ILLEGAL ORGAN TRADING

ILLEGAL ORGAN TRADING:

. Mdm Halimah Yacob asked the Minister for Health in light of the recent convictions of two men for illegal organ

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trading (a) whether the existing safeguards are effective and sufficient to prevent illegal organ trading; (b) whether the hospitals' ethics committees are well equipped to carry out their task; and (c) what is the status of his Ministry's investigations into this matter.

2.

Dr Lam Pin Min asked the Minister for Health in light of the recent revelation of illegal organ trading in Singapore (a) what additional measures will be put in place to ensure that similar illegal transactions do not occur; and (b) whether the Ministry will consider legalising the ethical sale of organs in the near future.

The Minister for Health (Mr Khaw Boon Wan): Mr Speaker, Sir, may I have your permission to take Question Nos. 1 and 2 together?

Mr Speaker: Yes.

Mr Khaw Boon Wan: Sir, both questions pertain to alleged illegal organ trading transactions in Singapore. As the case is before the courts and further investigations are still on-going, I should not comment on them. After the case has been fully wrapped up, my Ministry will review existing measures and fix any inadequacy.

Let me instead discuss this subject generally to outline the extent of the problem, our current approach and our strategy going forward.

End stage renal disease (ESRD) or kidney failure is a dreadful disease. Every year, about 1,000 new cases are diagnosed here. 38% of the patients will not survive the first year given the severity of their illness. For the remaining 600 patients, the treatment options are limited: either a kidney transplant or life-long kidney dialysis.

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Kidney transplant is the preferred option as patients’ life expectancy is longer and their quality of life is better as the transplanted patients do not have to be hooked on to a dialysis machine for a significant portion of their life. But kidney transplant is a major operation with its attendant risk. Old age and other co-morbidity of the patient can significantly increase the surgical risk to the patient and reduce the chance of a successful transplant. That is why only about a third of the 600 new patients, ie, 200, are suitable for kidney transplant and can potentially benefit from the transplant option. The other 400 new patients will have to depend on kidney dialysis.

Donated kidneys come from two sources: deceased donors and live donors. Like the rest of the world, we have worked to increase the kidney transplant rate. While we are not yet getting 200 kidney transplants a year, we have raised our transplant rate quite significantly. We are now about 50% sufficient, which is not bad as compared to many other countries. This is a result of our adopting the Human Organ Transplant Act (HOTA) based on presumed consent in 1987, 21 years ago, and our more recent efforts to promote living donor organ transplants. HOTA now contributes about 50 kidneys a year and living-related kidneys another 30, for a total of 80 kidneys a year. Another 20 Singaporeans go overseas for kidney transplant annually.

We can expect our kidney transplant rate to continue to grow. First, from next month, HOTA will be extended to cover Muslims. Second, the living-related kidney transplant rate has been rising and with greater awareness and understanding, should go up further.

There is scope to raise both cadaveric and living donor transplant rates, and this is what we will do. Currently, HOTA sets an age limit of 60 years on cadaveric donors. This is an arbitrary limit and has

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unnecessarily put many organs to waste. Many countries, including Spain, do not set such an age limit. The suitability of the organ depends on its condition, rather than the age of the donor. The condition of the kidney can be determined by the transplant doctor and that should be the criterion for determining if an organ is suitable. We shall remove the HOTA age limit to help save many more lives. We will need to amend HOTA and when I bring the Bill to this House, I hope to get the full support of Members for this initiative.

For living-related kidney donation, there are often family members who wish to donate to their loved ones but their tissues do not match well. Some hospitals in the US and Europe have shown that with proactive coordination, "pair-matched donations" can be done. This means matching a donor whose tissue is incompatible with the intended patient with another pair or even pairs in a similar situation. This has not yet been done in Singapore. My Ministry is working on this idea so that we can meet the altruistic wishes of such living-related donors. We will set up a live-donor registry to facilitate this. This may require the legal backing of HOTA and, if so, we shall amend HOTA accordingly.

With these two additional initiatives, we can aim to raise our sufficiency level from 50% to 70% in the medium term.

Dr Lam Pin Min asked whether we will consider legalising the ethical sale of organs in the near future. This is controversial and the current public debate shows that Singaporeans hold strong views both for and against. Moral and ethical issues aside, there are major practical concerns over legalising the sale of kidneys. Would it result in more or fewer kidney transplants?

