HUMAN ORGAN TRANSPLANT (AMENDMENT) BILL

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

4.15 pm

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

In 1987, this House, with the recommendations of a parliamentary Select Committee, moved the Human Organ Transplant Act (HOTA) after two days of debate. The debate in the House was, in turn, preceded by 12 months of public discussion and consultation, involving many stakeholders, religious bodies, professional groups, doctors and

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patients. The extensive public debate was necessary as we were then breaking new ground over the sensitive and emotional subjects of organ donation, organ transplantation, brain death and the concept of presumed consent.

Prior to HOTA, organ donation was done solely through the Medical (Therapy, Education and Research) Act of 1972, or MTERA, which allowed Singaporeans to pledge their organs through an opt-in system. However, globally, the experience with opt-in systems is that they have not been effective in saving many lives through cadaveric organ transplant.

Our experience with HOTA provides a good illustration. Prior to HOTA, the number of cadaveric kidney transplantations was only five per year, on average. With the introduction of HOTA, and especially after its amendment in 2004, the rate has gone up 10 times, saving the lives, on average, of 48 kidney patients every year, about one a week. Many other patients with liver or heart failure have also been saved. Many more patients have regained their eyesight through cornea transplants.

HOTA saves lives and is an important piece of legislation in our healthcare delivery system. On behalf of the many patients with organ failure, I thank Members for their continuous support of this piece of legislation. Singaporeans, too, support HOTA strongly. HOTA does not take away the freedom of Singaporeans to refuse organ donation for any particular reason. One percent of adult Singaporeans have opted out of HOTA. And we respect their decision.

Inclusion of Muslims

However, HOTA has not been able to bring major benefits to the Muslims, as a deliberate decision was made in 1987 to exclude them from HOTA. This was

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because the Fatwa then required the consent of two waris (paternal next-of-kin, according to Islamic hierarchy) for organ donation to proceed. Even so, the Majlis Ugama Islam Singapura (MUIS) made it clear that organ donation to save lives was permissible under Muslim law. Muslims who wish to donate their organs can do so by making a pledge under MTERA.

Because of the exclusion, Muslim non-pledgers are accorded a lower priority for organ transplant than non-Muslims who have not opted out of HOTA. In similar spirit, Muslims who have pledged their organs under MTERA generally need to wait two years before they are accorded the same priority as those who have not opted out of HOTA, if they made their pledge after the period prescribed in the Act. However, I should clarify that lower priority does not mean that Muslims have not benefited from HOTA. In fact, this morning I was flipping through Berita Harian and the top story was about one Muslim businessman, I think 42 years old with two kids had his life saved. He had liver failure and there was a cadaveric liver which was available. Tissues matched and his life is now saved and he has benefited from HOTA.

Unfortunately, there is a rising number of kidney failure patients among the Muslim Malays. New cases of kidney failure among the Malay population rose from 19% in 2000 to 22% in 2006. In Singapore, the primary cause of kidney failure is diabetes mellitus. According to the 2004 National Health Survey, there was a disproportionately higher number of Malays with diabetes mellitus (11%) compared to, for example, the Chinese population (7%). There is, therefore, a greater burden of kidney failure among Malays. This trend is also evident from the racial breakdown of the national waiting list for kidneys. Malays made up 21% of the total number of patients on the 2007 kidney waiting list, even though

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they formed about 13% of the resident population.

In 2004, MUIS, through the Fatwa Committee, made it easier for Muslims to pledge their organs. But this has not resulted in any significant increase in the number of Muslim pledgers, despite intensive publicity by the Muslim Kidney Action Association and the National Kidney Foundation. Since HOTA was enacted in 1987, there have been about 16,000 Muslim pledgers. In 2007, there were less than 200 pledgers. To date, these pledges have not yielded any organ donations. And this problem of voluntary pledging not producing enough organs for transplant is not unique to the Muslim community or to Singapore. It is observed all over the world - the US, UK, Spain, Europe. It is all the same. Some of you may have read that right now, the UK is going through a major public consultation,finally thinking seriously about enacting a similar legislation as ours of presumed consent, ie, the opting-out system.

When HOTA was amended in 2004, several Members asked if MUIS could review its position on HOTA to bring the disadvantaged position of the Muslim community up to par with the rest of Singaporeans. I remember SMS Zainul Abidin Rasheed stressing a point that "The disadvantages of (Muslims) being out of the system are real and the Malay-Muslims as a community cannot afford to let this continue."

In 2006, MUIS embarked on a series of public education campaigns concerning organ donation and the religious issues surrounding organ donation. While there were some concerns on the practical aspects of transplantation, the Muslim community generally voiced their acceptance of the permissibility of organ donation from a religious perspective, and

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supported the move to increase the number of Muslim donors. In parallel, the Fatwa Committee launched a review of the Fatwa on organ donation. The review eventually led to a new Fatwa being issued in July 2007, making it permissible for Muslims to be covered under HOTA.

With the new Fatwa , we are now in a position to amend HOTA to include Muslims like the rest of the Singaporeans. This is a significant achievement, both for the Muslim community as well as for Singapore.

The main objective of this Bill which is now before the House is to bring this about. Technically, the Bill itself is relatively straightforward as it merely removes the current exclusion clauses of HOTA. Accordingly, clauses 2, 3 and 8 of the Bill expand the target population under HOTA to now include Muslims.

