HUMAN ORGAN TRANSPLANT (AMENDMENT) BILL

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HUMAN ORGAN TRANSPLANT (AMENDMENT) BILL: Resumption of Debate on Question (23rd March 2009), "That the Bill be now read a Second time.". – [Minister for Health].

Question again proposed.

Mr Ang Mong Seng (Hong Kah): (In Mandarin) : [For vernacular speech, please refer to Appendix A.] Mr Speaker, Sir,

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with the advancement of medical technology, the number of human organ transplants is expected to increase further in the near future. Nonetheless, there remain certain risks in carrying out these operations. Last year, the Ministry of Health decided to collect public feedback and views from Singaporeans, grassroots organisations and other related institutions on this issue. I believe Minister Khaw Boon Wan and his Ministry would have a clear understanding of the public's view on this. So I would like to confine my remarks to how to best protect the interests of the donor, in particular their post-operative care and their medical insurance.

Under the current legislation, the donor and the recipient are not allowed to be involved in any monetary transaction. After the amendment, this Act will allow them to receive reasonable reimbursement for medical checkups, medical insurance and related expenses, and loss of income. Although the amendment does not stipulate the maximum amount for this reimbursement, the Minister said earlier that it would probably be at least a five-digit figure but not exceeding $1 million. The Ministry of Health also mentioned in the report that in order to protect the interests of the donors, they will consider providing long-term medical care to donors, as well as short-term medical insurance to cover post-operation risks. I believe that these measures would mean a lot to the altruistic living donors. As to the burden borne by the donors, I have some reservations. I would like to highlight these suggestions.

Firstly, for the donor and the recipient, the period immediately after the operation is very critical. Although the Ministry of Health will consider allowing some short-term insurance, so that the donors' medical expenses will be taken care of, I would like to ask about the definition of the "risk period after operation". How long is this potential risk period? For

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example, the risk period for liver and kidney operations are different. I understand that generally the risk period is about one year. Within one year, the task of getting medical coverage for the donor is challenging. Recently, a woman died after donating her kidney to her husband. Although this may be an exceptional case, it is something that we should look at carefully. Therefore, I would like to propose that the recipients give some reimbursement to the donors, and they should also bear the medical expenses of the donors after the operation.

Secondly, consider setting up an organ transplant fund and an independent committee. As far as I understand, insurance companies will not cover the insurance of these donors, as the risk for these donors will be very high. For those who are not covered under any long-term medical insurance plan, they will have to face an enormous medical expenditure if something goes wrong during the risk period. So this is a great challenge. Therefore, I propose that the Ministry of Health provide medical insurance and take over the responsibility of looking after these donors after operation. I would also like the Ministry to consider setting up a fund for this human organ donation, and appoint a group of specialists to set up this special Committee to look after this fund. This fund can be funded by public donations. For those who have benefited from organ transplants, whenever it is financially possible, they should consider voluntary donations to the fund. And the Government should consider dollar-for-dollar support for this fund. So this fund will be used if some of the donors face unexpected complications after operation. I hope they will be able to provide adequate medical treatment and a safety net for donors.

Thirdly, reimbursement by instalment. The amount of this reimbursement would vary under different circumstances, say, maybe $30,000, $50,000 or $80,000.

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Although these are considerable figures, for those who are not very good in managing their money, they may spend all the money in a very short time and end up without any money left. So I would like to propose that the Ministry of Health allow partial payment to the donor, while holding back 50% in the fund, and to give higher interest rate than the bank, so that this remaining 50% of the fund can earn some preferential interest in the account. And after the operation, the donors can choose to withdraw the money, or continue to keep some of the money in the fund to earn higher interest, and this will also serve as a protection for their long-term medical needs. Thus, this Bill will "kill two birds with one stone". So I hope the Minister will consider my suggestions.

Sir, I support this Bill.

*Cols. 3605-3608.

Dr Fatimah Lateef (Marine Parade): Sir, I rise in strong support of the Bill.

Consider the following:

(1) Patients with End Stage Renal Failure (ESRF) and heart failure dying waiting for transplants;

(2) Patients with ESRF waiting for a kidney, an average of at least eight years on heamodialysis, three times a week, lots of pain and complications, and something I see on a day-to-day basis, almost every day, every shift, that I work.

To raise the upper age limit – this is a timely and necessary move. Whether a kidney from a person can be used for transplant should depend on whether it is medically suitable and not on how old the donor is. Our population is living longer and our life expectancy follows suit. After all, every potential donor and transplant will be considered on a case-by-case basis.

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Currently, Singapore is still one of the countries with a low transplant rate and a very high haemodialysis rate compared to many other countries around the world. In the course of my work as an ethics tutor at NUS, I would like to share a quote from a first-year medical student’s essay:

"I think that it is unfair to set an upper age limit for practical reasons rather than medical ones. The age limit merely narrows down the long waiting list for organs in the most convenient way possible. Hence, perhaps, a fairer method of determining allocation of the limited pool of kidneys is using Quality of Life calculations ... but this too may not be favourable for the elderly will always have lower figures in general."

Last month, I met a patient, Mr A, 61 years of age. The former managing director of a company has been on heamodialysis for 20 years. He was on the transplant list but was recently removed as he turned 61. He mentioned how glad he was that we are debating this Bill to consider extending the upper age limit beyond 60. Therefore, I feel all efforts to increase organ availability must be supported. In fact, I would even go one step further to suggest we lower the minimum age from 21 to 18 years. Sure, the projected numbers of cadaveric organs from this age group may not be high, but even one donor from this group can provide two kidneys, one liver, one heart and two corneas, to save and give a more meaningful life to several individuals. After all, 18 years is also the recognised age for consent for our national service population.

There are challenges we face in the allotment of a scarce resource such as organs, especially in a small country like Singapore. Issues of equity (a fair opportunity for all waiting for the organ) and utility (optimal benefit from each organ) are often competing and complex ethical considerations will certainly arise.

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On the issue of paired matching, HOTA will now be amended to facilitate living donor transplant by allowing donor-recipient paired matching for appropriate exchange of organs. It is good to make this explicitly clear in this Bill. It is also a move in the right direction to enhance the chances of a patient getting an organ transplant.

In the public consultation done by the Ministry of Health last year (involving feedback from at least nine organisations as well as members of the public), 95.5% of respondents supported this idea. With its implementation, we will be following a practice similar to the United States. However, concerns about donors who are non-citizens will arise most certainly, given our very cosmopolitan and open society, thus the need to be very clear with the guidelines that we are going to draw.

This move will also call for a more systematic, proactive and well-organised living donor registry. It has to be very comprehensive, with rapid and efficient updates, as often we will be dealing with diseases, life and death issues which can be time dependent. There will have to be a dedicated secretariat covering all shifts throughout the day and night, which need to be well networked into all the relevant healthcare institutions and participating hospitals.

On the inclusion of the Malay-Muslim community into the HOTA, the international Fiqh Council, prominent Islamic scholars and the MUIS Fatwa Council have all ruled that organ donation, both cadaveric and living, is permissible. The act of organ donation exemplifies the value of kindness (IHSAN) and compassion (RAHMAH), and it is about the protection and saving of human lives. It is the onus of the community to reach out and help those who are in need.

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Islamic scholar, Dr Yusof Qaradhawi had stated:

"Removing a body part does not violate the sanctity of the dead. The sanctity of the body is preserved and has not been violated. This is because the operation performed is similar to that done on those who are alive … that is with care, meticulousness and respect."

On payment to donors, I am indeed glad MOH is going to accord this some recognition. It is about time. Because similar practices have been done in countries such as the United States and the UK, where there exists some form of reimbursement plan for donors. It is important to recognise donors and their contributions. But this is a step which needs to be monitored and surveilled closely to ensure no coercion, threats, undue force or pressure is utilised.

Ethical issues will certainly arise as we open a Pandora’s box. Thus, MOH will need to work very closely with hospitals and their ethics and transplant committees to come up with certain regulations and guidelines to be complied with. But I believe there must always be some flexibility and a case-by-case consideration, as long as reimbursements do not become inducements. Every individual in the chain of command must play their role and remain upright and ethical.

As a small nation, we have to be realistic as we face the issue of organ donation. But we cannot spare any effort to help our fellow brothers and sisters suffering in silence.

Sir, it is truly an altruistic person who can give up his or her organ, be it cadaveric or live donation.

Let me continue in Malay.

( In Malay ): [For vernacular speech, please refer to Appendix A.] The

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Malay/Muslim community makes up 22% of new cases of kidney patients each year. The inclusion of Malay/Muslims into the HOTA Act means that we can obtain five more organ donors each year. This means that there will be 10 kidneys, 10 corneas, five livers and five hearts that can save the lives and well-being of patients as well as sufferers.

The Malay/Muslim community is proud to be given this same priority as other communities in Singapore.

In the dialogue sessions which I chaired, active and positive feedback was given, and practical suggestions were presented. I would like to thank those who have stepped forward and given constructive views.

I would like to also express my appreciation to the Office of the Mufti of Singapore, and its proactive religious teachers, like Ustaz Nazirudin. Their presence in these sessions is important so that religious misconceptions and all doubts can be corrected.

I would also like to suggest that the Ministry of Health continue monitoring and cooperating with the hospitals, in order to study the process and procedures of organ donation. One aspect is skills upgrading and more counsellors should be trained to fully understand organ donation and its related issues, so that they can communicate well with the patients and their relatives.

Finally, I hope the Malay/Muslims will give their full and strong support towards this HOTA Bill.

( In English) : Sir, I support the Bill.

*Cols. 3609-3610.

Ms Sylvia Lim: Sir, we are all aware of the waiting list for kidneys, averaging nine years, and the suffering of kidney patients

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undergoing dialysis while waiting for a transplant, sometimes in vain. Thus, the proposals under the Bill to increase organ supply by removing the age cap for cadaveric donors, and to facilitate living paired donations, are welcome.

The cause of the long wait is a shortage of kidneys for transplantation. Why is there such a shortage?

One reason is that the demand for kidneys is high due to the high incidence of kidney failure in Singapore.

Secondly, it seems that Singaporeans are still apprehensive about organ transplants by living donors. Last July, a local kidney specialist, Prof. A Vathsala, noted that Singaporeans were reluctant to donate organs to their relatives unlike in Norway where the entire family would turn up for evaluation. It is well-known that in Norway and Spain, supply has almost matched demand. MOH has agreed that more can be done in Singapore by way of public education to encourage organ donation.

Another question to ask is whether the existing HOTA has been under-performing in cadaveric transplants. Even though the current HOTA auto-includes locals as cadaveric donors, has this scheme been efficient in producing results, or has it been under-used? During the Ministry’s consultation on the Bill, suggestions were received on how to improve the current processes for cadaveric donation, eg, by salvaging more organs from trauma deaths, earlier identification of potential organ recipients, and improving organ preservation. In response, the Ministry agreed that it would continue to strengthen the process.

With the promise of more public education to encourage living donors, enhancing the efficiency and pool of cadaveric donors, and the inclusion of Muslim cadaveric donors recently, this

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multi-pronged effort will increase supply to some extent. Should we not wait for these moves to take effect before enacting the proposals to increase payments to living donors?

Sir, regarding living donor payments, everyone can agree with the general principle that the donor should be reimbursed for losses connected with the donation. In this sense, the current HOTA needs to be expanded for more reimbursement to the donor. The problem is that the proposed formula under clause 3(f) could be used for profit and even become a backdoor for organ trading.

Clause 3(f) of the Bill relaxes the threshold of what can be paid to the living donor. Under the existing HOTA, section 14(3)(a) provides that a blood or organ donor may only be reimbursed for expenses which are necessarily incurred by a person in relation to the removal of any organ or blood. However, under the proposed section 14(3)(c), organ donors may now be paid sums for "defraying or reimbursing costs or expenses which may be reasonably incurred" in relation to a wide range of items, including travel, accommodation, cost of domestic or child care, loss of income and long-term medical care.

Therefore, we are now talking not just about reimbursement of expenses actually incurred but a projection of all losses, including future losses. The new formula leaves room for profit. First, it builds in a factor of speculation as to future losses, such as long-term medical care and future income losses. The wording contemplates losses even 10 years down the road. Any such calculation will be based on assumptions and uncertainties. What will the donor’s health be like after the donation? Will his earning capacity be affected? We may budget for poor health but he may recover very well. What if he comes from a region of high unemployment? If a foreign donor says

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he intends to seek the best medical specialist in Singapore for his long-term care, how do we ensure that he will do so?

The sum to be paid will need to be determined upfront before the donor will agree. The contract is therefore likely to provide for all possible costs, even as a lump sum payment. The Minister himself has said that the amount could reach six-figure sums.

One consequence of this is that only wealthier patients are likely to be able to afford to contract for an organ. On the flip side of the coin, would not the donors more likely be those who are poor, prepared to risk bad health for some money?

Secondly, Members have already highlighted some issues concerning foreign donors. At the Singapore Medical Association Conference in November on this issue, concern was raised about Singapore becoming a hub for transplantation tourism, with other countries following our bad example.

