HUMAN ORGAN TRANSPLANT (AMENDMENT) BILL

Column: 3426

HUMAN ORGAN TRANSPLANT (AMENDMENT) BILL: Order for Second Reading read.

5.26 pm

The Minister for Health (Mr Khaw Boon Wan): Mr Deputy Speaker, Sir, I beg to move, "That the Bill be now read a Second time."

This is the third time I am coming to the House to seek Members' support to amend the Human Organ Transplant Act (HOTA). I am grateful to Members for your strong support for the previous amendments. As a result, we have been able to save the lives of more patients with organ failure who would otherwise die prematurely or live in misery. Prior to the first round of amendments in 2004, there were, on average, 13 cadaveric kidney transplants in Singapore under HOTA each year. This is about one a month. Now, we are doing an average of 41 such transplants a year, more than three times as many. This is almost one every week. The two rounds of amendments have helped save many more lives.

I am now ready to seek Members' support for the third round of HOTA amendments. There remains a shortage of organs. Last year, 26 patients died while waiting for an organ; currently, more than 560 patients remain waiting. We must continue to try to raise both cadaveric as well as living donor transplant rates. And we intend to do this by making the following changes to the Act.

Proposed amendments

First, we propose to remove the upper age limit for cadaveric organ donation

Column: 3427

under HOTA. This will increase the number of cadaveric donors.

Second, we propose to allow paired matching for the exchange of organs between living donor-recipient pairs. This will facilitate living donor transplants.

Third, we propose to remove the prohibition of payment to reimburse or defray the costs or expenses of living organ donors. This will better protect their welfare and ensure that they do not suffer from additional losses because of their altruistic acts.

Finally, we propose to raise the penalties on middlemen and syndicates that engage in organ trading. This will help to deter organ trading.

Let me now go into the details of the amendments.

Remove upper age limit

Currently, organs from deceased persons who were over 60 years of age at the time of death are not removed for transplant under HOTA even though their organs may be medically suitable for transplant. The limit of 60 years was set many years ago as a proxy indicator of a person's health in relation to his suitability as a donor. In practice, however, whether an organ can be used for transplant depends on the organ's condition, not the age of the donor. Clause 2 of the Bill will remove the age limit of 60 years for cadaveric organ donation under HOTA. As it is with all transplants today, before any organ is removed, a transplant doctor will assess the organ's condition to ensure that it is suitable for transplantation.

We estimate that the removal of the age limit could increase the number of cadaveric organ donors by 10 to 12 each year – about one a month. This would potentially save and benefit 70 more patients a year.

Column: 3428

If the Bill is passed, we will carry out intensive public education to inform persons over 60 of how they will be affected. They will be given time to decide whether or not to opt-out of HOTA.

The Bill clarifies in clause 6 that those who have already opted out of HOTA before this amendment will continue to be excluded even when they turn 60, unless they have withdrawn their objections. In parallel, we will also remove the upper age limit of 60 years for patients to be placed on the transplant waiting list. This will allow more elderly patients to benefit from organ transplant, which I think is a fair arrangement.

Allow paired matching

Second, clause 3 of the Bill will allow "paired matching". This is a way of matching living donors with compatible recipients across two or more medically incompatible donor-recipient pairs. The recipients essentially exchange donors so that each recipient can receive a medically suitable organ. Currently, HOTA does not explicitly allow this.

We have had patients with relatives who were willing to donate their organs, but who were found to be medically incompatible. These patients thus had to be placed on the cadaveric organ waiting list for a suitable donor. With "paired matching", arrangements could be made for the relative of a patient to donate his organ to another medically compatible patient in return for that patient's relative to donate an organ to the first patient. This way, more patients can be matched with a suitable living organ donor.