With the inclusion of Muslims under HOTA, Muslims who do not opt out of HOTA will be accorded the same priority as other Singaporeans who have not opted out of HOTA. Muslims who have already pledged their organs under the Medical (Therapy, Research and Education) Act will also be placed in this group and receive the same priority. This will level the playing field for all Singaporeans who are in need of an organ transplant.

_Enforcement Powers
_

I am also taking this opportunity to amend HOTA, through clauses 4 to 7 of the Bill, to provide my Ministry with the necessary enforcement powers to investigate any offence under HOTA.

HOTA includes regulations on living donor organ transplantation to safeguard the well-being of the donor and ensure that he was not under any form of duress or coercion to donate his organs. HOTA also prohibits any trading in organs and blood as it is deemed unethical.

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My Ministry currently relies on the Police to investigate such offences as we lack the power to do so. The proposed amendment would allow my Ministry to appoint inspectors and provide them with the appropriate investigative powers, which would enable them to look into complaints and conduct investigations in a timely manner. We also need to be able to disclose donor or recipient-related information for the purpose of administering and enforcing HOTA, as well as for the purpose of referring complaints regarding any errant medical practitioner to the Singapore Medical Council for any disciplinary action.

_Lifting the Whip
_

Mr Speaker, Sir, as the issues concerning organ removal under the presumed consent framework are ethically and culturally sensitive, I have asked the Whip to be lifted to allow Members to debate and vote on the Bill based on their religious and ethical beliefs.

_Conclusion
_

Although the implementation of these amendments to HOTA will not fully resolve the problem of organ shortage, it will allow more Muslims to have the same chance as others in obtaining a new lease of life through an organ transplant. My Ministry has estimated that about 30 more patients per year may benefit from the proposed amendments to HOTA. I hope the House will join me in giving them this gift of life.

Mr Speaker, Sir, before I end, let me say a few words in Malay.

( In Malay) : [For vernacular speech, please refer to Appendix A.] Sir, for a few years, I was concerned about the problem of kidney failure among Malays. Even though this problem affects all races, Malays are a vulnerable group. The main cause for kidney failure is diabetes.

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Among the races here, Malays have the highest number of diabetes patients, much more as compared to the Chinese. Malays are overly represented in the list of patients awaiting kidney transplants. Before HOTA was introduced, we depended on voluntary organ pledging. But we find that such a scheme is not effective. On average, only five cadaveric kidney transplants were done each year before HOTA began. Now, the average rate of kidney transplants has increased by 10 times. So I am happy that the Fatwa Committee of MUIS, after reviewing the issue, has explained that there is nothing wrong under Islamic law to include Muslims under HOTA. With this explanation, we can now amend HOTA to remove the original exclusion of Malays from HOTA.

With that, we can save more lives, not only those who have kidney failure but also patients with heart or liver failure. I am happy that Muslims have voiced their support for this Bill. Some Malay MPs have helped me to reach out to the Muslims to explain to them this proposed Bill and to get their support. I would like to record my thanks to them. They include the Senior Minister of State for Foreign Affairs, Mr Zainul Abidin Rasheed, Dr Mohamad Maliki Osman, Mdm Halimah Yacob, Mr Zainudin Nordin and Dr Fatimah Lateef.

I hope the House will support this Bill to enable us to save lives.

*Cols. 183-184.

( In English) : Sir, I beg to move.

Question proposed.

4.29 pm

Mdm Halimah Yacob: Mr Speaker, Sir, I rise in support of this Bill.

This Bill makes a very important and significant change. After 21 years,

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Muslims will now be covered under HOTA. Instead of opting in, like other Singaporeans, we will now be automatically covered unless we decide to opt out.

When HOTA was introduced in 1987, because of the situation that existed then, Muslims were excluded from the ambit of the Act. The situation today has changed. Our experience with a voluntary system of opting in has not worked. It is indeed a dismal failure. To date, Muslims make up 21% of the 600 patients in Singapore who are waiting for an organ transplant but account for only 2% of patients who actually receive an organ transplant. Only Muslims who have opted in have the same priority as other Singaporeans who have not opted out of HOTA.

Hence, Muslim kidney patients have a much, much longer waiting time compared to other Singaporeans. Despite the larger percentage of Muslim patients waiting for a kidney, the number of Muslims who have pledged their kidneys is very small - only 16,000 have pledged their kidneys so far. The status quo is therefore untenable and has to change so that more lives could be saved. The change will result in a possible inclusion of 300,000 eligible adult Muslims in Singapore.

Indeed, this is the raison d'etre why Islam allowed organ transplants in the first place. Muslims need not have any doubt or concerns over this issue. Organ transplants are already widely accepted and practised in the Muslim world. In Singapore, MUIS had long ago allowed Muslims to donate their organs. The only issue that remained was whether the support of the waris of the deceased is required before the organ transplant can take place. The Fatwa issued by MUIS last year paved the way for Muslims to be included under HOTA. Under this Fatwa , there is presumed consent on the part of

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the waris . Saving the life of another human being is a philanthropic and unselfish act that is much encouraged by Islam. For those who have serious objections, they could, like other Singaporeans, opt out if they wish to. In the absence of any opting out by the person, then the family should respect the deceased person's wish to donate his organs after death.