Sir, currently, living donor transplants are regulated by hospital ethics committees who usually restrict such transplants to cases where there is a family or at least a strong emotional relationship between donor and donee. This is to reduce the likelihood of a money motive behind a proposed donation. Is the Ministry retaining this requirement of family relationship, or will it become a free-for-all where unrelated living donors can donate? If the requirement of relationship is retained, the risk of money motive is smaller but still present if false declarations of relationship are made or the relationship is remote. If unrelated donors are permitted, then the risk of organ trading in disguise is clear.

Members will recall the case of Mr Tang Wee Sung who was convicted under

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the Act recently. In that case, the hospital Ethics Committee had, in fact, approved the transplant relying on false declarations of family relationship and that no money had changed hands. The figure in that case was reportedly a five-figure sum of about $23,000, a sum which may not be large by local measures but apparently enough to induce.

We are aware of the suffering of kidney patients and can understand their overwhelming desire to improve their lives by obtaining a kidney by whatever means possible. However, as specialists have noted, there is still scope to expand our existing programme rather than prematurely wade into controversial waters. In 2004, the World Health Organization passed a resolution which encouraged live organ transplants but also warned of the risk of the poor and vulnerable to transplant tourism. Last September, the then Acting Head of the Centre for Bioethics at Monash University, Mr Robert Sparrow, made this observation, "It is hard to see how incentives could be large enough to make a meaningful difference to rates of donation without also establishing the risk of exploitation."

Most Singaporeans can probably accept a change to the Act to provide a more generous reimbursement of donors for losses which can be proved, based on the principle of "equity", as mentioned by the Minister yesterday. However, if a secondary purpose is to increase organ supply, then whether the sum is now geared towards inducement will arise.

The current formula in clause 3(f) is very wide and may prove to be a backdoor to organ trading. This is especially because we are surrounded by countries where money could be a real inducement. As such, we do not believe it is wise for Parliament to approve the current provision and leave the com-

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pensation framework details to be worked out later administratively.

We are of the view that the Minister should send the Bill to a Select Committee to have clause 3(f) scrutinised independently by Members of Parliament after receiving the opinions of the general public and experts, with a view to reduce the risk of profit and exploitation. One consideration could be administering the sums under a trust, especially sums relating to future costs and losses, to be disbursed at future dates.

If the Minister does not agree to send the Bill to a Select Committee, we would abstain from supporting the Bill due to concern about the wording of the clause.

2.52 pm

Mr Sam Tan Chin Siong (Tanjong Pagar): Mr Speaker, Sir, thank you for allowing me to speak.

I would like to support this Bill, mainly because I support the principle that one should enhance a better quality of life whenever possible. This is a pragmatic and utilitarian principle that underpins many of Singapore's policies.

But matters of health are unlike matters of bricks and mortar. When it come to health, we tend to think that it is a matter of life and death. Hence, people will do anything, go to any length to enhance their health and prolong their life. This explains why more than 2,000 years ago, the first Emperor of China, Qin Shi Huang, sent a contingent of 500 to a fairy land to seek the elixir of life. And this also explains why years ago, Michael Jackson was reported to have slept in an oxygen chamber just to remain youthful.

While this Human Organ Transplant (Amendment) Bill starts out with a good intention to save lives, it is not without controversy in some of the amendments.

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I have spoken to many people on how they feel about the HOTA (Amendment) Bill, especially the part on the reimbursement of money to organ donors. Many have no objection to this. But a minority has expressed reservations. Their chief concerns centered on the following principles, which they argue the present amendments to HOTA appear to contravene.

The first principle is that we do not believe that whether you are rich or poor determines whether you deserve to live or die. In our guts and in our minds, there is something abhorrent in the belief that the rich are somehow more entitled to something so fundamental as life. A rich man does not deserve to live any more longer than a poor one. I agree with this principle but, in matters of health policy, we need to see where this leads us and, more importantly, where it does not.

It leads us to give an equal shot to a good life to everyone, rich or poor. For example, this principle would forbid us to save the lives of the rich and ignore the poor, in a national emergency such as SARS. We do not, for example, quarantine the rich and not the poor. Everyone stands an equal chance from the helping hand of the state. In this sense, the rich and the poor are equal.

But to insist that in all matters of health, there is complete equality between the rich and the poor is specious. There are cancer drugs that cost $200 a pill and as long as you take them, your cancer is kept at bay. Once you cannot afford this drug, the cancer progresses and you are done for. So, in this sense, there is a difference between the rich and the poor in health care.

Those of us who support the amendments to this Bill know that each year, about 1,000 people here lose the use of their kidneys. But only between

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40 and 60 people get a kidney transplant locally. As it is now, 560 kidney patients are still waiting for their transplants. So, some of them, those who can afford it, would go overseas to try to buy a kidney for transplant. Those who cannot afford to go overseas, they have to do the transplants locally and often have to wait for about nine years before they get one.

Countries such as the Philippines and some states in the United States already allow living donors to be reimbursed for their time, cost and possible future health problems related to the kidney donation.

In Singapore, some potential donors say it is because of ethics, religion, or cultural norms or fear of transplant operations that make them reluctant. But if I may be so candid, I think if we had a compensation of, say, $50,000 or $100,000, we may see some of these "norms" changing amongst some people. And, indeed, that is the point of this amendment, ie, to change people’s behaviour so that more will donate their kidneys to save lives.

In short, I think that HOTA does not violate the above principle, even as it stands now, being silent on how much payment should be, how it is to be made, and so on. But I think we can protect this principle further, by discussing who pays. For example, do we allow the payment to come directly from the person who receives the organ? Do we have provisions that this is a blind process - in that the donor does not know whether the recipient is rich or poor? Or do we organise some kind of national insurance policy, from which funds for compensation will come? The last appears to be the most socialist and least controversial method.

In the end, I remain agnostic about the method and the final dollar amount. However, I do want to say that I know that money can and will change

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behaviour, and that we can work this to our good or to our harm.

This brings me to the second principle. Money does influence behaviour and measures must be put in place to prevent organ trading.

The HOTA (Amendment) Bill has certain provisions to guard against organ trading. The amendments include more severe penalties for organ trading. The penalty goes up tenfold – from the current maximum of one year in jail and a fine of $10,000 to 10 years and $100,000 in fine. So I hope this will be sufficient deterrent to dissuade people from going into organ trading.

An 18-member national committee on medical ethics had supported reimbursing donors so long as the sum is not so large as to become "an undue inducement, nor amounting to organ trading". Compensation should be for expenses incurred and indirect losses such as lost earnings.

But this merely pushes the question further on – what sum would be tantamount to induce and what sum would be merely compensation? I would frankly admit that I have no answer to all these questions, as the sum would vary from person to person. But I do know that this is a case where the question can be answered by the process rather than the content of the reply. So we need more conversation and deliberation on this subject till we have a general consensus.

Whatever the answer is, I am convinced that the present amendments do not contravene the two principles which I have highlighted above.

Sir, it is a temptation to think that because a principle is easy to assert, but difficult to put into practice, that we should not say it at all. In my view,

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because it is difficult to put into practice, it becomes all the more important to make a stand for it. While the proposed amendments to the HOTA Bill may generate controversial reactions, we should not take a "safe" position and not to tackle it head on. Because by not doing anything, nothing is done for Singaporeans dying while waiting for their organ transplants. So, the proposed HOTA (Amendment) Bill is a courageous and right move to save more lives.

Sir, on this note, I support the Bill. I would now like to speak in Mandarin.

(In Mandarin) : [For vernacular speech, please refer to Appendix A.] Sir, the purpose of the third amendment of the Human Organ Transplant Act is to save more people who need organ transplants. This is something that is worthy of our support. But there is a certain provision which has attracted the attention of many people and a lot of discussion. This is the question of whether the donors should receive payments for reimbursements of their medical expenses, medical insurance and loss of income.

On the issue of whether this payment is correct and whether it contravenes any moral standard, it is a question without an easy answer as different people have different views. So, before I discuss this matter further, let me tell a story on Zen Buddhism. I hope we can get some lessons from this story.

In a mountain, there was a certain monastery. One day, the senior monk went out and before he left, he told the young monks to look after all the things in the temple of the monastery, especially a few Buddha statues in the main hall. After the senior monk left, it started to snow heavily and because the weather was very cold, the young monks decided to chop some firewood to keep warm. But, unfortunately, the snow continued and did not stop. So these young monks

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could not go outside to collect firewood. What they did was to collect all the firewood inside the monastery. After that, the snow continued and it was still very cold. Unless they were able to find additional firewood, they were going to freeze to death. At that point, the young monks decided to burn the Buddha statues within the monastery. After a week, the snow stopped and the senior monk came back. When the young monks saw the senior monk, they were scared to death because all the Buddha statues had been burnt. In the monastery, the Buddha statues were the most precious things and they were afraid that the senior monk would be very angry. Surprisingly, after listening to the young monks' explanation, the senior monk did not get angry. What he said was, "Saving a life is better than building seven pagodas."

So the purpose of Zen Buddhism is to help ourselves and others to help the whole world. If burning the Buddha statues can prevent a few of the monks from freezing to death, then the Buddhist monks have played their role. If the statues are there for people to worship, they are only useful pieces of wood and not worthy of worship.

If we project this story to the Human Organ Transplant Act, I think there is a certain meaning to it. In our society, what we need are values and systems. From a macro viewpoint, these systems and values are the main points we should consider – whether they can improve our lives and peoples' lives.

I believe many Singaporeans believe that saving one life is better than building seven pagodas. Although the Bill has attracted some controversy, I hope people would look at it from a macro point of view, to support its implementation and put it into effect. There are currently 560 kidney patients waiting for transplants. Under the present circumstances, there

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are only 40 to 60 patients who receive organ transplants. Unless we do not, at this point, burn the Buddha statues to keep warm and do not send a gift of charcoal in the snow, then, out of these 500-over patients, I am afraid many of them will not be able to survive the severe winter.

Mr Speaker, Sir, I support the Bill.

*Cols. 3611-3612.

Dr Lim Wee Kiak (Sembawang): Mr Speaker, Sir, I declare my interest as a medical doctor. I look after some patients who had renal transplant or renal failure. I am currently seeing them for their eye problems. My heart and compassion are with these patients and I understand their suffering.

I wish to begin by applauding the Health Minister for his boldness and far-sightedness in introducing the amendments to this Bill. From a medical and ethical viewpoint, these initiatives, when incorporated into the Human Organ Transplant Act, will make it more comprehensive. This is an opportune time, given the increasing number of people with organ failure, arising from advancement in age and/or due to poor lifestyle habits. But, like my preceding parliamentary colleagues, I do have some concerns as far as reimbursement is concerned.

Let me start off by talking about the removal of age limit for cadaveric organ donors. Our retirement age has moved from 55 to 62, and will be moved higher later. The age limit of taxi drivers has moved from 70 to 73. So why should cadaveric organ donor's age limit stay at 60 years? With medical advancement and improved quality of life in Singapore, more people are able to live a longer life. This means death comes later and with it, the general perception that when they die, their organs and tissues are all useless, supposedly ravaged by the passage of time.

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This is a misconception. Indeed, there are a few age-related medical conditions that would take a toll on the organs. However, while some organs may not be in best shapes, others may be sufficiently functional to prolong the life of another person for many years. I, therefore, strongly support the removal of the age limit for cadaveric organ harvesting.

For example, a medical study that was published in the Journal of Cardiac Surgery revealed that patients who received hearts from donors 50 years and older, fared just as well as those who got their hearts from younger donors. The long-term survival rates were nearly identical among all patients.

In US, organ transplants involving deceased people in their 70s and 80s have generally been very successful. As long as a deceased's organ is still healthy, we should not write off the possibility of using the organ. No doubt stringent medical tests must be carried out to evaluate the health of the deceased's organ before deciding whether it is suitable for transplant. It is this point that I hope the Minister can enlighten the House whether more stringent criteria and procedures would be used, especially involving cadaveric donors who are more than 60 years old.

Last of all, for this particular Bill, by removing the 60 years old limit, I wonder whether we will be adding more recipients waiting in the line for organs at the end of the day, because there will be more people who are elderly who have organ failure. It is good that we give them hope but I think there will be a much longer waiting list than what was quoted by my colleagues earlier on.

Second, on comprehensive reimbursement, I think this is something many of my colleagues call, "Opening of Pandora's

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Box". It is a concern amongst many that I have spoken to. It is a process that is highly complicated as it involves many ethical issues, other than medical tissue matching of organs in question. The proposed third party reimbursement of living altruistic donor will be welcomed by future donors and also recipients. But it may also open the door and the system to abuse. I am worried about the ramifications of opening this "Pandora's Box". Is this a step towards the slippery slope of organ trading?

Although I know the Minister is strongly against organ trading, a key point in the whole discussion is the compensation or reimbursement for the altruistic donor. The two words do not really coincide with one another in terms of reimbursement and altruism. Too little money or a token payment may make a mockery of the donor's altruistic effort. Too much reimbursement may induce organ selling. The question is how much is sufficient and how much is excessive? Who will do this reimbursement? Where should the money for this reimbursement come from, seeing that it is clearly stated in the Bill that there will be no extra financial expenditure on the part of the Government? Who will decide what is a reasonable amount of reimbursement? Is it the Ethics Committee? Last of all, is there a cap to this reimbursement or is this as much as they like to claim?