Would it shrink the current cadaveric and living altruistic donor pool of organs? Some studies have shown that with a system for paying

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organs in place, the altruistic donations may simply dry up. In Iran, where trading of organs is legalised, the transplant rate remains low and the claim, that it has eliminated its kidney waiting list, has not been substantiated by independent studies. According to the WHO, the only two countries almost self-sufficient in kidneys are Spain and Norway. Both of these countries have successful altruistic organ donation systems built up through years of sustained public education. In Singapore, we have not yet maximised the yield through altruistic organ donations. Let us emulate them and push altruistic organ donations to their maximum potential.

With or without legalising kidney trading, HOTA and living-related kidney donations must be the predominant sources of kidney transplantation. But if altruistic kidney donations cannot fully meet demand, we should continue to search for good complementary solutions. We should not reject any idea just because it is radical or controversial. By forcing ourselves to think about unconventional approaches, we may be able to find an acceptable way to allow a meaningful compensation for some living-unrelated kidney donors, without breaching ethical principles or hurting the sensitivities of others.

Occasionally, I receive requests from some charities and religious bodies which wish to provide some compensation, in kind and in cash, for the organ donors and their families, to acknowledge their altruistic act. But they worry that this may be construed as organ-trading and they may be breaching the HOTA rules. My view is that we should encourage third parties, especially those from the charity and religious sector, to help promote altruistic organ donations, and that we should consider how they can be allowed to provide some financial

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compensation to the donors and their families after the transplants have taken place. My Ministry will study whether such an idea is feasible and, if so, whether HOTA needs to be amended to facilitate its implementation.

Meanwhile, the reality is that we have not fully met the demand for kidneys and there are desperate patients out there wishing to live and desperately poor people willing to exchange a kidney for a hopefully improved life. While countries and ethicists proclaim that organ trading is illegal and immoral, a black market of illegal transplants flourishes in many countries, and not just in Asia, with poor clinical results for many patients and exploitation of many in poverty. This is the stark reality and the human dilemma confronted by many in such desperate situations. We must therefore take a practical approach. Criminalising organ trading does not eliminate it. But it merely breeds a black market with the middleman creaming off the bulk of the compensation which the grateful patient is willing to offer the donor.

Prof. Arthur Lim, a senior doctor and a past President of the Singapore Medical Association, argued eloquently in a letter to the Straits Times just last week that organ-trading "laws should be removed or amended to take into account the desperate circumstances of dying kidney patients." While they have breached the technical aspects of the law, Prof. Arthur Lim argued that "It is wrong to consider them criminals ..... ­In the same way, kidney donors should be supported and not regarded as criminals." He appealed to Singaporeans to think over this important issue carefully, knowing that it is complex. He hoped that Singapore "will not go down in history as a nation with no support and empathy for those who are dying from kidney failure.".

As the practical problem of organ shortage grows, attitude towards com

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pensating kidney donors is gradually changing, and not just in Singapore. Prof. Gary Becker, Professor of Economics and Sociology and Senior Fellow at the Hoover Institution, published an article recently, entitled: "Should the purchase and sale of organs for transplant surgery be permitted?" Prof. Becker won the 1992 Nobel Prize in Economics and he studied the applications of economics to social policies. I would suggest to our media to publish this article of his so that more Singaporeans can be informed of this school of thought. The academic ethicists and medical doctors may be against the sale of organs, but the economists have analysed the problem from a practical perspective, which deserves to be considered. In the article, Prof. Becker carefully weighed the pros and cons and came to this conclusion: "My conclusion is that markets in organs are the best available way to enable persons with defective organs to get transplants much more quickly than under the present system. I do not find compelling the arguments against allowing the sale of organs, especially when weighed against the number of lives that would be saved by the increased supply stimulated by financial incentives."

On the part of my Ministry, even as we take action against those involved in illicit organ trading and unscrupulously exploiting the desperate and the vulnerable, we will take a sympathetic approach to the plight of the exploited donors and the basic instinct of kidney failure patients to try to live.

Mdm Halimah Yacob (Jurong): Sir, I have three supplementary questions for the Minister. I would like to welcome the two initiatives that the Minister has mentioned that will help to increase the number of donors available for transplants.

(1) The Minister has not answered this question but I think it is still a pertinent

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one, especially since we still have the current legal framework in place – will the Ministry consider setting up an independent Ethics Committee to assess donations of kidneys by non-related donors and recipients? One of the difficulties is that of getting the hospital ethics committee to be able to effectively assess whether there is a genuine relationship, especially when we have non-related donors and recipients.