Despite the clear Fatwa and the pervasive practice in many Muslim countries, we cannot expect 100% support as there are bound to be some in the community who may continue to harbour some doubts. Hence, it is important that we continue to engage them. However, the response from the Muslim community, based on the feedback received arising from the extensive consultations that the Ministry of Health had with Malay/Muslim grassroots leaders and Malay/Muslim organisations, have been very positive. Malay/Muslim leaders strongly supported the move as they realise that not changing the status quo only means greater hardship and pain for those who are suffering from kidney failure. What is more important is that there is also overwhelming support from the Islamic religious leaders in Singapore. We thank them for their continued support and role in helping us to explain to the Muslim community which has helped to instill greater confidence in HOTA.

Based on the feedback received, some had raised doubts over when death is deemed to have taken place. This is also, I think, an issue that was debated at the time when HOTA was introduced way back in 1987. It is internationally accepted by expert medical groups that death occurs when brain death takes place. I would also like to quote from the decision of the Council of Islamic Fiqih Academy of the OIC (Organisation of Islamic Countries) which, in its 44th session in Jeddah in Saudi Arabia in

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1988, ruled that "death" may take two forms: (a) when all functions of the brain come to a complete stop, and no medical cure can reverse the situation; and (b) when the heart and respiration come to a stop and no medical cure can reverse the situation.

Despite the accepted legal definition of death as covering a situation where a person is brain dead, the case, which occurred last year involving the late Mr Sim Tee Hua, serves to remind us that despite the presence of HOTA, we need to continue to educate people about HOTA and issues such as when brain death takes place. Also, we have to continue to deal with individual cases at the hospital level very sensitively. It is, therefore, important that hospitals adopt protocols to equip doctors and other healthcare personnel with the appropriate knowledge, skill and sensitivity in dealing with the family members of the deceased, so as to minimise conflict. At the same time, it is equally important that family members respect the wishes of the organ donor who by not opting out clearly wanted his or her organs to be put to good use after death.

Mr Speaker, Sir, the other aspect, which the Bill seeks to cover, is to vest the MOH with enforcement powers. This will enable the MOH to investigate any offence under the Act. This is an important amendment, as organ trading is believed to be on the increase. This prompted the World Health Assembly to urge governments to take measures to protect the poorest and most vulnerable groups from "transplant tourism". Organ trading is a scourge and should never be allowed to creep into our system. Seen in this light, the new measures introduced under this law will help to prevent abuses and exploitation of the vulnerable and needy in our society and instill integrity in our system.

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On this note, Sir, I support the Bill but please allow me to say a few words in Malay.

( In Malay ): [For vernacular speech, please refer to Appendix A.] Mr Speaker, Sir, I support the amendments that will be made to include Muslims under the Human Organ Transplant Act (HOTA). This is a progressive move and aims to save lives, something that is emphasised in Islam. Around 21% of 600 kidney patients who are waiting to get kidney transplants are Muslims. But only 2% are able to undergo transplant. This is because only someone who has included himself under HOTA will be given the same priority as other Singaporeans.

Our efforts to encourage Muslims to include themselves voluntarily under HOTA have no effect at all, because until today, only 16,000 have pledged their kidneys. With this amendment, 300,000 Muslims will be included under HOTA. I applaud the efforts taken, before this amendment was made, to get the opinions and agreement of Muslims. Such efforts allow Muslims to express their feelings, look at other communities' experiences and get explanations on issues that concern them. In the end, there is a consensus that the benefits are much higher if Muslims are included under HOTA, rather than if they continue to be excluded.

Our efforts to reach out to the community so that they further understand HOTA must be continued. And in this instance, the support of Muslim leaders and religious teachers is important. So far, the explanations given by MUIS, and the support of our religious teachers in providing explanations or assurances to our community, must be appreciated.

Regarding the HOTA amendment, Malay/Muslim bodies and community

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leaders, together with our community, have shown maturity and an open mind that is exemplary, and it shows that we are capable and able to change on issues that are important for the benefit of not only our community, but for the benefit of all Singaporeans.

I support this Amendment Bill.

*Cols. 185-186.

4.39 pm

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

This Bill, Sir, is an essential Bill, first introduced in 1987 as a presumed consent law. Over the years, we have seen the need to evolve the Bill accordingly. This Amendment Bill will help finetune our framework for HOTA, making it more robust and compatible with the evolving trends and determinants of organ need and donation rate in Singapore. Currently, our organ donation rate still lags behind countries such as Spain, the United States and the United Kingdom. We still have a long way to go.

Pertaining to the enforcement action of the Bill, the facts are clearly outlined for compliance. I support the strong signal it will send out to the public. It definitely has to be so, considering the seriousness of the offence if it does happen. Moreover, this deals with the human organs, ethics and the respect for the human body.

For the appointed inspection officers, I hope the Ministry will brief and explain the sensitivity of the circumstances to them when they deal with the issues on the ground. The phrases and the terms as well as the non-verbal communications given out by these officers are very crucial and must not be seen to be offensive to any race, culture or religion.

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Whilst errant practitioners will be dealt with appropriately and, when necessary, all records must be shared, I do hope for the assurance that patient confidentiality issues will not be breached unnecessarily by the officers. This will thus make it important for the inspection officers and inspectors to be briefed on the patient-doctor relationship and what information can and cannot be disclosed under different circumstances.

