not be really a possibility without the concept and acceptance of brain death.

Mr. Maurice Vellacott: Exactly.

The Chair: Dr. Jeffery.

Dr. John Jeffery: Many centres from around the world are now exploring and actually using what are called non-beating-heart donors. These are people who have arrived in the emergency room, have had a cardiac arrest, and have not been resuscitated. If one can get those patients to the operating room very quickly, with their family's consent, one can remove organs from those. This is actually practised in Halifax right now, quite widely in England, and I think will be one of the routes we have to explore in this country for increasing the number of organ donors.

Mr. Maurice Vellacott: Is Manitoba the only province in the country where there's an actual law on the books, as I understand it, and then the others, by default almost, followed suit with the law in Manitoba in respect to brain death? I know the medical associations have commonly accepted it from time immemorial, or for many years now, but if my understanding is correct....

You would know, in each of your respective provinces, whether there's a law on the books in terms of brain death. Manitoba does, I believe.

Dr. John Jeffery: No, there's no specific law with brain death. The law is that you are dead when a physician says you are dead. The law has left it up to the medical profession to decide what the criteria for death are. That was challenged in the Manitoba courts back in the 1970s. Brain death is accepted by law as being an adequate—

Mr. Maurice Vellacott: Okay, so it was upheld in law in Manitoba; I guess that's what I'm saying.

Dr. John Jeffery: Yes, but it's not written into law.

Mr. Maurice Vellacott: That's right, and the others use that as a precedent and go with that in view of the Manitoba court decision. Is that correct?

Dr. John Jeffery: Right.

Mr. Maurice Vellacott: Thank you.

The Chair: Thank you, Mr. Vellacott.

Madam Minna.

Ms. Maria Minna: Thank you, Mr. Chairman.

With the witnesses we had earlier, there was a great deal of discussion about the problems in hospitals, the problems of retrieval. Some hospitals have teams; some hospitals do not. We've had other presentations from previous presenters in the last couple of days.

What I wanted to ask all of you is: Would you see accreditation as a precondition for a hospital? In other words, a hospital would not get accreditation if it did not have on staff a specialist or a team or someone who would be involved specifically in addressing this issue. The recommendation was that it be not the emergency team that is working on the person who is ill, but rather someone who is separate from that and specializes in organ retrieval. Would you make that a precondition?

It seems we keep coming back to the problems at the local hospitals, in addition to whatever other structures one might establish.

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The Chair: Dr. Jeffery.

Dr. John Jeffery: A number of years ago, our program actually made the recommendation to the Canadian Council on Health Services Accreditation that as they go around the hospitals in the country, part of that accreditation should be that they look at what is in place to make sure that organ and tissue donation—we keep leaving tissues out of here—takes place.

I just want to mention tissue very briefly.

Ms. Maria Minna: Sir, that accreditation has not happened, though.

Dr. John Jeffery: That is not part of the routine accreditation process.

Ms. Maria Minna: Why has that not happened then, if that was the recommendation?

Dr. John Jeffery: You'd have to ask the Canadian Council. That was just from my program only.

Ms. Maria Minna: I see.

Dr. John Jeffery: Just to mention tissues, there are lot of people waiting for corneal transplants in this country. Almost every person who dies, unless they have an infectious disease or a malignancy, can be a cornea donor. Why do we have a shortage? We should have thousands and thousands of corneas in surplus. We're not talking about 1% or 2% of people who have died being donors; we're talking about 97% or 98% of people who have died.

We have some real problems.

Ms. Maria Minna: The other question I have is this. We've gone back and forth this morning on whether or not we need a national structure, a national list. The representative from Saskatchewan certainly said they would benefit from that. Could you all tell me what role you see specifically from the federal government?

We're doing this. We understand that a lot of it is provincial jurisdiction. Some of it comes down to local hospitals. I don't get the impression that money is necessarily the insurmountable problem here. In some cases it is; in some cases it is not. Ontario seems to have quantified per donor how much that would cost, although the province hasn't yet responded. What specific role would you see the federal government playing in this area, since this is a committee of the federal government?

The Chair: If you've given it some thought.

Let's start with Dr. Jeffery.

Dr. John Jeffery: There's the Advisory Committee on Health Services and the Conference of Deputy Ministers, which is a federal-provincial group. They could create a structure with appropriate funding. As long as each of the provinces bought into that structure and recognized the mandate of that structure, we could carry on these activities to make sure standards are in place and to look at accreditation rules.

A lot of that work can be delegated out. I'm not saying this organization nationally has to do it all themselves. They could make a recommendation to the Canadian Council on Health Services Accreditation saying, “Please incorporate this into your accreditation process”, then discuss back and forth and come up with solutions.

But we've never had any money, as a profession, to meet. If I want to talk with Dr. Kneteman and some other colleagues and have a conference call about something, I don't have any budget for it, even within my program. Certainly if I were chairing the Canadian Transplant Society's committee on sharing kidneys....

There's absolutely no money at all. Any money that comes forward has been either out of the membership dues or where some company has donated money to the society. We don't have the money to do the work of the day.

The Chair: Dr. Kneteman, do you want to answer that as well?

Dr. Norman Kneteman: Yes.

