The Health Ministry ’s recent statement that government hospitals will notperform live organ transplants because of its implications has highlighted themany issues surrounding organ transplantation. Dr Milton Lum addressessome of these issues.
THE gift of an organ is a gift of life. How else could you describe a procedure where a failed organ can be replaced with a spanking “new” one that takes over the function of the defective one?
The world’s first organ transplant was carried out in 1951, and this involved a kidney transplant. Since then, better understanding and advances in medicine have made transplantation of the cornea, liver, intestine, heart and lung available as a treatment option for those with organ failure.
Despite the many successes that have been achieved in the field, there are problems. This is mainly due to a shortage of available organs required to meet an increasing number of patients awaiting a transplant. The reasons for the shortage include an insufficient number of donors, a decrease in the number of road traffic accident fatalities, patients being re-transplanted and patients on the waiting list getting older.
The severe organ shortage in Malaysia is well illustrated by the 9th report of the Malaysian Dialysis and Transplant Registry (2001). During the period 1994 to 2001, of the 1,063 people who had kidney transplants, 67.07 % of the procedures were done abroad – 203 transplants (19.1%) were carried out in India; 492 (46.28%) in China. All the public and private sector hospitals in the country carried out only 350 (32.93%) kidney transplants.
As a result, living donor organ transplantation is increasingly resorted to address the shortage of cadaveric (dead bodies) organs. It is a widely accepted practice throughout the world and has been performed in countries like Canada, Germany, Norway, Singapore, United Kingdom and the United States.
Most living donors are close blood relatives of the recipients. They are known as living related donors and may be first-degree relatives, for example, parents, children or siblings, or second-degree relatives, for example uncles, aunts, nephews, nieces, grandparents, grandchildren or half siblings.
In general, only a small proportion of patients with organ failure can be considered for living related transplants. This is due to various reasons: blood group or tissue incompatibility; medical conditions identified in screening that preclude suitability for donation; unwillingness of potential donors to undergo evaluation; a small nuclear family with few potential donors available for consideration.
As a result, this has also given rise to living unrelated organ donors. In general, these can be divided into two categories:
Quality of living donor organ transplantation
Research has shown that living donor transplants, especially kidney transplants, are, on average, more successful than cadaveric transplants i.e. patient and graft survival rates are higher. Data from the United Network for Organ Sharing in the United States show that of the living donor kidney transplants done between 1987 and 1996, the kidneys still functioning after a five year period averaged 76.6% overall. Of the cadaveric donor transplants done during the same period, the kidneys still functioning after five years averaged 61.0% overall.
Organs from living donors almost invariably start working immediately after the operation. This is believed to be associated with the shorter delays in transplanting the organs, thereby limiting the ischaemic (lack of blood) time of the organ. Living donor transplantation also avoids the long and unpredictable wait for a cadaveric organ. When compared to cadaveric transplantation, the results of living organ transplantation tend to be of better quality.
Issues in living donor organ transplantation
There are many difficult ethical and legal issues regarding live organ donation, the basic question being: Is it right to expose a healthy living person to risks in order to benefit another person, and if so, under what conditions?
Surrounding this are the basic ethical principles of “non-maleficence” (doing no harm) for the donor and “beneficence” (doing good) for the recipient. The considerations include:
The primary concern in living donor organ transplantation is exposure of an otherwise healthy individual to the risks of major surgery, which may affect the life or future health of the donor.
Advances in donor selection, surgical techniques and care before and after the operation have reduced the risks to living donors, especially in kidney transplantation. The literature reports a risk of death of between one in 1,600 and one in 3,000 to the donor in kidney transplantation. This risk is no more than is associated with any anaesthetic. However, the risks to the donor in liver transplantation are higher with a risk of death of one to two in 100 cases, and a significant morbidity risk of 25 in 100 cases.
In view of the risks of mortality and morbidity, the donor needs to be given all the knowledge regarding the risks to himself or herself, the likelihood of success and any other alternative treatment for the recipient, prior to him or her giving consent.
There is also a need to consider whether a guardian for a legally incompetent person, for example a mentally disabled or a minor, can give consent for such a person to be a living donor.
Although living donation relies heavily on altruism, concerns are often raised about the motivation of the donor. There is concern about possible coercion or pressure, which may be put on donors by families, recipients or even transplant teams.
The most worrying and controversial issue in living donor organ transplantation is the financial inducements that may be offered to donors, thereby leading to its commercialisation. It is not uncommon for the rich of all countries to travel abroad, buy an organ, have it transplanted and then return home.
As organ trading invariably results in the exploitation of the vulnerable poor to benefit the rich, it is generally considered ethically unacceptable by virtually all countries. Organ trading also brings with it the concerns of possible cross infection and transmission of life threatening conditions like HIV.
The psychological and social implications of involvement in living donor organ transplantation should not be underestimated. The parties involved need to have time to reflect on their plans and discuss them with their family and friends. Potential donors should not be put under any pressure to donate. Similarly, potential recipients must be allowed to decide whether they want to accept the donor’s offer.
Safeguarding donors’ and society’s interests
There is increasing recognition and acceptance of the concept of “emotionally related” donations. The German Transplantation Act accepts living non-related donation from spouses, fiancés and other persons in an obvious close personal relationship with the recipient.
The United States President’s Task Force on Organ Transplantation concluded that “there is no reason to exclude all living unrelated donors, such as spouses and friends, but special care should be taken to ensure that the decision to donate is informed, voluntary and altruistic.”
The guidelines or regulations adhered to in living donor organ transplantation include the following:
Some countries require the concurrence of a regulatory authority before proceeding. For example, in the United Kingdom, donors and recipients in living unrelated organ transplantation require the prior approval of the Unrelated Live Transplant Regulatory Authority (ULTRA). The process involves an application by the donor, recipient and their respective doctors, a report on the donor and recipient by an independent third party who is usually a doctor who is not involved in transplantation, and documentary proof of the relationship between the donor and recipient, which are then reviewed by a panel of three members of ULTRA.
The announcement that living unrelated organ transplantations will not be done in public sector hospitals and is discouraged in private sector hospitals has raised concerns from everyone who needs a transplant now or who may need one in the future.
It would result in many more Malaysians getting their transplants done abroad, an option that only those who can afford can avail themselves of. Those who cannot afford to go abroad will have only death to face, sooner than later.
It certainly will reduce or even remove the possibility of organ trading in Malaysia. However, Malaysians who have their transplants abroad will not be immune from organ trading with all its attendant ill effects, which they will bring home with them.
In short, altruism in organ donation will be eroded considerably with economic imperatives reigning supreme.
There is, therefore, an urgent need to consider the extent to which living donor organ transplantation should be permitted in this country. Are guidelines sufficient or should there be statutory regulation?
If they are too stringent and limits potential donors and recipients to a very small section of the population, it may unnecessarily restrict the number of patients who could benefit from properly motivated living donations. If guidelines or regulations are too lax, it may encourage organ trading and may also lead to potentially dangerous practices, which may affect the quality of organ donation. As such, a balance is needed.
The Health Ministry, as the regulatory organisation and the lead health care agency, is best placed to seek the balance when addressing this controversial issue with the medical profession, those affected and society itself. Is the non-permitting of living unrelated organ transplantation an answer to the difficult medical, ethical, legal and societal issues surrounding it? It may appear so, but the issues will be addressed elsewhere without any Malaysian influence and our health system will pay a human and economic price for the decision made.