Despite the strict enforcements, I am also glad to see that allowances have been made for gender considerations. Part IVB, section 15G states that, "no women may be searched except in the presence of a woman officer". These guidelines on the protection of informers as well is also very necessary in addition to this new Amendment Bill. It will provide the reassurance to everyone with relevant information who would like to come forward.

Sir, I would like to say a little bit about the consent age. Currently, the lower limit for HOTA is 21 years of age. Sir, I would like to ask the Ministry to review and consider whether it would be necessary to lower this to 18 years of age. I suggest this because our driving and riding cut-off age group is 18 years and most boys are in National Service at 18 years of age where they are legally allowed to make many decisions. Others would probably be in institutions of higher learning or would already have started working by 18. I would like to ask the Ministry if it has been doing any calculations or mathematics to see how many more organs we are likely to get with the lowering of the cut-off age.

On the amendments for the Muslim community, including them under HOTA means more than just saving lives. It is a significant step forward indeed. It reflects just one of the many achievements and contributions of the community over the years. It also shows the willingness to

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change and adapt accordingly to circumstances with the objective of showing compassion to those in need, regardless of race, language, religion and background. In my opinion, there are two main factors which are essential in making everyone, not just the Muslims, understand and support HOTA even further. The first point is that we must not let up in promoting awareness and understanding. We must never slacken even after the initial hue and cry period is over. Sustained long-term education is indeed the way forward. The second point is that the handling of the situation itself has to be comprehensive and a complete package, which means we have to look into the medical and procedural aspects of organ donation as well as the emotional, social and other related issues on the matter; streamlining the process flow, making it a little easier for the grieving relatives, shortening the timing to the most minimum necessary. Sir, all these will help facilitate HOTA and, of course, we will get the buy-in. It will also instill full confidence amongst Singaporeans on HOTA.

Sir, I would like to continue to speak in Malay.

( In Malay) : [For vernacular speech, please refer to Appendix A.] Many of the Malay/Muslim community fully support this Bill. This is because lives are saved and patients' suffering is alleviated. Every year, about 24 patients die while waiting for a new kidney. The Fatwa Committee of MUIS has clearly stated that our Muslim community can participate in HOTA. During the many dialogue sessions carried out, it was discovered that our community has a lot of feedback.

A number of concerns have been raised, including, firstly, the issue of the surgery that must take place. Secondly, the time needed before the body of the donor is handed over to the next-of-kin. Thirdly, the confirmation of brain death. Fourthly, the condition of the body after

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the organ needed has been removed and how the body is stitched up before it is returned to the next-of-kin. This was questioned thoroughly during the dialogue sessions. Fifthly, the distribution system for patients who need the organ. Lastly, is the cost of removing the organs. Many of them asked whether they should pay this cost to the families concerned. These are the questions that have been raised by our community. Many of these have been answered during the dialogue sessions. However, it will be better for the Ministry of Health to explain to the public, so that more people, who are concerned and hesitant, will come forward.

The rate of diabetes among the Muslim community in Singapore is high compared to the international standard. It is about 11%. Diabetes is the main cause of kidney disease and this continues to increase every day. And this is important, because if HOTA can include our Malay/Muslim community, it will be a concrete and positive step to resolve this kidney problem or the need for this organ.

I suggest that MOH increase publicity on the projected statistics of the Malay/Muslim community's participation in more detail, so that more of them will understand the issues fully. It is expected that we can get five organs or donors every year with the inclusion of the Malay/Muslim community. This will produce about 10 kidneys, 10 corneas, five livers and five hearts. And think about it, this will save lives and will increase the quality of life for more patients.

Lastly, I would like to express my gratitude to the staff of MOH and MUIS on their professionalism and sensitivity when they conducted these HOTA dialogues with the Malay/Muslim community. I am also happy with the support given when I was chairing some of these dialogues. I think many people in the community are now well-versed when debating the issue of Islamic law.

*Cols. 187-188.

4.48

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Prof. Thio Li-ann (Nominated Member): Sir, the premise underlying the "presumed consent" model adopted under section 5 of the Human Organ Transplant Act (HOTA) is that organ transplantation, for treating organ failure, be based on organ donation as a gift.

This rejects treating human organs, after the heart stops or upon "brain death", as a public resource for the State to harvest. This would clash with other human values like the right of individuals to make decisions about their bodies before and after death.

Nonetheless, to more efficiently increase the supply of organs, HOTA rejected the "active consent" model, which removes the difficult task of asking family members for a deceased person's organs.

While the presumed consent model may annoy those who prefer that donation be a positive and conscious act, we must remember that the procedure for opting out of HOTA is relatively straightforward, although it means being placed at the bottom of the recipient waiting list.

Section 14 of HOTA correctly rejects the approach of allowing an individual unrestricted autonomy to contract to buy and sell organs at will. This would lead to the "commodification" of human organs, as anything has the potential, in a market economy, to become a saleable form of property, up for grabs by the highest bidder. A Japanese sociologist calls this treating of the human body as a menu of spare parts for prolonging life the "new cannibalism", which many consider dehumanising.

It is important that HOTA's public health values limit the freedom of contract of living donors, as the poor and

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vulnerable are most likely to fall prey to perverse monetary incentives for self-mutilation and most in need of protection from economic exploitation. We hear horror stories about the black market trade in organs, like people in India selling kidneys to pay for dowries or how a British woman sold a kidney for $50,000 over the Internet to an American to pay off her legal debts. World Health Organisation guidelines urge that human organ transplants not be commercialised.