There are four possible scenarios on organ donations. We may have a Singaporean donor to a Singaporean recipient, a foreign donor to a Singaporean recipient, a foreign recipient to a Singaporean donor, and last of all, a foreign recipient to a foreign donor. My feeling is that this amendment should start off slowly, which means that the amendment should apply to the first category of Singaporean donor to Singaporean recipient first and learn from the experience. It is highly contentious for the rest of the scenarios once foreigners are involved. We do not

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want to be perceived by the world as legalising organ trading using the backdoor method and becoming an organ trading hub to allow the exploitation of the poor, especially those from our neighbouring countries. So I hope the Minister can consider taking a step-by-step approach, rather than rushing in to include all categories. I know that the Minister's view is that discrimination of nationality should not be involved, but I think it is better to be careful and do it step-by-step.

No matter how healthy a donor is, it is too idealistic to assume that his health will not be compromised after the operation. He will require medical expenses to cover costs of post-operation medical care. If he is unable to work temporarily, he will require other sources of income to support himself and his family. The financial implications and uncertainties constitute major turn-offs for potential altruistic donors. I know that it is an excellent idea to call for reasonable provision of expenses for short-term medical care and long-term medical insurance protection for altruistic donor. I feel that the Government should play its part. As a community, we should care for these selfless donors by providing them with medical benefits, just as we have done for some of our retired civil servants. This is a practical display of how our society acknowledges selfless contributions by another fellow human being. Although I do not know exactly how much such an initiative would cost the Government, I am sure the individual expenses for each Singaporean donor cannot be more than the amount that has been used to sustain a renal failure patient on dialysis for life.

With regard to paired living donor organ transplant arrangements, it makes perfect sense as not all donors would have a tissue match with their intended recipients. Donors and recipients should be paired in accordance to the compatibility of their organs so as to

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reduce organ wastage and the painful aftermath of organ rejection.

Organ incompatibility is often the greatest obstacle in organ transplants. It accounts for delays in obtaining the much-needed organ, sometimes consequentially leading to death when the organ fails before the patient receives an organ. With this system in place, more patients will receive their organs quickly. However, my concern is that some donors may not fully comprehend this system and may baulk at the thought of donating their precious organ to a complete stranger over their loved one. To encourage donors to be open to such a system, counselling sessions and public education could be initiated to address these concerns. These donors must be assured that their original intended recipients would eventually also receive an organ through donor swapping. I would like to ask the Minister whether such paired organ transplant arrangement will be performed simultaneously? If not, what would happen if the second party backs out of the arrangement after the first organ transplant was performed? What safeguards are in place to protect all parties involved in the paired organ transplantation? Is there a legal redress to this issue?

There is a need for safeguards. The provision of comprehensive monetary reimbursement for living donors is a bold step forward and makes Singapore the second country in the world after Iran to legitimately pay a living donor for organ donation. This would greatly reduce the occurrences of underground organ trafficking. On the other hand, I am worried that we may just push it above ground. Are we taking the slippery slope to a dangerous precedence? A human life is priceless, but paying somebody to donate their organs is something we must manage in such a way that we do not impart the wrong values to our young ones. What safeguards can we put in

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place to ensure that this transaction is not only legal, but also ethical?

On enhanced penalties, I am pleased to see that penalties for offences relating to human organ transplants have been increased to 10 years' imprisonment and/or fines of up to $100,000. This is a good way to deter irresponsible commercial dealers who would indulge in trading, like trading cattle in the marketplace. The implementation of all these harsh measures is not simply about interfering with organ trade commercialisation, it delves deeper in the sense that it reduces organ wastage and the dangers of health complications and eventual deaths brought about through illicit transplants of mismatched organs and operations performed by unqualified surgeons.

The local saga last July is an eye-opener to Singaporeans. This malpractice had taken place within our shores. Although it was a regrettable incident that sparked plenty of controversy, it has sounded the alarm to remind us to be more vigilant and less compromising. Thus, I think that by reducing the grey areas, this Bill is the right way to go.

Sir, in Mandarin.

(In Mandarin) : [For vernacular speech, please refer to Appendix A.] "Saving a life is better than building a seven-storey pagoda". Life is precious and cannot be valued by monetary terms. The amendments proposed in this Bill included a clause on reimbursement of organ donors, and I am worried about this legislation. Firstly, there is the issue of how much should the reimbursement be. Will we be seen as putting a dollar value to a human organ or a human life? If this move can encourage more people to come forward to donate their organs, then it may be a good thing. But I am afraid that we will

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make a blunder and attract people to donate their organs for a wrong reason. I hope that the Minister can clarify this.

*Cols. 3613-3614.

Prof. Thio Li-ann (Nominated Member): Sir, the fact that the Whip has been lifted on this debate demonstrates the Minister’s appreciation that it implicates matters of conscience and ethics, that it raises troubling moral issues which Members struggle with.

The problem is clear enough: the current regime under HOTA, based on presumed consent and altruistic donation, has failed to meet the demand for transplantable organs.

The parameters of possible options are defined by various extremes we do not wish to resort to. First, organ conscription (where the state treats human organs as a public good and takes it by force). Neither has organ socialism been adopted, where anyone who needs an organ is allowed access to an organ pool, regardless of whether or not he has contributed to its upkeep. Under the Singapore system of presumed consent, priority is given to those who do not opt out of the scheme. In form, our model still rests primarily on that of the altruistic donor.

One way to increase the supply of organs is to allow people to sell their kidneys and lobes of liver. However, we have not embraced the market solution as the optimal solution to resolving a shortage of organs or indeed, any other desirable thing. Nor should we. GK Chesterton quipped: "Art like morality, consists of drawing the line somewhere."

So we have drawn the line against organ commerce. We have not gone the way of unhinged organ capitalism, where body parts are treated as commodities for sale to the highest bidder. Just as some desires are not desirable, there are some choices we should not choose. Singapore

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still prohibits organ trading. The Minister has emphasised that these amendments do not carry the intent of legalising organ trading.

The motive or intent of this current amendment is clear enough: there is a need to do something about the persistent and persisting gap between the demand for and supply of organs which can save lives, or really, prolong a finite human life and ease suffering. That is a worthy goal.

The entire thrust of this amendment represents the latest efforts to increase organ procurement, to reduce the organ deficit.

The method is threefold, one more controversial than the others.

First, the age limit of 60 for cadaveric donations has been removed by deleting section 5(2)(d). This is not problematic.

Second, the new section 14(7) will allow for paired living donor organ transplants by stipulating that this is not tantamount to a contract for the selling or buying of organs, which the law continues to prohibit under section 14 of HOTA. Paired living donor organs will not constitute "valuable consideration" where donor consent is present. This is a form of voluntary reciprocal altruism. The intent is that by allowing recipients to swap their incompatible donors with another donor/recipient pair to make a good donor-recipient match, more people will get a new kidney. This is quite an innovative solution and has worked to increase organ supply in other jurisdictions.

To this second method, I will only ask whether the Minister could clarify what measures will be taken to ensure that no one backs out of this sort of arrangement? I understand in other jurisdictions that such operations are done simultaneously, requiring four operating

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rooms, to ensure the recipients that both will receive their donated kidneys. Does the Minister see the need for the state to supervise this process or does it prefer to leave it to the relevant parties to sort out amongst themselves?

The third method is cause for some controversy. It relates to the novel proposal to allow living organ donors to receive compensation or, to use the preferred term, reimbursement for expenses incurred other than those directly related to the surgical process itself. In a nutshell, while the intent of the amendment is not to legalise organ trading, the fear is that this will be the de facto effect.

There has been some thought given to appropriate nomenclature. The very fact that the term "reimbursement" is being used rather than "compensation", which sparks connections with commerce or contract, reveals an underlying uneasiness. I believe this is because of a felt disconnect between a laudable end but questionable means.

The fear or concern is that we are ushering in a market for organs because of the thin line between defraying the out of pocket expenses of donors and the organ-for-profit model, the market model. The idea of a market for organs, of kidneys for cash is distasteful and strikes many as morally repugnant. Are we engaging in semantics to disguise or distance ourselves from our discomfit with the underlying issues? What’s in a word? We need to heed the advice found in an old Talmudic proverb to "examine the contents, not the bottle."

Whatever the intent of the HOTA amendments are, we need to ask what is their effect. Are we effectively exchanging a model for organ donation based on selfless altruism to one based on the commercialisation of organs, the sale of body parts governed by the profit

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motive? As a worst case scenario, are we exchanging altruism for organ capitalism?

It bears reiteration that this is not the intent of this amendment. Indeed, one might view section 14(2A) as a guard against commodification, where the human body is treated as a form of property which can be traded and where human beings are viewed as vendors of saleable spare body parts, which is an affront to human dignity.

Section 14(2A) seeks to close the front door to commercial dealings in organs by intermediaries. Penalties for third party transactions have been significantly enhanced, with fines raised from $10,000 to $100,000 or imprisonment from one to 10 years. This is laudable.

In relation to the issue of reimbursement, this amendment appears to view "pure" altruism as a romanticised myth. Section 14(3)(c) represents a "sea change" or distinct and major policy shift in relation to living organ donation.

Under the existing HOTA scheme, a contract or arrangement to reimburse expenses necessarily incurred by a person in relation to the removal of an organ is not prohibited.

The new section 14(3)(c) will significantly broaden what expenses the donor can be reimbursed for. The standard shifts from necessary to reasonable expenses. It permits the comprehensive reimbursement in money or money’s worth of various costs which are "reasonably incurred" by a living organ donor in relation to the entire process of donating an organ, such as the removal or storage of the kidney or part of a liver. A contract for such costs does not fall

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within the existing category of prohibited contracts for the sale of organs.

This exemption of arrangements relating to reimbursing the costs incurred by an altruistic living donor is meant to be comprehensive. It extends not only to direct costs, but also to any loss of earnings, accommodation, travel and childcare expenses "reasonably attributable" to the living organ donor.

In addition, because organ donation is not risk-free, compensation also extends to short or long term medical care and insurance protection which is "reasonably necessary" flowing from the donor operation.

The basic thinking is that reimbursing living donors may increase organ supply. We know what we have to gain from this policy change; but we must also ask, what do we have to lose? Clearly there is more at stake here than increasing organ supply. We have to look at the issue holistically from all angles, consider all interests – the welfare of the patient, the welfare of the donor, the role and duties of doctors and Ethics Committee, and the gains and moral costs to society. Only then can we know what is at stake.

While I do not have an issue with providing compensation for justifiable expenses, such as the loss of earnings for a live donor, which could act as a disincentive, what is unsettling is the fear that section 14(3)(c) opens the back door to what is in substance, though not in form, a de facto contract for the sale of an organ. If commerce rather than altruism becomes the norm, if organs are given in return for something of material value, something is lost because organ donation is no longer about altruism but is about less virtuous motives. Living donors are heroic precisely because of their personal sacrifice for the benefit of the health of the community.

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The scheme for comprehensive reimbursement presumably applies only to directed donation as opposed to non-directed donation where the donor gives to a general pool and the donated organ goes to the neediest stranger. In such cases, the Government might underwrite compensation in recognition of donation as a form of public sacrifice, whether in cash or in kind, such as free health insurance for life, educational support or tax credits. Has this avenue for increasing organ supply been considered for the Singapore context?

Directed donation could be to a loved one or intimate friend, where one can appreciate the pre-existing emotional bond and the willingness of a prospective donor to risk surgery and assume a personal risk for the benefit of the recipient, who is someone whom they care about. The donation is an expression of love.

While one cannot love without giving, one can give without loving. Directed donation could also involve, in an act of radical altruism, a Good Samaritan donor giving an organ to a specific person to whom the donor has no prior emotional connection. This is a potentially life-threatening sacrifice.

While this amendment does not embrace the market solution and indeed seeks to heavily penalise third party organ trading, the concern is that the quantum of compensation may be significant enough to induce potential living unrelated donors to sell their kidneys or lobes of liver.

Aside from commodifying organs, and the thorny question of computing reimbursement, the problematical issue of exploitation also arises because it is the poor who will find the prospect of compensation or reimbursement attractive, particularly if this runs into five or even six figures. What may appear as innocent incentives to some will look like irresistible offers to others. This

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temptation may arise where the compensation package may be viewed as a quick fix to financial problems, given the duress that flows from desperate poverty.

This is the sadness of the problem. It is a problem of Desperate Need and Desperate Supply. Mdm Halimah has eloquently demonstrated the transnational dimensions of this sorry deficit: what if foreign donors working in Singapore, suffering economic woes, are the ones who are tempted to donate organs for cash? What if Singapore becomes a hub for organ transplants flowing from wealthy recipients and indigent donors?

Thus, reimbursement for reasonable expenses might disguise an "organ for profit" model. How do we draw the line between comprehensive reimbursement and organ sales contracts for "valuable consideration"?

What will be the role of the Government in this? Will it adopt a detached, "hands off" approach, privatising donor-recipient transactions and adopting essentially a "contract"-based model? Or will supervisory oversight, which I think is absolutely necessary, be retained? I do not think a laissez-faire model is appropriate here; some element of protectionism is needed for various reasons.