Such "pair-matched donations" already take place overseas, such as in the US and UK. The Johns Hopkins Hospital was particularly successful, having transplanted over 50 patients involving more than 20 exchanges since its paired kidney exchange programme

Column: 3429

started in 2001. It also performed the world's first three-way swap, that means three pairs, bringing six willing donors and recipients together for simultaneous operations in 2003. Recently, two lives were saved in Hong Kong's first paired exchange liver transplant where the wife of a patient and the sister-in-law of another patient cross-donated part of their livers. With our small population, the number of donor-recipient pairs that can be successfully matched may not be large, but such exchanges should be allowed wherever possible. To facilitate matching, we will set up a living donor registry.

Allow payment for living donors

Currently, HOTA prohibits all forms of payment to organ donors, including the reimbursement for the costs and expenses that they incur. For example, any reimbursement of lost income or medical expenses incurred by the donor is illegal. This position is really outdated and is unfair to the donors. It is not in line with accepted ethical practice in other countries. Many countries have already updated their legislations to provide for such reimbursements. For instance, US law permits reasonable payments associated with the medical costs, and other expenses of travel, housing, and lost wages incurred by the donor due to the donation. In UK, payments to defray or reimburse any expenses or loss of earnings incurred by a living organ donor so far as reasonably and directly attributable to his donation are allowed.

Clauses 3 and 5 of the Bill will amend the Act to permit the comprehensive reimbursement of costs and expenses – such as for short- or long-term medical care or insurance protection – and loss of earnings, which may be reasonably incurred by living organ donors as a result of their donation.

Column: 3430

This amendment does not condone organ trading or legalise it. It seeks merely to allow some patients who wish to defray or reimburse the costs or expenses which their donors may incur, to ensure that these donors do not suffer financially as a result of their altruistic acts. This is based on the ethical principles of equity and fairness, which demand that we protect not just the welfare of the recipients, but also that of the donors. Our proposed amendment does not mandate, but merely allows, some reasonable payments to be made to the donors, insofar as they do not constitute an inducement to the donor.

Increase penalty for syndicated organ trading

Finally, clause 3 of the Bill increases the penalty for syndicated organ trading. The current penalty in HOTA for organ trading does not distinguish between the buyer, the seller and the middleman.

In syndicated organ trading, both the buyer and the seller are exploited by the middleman, who often creams off a significant portion of the transacted amount. We all sympathise with the plight of patients suffering from organ failure, as well as those who may be driven by desperation to sell their organs in order to make ends meet. Within the existing framework that criminalises organ trading, we propose a specific, aggravated offence for middlemen and syndicates who engage in organ trading, with an increased maximum penalty of a fine not exceeding $100,000 or imprisonment not exceeding 10 years, or both. This is a ten-fold increase from the current maximum penalty and will serve as a greater deterrence for these middlemen and syndicates and protect the vulnerable from being exploited.

Public consultation

These proposed amendments were extensively discussed over several months

Column: 3431

last year, among the public, the medical and the professional organisations. A formal public consultation based on the text of a draft Bill was further organised during the last few months of the year. We received strong support for all the proposed amendments. There were two concerns with regard to payment for living organ donors.

Use of the term "compensation"

First, there was concern over the use of the term "compensation". We use that term in the original draft Bill. Some Singaporeans felt that it might be misconstrued as the legalisation of organ trading.

We have thus removed the term "compensation" and instead used the words "defraying" and "reimbursing" to refer to the payment to cover the costs or expenses that a donor incurs as a result of his donation. Hospital transplant ethics committees will continue to screen living donor transplants to weed out organ trading. In addition, clause 5 of the Bill allows us to make subsidiary legislation, if necessary, to regulate and administer reimbursement and the payment process, as an added safeguard against organ trading.

Applicability of the law on payment to foreign donors

Second, some suggested that foreign donors should not be paid, as what is a reasonable quantum in Singapore may end up inducing the poor in the region to sell their organs. We appreciate the underlying concerns and we certainly do not intend Singapore to become a regional organ trading hub. But we cannot address these concerns by enacting a law that unfairly discriminates against organ donors based on their nationality. The principle underlying this amendment is one of fairness to donors. We achieve this by

Column: 3432

allowing donors to be comprehensively reimbursed for costs, expenses and lost earnings that they incur. It would be patently unfair if a donor in Singapore who is a citizen can be reimbursed, but a donor in Singapore who happens to be of a different nationality cannot. Instead, we will continue to rely on the hospital transplant ethics committees, and our law, to prevent organ trading.