It is heartening that our domestic laws share this same ethical commitment. Under section 15A, the donation of organs by living persons must be as a gift free from duress, which affirms the vital principle of charity.

It is an offence under HOTA to enter into these prohibited contracts (section 14) to make related advertisements (section 15) and to carry out unauthorised living donor organ transplants (sections 15A, 15C).

Enforcement powers

Sir, the amendment Bill seeks to give more "teeth" in the form of enforcement powers to the relevant actors in investigating these offences.

Under the new Part IVB, inspectors are given broad powers of search and seizure to procure evidence relevant to HOTA offence proceedings. They are authorised under section 15I to arrest without warrant persons reasonably suspected of committing an offence. This entails a deprivation of personal liberty, which Article 9(1) of the Constitution safeguards.

The rule of law demands that administrative actors be held accountable for their exercise of public powers, which should have clear legal limits. In all instances, statutory law should be consistent with constitutional standards,

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as the Constitution is the supreme law of the land.

In this regard, I have some concerns over the meaning and scope of the powers of arrest under new section 15I, in relation to Article 9(4) of the Constitution which constitutionalises the common law writ of habeas corpus .

Bringing before a Magistrate

Section 15(2) states that arrested persons should be produced "without unnecessary delay" before a Magistrate. Standing by itself, no guidance on how to compute "unnecessary delay" is provided.

Article 9(4) of the Constitution requires that an arrested person be produced before a magistrate "without unreasonable delay". I have two queries. First, is the use of the word "unnecessary" delay in HOTA meant to differ from the constitutional standard of "unreasonable" delay? If so, could the Minister elaborate?

Second, Article 9(4) requires that an arrested person be produced before a Magistrate "in any case within 48 hours (excluding the time of any necessary journey)." This puts a ceiling or upper limit on what an "unreasonable delay" might be; a violation of the 48-hour rule could be challenged by judicial review. My question is, does the 48-hour rule also apply to arrests under section 15I clause (1), so as to qualify what an "unnecessary delay" might be under section 15(2), in relation to producing the arrested person before the Magistrate?

In other words, should section 15I(2) be read with section 15I(4) which states persons arrested under section 15I(1)(a) may only be detained in custody for a period not exceeding "48 hours (excluding the time for any necessary journey to the Magistrate's Court)"? If this is the intent,

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it may be better for purposes of clarity to include an express reference to the 48-hour rule in section 15I(2), concerning the time period within which an arrested person must be produced before a Magistrate. Or, should section 15I(2) be read as a stand-alone provision? I hope the Minister can shed some light on this.

Period of detention

Sir, another issue I am unclear about is the length of the permissible period a person arrested under section 15I(1) may be detained in custody. Section 15I(3) says this should not be "for a longer period than is reasonable under the circumstances of the case." Section 15(4) then says that such period of detention "shall not exceed 48 hours".

Does 48 hours then represent the upper limit of a reasonable period of detention? If not, can an arrested person be further detained beyond the initial 48 hours and does the Minister consider that such further detention may be necessary? If detention beyond 48 hours is contemplated, who will authorise this, the executive or judicial branch? Article 9(4) of the Constitution provides that in such cases, there shall be no further detention in custody "without the Magistrate's authority." If HOTA does not envisage a period of detention beyond 48 hours, I hope the Minister can confirm this or otherwise clarify who will authorise further detention.

Extension of HOTA regime to Muslim community

Sir, the amendments to HOTA today have been called a "milestone" insofar as the HOTA "presumed consent" regime is extended to the Muslim community, who were previously exempt from it.

I note that in the history of discussions surrounding HOTA, a host of

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bioethical and legal issues have been canvassed. The regulation of human organ transplantation provokes strong emotions as it compels us to face our own mortality and to grapple with a complex calculus of competing interests, such as the public interest in healing the sick, prolonging life and improving quality of living, as against the dignity of bodily integrity in life and death.

This Bill makes us face the issue of how to formulate and renovate the most prudent and ethically responsible policy for procuring cadaveric organs.

In treading carefully into these complex waters, the Government has taken pains to consult extensively. It adopted a gradualist approach towards extending HOTA, first, in terms of including other organs besides kidneys like the liver, heart and corneas, and, now, in broadening the class of persons HOTA applies to.

From forbidden to permissible to encouraged

It is apparent from the series of fatwas on human organ donation issued by the Islamic Religious Council or MUIS that what was once considered forbidden under Islamic law was later considered permissible to save life in cases of dire necessity and now even encouraged as an act of charity. The issue of ownership of the deceased's body as belonging to the guardians of the estate or waris and the need for their consent grounded religious objections against the presumed consent model.

From the perspective of public health policy, the problem is that patient demand for organ transplants far exceeds donor supply. In particular, the mainly Muslim Malay community suffers a disproportionate incidence of organ failure.

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At its inception, the HOTA provisions relating to the removal of organs after death applied to all Singaporeans and Permanent Residents between 21 and 60. An exception was carved out for Muslims on the basis of religious objection. The then Minister of State for Health said in 1987 that the "Islamic religion specifically prohibits organ donation under the presumed consent system". Nonetheless, it was recognised that "Islam does permit donation of kidneys if it is to save lives". Individual Muslims had the liberty to opt in and actively pledge to donate their organs under the 1972 Medical (Therapy Education and Research) Act (MTERA) for the purposes of immediate transplant rather than storage, under certain MUIS stipulated conditions. Practically, this placed Muslim donors on an equal standing with those who did not opt out of HOTA and who enjoyed priority over those who opted out.