The Act appears to oppose organ trading while supporting the view that compensation and reimbursement to donors not amounting to inducement is ethically permissible.

The amendment may be designed to remove financial disincentives, and it is a fair enough point, to ameliorate the financial hardship incurred by donation, including reimbursement for lost wages for instance. However, how does one ensure a distinction is preserved between removing financial disincentives and providing financial incentives or profit?

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The introduction of money, in the form of reasonable costs incurred, into the equation changes everything. Commercial transactions may be cloaked as altruistic donations. This cannot be desirable.

Various problems relate to the comprehensive reimbursement regime arise. First, what is the standard of reasonableness to be applied to altruistic living donors? The differences in the loss of earnings for the CEO of a Fortune 500 company and of a rural subsistence farmer are huge, although it is really only the poor who would be monetarily induced to donate organs. So too reasonable costs of medical care will turn on variable factors like the age and health status of the donor.

How will reasonable costs be calculated?

What standard will be applied to assess reasonably incurred expenses, costs, insurance and the underwriting of medical care?

Will this be left to the two parties involved, treating this as a private affair? Or will the Ministry of Health set and enforce a ceiling for compensation? Or provide a tariff or guidelines for each compensable item whether in the form of a minimum sum, a ceiling, a percentage, a flat rate? Or will it leave everything for calculation on a case by case basis where relevant factors might include age, financial status, the type of organ, the length of the recovery period, etc?

There have been some newspaper reports suggesting that $50,000 constitutes reasonable reimbursement: will an upper limit for reimbursement be stipulated? What is the guarantee that initially modest payments will not increase over time until the point it does in fact become valuable consideration?

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Are items like the potential expenses of long-term medical care even known? What if a kidney donor should develop renal failure down the road, will provision be made for that risk?

Who will regulate and ensure adherence to reasonable terms? How do we ensure fair terms where one party has unequal bargaining power, this usually being the richer party who can afford to foot these considerable costs? How do we protect poor donors from exploitation?

While HOTA makes provision to deal with commercial dealings in organs by unscrupulous intermediaries who exploit the poor and disenfranchised, both within and frequently beyond national borders, what about national de facto commercial dealings guised as "reasonable reimbursement" arrangements? What safeguards are there to ensure against this eventuality, to especially protect non-resident donors from lower income countries?

A related issue is should we preclude foreign donors from receiving reimbursement. The Minister has said we should not discriminate between organ donors based on nationality. However, while Article 12 of the Constitution does provide for equality under the law, Parliament is able to draw distinctions, even on the basis of nationality, if it is reasonable to draw such a classification. If there are good reasons for distinguishing between national and non-national living organ donors, the law permits this. A good reason to draw this distinction is to prevent commercial exploitation and so not to facilitate de facto contracts for organs. I would echo the sentiments of my fellow parliamentary colleagues that we should perhaps take an incremental gradual approach towards rather than allowing HOTA to apply to both foreigners as well as Singapore citizens.

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With advancing medical technology able to prolong human life, demand for organs will continue to increase – but how far do we carry this? What are the competing considerations and what is the Government’s role and responsibility in all this?

Sir, a real concern is that this law will essentially provide an option for the Rich and be a lure for the Poor, who may take the risk of donating an organ to escape straitened financial conditions. Only the rich can afford this high-end medical treatment through their financial resources or insurance status. The vulnerable poor are frequently the sector of the population desperate enough to provide an organ. We do not want to arrive at a situation where this becomes the case.

This would be nothing short of discrimination against the poor.

What steps will be taken, if at all, to ensure fairness amongst those in need, especially poor Singaporeans? Will some form of public assistance be extended to them? Or is this just a scheme they have no access to? A preferential regime for the rich?

So long as the transaction takes place directly between a donor and recipient, the rich will be more likely to receive transplants than the poor, though one might argue that if a wealthy person procures his own private kidney, without resorting to the black market, the entire public pool of kidney increases which may benefit poorer patient with renal failure.

If saving lives is a paramount value, this surely cannot be limited to saving the lives of those with financial means. Will the Government step in to level the playing field, for example, through grants or subsidies? Or perhaps disinterested private charities can be encouraged to sponsor and underwrite reimbursement costs wholly or partially? This would

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minimise the role of that personal wealth place in the likelihood of a recipient receiving an organ.

From the perspective of the donor, what steps will be taken by the Government as regulator to ensure that the prospect of reasonable reimbursement of costs does not serve as a financial inducement or otherwise exploit the poor, whether from home or abroad? Will there be a regulatory body to oversee the interests of donors and to ensure that those donor-recipient arrangements are above board? To ensure that financial stressors, rather than genuine altruism, are not the sole, if primary, reason for the arrangement being undertaking place?

If non-resident donors are eligible under the comprehensive reimbursement scheme, is there not a danger of exploiting people from poorer countries? An article in Kidney International (2008) reported that often the very poor are the ones who exchange their kidney for a payment of some US$1,000 to US$5,000 while brokers charge recipients anything from $100,000 to $200,000.

It is estimated that in 'kidney colonies' like Tamil Nadu, where poverty is extreme, kidneys are considered a financial reserve and some 5,000 people are estimated to have donated kidneys for cash. In addition this has not led to their long-term economic benefit and in fact, they have suffered a deterioration in health status.

Second, there is often an information asymmetry or deficit on the part of the donor. What safeguards are in place to ensure that a donor appreciates the range of risks associated with living organ donations, to the extent this is known, to ensure he freely consents to it?

There appears to be some debate within the medical community about the under-estimation of health risks to healthy

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donors and their emotional well-being in the long run, as well as an overstatement of recipients' quality of life, in understating the long-term toll of powerful anti-rejection drugs.

The immediate operative risks to donors can be stated with some certainty but what about the long term effects? For kidney donors, for example, there is a risk of renal failure as kidney function normally declines with age? Are the increased risks of hypertension, long-term psychological effects on the donor, transfusion transmitted hepatitis or AIDS adequately explained to the living donor? Has the Ministry commissioned research or consulted existing research findings on these issues?

Third, is there or will there be standardised criteria for donor suitability, in both medical and psychosocial terms, which the Government will ensure is implemented? What role with the Government play, if any, in relation to guarding the well-being of potential donors as well as the follow-up of their welfare? Can the Minister shed light on the process by which a donor is considered medically suited as well as psychosocially suitable? What criteria is used, by whom, and who supervises this?

Sir, the physician's duty is to do no harm. In the case of living organ donation, the physician must risk the life of a healthy person to save or improve the life of a patient. To what extent can we justify causing physical injury to a healthy donor for the benefit of a sick recipient? Surgery is risky business. An article I read in a medical journal estimates the risk of death for kidney donors as being one in 3,200.

How is permissible risk in relation to the donor, to whom no physical benefit accrues, measured? Is there any agreement on criteria or guidelines for

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which health conditions, such as hypertension or vascular disease, may disqualify a potential living donor?

Who determines competency in allowing individuals to choose to donate? Is the team that evaluates donor suitability the same team that evaluates recipient suitability – if so, how are the conflicts of interest handled?

Lastly, what is the moral or social cost to society? Will a reasonable reimbursement regime sound the knell for altruism where the motivation to donate is monetary? Will the ends justify the means?

Will this take us a step closer towards commodification? Will this induce the poor to enter a devil's bargain to become a source of spare body parts, for the rich, in order to support themselves?

With the increasing objectification of the human body, the treatment of individual human beings as saleable commodities follows from the logic of the slave trade. There are parallel concerns in relation to the objectification of the body in relation to surrogate motherhood, cloning and genetic testing. What is being lost by this? We cannot lose sight of these bigger issues.

Sir, since the Government intends to go ahead with this scheme, how do we prevent the scheme's exploitation, to ensure that the prospect of reimbursement of reasonable expenses is not the sole incentive for organ donation? How will the Government ensure an effectively monitored scheme which provides fair, equal and publicly controlled compensation or reimbursement?

I hope the Minister will fully address these concerns.

Mr Christopher de Souza (Holland-Bukit Timah): Mr Speaker, Sir, the amendment

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displays the MOH’s ability to look at unconventional methods to solve sensitive issues.

There is nothing wrong with reimbursing a living organ donor for his altruistic act. But the Bill needs considerable tightening up in order to prevent abuse. I will raise five possible abuses. The aim of this is to request MOH to give further thought to how it will ensure that any reimbursement will be not-for-profit, transparent and devoid of abuse:

First, altruism – how will the Minister assess whether a donor's motivation is altruistic? How will the Minister ensure that the donor is not donating his organ because of the potential benefits he stands to reap from the compensation? I use the adjective "altruistic" because it is found in the Explanatory Statement attached to the Bill. It is a criterion which has to be fulfilled before a donation will be compensated. This is a relevant issue because the Bill does not state that donors must be Singaporeans or residents in Singapore. And this was a concern raised by Mdm Halimah Yacob. In fact, this was a concern raise by members of the public who responded to the Public Consultation Paper on the Bill. Simply put, how will MOH ensure that foreign donors travelling to Singapore for the transplant operation, or local donors for that matter, are donating for altruistic reasons? Would MOH consider implementing a detailed interview process of the donor – whether the donor is Singaporean or not – to ensure that he has not been cajoled or forced into the donation? This leads me to the second point.

Compensation or reimbursement – I seek the Minister's clarification on how reimbursement will be quantified. In particular would (a) a donor who earns less (ie, has lower salary and therefore has lower loss of earnings) be reimbursed

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less than a donor who earns more? (b) would a recipient be expected to pay towards such reimbursement? If yes, this means that a recipient who has more disposable income will be in a position to pay more than a recipient with less disposable income. This leads to two inequalities. Firstly, there is more incentive for a donor to donate his organ to a recipient who can afford to pay larger compensation. Secondly, the wealthy recipient has a wider range of potential donors to choose from, as he can afford to pay more compensation. This shows that a consistent and transparent method to quantify compensation is needed. One way is to introduce, by way of a Schedule to the Act, compensation caps or ceilings. Such caps are needed especially in light of the proposed section 14(3)(c)(ii) which allows for compensating the donor's costs of travel, accommodation, domestic help and child care. The latter two – domestic help and child care – could be lifelong expenses incurred by the donor. In which case, the reimbursement or compensation package could be huge. An open-ended and loose method of calculating compensation could open a backdoor to organ trading. Compensation caps are important. These will ensure the amended HOTA is well and truly facilitating a not-for-profit compensation mechanism. I note that clause 5 of the Bill amends section 21 of HOTA to empower the Minister to make regulations pertaining to the payment of costs and expenses and medical benefits. However, details pertaining to the administration and payment of costs and expenses are central to this entire Bill. I would query why they are being relegated to secondary legislation which is not debated in Parliament. We are dealing with a compensation mechanism. There is nothing more important than the details of how this mechanism will quantify compensation. These details will ensure that the mechanism compensates or reimburses rather than profits the donor. Yet, the Bill is devoid of these details. Instead, Members are forced to have to

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predict quantifications and cite hypotheticals, as did the hon. Member, Mr Sam Tan. The Bill should have included these details, thereby subjecting them to Parliamentary debate and scrutiny. Would the Minister explain what regulations will be put in place to ensure the amended HOTA does not deteriorate into legislation which legalises organ trading. Also would the Minister explain who will ultimately be paying the compensation; who will have administrative oversight of the payment of such compensation; and who will determine what are "reasonable" levels of compensation or reimbursement.

Just as a proposal, would the Minister consider introducing a third party compensation authority? Would MOH consider facilitating third party NGOs such as KDF to decide on the amount of compensation the donor is to receive. Public monetary donations to these organisations, with matching grants from the Government, could be used to pay such compensation to the donors. Alternatively, MOH itself could take on this role. If the compensation is quantified transparently and on a not-for-profit principle, this could ensure fair compensation or reimbursement and that organ donations do not just reach recipients who can pay more.

Third, Sir, over-compensation – one cannot help but be reminded of the recent case involving Mr Tang where a foreign donor was involved. What we deem conservative compensation in Singapore could be deemed by foreigners as a significant amount sufficient to justify the donation of an organ. Therefore, the issue of over-compensation comes in. How will the Minister ensure that the compensation offered through the Bill does not unwittingly open the door to organ trading by virtue that conservative compensation in this country might mean a lucrative

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windfall by the citizens of countries within the region?

Fourth, how is the recipient chosen? Given compensation's entrance into the equation, how will MOH ensure that the recipients who need the transplant most will receive the donated organ – and that donated organs do not veer to those who can compensate the donor the most?

Fifth, organs needed for the donor's sheer survival – May we receive from the Minister his clear assurance that the HOTA amendments will not allow, even in the future, compensation for living organ donors where the transplants involve vital organs needed for the living donor's sheer survival – eg, a heart. While such a position seems obvious, the Minister's assurance will be comforting.