Lifting the Whip

Mr Deputy Speaker, Sir, as with past amendments to HOTA, I have asked that the Whip be lifted to allow Members to debate and vote on the Bill based on their religious and ethical beliefs.

If the House supports this Bill, my Ministry will continue with its efforts to increase the awareness among Singaporeans of these amendments and their implications.

Sir, today, many Singaporeans continue to suffer as a result of the shortage of organs for transplant. We must try all reasonable means to maximise our yield of cadaveric donors and to promote altruistic living donor organ transplants. Our proposed amendments will not eliminate the shortage of organs, but they will help to save more lives and reduce suffering. I hope this House will join me in this mission.

Sir, I beg to move.

Question proposed.

5.40 pm

Mdm Halimah Yacob: Mr Deputy Speaker, Sir, the present Bill proposes three amendments to increase the number of organs available for transplants. The first two on removing the upper age limit for cadaveric organ donations and

Column: 3433

allowing paired matching of organs are pretty straightforward.

The experience of Spain, which has a short waiting list for kidney transplants, is useful as a third of the cadaveric kidneys are from people over 60 years old. Likewise, paired matching is not new and will help to increase the number of living donors.

These two changes are welcomed. I also strongly support the increase in penalties for those who are engaged in organ trading.

Sir, the third amendment, however, which allows payment for living donors, has raised some concerns as it can be viewed as a modification of the hitherto accepted principle of altruism in organ donation. In fact, in my humble opinion, Sir, it would have been better if the three amendments were done in two stages. We could have first proceeded with the two amendments, which remove the upper age limit for cadaveric organ donations and allow paired matching. This would give us time to assess the effectiveness of the changes in reducing the waiting time for patients before proceeding to the more controversial amendment, which allows for payment to the donors. We could then study in greater depth the experience of countries like Spain and Norway, which have very successful living donor programmes and short waiting lists. If we fail, then we are clearly in a much stronger position to change the basis for HOTA and allow payment for organ donations. Notwithstanding this, although the amendment covers all three situations, I believe that the implementation could still be in stages. I would like to suggest that the Ministry of Health consider this proposal. This would give the Ministry more time to examine in greater depths some of the issues raised in relation to payment to

Column: 3434

living donors. Sir, as I see it, the amendment to allow for reimbursement or payment for living donors is meant to tread the middle path. On the one hand, we have the current situation where there is absolutely no ability for any payment whatsoever to be made. On the other hand, we have the extreme situation where there is organ trading which is highly deplorable.

I note that under the WHO Guidelines, Guiding Principle 5, certain reimbursements are allowed, for example, costs of recovery from operation and loss of income. Minister Khaw, too, has stressed that this amendment does not condone or legalise organ trading.

Sir, I have a number of issues to raise with regard to the proposal to pay living donors.

The real challenge, in my view, will lie in the implementation. Although the intent of the law is clear in practice, once payment is involved, it will be very difficult to say which donors are motivated by only altruistic reasons, especially when foreign donors from poorer countries with no relationship whatsoever with the recipients are involved. This is the crux of the issue: when is a payment only a reimbursement of expenses and lost wages and when does it become an inducement, which is prohibited under HOTA, especially when it involves living non-related donors? At what point would a transaction involving an exchange of money become organ trading?

Sir, other questions also arise. One of it is how is the price to be set? What is reasonable compensation? If the amount is too low then it will be unfair to the donors, which then defeats the purpose for this amendment. But if it is too high, then it will no longer be a reimbursement but becomes an inducement. Another question would be: how do we assess

Column: 3435

loss of earnings? Would a person who is unemployed receive much less than someone who is working and would a high-income earner receive more than a low-income earner? Is it fair to make these distinctions since it is the unemployed and low-income earner who is more likely to donate compared to the high-income earner? In fact, this is the experience in the Philippines. Most of the donors are unemployed or they do jobs

that earn very low income. And what about foreigners? Should they be paid the same amount as Singaporeans? If so, would it not be an inducement especially if they are from poorer countries because of the income disparity among countries?