Thus, organ allocation under HOTA is not strictly based on need but on a principle of fairness and reciprocity, that those who give should be the first in line to receive.

However, the Minister also noted in 1987 that the "active consent" model under MTERA had been a "dismal failure", which was why HOTA adopted a "presumed consent" approach.

In July 2007, the MUIS Fatwa Committee issued a fatwa stating it was permissible for Muslims to come under HOTA, to ensure that Muslims suffering organ failure had enhanced access to donated organs. This is consistent with the principle of saving lives and the fatwa presumably played a crucial role in "green-lighting" the extension of HOTA to Muslims.

Under the 2008 amendment, section 5(2)(f) of HOTA will be deleted. This is a religious exemption excluding Muslims from the operation of section 5 which

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provides for organ removal after death by designated hospital officers for transplant purposes.

Muslims are now placed under the same general regime of presumed consent as every other citizen and PR. In addition to yielding more donor organs, the scheme increases the prospects of Muslim patients in receiving donor organs, by placing them in the top priority group, unless they opt out of HOTA.

Sir, the extension of the HOTA regime to Muslims implicates matters relating to our constitutional order and more practical concerns.

This amendment is a significant policy shift; how this was arrived at sheds lights on three aspects of constitutional practice in relation to the model of religious liberty and religious pluralism Singapore has adopted.

First, it speaks to how the interests of a religious minority are safeguarded under the Singapore model of secular democracy; second, to the general inter-relationship between State and religion; and, third, to the relationship between a religious community and its individual members.

Article 152 and racial and religious minorities

Sir, human organ transplantation raises religious, cultural and personal concerns. The process by which the Muslim community was consulted in this regard indicates how the State treats a religious minority.

It implicates the practical operation of Article 152 of the Constitution, which obliges the Government to constantly care for the interests of racial and religious minorities and especially, to safeguard the socio-cultural interests of Malays as the recognised indigenous people.

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Within a deliberative democracy, giving due attention to different interests is part of rational, responsible policy development. Thus, Muslims were originally exempted from HOTA out of deference to their religious teachings.

This departure from the rule of law principle that the law applies to all citizens with equal force is justified as the Constitution mandates a limited degree of legal pluralism. Under Article 153, Parliament is authorised to enact law to regulate Muslim religious and personal affairs, and did so in the form of the Administration of Muslim Law Act. The Government has also sought to accommodate the concerns of the Muslim community in other matters like the Compulsory Education Act, for example.

Sir, by not imposing a uniform "one size fits all" model on the Muslim community when HOTA was introduced in 1987, the Government showed that it does take religious sensitivities seriously in formulating law and policy. Indeed, a Muslim MP in 1987 said it was proper to exclude Muslims from the HOTA presumed consent model as this was in accordance with Muslim law.

Within the Muslim community, with MUIS as the chief representative organ, the issue of human organ procurement and transplants has been the subject of review. In 1973, a MUIS fatwa stated it was not permissible to donate one's kidneys to another kidney patient by will.

Today, the jurisprudence has evolved, in the light of changing social needs and advanced medical technology that made organ transplant a viable form of medical treatment. It is now considered permissible because it serves a pressing, grave need and helps save lives. Organ donation blesses the donor, whose

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continuing donation will yield rewards in the afterlife, and the recipient, whose suffering is alleviated.

It is good that the Muslim community and their religious leaders enjoyed the autonomy to work out the tenets of their belief system, to demonstrate the relevance of a living faith and how this applies to novel situations, without forsaking the integrity of basic beliefs.

This is both prudent politics and shows fidelity to constitutional obligation under Article 152. Article 153 of the Constitution also recognises the right of religious groups to manage their own religious affairs.

_The relationship between State and religion
_

Sir, while it is sometimes appropriate for the State and religion to co-operate, there are instances where the State must keep out of religion. In particular, the Government must recognise the limits of its jurisdiction and competence and not presume to interpret religious or theological questions. This would be an egregious violation of religious freedom as the State has no business determining religious orthodoxy.

This is consistent with the principle of secular limited government which recognises the co-existence of two distinct realms, the sacred and the secular, such that Caesar should not usurp the realm of God and vice versa. This speaks to the broader issue of religion-State relations and the model of secularism Singapore espouses.

The Government has consistently and wisely rejected a militant form of secularism which is anti-theistic and regards religious faith with hostility. Our version of secularism views religion as a constructive social force and respects it

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as an important source of identity for the majority of Singaporeans professing a religious faith.

The Government, in engaging with the Muslim community, through consultation and dialogue over the issue of organ transplants, displayed respect for the autonomy of religious communities. It did not ride roughshod over religious reservations but provided space for the community to determine the issue internally.

Freedom of individual conscience

Sir, it is highly unlikely that views within any one religious community are unanimous. While the Constitution enjoins the state to respect religious group autonomy, Article 15(1) also safeguards the religious freedom of each individual within a religious community. While the Government can regulate external manifestations of religious practice and propagation, it cannot invade the internal dimension of religious profession or belief. Indeed, the Court of Appeal in 1999 stated that Singapore practised a form of "accommodative secularism" which sought to remove restrictions to an individual's choice of religious belief, or unbelief, I might add.