In conclusion, Mr Speaker, Sir, I support, wholeheartedly, the MOH's principle of reimbursement but the Bill lacks a clear, transparent formula on how appropriate compensation levels will be quantified and regulated. If there were clearly articulated and expressed provisions within the Bill itself to ensure the reimbursement mechanism is kept not-for-profit, transparent and devoid of abuse, I would support the Bill. However, the Bill lacks these. So, while I agree with the principle of reimbursement, I do not support the Bill. This is because without the details, the framework in the Bill could be the subject of abuse. I am aware that the Bill seeks to allow the removal of organs from a deceased person above 60 years of age, I support this. I am also aware that the Bill seeks to create a specific offence of organ trading within enhanced penalties, I also support this. Unfortunately, these initiatives have been bundled together with the reimbursement amendment which lacks details and can lead to abuse. These initiatives, that is donations from those about 60 years of age and the enhanced penalties, should have been unbundled into separate Bills

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seeking to amend the same Act. Therefore, bearing in mind that the Whip has been lifted, I do not support the Bill. I would urge the Minister to insert into the Bill details on how the reimbursement is to be quantified to prevent abuses. If such details sufficient to check abuses are included, I would support the Bill.

Therefore, Mr Speaker, I do not support the Bill in its current state.

Mr Speaker: Order, I propose to take the break now. I suspend the Sitting and will take the Chair again at 4.05 pm.

Sitting accordingly suspended

at 3.44 pm until 4.05 pm.

Sitting resumed at 4.05 pm

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[Mr Speaker in the Chair]:

HUMAN ORGAN TRANSPLANT (AMENDMENT) BILL: Debate resumed.

Ms Ellen Lee (Sembawang): Mr Speaker, Sir, in the interest of time I shall not repeat what my colleagues before me have said about how this Amendment Bill will bring about the milestone changes to immensely benefit more people needing organ transplants.

Although I do share some of their concerns, I nevertheless support this Bill as it will give more people hope and a second lease of life. However, I have my concerns which I hope the Minister would consider and re-examine as these may have unintended repercussions.

First, the issue of compensation, costs incurred or reimbursement. It has been suggested that only verifiable or documented expenses should be allowed as it is ethically unproblematic. The primary concern with the so-called payment, compensation or reimbursement is that it is often unclear when it tips over

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to become payment for an organ. Furthermore, there will always be some genuine payments for which no verification or documents can be produced, especially when the cultural practices of different ethnic groups in nourishing their bodies to aid recovery may differ. For example, the Chinese believe in using ginseng, dangui and cordyceps , amongst others, and these are pricey. Would the Minister consider additionally allowing for a one-off payment of, say, $2,000 to cover these payments?

By the same token, whenever there is payment, whether in cash or kind, we will never be able to satisfy everyone. Some people over-estimate their own worth and value and will price their worth and earnings differently. If the Ministry eventually allows or follows a set of international practices and guidelines in working out a legally acceptable and ethical mechanism to allow for reasonable payment to cover out-of-pocket expenses, and for anticipated and quantifiable medical and non-medical expenses, it should be communicated simply and clearly to all Singaporeans, especially since the Act is one of an opt-out scheme. The regulations to be drafted must be clear and unambiguous and simply understood by the laymen. As it is an equally important piece of subsidiary legislation, would the Minister consider calling for a public consultation to gather more feedback as well before the subsidiary legislation is drafted?

The Hospital Transplant Ethics Committee has an unenviable task in this whole exercise. As such, the selection of the members of the Committee must again be carefully carried out. This Committee must not only be seen as transparent but also be respected as being highly ethical and compassionate. MOH should conduct regular audits, checks and balances on these committees as they may become the sole arbiter of what is reasonable compensation or reimburse

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ment. This is to prevent compensation from becoming an inducement to the poor and desperate to donate their organs.

In short, people must understand the rationale and the concept of the payment, and accept it as fair compensation. Introduction of mandatory counselling of the possible consequence of such organ donation would also help to underscore the importance of the donor's decision and if it were truly mercenary, then hopefully, he would be deterred and change his mind. However, if it were altruistic, then it reinforces in the donor the need to have regular due diligence check of his health.

Another concern is the impact of insurance on donors. Donors could be discriminated against and be rejected or subjected to higher premiums by insurance companies. I am aware that the Bill attempts to address insurance costs through the compensation mechanism. However, the impact of organ donation to donors' pre-existing health or life insurance products is still unclear. Premiums aside, how would the donor's existing policies be affected? There must be adequate safeguards, especially for those donors who are risking their lives to save or help others in need as this may be an aspect that they may not have considered or given due consideration to.

In the same vein, what if after accepting payment, the donor develops more or unforeseen health complications? And what if the healthcare costs escalate beyond what the compensation or payment can cover? Is there a safety net of sorts?

Donating organs to help another life is a sacred and laudable act. If it has to descend to a point where the blame is transferred to the Government for enacting this legislation to encourage the

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donation that result in the donor suffering poorer health, it will leave a bitter taste. Inevitably, the Government would be blamed for its role in enabling the rich to exploit the weak and poor. The question then is whether the Government should have the moral duty to take care of the health of the donor?

Mr Speaker, Sir, having aired my concerns and hoping that the Minister would give them due weight where appropriate, I support this Bill.

Mr Hri Kumar Nair (Bishan-Toa Payoh): Mr Speaker, Sir, I rise in support of the good intentions behind these amendments. They are clearly noble. Who could disagree with giving more hope to those whose lives hang in the balance, and whose only prospect of survival is to receive a transplant? The repeal of the prohibition against removing organs from a deceased person over 60 years old is timely. So long as the organs are healthy, there is no reason to impose artificial age limits on prospective donors. Likewise, the enhancements on penalties.

The amendments to allow a donor to receive compensation are more controversial. Many around the world will criticise us for this move. But as a matter of principle, I see no difficulty with it. Some have argued that many countries have not allowed this, so we should not. That by itself is not a good reason not to do something. Some say it is immoral to donate your organs for money. I say it is equally, if not more, immoral to simply ask patients to accept death gracefully when there is a feasible option. It is also immoral to stop someone from saving a life, if that is his real intention.

What are the critics really concerned about? That this new regime will prove an irresistible source of income for the poor, the ignorant and the desperate, and that ultimately, the rich will obtain transplants at the expense of the poor.

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These are powerful, emotional arguments that cannot be ignored. But what is the reality? A father of a friend died on an operating table in India during a kidney transplant; an acquaintance of mine is still alive after receiving a kidney in China.

Many of us know similar stories. This is a life and death issue. People who face death will move mountains to survive, and do things and take chances which most of us do not even want to think about. So there is a thriving black market, where organs are traded for huge sums of money, and the poor, the ignorant and the desperate will continue to be a ready source of organs for those who can pay. HOTA did not bring about that situation, and these amendments, if properly applied, are not going to make it worse. In fact, creating a framework to handle compensation for organ donation may help stem the rise of a black market.

But there is no doubt that even with the enhanced penalties, introducing a financial element will prove too tempting for some to make money from donating their organs, and for others to take advantage of that temptation. We cannot leave the weaker members of society to fend for themselves. We need to ensure that the law and spirit of HOTA are preserved.

The key phrase, which appears in the Explanatory Notes to this Bill, is altruistic living organ donor. In other words, the amendments are not supposed to facilitate transplants by persons who are motivated by money. Further, as I understand them, these amendments do not remove the requirement that there must be a deep emotional connection between the donor and the recipient. Could the Ministry clarify that this remains the position? If a relative or close friend of the patient is willing to give up his kidney to save him, but is naturally concerned about his own future medical expenses and potential loss of earnings,

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why should we not allow the patient to compensate that relative or friend?

The problem, however, is that the amendments do not say all this. The phrase altruistic living organ donor appears in the Explanatory Notes, but not the amendments themselves. The requirement that the donor and recipient must have deep emotional ties is also not found in HOTA. Therein lies my difficulty with these amendments, and with HOTA in general. The vital organs are missing. Let me explain.

The way the Act seeks to ensure that organ trading does not take place and that donors are not exploited is to depend on the Hospital Transplant Ethics Committees to assess the application, and to approve genuine ones and to reject non-genuine ones. But HOTA and its regulations make it clear that this committee is not equipped for this important role.

Section 15B of the Act provides that the committee shall consist of not less than three persons, of whom one shall be a medical practitioner not employed or connected with the hospital and one shall be a lay person.

But the lay person apparently can be employed or connected with the hospital. In other words, that committee can be constituted by a majority of persons who have an interest in promoting the business of the hospital. In fact, the third person, ie, the medical practitioner not connected with the hospital, may be from another hospital which carries out transplants or is otherwise interested in promoting transplant operations.

Next, of the persons sitting on the committee to decide a particular application, the only disqualification from participating is that they cannot directly be involved in the care of the donor or the recipient, or will be involved in the transplant procedure itself. Surely, there are other obvious instances of conflicts,

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such as blood relations or friends. But the members of the committee are not even required to declare their interests.

Further, neither HOTA nor any other law or regulation sets out how the committee must discharge its duties. All it has to do is to submit a report of its decision to the Ministry of Health. What that report should contain is not clear. The committee has complete discretion in the manner of its deliberations. It has the power to make rules to regulate its own procedure. There are no requirements to keep a record of the proceedings or the interviews with the donor or the recipient, so we do not know what questions, if any, were asked. In fact, the committee is not even obliged to interview the donor or the recipient. Why is that not a mandatory requirement? How is the committee able to properly discharge its duties unless its members actually speak to both the donor and the recipient? A committee can therefore rubber stamp an application and no one would be the wiser. The committee is obliged to have regard to the considerations of "public interest and community values" when assessing applications, but these terms are not defined, so the committee decides what they mean. There is no accountability for its decisions. The Ministry of Health does not carry out audits of the files, if any, kept by the committee, and I can go on with other deficiencies.

The Hospital Ethics Committee currently represents our only real check against abuse – yet we demand so little of it. The hospitals may argue that it is not their responsibility to determine if what is declared by the donor or the recipient is true. If that is the case, then it would appear that no one is taking any responsibility for this entire process – not the doctors, the hospital or the Ministry.

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If we are going to allow compensation, and if we are serious about not allowing organ trading, there clearly needs to be a complete overhaul in the manner in which applications are approved. I know the Minister would prefer to keep things flexible. But flexibility without accountability is not a good recipe. Otherwise, a law which has such good and noble intentions may fail in its execution and that would be a real shame.

These matters should be addressed in HOTA, or at the very least, in subsidiary legislation. If any Hospital Ethics Committee is not prepared to assume these basic obligations, transplants should not be carried out at the hospitals it represents. There is also no reason why MOH should not audit every approved transplant to ensure that the letter and spirit of HOTA have been observed. It will provide an essential check to ensure that the committees are doing their job. Surely, that is not an onerous obligation. How many living donor transplants take place every year? Even if many, is that not the least that MOH should do in the public interest? If it does not, who will? So improving the process will not reduce the number of genuine donors. In that light, may I ask the Minister if he intends to improve the current approval process and, if so, what he proposes to do.

Likewise, I am not comfortable leaving the details of the compensation scheme to another committee without any legislative guidance or oversight. Delegating may be a convenient and efficient way of dealing with these issues, but the devil in these amendments is really in the details.

I accept that it will be impractical for this House to deliberate on all the details of the compensation formula or mechanism. But there are some fundamental questions we should talk about. For example, what does compensation for

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"loss of earnings" mean? Should compensation be restricted only to Singaporeans and PR donors? Should there not be a cap on the amount of compensation? Should foreign donors and recipients be subject to different rules? How is the compensation sum to be disbursed? Other Members of this House have raised many good questions as well.

We should debate these questions in this House, instead of giving a committee, which has not even been formed, a blank cheque to decide them. May I also ask the Minister if his Ministry intends to take a similar light-touch approach with this committee as it does with the Hospital Ethics Committee. If it does, then I have serious concerns.

A compensation regime which does not adequately address the interests of donors, or worse, encourage less than altruistic behaviour, will undermine the very amendments that we are being asked to vote on today. If the system is inadequate, and there is exploitation as a result, the failure should be ours and not laid at the door of some committee.

I hope that the Minister will clarify these matters so that we can take this important step, confident that we are doing the right thing for Singapore and Singaporeans. But absent of the overhaul of the approval process and clarity in the compensation scheme, which I say is fundamental to this Bill, I cannot support it.

Dr Loo Choon Yong (Nominated Member): Mr Speaker, before I join the debate on the amendment to HOTA, I would like to declare my interest as the Executive Chairman of Raffles Medical Group, whose Raffles Hospital conducts renal transplantation surgeries in the course of its business, and I am also a practicing member of the medical profession.

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This amendment has stirred some age old controversies because the amendment calls for payment to organ donors. Why is it so controversial to make payments to organ donors? Let me explain. The medical profession believes in the sanctity of life. Doctors are supposed to put the interest of their patients above all else. They are taught to "cure sometimes, relieve often and comfort always". They are also ethically bound to "do no harm" to their patients. Hence any cure must never be worse than the disease. It is therefore not surprising that the medical profession here and elsewhere feel uncomfortable if body parts were to be traded for cash or kind. They are uncomfortable because while society may want to change its norms, customs and laws, it is the doctor who ultimately has to wield the scalpel and do the harvesting of organ from the donor.

Some doctors believe they are conflicted ethically when they have to harvest an organ from a donor whom they also regard as their patient. How can they be not doing harm if they are removing the kidney from the patient?

