Interviewed by: Emily Sodhi

Western Chapter

Dr. Ian Ball currently chairs the Critical Care Research and Scholar Programs at Western University. In addition, Dr. Ball plays an active role in the organ transplantation community. He chairs the London Health Sciences Centre Organ Donor Management Committee and is the Regional Medical Lead for Organ Donation with the Trillium Gift of Life Network. One of Dr. Ball’s research focuses is on the implications of Medical Assistance In Dying (MAID) on organ donation. He recently published an article in the New England Journal of Medicine regarding the ethical questions and challenges that arise for organ donation in cases where patients have elected MAID. We had the opportunity to chat with Dr. Ball about his work in the organ transplantation field.

What inspired you to choose your practice and get involved in the field of organ transplantation?

Dr. Ball: So I trained here at Western. I did medical school here as well as my residency and fellowship. Particularly, during my fellowship which was in critical care, as you know London is a really big organ donation and transplant centre, [the organ donation work and research] is something that everyone is involved in and I think everyone is very proud of. And so to me it was very normal to be pro-organ donation since it improves the quality of lives and saves lives. When I graduated and finished my fellowship, I went on to join a faculty at Queen’s University, and I carried that enthusiasm with me in taking over as the chair of the organ donation committee there. Then, I got involved in Trillium and things snowballed from there.

And how did you get involved with MAID and organ donation?

Dr. Ball: I originally got involved with MAID and organ donation when my colleague, Dr. Robert Sibbald, came up to me a couple years ago before MAID and organ donation was legalized. He asked me how we could handle MAID patients who wished to be organ donors. In fact, when the idea of MAID and organ donation came up for the first time, Trillium didn’t want anything to do with it, since they feared the effects its publicity could have on Canadians’ opinions on organ donation. At the end of the day though, organ donation for MAID patients is all about pleasing the donor, not the recipients.

As a critical care doctor, how does your clinical practice relate to organ donation?

Dr. Ball: It’s really important as a critical care physician that our priority is to the patient in the bed. And, you know, it’s really important that there not be any thought regarding organ donation or a patient as a potential donor until one of two things has happened:

  1. They’ve been declared dead by neurological criteria (also known as brain dead). After that happens, then we’ll approach families about organ donation to see if their loved one would have wanted to be an organ donor.
  2. If someone’s prognosis is so bad that there is a discussion with family about withdrawal of life support. For example, somebody who is very badly head-injured who is going to live in a vegetative state, if their family tells us that they wouldn’t have wanted that quality of life and would rather die, then we talk about withdrawing the life support, or allowing them to die. After that discussion and the family’s agreement to withdraw, we bring up the concept of organ donation. And this happens at least a few times a month, since we are such a busy trauma and transplant centre.

What happens in the case of directed organ donation — where the donor asks for Medical Assistance in Dying (MAID) to give an organ to someone who needs a transplant?

Dr. Ball: We have not got a lot of experience with MAID and organ donation in the whole country. I know we’ve only done two cases in London. And considering that MAID’s been legal now for almost three years, and we’ve done over 100 named cases, there have only been two eligible to donate. And the reason for that is a lot of patients who want MAID also have cancer, and this precludes them from being donors. And so, directed decease donation is fairly rare. Lots of criteria need to be met. […] You have to have a close relationship between the donor and the recipient (i.e. close friend or family member), the potential recipient has to already be on the transplant list, and the transplant team has to be comfortable with the concept, since the directed recipient would jump the queue a little bit. To summarize, there have been very few cases in Ontario and in Canada.

According to the Organ Project, 90% of Canadians support organ and tissue donation, but less than 20% have made plans to donate their own organs. What do you think contributes to this disparity?

Dr. Ball: I’ve worked at Trillium Gift of Life Network for 5 years, researched with Canadian Blood Services because they supervise all organ donation in the country, and I’ve worked here locally in London. And this is a huge problem; we know from research that over 90% of Canadians support organ donation, and yet, you can go on www.beadonor.ca to register and in various jurisdictions the registration rate is from the low 20s to the low 40s.

So why the gap? I think a lot of it is that unfortunately people just don’t think about it. It surprises me how often people don’t talk about end-of-life care in general. And as an ICU physician, when you approach family members and say, “What do you think they would want at this point?”, people who have known each other for 40 years say, “I have no idea, we’ve never talked about it.” So, if you’re not talking about end of life issues, then I think it is logical that you also wouldn’t talk about organ donation. If you’re not even talking about it, you’re not going to go on the website and register. We made a swing from signing donor cards on the back of driver’s licenses to going online a few years ago, and I’m actually not sure the impact that has had. But anyway, it’s definitely something we need to work on to try to reduce that gap.

Currently, what has been the impact of MAID on organ donation wait times in Canada and other countries who have legalized this procedure?

Dr. Ball: So to my knowledge, there are only 5 countries in the world that do MAID: Canada, Belgium, the Netherlands, Switzerland, and now Columbia. And to my knowledge, only 3 countriesCanada, the Netherlands, and Belgiumhave ever done both MAID and organ donation. They haven’t done many of them in the Netherlands and Holland. We’ve done less than 30 to date. So, the whole goal of offering organ donation to MAID patients is not really going to have an impact on the waiting list.

The goal is not really to have a benefit on the recipient, but rather to benefit the donors. For a lot of [donors], it’s really important to them; it’s one of their last wishes in life to be a donor and to contribute their organs to try and save someone else or improve their quality of life. So, we are really focused on the donor, not the recipient.

Some worry that allowing organ donation after assisted death may give people an additional incentive to end their lives, and that vulnerable patients could be pressured into giving up their organs for the good of society. In your opinion, what might be a solution to address this ethical issue (if there is any)?

Dr. Ball: Sure, that’s a great question. So there’s a firewall between the two healthcare practitioners that are doing the assessment to see if somebody is eligible for MAID and the donation and transplantation teams. So those two doctors are acting as they always would. I mean organ donation might be a potential motivator for someone to get MAID, but so might no longer being a burden to their family or not costing as much financially to their family. You know, there’s many other motivators that the MAID assessor need to rule out before they deem somebody eligible for MAID. And I just see organ donation as among many motivators.

So you mention the issue of medical staff’s discomfort with MAID and organ donation, and what should be done in this case. Do you think that medical staff opposed to assisted dying should be compelled to retrieve the organs or assist in the transplant?

Dr. Ball: Absolutely not. I think it’s really important that we respect people’s wishes. Everybody’s different, and different people have different values and beliefs. So no, we shouldn’t force or pressure somebody into something that they don’t want to do.

What impact do you hope MAID will have on the organ transplant waitlist in the future? And in your opinion, what still needs to be done legislatively, in order for this to be realized?

Dr. Ball: I think the legislation is in place in Canada, and I’m really proud of our country for making this happen, for making MAID and MAID donation possible. But once again, the goal of MAID donation is to respect the wishes and autonomy of the donor. It’s not about trying to reduce the wait time on the transplant list.

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From our discussion with Dr. Ball, we learned much more about the process of MAID and organ donation, and how it serves to honour the final wishes of MAID patients who wish to donate. If you’re interested in learning more about MAID and organ donation, you can read Dr. Ball’s published article in the New England Journal of Medicine, entitled “Voluntary Euthanasia — Implications for Organ Donation”.

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