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BMJ. 2007 June 9; 334(7605): 1194–1195.
PMCID: PMC1889948
Medicine and the Media

The dangers of triage by television

Inez de Beaufort, professor of health care ethics, and Frans Meulenberg, science writer and research associate

The much criticised “win a kidney” gameshow on Dutch television may have turned out to be a hoax that was later hailed as a “fantastic stunt,” but that still doesn't justify it, write Inez de Beaufort and Frans Meulenberg

Shame and scandal

“Shameful,” “Disgusting,” and “An idea so sickening: it must stem from Holland”—these were some of the headlines on 25 May, the day the Netherlands' BNN Broadcasting Company announced its Big Donor Show. The idea of the programme was that a terminally ill woman, 36 year old Lisa, would talk live in the studio with three pre-selected young patients, all in need of a kidney. Then she would choose which of them would receive her kidney before her death. Viewers would be able to advise her via SMS messages.

Predictably, news of the show provoked a worldwide storm of moral disgust: “Outcry over TV kidney competition,” reported the BBC, while the New Zealand Herald referred to “Organ Idols.” When the programme was broadcast on 1 June, 1.2 million people tuned in, 23 000 “voted,” and 50 000 people downloaded or ordered a donor-registration form.

The founder of BNN, one of the Netherlands' public networks, died from kidney disease in 2002, after two transplants. Defending the show, BNN's chairman said, “We know that this programme is super-controversial and . . . that some people will find it tasteless, but we think the reality is even more shocking and more tasteless.”

But indignation reigned. The public for the most part (61%, according to a poll) was against the show. The Dutch minister of education, culture, and media, Ronald Plasterk, said he disliked the “competition element,” but media law offered no possibility for a ban. The transplantation centres stated that the programme makers had not contacted them. The Royal Dutch Medical Association advised doctors not to cooperate, saying, “People's sufferings should not be the topic of an amusement show.” The Kidney Foundation reacted cautiously, saying the programme makers “encourage initiatives that lead to more discussion on organ donation . . . but the format—a show programme—would very certainly not be our choice.” Only a few hours before the broadcast, Dutch prime minister Jan-Peter Balkenende expressed his regret and worries about “the Dutch image abroad.”

Background

In the Netherlands, which has a voluntary registration system for postmortem donation, people can register as donors, they can refuse donation, or they can register for others to decide on their behalf. Out of a population of 12 million adults, 2.8 million people are registered as potential organ donors.

Every year hundreds of people die because of the lack of an organ. On 1 May 2007, 1049 people were on the waiting list for a kidney from a postmortem donor; 151 were on the list for a liver and 144 for a lung transplant. However, in 2006 only 360 kidneys, 83 livers, and 52 lungs became available from deceased donors; 274 kidneys were given by living donors. One in three people on the waiting list dies without having had a transplant. Besides a declining willingness to donate, there is also the problem of family members who refuse donation when the deceased has left the decision to them or made no arrangements on the matter (280 refusals out of 398; source: W Weimar, personal communication). Several government campaigns to increase the number of organ donors have not resulted in the availability of enough organs.

What are important arguments in the debate?

The show may have been condemned as being in bad taste, but there is no law against bad taste. The notion of impropriety is notoriously difficult to pin down, and the debate on what is or is not improper is ongoing. It has to do with witnessing private moments that are “none of your business” (to publish the pictures of Princess Diana after her road crash, or to broadcast a live euthanasia, as in the Netherlands in 2003), and with people publicly being put in embarrassing or humiliating situations (as in Big Brother).

Pleading for yourself publicly in a matter of life and death is degrading. To be manoeuvered into such a position implies deep desperation and an ensuing willingness to do anything, including advertising one's personality to a sensation-greedy public. But as the candidates in The Big Donor Show autonomously agreed to participate, doesn't that “undo” the impropriety? People can compete for the oddest goals and in the oddest situations on television, so why not for a kidney? Don't desperate situations justify desperate measures, as the argument of BNN ran? No. One could still argue that people shouldn't be put into this situation and they should be protected against such an exhibition. It is not only the matter of being on public display, it is also that the situation is so bad that you have to resort to such a solution. This also holds for the 25 candidates in the preselection process, a number Lisa efficiently reduced to three on criteria such as age, responsibility for lifestyle, and being active in society.

Not only was the dignity of the candidates at stake, but also that of the audience. Was this not a modern version of the freak show, rejoicing in the circus of the needy? Impropriety attracts attention. A tabloid mentality could make people enjoy live television about road crashes and emergency rooms, etc (already a popular genre of programme in Russia—see BMJ 2001;322:871).

Nothing personal?

The show's morbid attraction also thrived on the idea that people enjoy having power over others, even in life or death, and love to decide the fate of their fellow men. As the public (23 000 of them) sent SMS messages expressing their preferred candidate, all too eager to assist Lisa in her God-like role, they apparently knew who deserved the kidney.

Of course we all pass judgments on each other. We select, reject, evaluate, we like, we dislike. But in the realm of medical scarcity, allocation criteria should be relevant for the treatment in question, and public popularity based on “X factor” charm and eloquence is unrelated to the need for a transplant. There are unattractive, uninteresting people with no media X factor desperately needing a transplant. They should have equal access and be able to trust the fairness of the allocating system. Not to have a transplant because of bad luck, or the bitter arbitrariness of fate, is hard to cope with, but it is even more cruel to be rejected because the public inquisition weighed you and found you wanting.

The slippery slope

If the selection for kidneys can be turned into a spectacle, where does it end? Will there be an increasing industry of shows, games, bingos, and lotteries to perform triage for scarce medical resources? Who is the best mother whose baby deserves to be on the ventilator? Who wins a bone marrow transplant for his child? “Temptation Transplant Island,” “Dancing with Stars for Hip Transplants”?

Slippery slope arguments are to be used with caution. One has to argue why a slope would indeed be slippery and why it would be a realistic scenario. In this case the argument seems convincing: the fact that so many people watched and participated in the “voting” is telling and worrying.

The apotheosis

Just as Lisa was about to reveal who would get her kidney, the host of the show stopped her and revealed that “Lisa” was Leonie, an actress, in perfect health and not donating a kidney. The three candidates were real patients who had known all along that this was a stunt. The aim of the programme was to draw attention to the scarcity of organs.

And now?

So, the controversial “show” was a hoax, a publicity campaign. The press agencies Reuters and AFP reported this as “breaking news.” Immediately after the show Minister Plasterk said that it was “a fantastic stunt.” But is it? Three mechanisms proved to be effective: the medium of television, the personification of the problem, plus the sense of moral outrage. Evoking the latter was especially impressive. But the show's long term effect remains to be seen. Will more people register? Will they donate as living donors? According to one newspaper, six people volunteered as living donors right after the show. But the programme could have the opposite effect: people could feel they were fooled, and turn their back on the issue of organ donation. Certainly BNN stressed the need to keep the scarcity of organs high on the political agenda.

We wonder: those who watched the programme and felt a preference for one of the candidates: are they ashamed? We were (and we watched only for the purposes of writing this article).

Notes

We thank Dr M Schermer, Dr S van de Vathorst, and Professor Dr W Weimar for their help with previous versions of this article.


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