Sir, in this context, I would like to ask the Minister to share more details with this House on how the Ministry intends to regulate and administer the reimbursement and payment process. I hope that these details would add greater clarity and depth to this debate and address concerns over whether allowing reimbursements could lead to organ trading.

Sir, another major concern now that reimbursements are allowed is the issue of equitable allocation of kidneys. If in the past, criteria could include factors like age, health condition or likely benefit from the transplant, without regard to a person’s financial situation, what is the criteria today? Could a recipient who is low in priority now be able to jump the queue because he or she can afford to pay the reimbursement? This is an important point and I hope that the Minister could elaborate whether there will be any impact on the equitable allocation of kidneys and how the Ministry intends to assist poorer patients who cannot afford to pay so that they do not end up seriously disadvantaged.

Sir, organ transplants involving living donors carry certain risks for the donors. Where living related organ donors are concerned, this would not be a major issue as love, care and concern arising

Column: 3436

from strong family ties would be key considerations. But when living non-related organ donors are concerned, especially now that there will be payment, it is important to have in place a proper system to educate would-be donors on what is involved in donating one of their kidneys so that they can give informed consent. Kidney donors need to undergo proper health and psychological counselling. For example, they need to know that with only one kidney, if that kidney fails to function, they may end up having to receive dialysis or kidney transplants themselves! They need to know whether it would impact their ability to work and they need to have regular post operative medical check-ups. In a survey which was conducted recently among 311 living non-related kidney donors in the Philippines, about 25% reported that their health deteriorated after the surgery and 40% felt that their economic status worsened or did not change after they donated their kidneys. So, I would like to ask the Ministry of Health to look into this. I would also like to suggest that the Ministry creates a database of all living donors to ensure that there is a proper checking and follow up on their welfare.

One of the biggest gaps found in many countries, including the Philippines, is this lack of effort to provide for the needs of donors, particularly in medical care after the transplant.

Sir, I would also like to suggest that instead of paying everything in cash, the Ministry could require that part of the payment go into the Medisave account of the organ donors, which they can then use to pay for their medical insurance or any hospitalisation cost in the future.

Two other points which I hope the Ministry would address is the question on whether allowing payment for living organ donations would affect altruistic organ donations, including cadaveric donations. Would people now feel that they are less

Column: 3437

compelled to donate their bodies or donate their organs after their death? Would they opt out? Would this also make even living organ donors, who are related to the patient, also feel that if there is payment to be made there is no need for them to donate to their loved ones.

There is also a need to strengthen the hospital ethics committees as we now have enhanced roles having to assess whether or not there is inducement when a living non-related donor appears before them. I am not quite sure whether they are equipped for the role and the Ministry may want to consider whether it wants to follow the Philippines' model of appointing a separate committee to perform this task.

Generally, Sir, subject to proper regulations and safeguards on the points which I have raised earlier, and so long as it is in line with the World Health Organization (WHO) guidelines, reimbursements for organ donations among Singaporeans is still acceptable as the element of inducement and exploitation would, in my view, be much less and, thus, more manageable. Even on this, the Ministry may want to be pre-emptive and consider disallowing Singaporean living organ donors, who are not related to the foreign patients, from donating their kidneys. This is the situation in some countries to prevent the exploitation of their own citizens by foreigners. Although the odds of this happening in Singapore is quite low because of the level of our development and the standard of our education, one can never tell what may happen in the future.