Besides cadaveric donors, many doctors are willing to make a concession for the harvest of organs only from clearly altruistic living related donors. They are absolutely against the trading of body parts. Some are even against the donation of organ by living unrelated donors, that means strangers, no strong emotional ties.

Some religious groups have also expressed objections to the organ trading as they view it against the Almighty’s design for the universe and not part of divine will for us mortals to trade organs.

Some non-religious but fair-minded people see organ trading as exploitative as only the wealthy members of a society can afford to pay for body parts and usually the "donor" or "seller" of such body parts is a member of the poorer,

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disadvantaged and vulnerable group. There is also the concern that when it comes to cross border organ trading, "donors" or "sellers" are always from poorer, less developed countries where healthcare facilities and services are poor or sometimes non-existent. The future health risks to such a "donor" are often greater than the risks for people from better developed countries. There is also often gross exploitation in such situations.

Against all these objections and concerns, there are equally unhappy circumstances and problems that this amendment seeks to address. We know the statistics by now. Every year, 750 people are diagnosed with kidney failure. These are new cases, and we have in Singapore a backlog of 563 cases waiting for kidney transplant and are on chronic dialysis in 2007. We all know that the waiting time is about nine years. These patients need to undergo renal dialysis two to three times a week just to stay alive. Each haemodialysis episode lasts four to five hours. It is a costly, inconvenient and uncomfortable process. Few patients on renal dialysis can lead full and productive lives for sustainable periods. Their family members, especially their children, suffer. Their spouses often bear the brunt of the burden of support.

Living related donors are actively encouraged. Often the patients' spouses have donated their own kidneys to give their spouses a new lease of life. Such a self sacrificial act must surely be the supreme act of love. But we still have a grave shortfall of kidneys for transplantation. Many such patients die whilst waiting for a kidney donor, whether living or cadaveric.

Sometimes, out of desperation, these patients resort to buying kidneys and having kidneys transplanted in them in some lesser known hospitals in China and

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India. Many of these patients end up with less than optimal kidneys. The transplanted kidneys often get rejected and the poor desperate patients often get even more sick, with acquired infections.

So doing nothing is not an option. Sir, I support the repeal of section 5(2)(d). Those 60 years and above are no longer prevented from donating their organs. With modern living and modern medicine, many 60-year-olds keep their organs well maintained. Besides these are not only healthy organs, but experienced ones too.

I also support the amendment to allow for paired living donor transplantation. These measures should help to increase slightly the number of kidneys available annually.

Sir, in an ideal world, we would never be short of cadaveric or living donors, and all the unfortunate people who suffer from end-stage kidney, liver or heart diseases will have enough organs to be transplanted to take over the functions of their failing organs.

But this is an imperfect world, like Jack Neo said "not only money no enough, organs also no enough".

The recent prosecution of seller, buyer and middleman in organ trading has brought this issue into the open. There are also strong advocates for allowing healthy persons to part with their organs in exchange for cash or kind, as long as it is a "willing buyer" and "willing seller" situation. I believe this is dangerous and wrong.

It is further argued in support that the money that the seller gets for his kidney will enable him to survive or even thrive economically from whence he comes. In short, there can be a new lease of economic life for him and his family when he sells one of his two healthy kidneys or part of his liver.

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It is also known that there is already a well-developed underground network for wealthy Americans to purchase kidneys. These kidneys are bought from Brazil through middlemen in Israel and Brazil, and the kidneys are transplanted into the buyer in Brazil or South Africa. There have also been kidney thefts, where innocent job seekers are brought to a hospital in London for what was supposed to be a pre-employment checkup, only to wake up with a loin scar and one kidney stolen.

What does this amendment to HOTA seeks to do? It is supposed to enable altruistic living donors to be able to be compensated fairly for their trouble and to provide for future expenses. Sir, the WHO Guidelines' guiding principle five has stated that "the prohibition on sale or purchase of cells, tissues and organs does not preclude reimbursing reasonable and verifiable expenses incurred by the donor, including loss of income, or paying the costs of recovering, processing, preserving and supplying human cells, tissues or organs for transplantation".

So the guidelines, we are actually within the guiding principle of WHO. But objectors to the trading of organs will see this as a backdoor way to allow legalised organ trading. Proponents will see this amendment as recognising today’s realities and avoiding social hypocrisy.

A very sensitive and important point has been raised in this House by Mdm Halimah yesterday

and some of my other colleagues today. She is rightly concerned that the poor and vulnerable from neighbouring countries may flock to Singapore to offer their organs. Unemployed foreign workers may also offer their organs for sale before they go back.

I admit this is a delicate point but we also have the poor and vulnerable amongst us in Singapore. Whatever the

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rule is, I think it is only fair that we apply them to locals and foreigners as well. Otherwise we will be precluded from compensating an altruistic donor, say, a distant relative or a religious person from our neighbouring countries where healthcare facilities are not as readily available. It would be unfair and exploitative if we do not extend the same rules to them.

Sir, on balance, I believe there is more good to society for this amendment allowing reimbursements and compensation to be accepted. My reasoning for saying so is:

(a) it will enable us to bring cure and relief to the many patients on the waiting list for renal transplantation;

(b) it will prevent the desperate patients and their families from being exploited and cheated by middlemen helping them to get kidneys unlawfully;

(c) compensating and reimbursing the altruistic donor is not necessarily allowing organ trading;

(d) exploitation of the poor and vulnerable can be minimised if a proper regime is instituted; and

(e) the medical profession should not feel the existence of an ethical conflict as this is a conscious variation from medical ethical rules that the Singapore society makes for the greater benefit of society.

Sir, I also wish to make the following suggestions to the Minister:

(a) that MOH or a MOH agency regulates and administers the living related and living unrelated organ transplantations in Singapore, and not leave it to hospital committees;

(b) a committee be set up to set the quantum of fair and reasonable

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compensation and reimbursements for donation of various organs and review these quantums periodically to keep up with changing circumstances;

(c) that foreign and local donors be treated alike;

(d) that the lead agency for all organ donations, local and foreign donors, be responsible for ensuring that they are well-informed of the risks and that informed consents are taken properly. They should also ensure all aspects of organ transplantation are carried out lawfully. They should also ensure that the compensation or reimbursement is paid directly to the donor. This should help to prevent or reduce exploitation;

(e) that doctors, working in public hospitals, who are conscientious objectors to this amendment be exempted from such kidney harvesting; and

(f) greater steps be taken to promote and also to recognise living related and other altruistic donors of kidneys and other organs.

Sir, I am also supportive of the enhanced penalties for organ trading and, on this basis, I support the amendment.

Mr Khaw Boon Wan: Mr Speaker, Sir, I thank Members for their very valuable and thoughtful comments. As I listened carefully to all the speeches, I can understand how US Treasury Secretary Tim Geithner must have felt these few weeks. He was determined to do a good thing but was being criticised left, right and centre. But I appreciate the comments, including the last one by Dr Loo Choon Yong. If this were a piece of legislation to decriminalise organ trading, then I can understand where the objections are coming from. As I will explain very carefully later, it is not. As

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Members listen carefully to what I have to say, I hope most, if not all, who have objected earlier may find that it is in their conscience to be able to support this Bill without feeling guilty about it morally or ethically.

Let us start with the easiest one. All supported the proposed lifting of the age limit for cadaveric donors. Dr Lim Wee Kiak gave a good explanation of why healthy organs from elderly donors can remain suitable for transplantation. He asked how we would assess the health of the organs in practice. We have an expert committee to help us on this. They have drawn up comprehensive requirements for the evaluation of potential donors. This will include a rigorous evaluation of the donor's medical history and organ function just before death and, where indicated, pre-implantation biopsy of the organ, to ensure that only healthy organs are used for transplantation.

Dr Lim Wee Kiak asked what would happen to the waiting list once we lifted the age limit. Dr Loo Choon Yong has mentioned the figure of 563 – I think that is correct. As I said before, once we lift the HOTA age limit, we must by reciprocity also allow seniors above 60 to remain on the waiting list. Our preliminary projection is that the list will then surge beyond 1,000. But that has to be the case because once we lift the age limit, we must expect that more seniors will be able to benefit from the amendment. This gets to show the real quantum and the size of the problem that we have to deal with.

Dr Fatimah Lateef would like us to go further and lower the HOTA age limit from 21 years to 18 years. While I am open to the suggestion, the yield will be small. While every donor counts, organ donation is an important decision and we do want people to have carefully considered the implications of HOTA before they decide. That is why I think 21 is still preferred to

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18. In any case, those between 18 and 21 years of age who feel that they have sufficiently considered the matter and wish to take an active step forward can make a pledge of organ donation under the Medical (Therapy, Education and Research) Act.

All supported the proposal to allow paired matching. Dr Fatimah Lateef called for the establishment of a "systematic, proactive and well-organised living donor registry" to support paired matching. I agree. The National Organ Transplant Unit of the Ministry of Health will take charge of this assignment.

The same unit will also take charge of setting up a Donor Care Register to monitor the health of the donors. Mdm Halimah and some other Members are curious about the long-term health of the living donors. If the donors are well selected, there is good medical evidence overseas to suggest that there are few adverse medical impacts. But there is little local research on this. The proposed register will allow us to track long-term clinical outcomes and allow us to better understand the long-term impact of organ donation, if any.

Prof. Thio asked how pair matched organ transplants will be regulated. She noted that in other jurisdictions, the transplant surgeries are carried out simultaneously to avoid situations where one of the donors decides to back out. Dr Lim Wee Kiak stressed the need to carry out such procedures simultaneously. Indeed, this will be the requirement for paired matching, that the surgeries will all be done simultaneously. Our Bill includes provisions for subsidiary legislation to be made to regulate organ transplant arrangements, including mandating that paired transplants be simultaneously performed, if it is necessary. We can achieve such an outcome administratively because the operations are carried out in

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our hospitals, but we will study if there is a need for an explicit regulation.

Let me now address the more controversial issue of payment for living donors.

While all Members supported the good intention to reduce the financial losses incurred by donors through reasonable payment, Members were concerned that it might lead to organ trading, and Singapore becoming a regional organ trading hub. For example, Miss Sylvia Lim was concerned that the coverage of reimbursement under clause 3(f) of the Bill was so wide that it could be a backdoor for organ trading. I think a number of other Members mentioned this point too. During the public consultation stage, the World Health Organization and many Singaporeans expressed a similar concern.

Let me reiterate that this Bill does not legalise organ trading. During the public consultation, decriminalising organ trading and the Iranian model were often cited. But this Bill is not to legalise organ trading. Hence, Mdm Halimah's concern about the Bill affecting Singapore's relationship with its ASEAN neighbours, does not arise. Our Bill, in fact, contains an amendment to raise the penalty on syndicates involved in organ trading. This Bill is to catch up with what many OECD countries have already done for many years. In drafting our amendments, we took reference from similar legislations in several of these countries, copying almost word for word and using their various phraseologies, including some of the terms in clause 3(f) that Members talked about.

We are correcting our current extreme position of criminalising all kinds of payment to the donor. For example, currently donors are charged by the hospitals for all their transplant-related medical and surgical expenses. The recipients are prevented by HOTA from reimbursing the donors for these expenses. The proposed

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amendments will bring us in line with jurisdictions such as the US and UK to allow some payments to be made to the donor.

Let me also clarify that we are not making it compulsory to reimburse living donors. We are not compelling every patient to reimburse his/her donor. We are merely allowing organ recipients, if they wish, to make some payment to cover the financial losses incurred by their donors. In fact, I will not be surprised if many living donors continue the current practice of not requiring any reimbursements from the recipients. This would address the concern of some Members that low-income recipients may not be able to afford such payment, because they may be able to continue to get donors who are not asking for such reimbursements. But in the event that some donors may need such reimbursements and the recipients agree to do so, the law should not prevent it from happening. The law is currently preventing this from happening, and that is what this Bill is all about.

I must also explain that reimbursement only applies to living donors. It does not apply to cadaveric donors where allocation of organs will continue to be based on tissue matching, time on the waiting list and other clinical factors, as objectively determined by an expert committee. Hence, the concern of Mdm Halimah and Mr de Souza about rich patients jumping the queue for the cadaveric organs, does not arise. Indeed, as carefully pointed out by Mr Sam Tan, the Bill does not discriminate against the poor. Among living donors today, there is a good mix of high and low income donors.

But as Members put it, the real challenge in donor reimbursement lies in the practical difficulties of making a distinction between what is reasonable payment and what is inducement. I agree

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with Members that the key lies with putting in place appropriate safeguards. Fortunately, we have examples to follow. The US, UK and other countries have systems in place to allow this to be done properly.

We have studied their systems very carefully and we will incorporate the practical ideas in ours including, as I said earlier, some of the legislative clauses. We are also not starting from scratch ourselves. My Ministry has a working system in operation today to prevent organ trading and we will be strengthening it. Members rightly asked that MOH should provide operating details. As Mr Hri Kumar put it, the problem does not lie with the primary legislation but the problem lies with the processes in place to ensure that organ trading does not take place. So let me spend some time on how exactly we are going to do it.