The issue of a national structure, as mentioned, has been brought up many times, and it has fallen flat on its face. The bottom line is it's fallen flat on its face because no one is willing to fund it. Actually what is now the federal-provincial Advisory Committee on Health Services elected not to fund it.

That is the federal government's role in this area. Obviously the funds that flow from the federal financial pot to the provinces are what run health care to a large extent, so clearly money is part of it. What you can actually do is clearly enunciate your expectations that there will be such a structure, that it will have the mandate to look at the guidelines that have been created through the Bureau of Biologics of Health Canada so that there will be a structure to actually do something with it, and that you will be willing to fund that organization to do its job.

It won't be free. The Spanish system, which we've heard about working so well, costs several million dollars a year. The potential savings—in fact, even if we only raised our kidney donation rates a small amount—would easily cover that expense. So we're going to have to put something into the system to make it work in order to generate the savings that really are there. According to every health care economist I've ever seen in the area, tremendous savings are possible.

That national structure is probably one thing you can really do something about, and that's what I would certainly like to see come out of this.

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[Translation]

The Chair: Mr. Langlais.

Mr. Donald Langlais: I'd like to answer your concern about the accreditation by hospital centres. Accreditation by the Canadian College does not lead to any penalty in case of default; the hospital continues to work. The accreditation is an advantage, but it does not impose any obligation. Something has to be found to make all those people more answerable.

As for the evaluation, in Quebec, it's the college of physicians who's responsible for evaluating the quality and all the procedures. In Quebec, the college of physicians is preparing an evaluation process for organ donations, from retrieval to transplant, taking into account the objectives the hospital should have had in terms of potential.

I think there are ways to attain this, but what my two colleagues have said is true. I agree that there probably should be a federal umbrella.

I'd like to point something out. I heard Ms. Boechler talking about a national list. I agree with her that it would be most regrettable if it were to disappear in the present form. I will support her with great pleasure. This list allows everyone to be aware of what mutual help we give one another. If we lose in its present form, that will complicate things.

Dr. MacDonald said before that the coordinator would have to make five or six extra phone calls. During the time those five or six extra phone calls are being made, transportation can be organized, retrieval crews can be called in to be ready... We know that the work that has to be done with a donor is not extensive. If the donor has a cardiac arrest during the process, you'll lose him. So the more time is saved during the process, the better it is. I don't know what you can do for the national list, but if anything immediate were to be done, that would be it.

The Chair: Thank you. D. Jeffery.

[English]

Dr. John Jeffery: In terms of cost, one more donor who provides two kidneys will save the taxpayer roughly $750,000. So this can be very quickly a positive financial venture.

On the second point that Mr. Langlais was just making, it's very important that, whatever national organization we have, it has a recognized mandate and also some clout. And the provinces have to buy into that in some way, however it's done.

The Chair: Dr. Jeffery, I just wanted to ask you, since you're only responsible to yourself, would you be one of those individuals who would prefer to be responsible to somebody else in an effort to establish the kind of national coordination that's been talked about?

Mr. John Jeffery: I've been proposing a national organization for many years. There are examples in the past—and I don't want to go into history—of provinces going their own way and not doing well. If somebody is not doing well in B.C. or Newfoundland or Manitoba and I can do something about it, I will.

The Chair: Very good. Thank you.

I have one minute only, so Madam Caplan, if you want to make a statement, you have to keep in mind that the response has to come in within that one minute.

Ms. Elinor Caplan: Okay. I'll place the question, and if there's no time for answering, I'd be happy to have it in writing.

You've mentioned savings. What I'd like to know is, what mechanism could we use to use the savings to pay for the program? We all hear about savings, but we never see the savings being used to fund the program.

The Chair: Dr. Kneteman.

Dr. Norman Kneteman: As I said earlier, the rates of dialysis, at least in Alberta—and I'm sure it's the same everywhere—are rising at 10% to 12% every year, and our government has to put more money into dialysis every year. You're not going to save money that you can then redistribute. What you're going to achieve is you will not necessarily have to put the additional 10% or 12% in next year.

Ms. Elinor Caplan: But that initial expenditure.... You're calling for federal funding for this organization—

Dr. Norman Kneteman: I agree, but—

Ms. Elinor Caplan: I'm asking how do we get the savings that are out there to fund this federal or national initiative?

The Chair: According to my watch, one minute only runs about 60 seconds.

Ms. Elinor Caplan: Okay.

Dr. Norman Kneteman: The provinces are spending money collected by the federal government significantly as well, so it's not just one side or the other.

The Chair: Do I sense that a debate is developing here, rather than an answer to a question?

Dr. Jeffery, you have the honour of shutting everything off.

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Dr. John Jeffery: I need five seconds for the funding: federal 20%, provincial on a per capita basis. That's the way the Advisory Committee on Health Services funds things.

The Chair: Dr. Jeffery, Ms. Boechler, Monsieur Langlais, and Dr. Kneteman, I want to thank the four of you for a very interesting presentation and for the frankness of your responses. I can assure you that the committee, in its digestion of all of those inputs, will find some very interesting material, and I hope we can live up to the task as well.

Thank you very much. The meeting is adjourned to the call of the chair.