My biggest concern, Sir, is over allowing payment to foreign organ donors. The Minister had said that we should not discriminate against foreign organ donors. According to him, it would be unfair if a donor in Singapore who is a citizen can be

Column: 3438

reimbursed but a donor in Singapore who happens to be of a different nationality cannot. Whilst we want to ensure fair treatment between local and foreign donors, there are other more compelling reasons why we should seriously reconsider whether it is wise to extend payment to living non-related foreign donors. A key concern would be whether this would lead to an influx of poor donors from developing countries, brought in by unscrupulous middlemen, and whether this would tarnish our reputation as a medical hub. Would we end up as a major transplant centre where rich patients can take advantage of cheaper transplants with organs secured from poor living unrelated foreign donors? Surely this is not the kind of distinction that we want for ourselves. Even the Philippines – which has had a reimbursement scheme similar to the one that we now want to introduce and has two non-profit institutions handling such transplants, namely, the Kidney Foundation of the Philippines and the Philippines Organ Donation Programme, which is a government body – has not been able to stop the black market and exploitation of the poor. A review of the Iranian system in the British Medical Journal also shows that even with legalisation of organ trading, Iran has not been able to correct the problem of the black market for organs and the exploitation of the poor.

Sir, because of the severity of the problem, in June 2008, the Philippine government banned foreigners from getting organ transplants in the Philippines. India, too, has plans to tighten its organ transplant laws and put more curbs on foreigners who come for such operations. The Philippine government’s concerns are valid. In 2007, just over half the 1,046 kidney transplants in the Philippines were for foreigners despite a 10% foreign recipient rule in each hospital. Some hospitals were doing as many as 90% of their transplants on foreign patients.

Column: 3439

So, there are really serious concerns when we open the doors so wide to allow compensation for foreign living unrelated organ donors. Could I ask the Minister, how would this affect our relationship and solidarity with other countries, particularly those from the ASEAN region? How would the Philippine government, for instance, view our efforts to allow their nationals to donate their kidneys in Singapore for a reimbursement to non-Filipino foreign patients when such transplant operations are illegal in their own country? Would this create friction among ASEAN countries? Would we be seen as condoning or encouraging their citizens to break their law?

I would also like to ask the Minister on WHO’s reaction to our proposal and whether they have expressed any concerns about the potential for such cross border transplants to promote trafficking in human organs? If the WHO had expressed reservations, then I would like to ask the Minister how do we intend to address this and whether it would affect our efforts to promote Singapore as a medical hub? Would we be seen as exploitative and would this affect our reputation?

Sir, the other reason I am very concerned about this proposal to reimburse living non-related foreign organ donors is we have a huge presence of foreign workers in Singapore. Many are now affected by the global economic downturn. There are unscrupulous agents who have brought in such workers but have no jobs for them or want to send them back after only a few months. Foreign workers had to pay their agents thousands of dollars before coming to Singapore. Because of poor business, many foreign workers are also affected because they used to depend on overtime, which is now very much reduced because of economic situation. I am afraid, Sir, that if these foreign workers cannot earn

Column: 3440

enough to pay off their debts, they will become a ready, vulnerable pool of organ donors to be exploited and abused. And this will really be bad for Singapore. For the reasons that I have mentioned earlier, I am not convinced that we can completely eradicate the problem of the middlemen. The same unscrupulous agents that have brought in these workers could now become their middlemen because it is not possible to stop under the table payments as organs can now be allocated based on who can pay. If someone is prepared to pay more than what is recommended by some government appointed agency, then I am certain they will find a lot more donors. Desperate, vulnerable and badly in need of money, many of these foreign workers will be pressurised to become donors. To a desperate foreign worker, even a reimbursement of $10,000 would be attractive compared to going home empty handed with a huge debt waiting for him.

I truly hope to hear the Minister's comments and responses to these issues.