(2) I think the premise of wanting to legalise organ-trading is that it would eliminate the black market, but as the Iranian situation shows us, even with a legal market, under-the-table arrangements and payments cannot be eliminated. It still prevails. How confident are we, even as we consider this as part of the debate and on-going discussion, that this area will be addressed?

(3) Sir, may I ask the Minister whether we are focusing on the right issues? As we know, there is a huge number of Singaporeans suffering from diabetes and hypertension which are contributing factors to renal failure. Instead of just focusing on organ transplants, should we not be focusing more on prevention at the primary care level to prevent people from contracting these chronic diseases? And if indeed they have contracted them, should we not be spending more efforts in preventing their conditions from worsening, in other words, address the pipeline issue that contributes to the growing numbers of renal failure cases?

Mr Khaw Boon Wan: Sir, I thank the Member for her support in advance of the proposed HOTA Amendments which I will bring to this House. I agree totally with the Member on prevention as the best approach, going forward. But no matter how hard we try on this front – and we will push it to the limit – patients will still fall sick and there will be kidney-failure patients. Our end-stage renal failure rate is high, as compared to other populations.

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So there is scope for us to bring it down further. But no matter how hard we try on this front, there will still be patients with kidney failure and we have to seriously think about how to manage those kidney-failure patients.

On the existence of a black market in Iran, that is a model that we will study because, currently, this is the only country that legalises it. They themselves admit that their solution is not perfect. That is why this topic needs a fairly deep study. It is not something that I will bring to this House immediately, certainly not this year, but the more we discuss the practical difficulties of pushing this front, the more we may be able to find better solutions out of it. The stark reality remains that a black market exists in this part of the world and, as I have said, not only this part of the world but in Europe as well. I was having a conversation with a transplant surgeon from the UK who knows this business very well, so I asked, "Where do desperate British patients with kidney failure go to?" He said, "There are many countries in Europe where such things are happening." Ethical concerns, I can understand. To me, the biggest concern about the ethics of this activity is the exploitation that is going on. But if we apply our minds, if we do not shut off our minds to options like this, I hope to be able to find practical solutions that can minimise or even eliminate the exploitation. Is that not a better outcome than the current situation?

Mr Speaker: Dr Lam. Keep your question short, please.

Dr Lam Pin Min (Ang Mo Kio): Sir, I would like to thank the Minister for the comprehensive reply. I have three supplementary questions.

(1) Under the current HOTA for altruistic living organ donations, is there a

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provision for employers to provide the necessary support to the donors in terms of paid leave or even extended medical leave? If not, would it not be useful to mandate donor-employer support so as to minimise the sufferings and sacrifices of these living donors?

(2) By increasing the age limit of donor organ above the age of 60, is there any study to indicate the survivability of such organs; and

(3) What is the cost of dialysis per patient per year? Will the legalisation of a kidney white market result in significant cost savings and better usage of limited medical resources, in addition to the alleviation of pain and sufferings among kidney-failure patients?

Mr Khaw Boon Wan: Sir, the lifting of age limit is something that is common in many countries. Our setting this arbitrary limit of 60 is quite unique. I remember the history to this. We were breaking new grounds with a presumed consent legislation, so for conservative reasons, my predecessor decided to set this age limit of 60. We can certainly study the survivability or success of kidney transplants in other countries where elderly donors are involved. But the fact that in Norway and Spain, for example, many donors are above 60 and their population life expectancy is not worse than ours suggests that this is a very viable and practical option, going forward.

As for employer support, this is not covered under HOTA. My understanding is that employers are generally supportive of employees who are donors, including insurers. I have checked on this point before, for example, whether insurance premiums of donors will be affected, and the answer is "No".

I think I missed an earlier question from Mdm Halimah, which was on hospital Ethics Committee, and whether

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we should set up other ethics committees to just look at unrelated organ donors. Our system is not unique. We have a National Ethics Committee which provides guidance to the various hospital ethics committees, but we leave the decisions at the ground level to the hospital ethics committee. It is their job to assess carefully the donors. There are two things they have to look out for:

(1) Are the donors well informed about the risks that they are going into; and

(2) Are they being pressured by financial considerations?

That is the arrangement we have in Singapore, which is also the system elsewhere. If we bring it to the Ministry of Health to perform such a role, can we do a better job? I am not so sure. I spent many years running hospitals and I am used to listening to the talks in the doctors' lounge or in the corridors, and often you get better information at the hospital grounds than far away at the Ministry headquarters. So whether there are unethical practices happening on the ground, if you bring the committee to a level which is much more remote from the ground, I do not think we are improving the situation.