First, we have a system for donor evaluation and selection to ensure that only healthy and suitable donors are selected. This is the first important step because the health of a living donor after organ donation is dependent on his health prior to surgery. We require all transplant centres to have a system in place for this, but we will go further. We are now working with the expert committee to formalise a set of best practice guidelines for the medical and psychological evaluation of all potential donors and there are such internationally accepted guidelines, eg, the Amsterdam Forum guidelines for kidney donors and the Vancouver Forum guidelines for liver donors. We will require the transplant centres to adopt such guidelines.

Second, we have a system for informed consent established under the Human Organ Transplant Regulations, to ensure that the donors fully understand all aspects of the donation as well as the implications of becoming a living donor. Mdm Halimah, Dr Lam and Mr de Souza have stressed this point – every donor has

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to be fully informed about the potential risks, the need for long-term medical follow-up, as well as the cost implications, before consent is obtained. We will further tighten the consent process by drawing up a comprehensive checklist that transplant centres must run through with their potential donors to ensure that they are well informed. We will require every transplant centre to develop suitable communication materials and documents for informed consent that are easily understood by the donors, in accordance with their educational levels and their mother tongues. This is an important step and we will make sure it is done well and in line with international best practice. I feel very strongly about this particular point of informed consent because I have seen with my own eyes any failure to do so. I have talked to foreign donors in the Philippines who were exploited by the syndicates. So I personally feel very strongly about this step of ensuring that proper informed consent will be taken and it will be done.

Third, every living donor organ transplant is subjected to a review by a Hospital Transplant Ethics Committee, whose job is to ensure that the donor is free from any undue influence, coercion, emotional pressure or financial inducement. Mr Hri Kumar has suggested, among other things, that these committees are not subject to sufficient regulatory oversight and that, technically, they are free to rubber-stamp applications for living donor organ transplants. Let me clarify that this is not the case. This is Singapore. This is not some Third World country. Any proposed payment arrangement between the recipient and the donor will be scrutinised and assessed by the committee as part of this review. The committee members must be fully satisfied that any proposed payment does not constitute an inducement to the donor. They would have to take into account at least the following factors:

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(i) the donor's age and nationality (local or foreigners);

(ii) his relationship with the recipient;

(iii) his financial and employment status;

(iv) the post-surgery medical follow-up plan, whether he has adequate life and health insurance; and

(v) the justification for any proposed reimbursement, including the relevant supporting documents.

I agree with Ms Ellen Lee that the committee should be subjected to checks and balances. The composition of the committee requires my Ministry's approval. We can argue about whether is three enough or we need more, or if the composition needs to be changed. I can look into those areas, if necessary. We will work closely with these ethics committees and provide guidelines to help them conduct their assessments. We will enhance their capabilities by requiring them to undergo training, especially in medical ethics. We have the advantage of being a small country. There are only five hospitals where living donor transplant surgeries are done. This is unlike in other countries where there are hundreds, sometimes thousands of transplant centres, and the regulators there have a real problem of fully knowing the quality of the committee deliberations and ethical inclination of the members.

Fourth, my Ministry will closely monitor the processes of these transplant ethics committees by requiring the hospitals to submit the relevant data after every transplant. We will conduct regular audits to ensure that these ethics committees fulfil the legal requirements in evaluating the transplant applications and comply with our guidelines. We will not hesitate to require the transplant centres to reconstitute their transplant ethics

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committees if we lose confidence in their ethical standards. We have such power.

Fifth, we have an enforcement system to detect fraudulent practices and that was how we were successful in making a prosecution of organ trading last year. For the comments that I have heard overseas – who were preaching to us about organ trading – Singapore remains today, one of only a handful of countries where there has been successful prosecutions. And I think this illustrates the hypocrisy that Dr Loo mentioned just now. Given the diversity of donors' backgrounds, I agree with Dr Fatimah that the system needs the flexibility provided by the transplant Ethics Committee, to carefully consider all the relevant facts on a case-by-case basis.

As pointed out by Mr Sam Tan, "the sum would vary from person to person". Hence, we have real difficulties hard-wiring in quantitative formulae, or reimbursement caps in the primary legislation as suggested by Mr de Souza. Though I appreciate his intention of wanting to do so (I would like to be able to do it if I can), I have a practical problem of doing it. Based on what I have read, all similar legislations in US and UK do not do so, for the reason that it is difficult and impractical. But we can certainly articulate the principles in guidelines, in both qualitative and quantitative manner, and provide a platform for the transplant ethics committees to share their experiences, compare notes and learn best practices. My intention is to use the next few months to discuss and firm up these guidelines with the transplant ethics committees. They have to be practical and defensible and fair to the donors.

As we are breaking new ground, we will closely supervise the implementation, especially in the initial years. We will

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enhance our guidelines in the light of experience. We plan, for example, to include in the guidelines, a range of reasonable payment quantums, after we have had some experience dealing with actual applications for such payments. And that is the reason why we have difficulty, just like other jurisdiction elsewhere, on fixing the quantum from the start because until we have actually tried it out and learnt from the experience, we are all projecting and speculating. I hope Mr de Souza will accept that this is a practical way forward. We will not allow the transplant ethics committees to run unsupervised.

Mr de Souza does not support the Bill because of the lack of details on the reimbursement mechanism. He is concerned that this may unwittingly open the door to organ trading. I would like to emphasise that the key principle of prohibiting organ trading, and the circumstances under which comprehensive reimbursement may be permitted, are clearly spelt out in the Act, and all subsidiary legislations have to follow these principles. We will issue subsidiary legislation, if necessary, to deal with technical and administrative matters and build in additional safeguards needed. These may need to evolve quickly and frequently over time, as we gain experience. I would therefore prefer not to hardwire technical matters into the Bill. In any event, all legislation is subject to Parliamentary scrutiny.

I am confident that we can make this work as it has worked in many other countries. The easiest thing is for us to do nothing, but as pointed out by Dr Lam, that will be patently unfair to the donors who have parted with their organs and yet have to suffer the financial losses.

Several Members asked who would pay the donors? The organ recipients would make the payment. Some Members suggested that a third party should

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administer the payment. Some payments will indeed be via a third party. For example, reimbursement for hospital expenses incurred by the donor can be done via the hospital. But there will also be payments which are made directly between the donors and the recipients, without going through any third party. Mdm Halimah suggested that part of the payment can be made via the donor's Medisave Account. I think it is a good idea, provided the CPF rule allows such a voluntary contribution. Mr Ang Mong Seng suggested having a trust to hold half of the money received by the donor to ensure that it is not frittered away. But such arrangements are best left to the donor and recipient to decide.

On the other hand, there may be voluntary welfare organisations (VWOs) which want to promote organ donation and help some of these donors through ad-hoc financial assistance. I have received such an expressed interest in the past. Mr Ang Mong Seng and Mr de Souza made a similar suggestion for a charity fund to be set up to support living donors. VWOs have, in the past, been concerned about whether such initiatives are legal. The amendment will now allow such third-party payments to take place. I hope some of these ideas will materialise. Members who feel strongly about this and who spoke about it a few hours ago, I hope will come forward, volunteer, champion and support this cause.

Several Members raised the additional challenge posed by foreign donors. To avoid the pitfalls, they suggested that we apply the law to Singaporeans only. Prof. Thio, in fact, argued that it is legitimate to draw a distinction between local and foreign donors in this manner. This will effectively prohibit any payment, even if reasonable and hence ethical, to foreign donors. I have a problem with this suggestion. How can we discriminate against foreign donors in this fashion? We either decide whether the payment is

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ethical, or not. Once we accepted that the payment is ethical, then it must be paid out. It must be allowed to be paid, whether you are a foreigner or a local. Our law cannot unfairly discriminate against organ donors purely based on their nationalities. The law must assure both locals and foreigners who undergo organ transplantation in Singapore, of the same high medical and ethical standards.

The concern about organ trading should be addressed by the comprehensive safeguards that I have highlighted above and not by sacrificing the welfare of our foreign altruistic donors. But the Members' underlying concern is real. I know that and I am mindful of it. Mdm Halimah was worried particularly that the current recession would expose many poor foreign workers in Singapore to temptation and they would become easy target for exploitation by organ trading syndicates. Unfortunately, organ trading is happening in this region even as I speak. This Bill, I think as Dr Loo or Mr Hri Kumar put it, does not add to this phenomenon. The way to address this problem is better regulation and more effective safeguards, as what we are proposing in this Bill and what I intend to put in.

There are ways to address this concern about possible exploitation of foreign donors. For example, if I were in the transplant Ethics Committee, I would be particularly alert to any representation by potential donors, who are recently retrenched unskilled foreign workers, and satisfy myself that there is no exploitation by the patient or an organ trading syndicate. It is difficult to codify the assessment as each case will be different, but if the ethics committee is well briefed on the ethical principles and mindful of the potential for exploitation, it should be able to distinguish genuine donors with full informed consent from victims of exploitation. As I said, we will be meeting with the Ethics Committee members and

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we will brief them thoroughly of the potential pitfalls. We will highlight Members' concerns in our briefing materials to the Ethics Committee members.

And clearly, in determining a reasonable quantum of reimbursement, we must take into account the vastly different costs of living here and overseas. When formulating quantitative guidelines for the hospital transplant Ethics Committee, we will prescribe a different and much lower reimbursement cap for foreign donors. This will not be discriminatory as the payment is for the reimbursement of expenses which is dependent on cost of living, not compensation for the value of the organs.

The US allows payment for human eggs (we do not), the American Society for Reproductive Medicine has issued payment guidelines which I find useful for our reference. The guidelines effectively advise reproductive centres to probe more deeply for any proposed payment exceeding $X and to frown upon any proposed payment exceeding $Y. This, I think, could be a suitable model for our consideration. We can set smaller X and Y amounts for foreign donors as an example.

Ms Ellen Lee and Mr Ang Mong Seng asked if organ donors are insurable or if they will attract additional premiums. If the potential donors are already insured, their insurance policy should not be affected by the transplant. But if they are not yet insured, insurers may require medical underwriting. As noted by Mr Ang Mong Seng, the critical period after each major surgery is the initial few days or weeks. But post-surgery complications may linger on much longer. Ms Ellen Lee was worried that, in the event of major complications, the healthcare costs and expenses may exceed the payments made to the donors. This is precisely why we

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must support this Bill. The Bill cannot fully cover all eventualities. For example, one known surgery complication is death and how do we put a value to human life? How much is enough payment? The key is to ensure that the donors are fully informed of the risks that they are undertaking and that they are not coerced or induced into parting with their organs. The value of this Bill is that it will at least ensure that known financial losses to be incurred by the donors can be suitably reimbursed.

Ms Ellen Lee commented on the Government's moral duty to take care of the health of the donors. Dr Lim and Mr Ang Mong Seng felt that as a society, we should care for these selfless donors. We do. We seek to take care of all Singaporeans, and not just organ donors. Our 3Ms framework ensures that. But citizens have a duty too, to save in Medisave and subscribe to MediShield and ElderShield from day one, and not just prior to any hospitalisation. The Government takes care of the rest, through heavy subsidy and offering the protection of Medifund. Over and above this, for those who feel strongly about caring for the donors, they can do so by donating to the VWOs when they are set up to provide additional assistance to the donors.

Mr Christopher de Souza wanted my assurance that living donors would not be allowed to donate vital organs needed for survival, such as the heart, for payment. Let me assure him that no doctor will perform such a transplant as it will be tantamount to killing him.

Mr Speaker, Sir, I know the controversial nature of paying donors. We all know the misery of patients with organ failure. We see the poverty around us in this region. We are all disgusted with the exploitation of the vulnerable by unscrupulous organ trading syndicates. But we also realise that it is unfair to

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allow genuine donors to bear all the financial consequences of their altruistic acts.

It is a challenge to address the dilemma but we need to face it. Mdm Halimah said that she struggled with this Bill. I am sorry for imposing this on Members. But we are not alone in having to manage this predicament. Elsewhere, legislators face the same moral dilemma and that is why legislations on paying donors have also evolved slowly and gradually. Our current legislation, pretending that donors need not be compensated, is one extreme. Iran's legislation represents the other. I have spoken to patients on the waiting list for organs. I have spoken to genuine donors who parted with their kidneys knowing all the risks but who lamented to me the extra financial burdens they had to bear. I have also met foreign donors in the Philippines who were harshly exploited by organ trading syndicates.

The law is not a mere product of an intellectual exercise. The law must be humane, practical and realistic about the imperfect world that we live in. Globally, the organ shortage problem will only get worse and the more we pretend that the black market in organ trading can be legislated away by simply prohibiting any kind of payment to the donors, the more it will grow. I do not believe that global legislations on donor payment will remain static. But I cannot run too far ahead of public opinion. From the public consultation and the concerns that Members have shared with me in the past, I have gathered that Singapore is not prepared to legalise organ trading and this Bill does not seek to do so. If you find the Bill objectionable because you think it is legalising organ trading in the Iranian style, please read the Bill again. It is not. This is a Bill about fairness, being fair to donors who do suffer financial consequences as a result of their act of donation. The current law shortchanges

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them. I feel strongly that we should move out of our current extreme position of ignoring the financial losses incurred by donors; we should allow some reasonable payments to be made to donors if their recipients wish to do so. Many other OECD countries have already taken this step a few years ago. This Bill does not make us a trail-blazer, as Mdm Halimah thought. Genuine donors are looking to us to give them a fair deal. Ms Sylvia Lim suggested that we put this Bill to a Select Committee. I have considered that but I am not proposing it because the primary legislations are straightforward. As Mdm Halimah noted in her speech, when she read the Bill conscientiously from page one to the last page, she found it a neutral legislation, for the simple reason that it was so by design. I extracted phraseology, clauses from legislations which are WHO consistent and globally acceptable. So how does submitting it to a select committee help to further improve on the language? As Mr Hri Kumar recognised it, it is the details following the passing of the legislation which are important – the regulations and guidelines that we will be sending out to the Ethics Committee. Ms Ellen Lee suggested that we can do more public consultation at that stage, and that is my plan. Members know my style. I subject all serious policies to public consultation. This particular Bill, for example, has gone into the end of second year. We have had two major rounds, the first round without a Bill, the second round with a draft Bill, and now this process in Parliament.