In conclusion, Sir, I struggled quite a bit in deciding whether or not to support these amendments because I feel that there are serious ethical issues, particularly involving payment to foreign organ donors. But as I studied the amendments, they are neutral as there is no specific mention of the donors’ nationality. And I do believe that subject to safeguards and the various clarifications that I have sought and also so long as it is consistent with the WHO guidelines, reimbursing Singaporean organ donors for costs incurred, such as medical costs and income losses is acceptable. And as a whole, the amendments would make available more kidneys and organs for transplants, which is good for Singaporeans. But I do hope that in its implementation, the Minister would seriously reconsider the idea of paying foreign organ donors because there are many pitfalls and there is really no need

Column: 3441

for us to be the trail-blazer in this especially when the potential for abuse is great.

On this note, Sir, I support the Bill.

Dr Lam Pin Min (Ang Mo Kio): Mr Deputy Speaker, Sir, I rise in support of the Human Organ Transplant amendment Bill.

The organ trading debacle last year has raised many eyebrows and mixed reactions from Singaporeans. Organ trading or organ sale is a highly controversial subject, with Singaporeans clearly divided on the issue. The one good outcome that arose from the hype and debate of this issue last year was the enhanced awareness of the plights of many organ failure sufferers and the controversies related to illegal organ trading.

Organ failure can affect any organ in the body, such the kidney, liver, heart, lungs and cornea. Organ failure can also affect anyone in Singapore. Whilst dialysis can help to prolong and sustain lives in patients with end-stage kidney failure, sufferers of liver, heart and lungs failure often die before a suitable cadaveric donor can be found.

In Singapore, there are currently about 560 patients on the waiting list for a kidney transplant. The wait is long, averaging an arduous nine years, and often futile for many, dropping out of the list from either death or becoming too ill to eligible for one.

The main controversy in organ trading stems around the ethical concerns, for fear that the poor and ignorant donors may be exploited by the rich recipients, and that those who can afford to pay will step out of the queue sooner to get a transplant. The opponents of organ

Column: 3442

trading frown upon the idea of even putting a price tag on any human organ. Some found the thought of selling one's organ demeaning and repulsive. They argued that organ trading can potentially divide people into "worthy patients" and "worthless sellers". Ethics aside, many religions also do not condone the sale of human organs.

On the contrary, proponents of legalising organ trading argue that if there were willing buyers and willing sellers, why not? If the availability of an organ could save a life, who are we to judge and nail the death sentence on the sick, when the transplant operation could well be the gift of a new life?

However, the current state of affair is less than ideal. The current HOTA makes the payment of any kind illegal and this has inevitably pushed desperate patients into seeking quick and often reckless solutions from the black market. It will be naive of us to believe that all is well and that legalising organ trading will only result in the poor being exploited. The near-global ban on organ trading has forced the practice underground, with little control over the standard of medical care and the welfare of the poor organ sellers. The very fact that the black market exists to serve the high demand from patients all over the world already result in possible and unreported ignorant donors being exploited by the buyers and their middlemen, since there is currently no law to ensure a fair, un-coerced deal.

Unfortunately, the terms "Organ Trading", "Organ Sale" or "Compensation" exuberate very negative connotations. A better and more appropriate term, as proposed by the Minister, after public consultation, will be "reimbursement".

Many have argued that allowing reimbursement of organ donors will result in the significant shrinking of the number of altruistic "live" donations. Whilst the

Column: 3443

number of altruistic unrelated "live" donations may drop, the proportion of unrelated "live" donations is indeed minuscule in the first place. Altruistic related "live" donation, however, is unlikely to experience significant decline as majority, if not all, of such donations were done out of love and care for the related recipients. And I sincerely believe no amount of monetary enticement will deter or change the minds of these altruistic donors in giving a new lease of life to their loved ones.

The sole objective of reimbursement would be to compensate the donors for the sufferings and inconveniences experienced as a result of the organ donation. There is no doubt that the donor suffers the pain and discomfort of the surgical procedure and the recuperation period can last up to a few months. This period of downtime will render the donor economically inactive with consequential loss of potential income. This could only serve as a disincentive for a willing altruistic "live" donor to step forward. The all-important question of how this can be done fairly and ethically will warrant a comprehensive and robust study by all stakeholders.