Ideological diversity in religion and philosophy is integral to a free society and rests on protecting the sanctity of a free conscience. Part of the freedom to believe in any faith includes the freedom to work out how that religious belief shapes our choices. This includes acting out of personal conviction with regard to how we discharge our duty towards the Creator, which may involve how we wish our bodies to be handled when we have shuffled off our mortal coil.

As James Madison, the fourth US President opined, duties owed to God preceded the claims of Civil Society as "Before any man can be considered as a

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member of Civil Society, he must be considered as a subject of the Governor of the Universe."

So, too, this round of HOTA amendments respects the principle of freedom of individual conscience which is central to religious liberty. Matters of conscience belong to the individual, not to any group or the State. Muslims who continue to feel unease towards the HOTA presumed consent scheme retain the option, like any other Singaporean, to opt out under section 9, whereupon their names will be entered into a register of objectors which the public cannot inspect. While HOTA operates on the basis of a default presumption of consent, the State cannot and does not take away our choice in this regard.

Under HOTA, Muslims are able to participate in mainstream society in relation to organ transplants. This should strengthen the sense of solidarity in our common identity and destiny as Singaporeans.

However, I am unclear about whether organs donated by Muslims will go into a common pool for all citizens or not. From the "Fiqh of Organ Transplant and its Application in Singapore" on the MUIS website, it is clear that Muslim organs can be donated to non-Muslims, but does this work the other way round? Can a Muslim receive an organ from a non-Muslim?

Practical matters

Sir, on a more practical note, how can we ensure that the Muslim community at large, which includes non-Malays, is fully informed about the implications of these HOTA amendments? The issues must be explained clearly in the relevant languages, and the opting-out procedure must be simple and accessible. Presumably, they will be notified by mail in the same way those turning 21 are notified, but is this sufficient?

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The MOH website provides much relevant information. However, since HOTA is being applied to the Muslim community for the first time, not all of whom may be Internet-savvy, does the Government have plans to ensure that those with questions about organ donation, both medical and religious, have someone to talk to?

I also note that the opt-out form is available on the MOH website but has to be posted - in the age of the Internet and e-filing, could we not allow those wanting to opt out to do so electronically, via the Internet?

This ties in with the larger issue of the continuing need for public education, given that every year, the class of people subject to the HOTA regime changes as people turn 21 or 61, or assume citizenship.

The perennial concern remains that Singaporeans still have not sufficiently grasped the implications of HOTA's presumed consent model, out of ignorance or apathy, such as the fact they can lodge objections for some but not other organs. Will or are separate registers kept for each organ, and will individuals who object, for example, to cornea transplant alone, nonetheless enjoy priority for kidneys?

The reason why calls for further educative and publicity measures keep being reiterated is probably because the message is not getting through sufficiently.

This was demonstrated starkly in February 2007 by the unfortunate incident where the relatives of a dead man pleaded with the Singapore General Hospital staff not to remove his organs. After the incident, I read press reports of a spike in the number of requests for opt-out forms such that hospitals ran out of it. Nothing like bad press to cure apathy.

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Adopting a presumed consent model places the Government under less pressure to conduct a public campaign to encourage organ donation, since that is the default position.

If HOTA's chief purpose was mainly to increase the supply of human organs, the coercive force of the law would suffice to accomplish this. However, HOTA also has the noble purpose of promoting benevolence to others, in building a generous-hearted society.

I hope the Minister can give some assurances that concerted efforts will continue to be made to inform the public about the medical benefits of organ donation and transplants to ensure that they actively support it. For example, could students be informed about these issues as part of their curriculum?

Ultimately, HOTA reminds us that 'no man is an island entire of itself' as John Donne so eloquently put it. We all have the opportunity to demonstrate "compassion" by helping to bear the distress of the suffering, with whom we share a common humanity.

Prof. Thio Li-ann (Nominated Member): 5.08 pm

As human beings, we taste of the same pool of sufferings; perhaps the only thing that makes sorrow bearable is that there can be something redemptive about it, by blessing another out of a tragedy. This is no mere cliche but a fundamental principle and profound spiritual reality.

Naked, we are born into this world and naked, we depart from it. We cannot take anything with us, except the legacy of how we lived our lives. The message behind HOTA is: don't take your organs

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with you - others have need of that which you cannot use anymore. To quote Peter Petrelli, a character from the TV show, Heroes: "Death is the one thing that connects us all. It reminds us that what's really important is who we've touched, how much we've given. It makes us realise that we have to be good to one another."

Madam, I support the amendments.

Mr Zainudin Nordin (Bishan-Toa Payoh): Mdm Deputy Speaker, I rise in support of the amendments proposed, specifically the inclusion of the Muslims under the presumed consent framework of organ transplantation and the provision of enforcement powers to investigate offences under HOTA.

When the Human Organ Transplant Act was introduced more than 20 years ago, Muslims were not automatically included as organ donors. Muslims could, however, choose to opt in and pledge their organs for donation under the Medical (Therapy, Education and Research) Act (MTERA). This option was provided in view of the sensitivity of organ transplantation at that point in time.