Mdm Halimah asked that we implement the Bill in stages. This will, in fact, be the case. Payment for donors will not happen overnight. We require the next few months to discuss with the transplant Ethics Committee, work with them on practical guidelines, discuss the first few cases of such payments, so as to forge some consensus on what reasonable quantums will make sense for Singaporean and foreign donors. We will

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be deliberately conservative at the start, and widen the range of reasonable quantums as we gain more experience and confidence. We will advise the transplant Ethics Committee to be particularly conservative when assessing donor-recipient pairs who are all foreigners, this is a concern that Dr Lim Wee Kiak mentioned. Singapore healthcare has a reputation for being of a high ethical standard. This is a reputation carefully nurtured over many years. We have no plan to destroy it. I value the comments made by Members in this House and I fully understand your underlying concerns. I will not let you down. In fact, I hope some of you will come forward to serve in the hospital transplant Ethics Committee, so that you can experience in real-life the struggles that patients and donors go through.

There is now very strong medical evidence that the outcome for renal failure patients who get a renal transplant without waiting and undergoing dialysis is much better and more superior, than someone who receives his kidney after dialysis. In fact, the longer they undergo dialysis, the poorer the outcome, even with the transplant. That is why I am so passionate about wanting to raise the transplant rates, whether it is cadaveric or living. Very few countries have achieved a high cadaveric donation rate to be self-sufficient. Where it is achieved, there are also critics who say that it was the result of very aggressive
"ambulance-chasers" which they find distasteful. There is no ideal system and we have to balance cadaveric organ donation with a higher living donation rate. Reimbursing living donors will, I hope, make it easier for some donors who are prepared to help their loved ones but rightly worry about the financial losses that they may incur and which they may not be able to afford, going forward. They look to us to help them fulfil their altruistic wish. On this

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note, I look forward to a strong vote of support from the House for this Bill. Please join me to protect the welfare of donors and save some more lives.

Mr Speaker Sir, I beg to move.

Mdm Halimah Yacob: First of all, I would like to thank the Minister for his very detailed explanation. I hope that his clarifications on some of the key areas would have shed some light on some of the core concerns that we have. This topic is a very important one and the concerns that we have raised are equally important. Because what we do not want to see is the opening of illegal organ trading in Singapore and affecting our reputation as a medical hub. But we are also very concerned about the need to save lives and I think, at the end of the day, this is what this amendment is all about.

I have a couple of clarifications to seek from him because these are important in order for me to make my own decision. First, I would like to ask the Minister whether it is practical, in his view, for a foreign worker, who is under tremendous pressure because of a huge debt that he has incurred, to admit to the hospital's Ethics Committee that he is under duress, or is he likely to say that he is doing it out of his own free will and that the money is not an inducement to him. This is going back to my earlier concern about the presence of foreign workers and their susceptibility to being pressurised to become organ donors because of their own condition, and tremendous need, they are in financial hardship, and are in need of money.

My second clarification is to ask the Minister how does the Ministry intend to ensure that the foreign donor who has returned home has proper post-surgery medical checkup? Because the Minister said that this is an important part of the ecosystem that will be put in place in

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order to take care of the needs of the donor, to make sure that he is properly taken care of. In fact, I think the whole reason of this legislation, this amendment, is to be fair to the donors.

The third issue I would like to seek clarification on is equitable allocation of kidneys. A patient who can pay will now be able to get a kidney transplant faster. He gets a donor, he reimburses the donor, he gets the transplant faster.

Could the Minister clarify what would be the situation of a poor patient who needs a transplant very quickly and urgently but, unfortunately, he has no money? Will this mean that he has to live with a lower priority because he does not have the means to defray or reimburse the donor?

Finally, I listened very carefully to the Minister's point, and he said, yes, indeed, there will be phased implementation. But I would like to ask for the reimbursement for foreign donors. Would the Minister go one step further to say that if and when payment for donors is implemented, it will start with Singaporean donors and then later on, after the experience is gained, the system is more mature and established, and safeguards are appropriately secured, it will be opened to foreign donors?

Mr Khaw Boon Wan: On the first question of how the Ethics Committee will review each case. One Member made a comment that part of that process requires very detailed interviews with the patient, the donor, and those related to the transaction. And that is important. I would not say it is straightforward or easy, but it can be done, if you set out to do so thoroughly, to probe. Certainly, it will also depend on the amount of proposed quantum. If the quantum is large, we have to be more probing. So, what I would say is that it is not straightforward but it can be done, if you are determined to do so. My intention is to discuss with the Ethics Committee

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members, and we can learn from that process.

The second question is how foreign donors look after their health when they go home. Once they go home, it is beyond my purview. But what I can ensure is that at the stage of taking consent, the risks involved and the requirements that they need to shoulder are fully explained to the donors and understood by them. That is why when setting the quantum, we have to take into account some of these costs. If the reimbursement amount is adequate, then at least my conscience is clear. The donors have received enough money to help them look after their post-surgery health. But if they decide to gamble that away the next day when they reach home, there is very little I can do.

The third point on equitable allocation – those who are rich may have greater means of securing donors. I thought Mr Sam Tan made a thoughtful intervention this morning precisely about this point. Let us not talk about rich or poor. Let us talk about those who have larger families and therefore have more chances of getting a donor who is willing to help out than those who have smaller families. The outcome cannot be equal because the situations are different. But let us not begrudge somebody who is able to secure an altruistic donor, as explained by one Member, once he is out of the queue, it benefits everybody else who is on the waiting list, rich or poor.

As to the final point on stage-by-stage implementation, that is something that I can consider as we proceed to discuss the details. The key point is we will engage the various hospital transplant centres and Ethics Committee members to see how we can operationalise many of these details, and if it means that step-by-step approach is better, we may do so.

Mr Christopher de Souza: First, I would like to thank the Minister for his

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instructive and insightful response. I agree that this Bill is not transplant a la Iranian style. I fully agree with that. Given the Whip is lifted, I would like to seek clarifications. First, there is no doubt that organ trading is prohibited and new section 14(2A) actually increases the penalty. But if one was to read the Bill very carefully, there is an exception to the penalty. And the exception to the penalty is what this House has been debating – that one can be compensated for loss of earnings, accommodation, travel cost, childcare and domestic help. If it is really that mechanism that is being debated and that has been excepted from the penalty of organ trading, then there is really nothing more important than the details of how this mechanism will quantify compensation and that it compensates rather than profits the donor. So I ask the Minister: why not include these details like caps and ceilings in the substantive Bill? The Minister mentioned a range that could be included via subsidiary legislation. Why not if that is anticipated to be beneficial in subsidiary legislation, include it in the substantive legislation, which is the Bill? This would ensure that what HOTA intends to do – which is to prevent organ trading and facilitate organ donations – is achieved.

To clarify, I am not advocating maintaining the status quo or doing nothing. I am suggesting something very active, Sir. I am suggesting to tighten the Bill to prevent abuse. Then, we can preserve our healthcare system as first-class and well-known throughout the world to be ethical. So, I would ask for the Minister's clarification on why the hesitation to include details, that the Minister envisions will be included in the subsidiary legislation, in the Bill.

Mr Khaw Boon Wan: Mr Speaker, Sir, the short answer is this, I have looked at other legislations and nobody has done it

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that way. There are real practical difficulties. I am not finding excuses not to do so. I have mentioned " x " and " y ". If you ask me now what is " x " and what is " y ", I have a real problem telling you what should be " x " and what should be " y ". From the comments I have heard this whole afternoon, Members are saying there must be consultation. Without passing this Bill, I cannot go to the next stage of consultation. Because if we decided that there is no need to pay at all, then the issue of how much should be " x " and how much should be " y " does not even arise. So, we need to go through this primary stage of allowing reasonable reimbursements, before I can carry on to the next stage for which we will consult widely. And, please, feel free to comment. I will welcome comments from Mr Christopher de Souza and others on what they think " x " and " y " ought to be. Until then, we are not able to build it into the primary legislation. That is my problem.

Dr Loo Choon Yong: Sir, the Minister accepts that there are a lot of details that are important. I know for a fact that there are a lot of technical details. Would it not be possible, under HOTA (section 21), that Minister makes the regulations? I agree that the details should be in the regulations. Will the Minister be prepared to assure this House that he will bring back the regulations and table them for discussion at a later stage, so that Members will see the nature of the regulations and be able to comment on them?

Mr Khaw Boon Wan: There are two steps to this, and the process is important, as noted by many Members. My intention is that it will take us quite some time – it may take us a few years – before we stabilise on what is a good system. What I plan to do is, through the administrative system, we will craft, discuss and forge consensus on guidelines, which will then go to the transplant Ethics Committee for imple

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mentation, and we then study whether we need to tighten or loosen further. At some stage when things have stabilised and we can comfortably codify it into regulations, I will do so. As to regulation itself, Members are familiar with the process. You can always file a question in Parliament, and I will defend why we put the regulations one way or the other.

Dr Lim Wee Kiak: Sir, I would like to thank the Minister for his comprehensive replies. We are more assured that with safeguards put in, this Bill can be better supported. I would like to ask the Minister to clarify the situation of a foreign recipient – foreign donor. We know that some of our neighbouring countries forbid foreign recipients to go and harvest organs from their people. Will this Bill apply to foreign recipients and foreign donors, and will we be opening up a loophole for rich foreign recipients coming over to exploit the poor of the region?

Mr Khaw Boon Wan: You know we are a medical hub and we treat patients from all over the world, and they come for all kinds of reasons. And for transplants, kidney failure or liver failure, there is a genuine illness that requires treatment. I see no reason why we should single out organ transplantation, and say that organ transplantation that happens in Singapore must only be for Singaporeans. As a hospital that deals with foreign and local patients, we will treat all. The ethical principle of fairness, which I described earlier, still applies. But knowing the concerns, we will be discussing with our Ethics Committee to make sure that when they receive applications where the pairs are purely foreigners, they will have to be extra careful and much more thorough in their evaluation. What is the concern? The concern is not the transplantation itself. The concern is exploitation of the vulnerable, which applies to whether you are a foreigner or a local, and that process has to go through anyway.

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Mr Hri Kumar Nair: I would like to thank the Minister for his assurances and clarifications. In my speech I have outlined that my main difficulty with HOTA is really the approval process. The Minister said something which really illustrates the point. He said that it was suggested by a Member of this House that the approval process would include detailed interviews with the donors and recipients. But the regulations do not provide for that. The regulations provide that the Ethics Committee has a discretion whether to interview the donor and recipient. That is my point. Too many things are really left to the discretion of the members of the Ethics Committee. So, will the Minister relook at these rules to make the entire process more transparent, to ensure that the Ethics Committee take steps to ensure that it has all the facts and to make the basis of its decisions clear?

Mr Khaw Boon Wan: Yes, I will. And if we need to tighten the guidelines or regulations, we will do so.

Question put, and agreed to.

Mr Low Thia Khiang (Hougang): Mr Speaker, Sir, I wish to abstain.

Mr Speaker: Do you want it recorded?

Mr Low Thia Khiang: Yes.

Ms Sylvia Lim: Mr Speaker, I as well.

Mr Christopher de Souza: Mr Speaker, please record my "nay".

Mr Speaker: Yes, Ms Phua?

Ms Denise Phua Lay Peng: Abstain.

Mr Speaker: Yes, Mdm Halimah?

Mdm Halimah Yacob: Abstain.

Bill accordingly read a Second time and committed to a Committee of the whole House.

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The House immediately resolved itself into a Committee on the Bill. – [Mr Khaw Boon Wan].

Bill considered in Committee.

Mdm Halimah Yacob: Question put, "That Clauses 1 to 6 inclusive stand part of the Bill."

Mr Christopher de Souza: No.

The Chairman: One "no".

Question agreed to; Bill reported without amendment.

Question put, "That the Bill be now read a Third time" .

Mr Low Thia Khiang: Mr Speaker, abstention.

Ms Denise Phua Lay Peng: Abstention.

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Mr Christopher de Souza: No.

Ms Sylvia Lim: Abstention.

Mdm Halimah Yacob: Point of clarification, Sir. I thought the first "abstention" covered all the rest?

Mr Speaker: No.

Mdm Halimah Yacob: Then, I abstain.

Question agreed to; Bill accordingly read a Third time and passed.