The amount to be reimbursed should ideally be fair, yet not large enough to become an inducement. The mode of reimbursement also needs to be worked out. There have been suggestions of paying a monthly allowance or setting up a fund for the donor's family. Others have also suggested putting the amount into a CPF account or using it to pay for the donor's medical insurance in the long term.

One plausible proposal would be to have a neutral third party to administer the reimbursement for organ donation. This would prevent the direct negotiation between the donor and the recipient, which can sometimes make the whole process look so commercial.

Column: 3444

In addition, sufficient safeguards must be put in place to ensure that there is no coercion or enticement into donating, and that the donor is adequately counselled on the decision. In Iran, the "sharing of organs", as they have coined it, is controlled by the Charity Association for the support of Kidney Patients (CASKP) and the Charity Foundation for Special Diseases (CFSD), with the support of the Iranian government. Whilst the current system in Iran may not be perfect, it is definitely worth a look and the important lessons learnt can be useful during the formulation of our system.

The shortage of donor organs is a worldwide phenomenon. It is estimated that there are 40,000 patients waiting for a kidney in Western Europe, 6,000 in United Kingdom and about 70,000 in the United States. Against a backdrop of this critical shortage in supply of organs, the cost of organs in the black market has escalated significantly. The rising cost of human organs is driving syndicates to resort to even murder to harvest human organs. The organ transplant market has become so lucrative and is also the driving force behind the transplant tourism in certain countries. There is, therefore, an urgent need for Governments to take bold steps to regulate and prevent exploitation of the vulnerable.

Sir, with the passing of this Bill, Singapore is likely to be one of the leaders in formulating reimbursement for "live" organ donation. It is, therefore, imperative for the Government to guard against, wittingly or not, from promoting transplant tourism. After it was reported in some websites our intent to liberalise and sanction the reimbursement for organ donation, there have been several postings from India, Pakistan and Bali, asking for information on how they could donate their kidneys for a price. This is the image that we do not intend to portray to the rest of the world.

Column: 3445

I would like to seek clarification from the Minister if the reimbursement is restricted only to Singaporeans and how would foreign donors and recipients, ie, a foreign donor donating to another foreign recipient, be managed should the transplant procedure be performed in Singapore? Would the donor be reimbursed, and if so, who will pay for the amount reimbursed?

Singapore's current opt-out system of cadaveric organ donation is one significant step in improving the supply of organs. In order to further tackle the shortages, immediate steps must be taken to improve on the current number of cadaveric and altruistic "live" organ donations. There are several limitations in the current HOTA and I am glad that the Ministry of Health will be introducing two new initiatives to boost the organ supply in Singapore.

The current HOTA forbids the harvesting of organs in consented deceased above the age of 60. This has led to unnecessary wastage of potentially healthy organs. Many countries, including Spain which has one of the world's highest transplant rates, do not set such upper age limit.

Lifting the arbitrary age limit of 60 for cadaveric organ donors would definitely increase the pool of potential cadaveric donors. There is currently no scientific basis to the viability of the donated organ based on its age. The decision on the suitability and viability should lie on the transplant specialist, who should decide based on the medical history of the donor.

The second initiative would be the setting up of a "live" donor registry where matching of a donor whose tissue is incompatible with the intended recipient with another pair in a similar situation. These paired matching donations would

Column: 3446

hopefully minimise the situation whereby altruistic donors are turned away because of incompatibility with the intended recipient and thus boost the number of altruistic "live" donations in Singapore.

Sir, with the increasing prevalence of chronic systemic diseases such as hypertension and diabetes mellitus in Singapore, the number of patients suffering from organ failure is expected to increase further. Whilst the amended Bill will serve to increase the supply of both cadaveric organs and altruistic "live" organs, it is imperative to target the underlying factors contributing to the causation of organ failures.

Continued health education and promotion of healthy lifestyles must be stepped up to keep Singaporeans in the pink of health. As the saying goes, "Prevention is better than cure". This would hopefully keep the number of organ failure patients in check.

On that note, I support the Bill.