Following the recent edict or fatwa by MUIS on Muslim organ donor and transplantation, all apprehension on the matter has been generally lifted and doubts have been widely cleared. More importantly, through extensive dialogues and feedback sessions, we have noticed the positive change in mindset towards organ donation. And with these proposed amendments, we have been presented with a clear path to move forward.

While the scope of HOTA covers vital organs such as our kidney, liver, heart and cornea, I would like to focus on one of the top 10 causes of mortality in Singapore, ie, kidney disease. Kidney disease can lead to kidney failure. It heightens the risk of heart attack, stroke, high blood

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pressure and premature death. It causes anaemia, bone disease and malnutrition. We all know that the escalating prevalence of diabetes and hypertension are some of the common factors that contribute to the increasing incidence of kidney disease. Coupled with the increase in life expectancy, we foresee that a higher percentage of the senior population will be affected by this disease.

A recent study cautions us that by the year 2030, it is estimated that 14% to 15% of the adult Singaporean population will be diabetic. Furthermore, based on some recent statistics, the incidence of end stage kidney failure among the Malays is disproportionately higher than in other races. Of the new cases of end stage kidney failure, 22% were Malays, although we make up only 14% of the total resident population.

The National Health Survey reported that an estimated 11% of Malays have diabetes mellitus compared to 7% of Chinese and 15% of Indians. Diabetes mellitus is the main cause of diabetic neuropathy which results in kidney failure. We know disease patients who are seeking treatment would have to face some tough decisions about the choice of treatment - either haemodialysis, peritoneal dialysis and kidney transplantation. Each treatment has advantages and disadvantages and the choice of treatment will have a big impact on the patient's day-to-day lifestyle.

Although kidney transplantation is the best treatment for kidney failure, in reality, only a small proportion of the patients receive a kidney transplant. Of the total population of kidney failure patients, only 5% to 10% receive a kidney transplant.

Matching a transplant candidate and recipient is complicated due to multiple

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factors including medical and biological profile compatibility. I was told that we currently have about 600 dialysis patients waiting for deceased kidney donor transplant, and the average waiting for a deceased kidney donor transplant in Singapore is seven years. While waiting, patients undergo other treatment options such as haemodialysis.

I mentioned earlier that the choice of treatment will impact the patient's lifestyle. A typical haemodialysis treatment involves three sessions per week, with each session lasting about three to five hours, and treatment is generally done at a VWO-run dialysis centre and in Government or private hospitals. And after each session, patients sometimes suffer from side effects such as hypotension, lightheadedness, nausea, muscle cramps and fatigue.

Apart from the time factor, treatment cost is certainly a concern because unsubsidised haemodialysis is about $80 per day, which comes to about $2,400 per month. This does not include the costs of medication, transport and patient care.

As of end 2007, there are about 2,100 patients on haemodialysis. To help these patients, we need to increase the likelihood of finding a suitable donor and recipient match. And we can do this by having a larger pool of donors and donated organs. This is a proven fact. Prior to HOTA, deceased donor kidney transplantation only averaged five per year and after HOTA, the number increased to about 13 per year.

We have basically tripled the number of lives saved per year and, I think, the Minister has mentioned, it is even more than that. The patients who benefit from organ transplantation came from all races and background. And, hence, it is only fair that all should contribute to help the

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whole community. With the inclusion of Muslims under HOTA, we can expect up to five additional organ donors per year and, as mentioned by Dr Fatimah earlier, yielding up to 10 kidneys, 10 corneas, five livers and five hearts.

Based on records in the year 2006, Malays made up 21% of the total number of patients on the kidney waiting list. However, in the same year, only 16% of the transplanted patients were Malays. Muslims make up 21% of the 600 patients in Singapore who are waiting for an organ transplant but account for only 2% of the patients who actually receive a new organ.

The purpose of the HOTA Amendment will improve this situation by allowing enhanced access for Muslim patients to donated organs, as those who require an organ transplant will enjoy equal priority for organ transplants as all other Singaporeans who have not opted out. By consenting to donate our organs, the Muslim community is showing compassion to all and also, in return, benefit from our support.

Mdm Deputy Speaker, as we debate on this Bill today, I am sure the thing that is top of the mind of all that is present here is the patients placed on the organ waiting list. Here and now, we have a chance to make a difference to their lives. Without even lifting a finger, we have a chance to save lives.

Mdm Deputy Speaker, I support the Bill.

5.15 pm

Dr Ahmad Mohd Magad (Pasir Ris-Punggol): Mdm Deputy Speaker, it has been 20 years since the Human Organ Transplant Act (or HOTA) was instituted for non-Muslim Singaporeans. It has been

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20 years of analysing, discussing and trying to understand the complexities of organ pledging and donation, both from the social and religious point of view. It has been 20 years of trying to cajole and convince Muslim Singaporeans to pledge their organs, in particular their kidneys, through myriad ways.

Madam, 20 years is a very long time, especially when the issue has to be with life and death and to deliberate a worthy change on the subject. For many Muslim kidney patients, it has been 20 years of anguish, suffering and pain and, unfortunately for some, the end of their lives as they waited in vain for a chance of an organ transplant. Just over the last two years, 30 Muslim kidney patients had died. There are stories of recovery and hope for those who underwent transplants but these are few and far between. This is why I believe today is a very important day for Muslim Singaporeans. The Ministry of Health has estimated that 30 more patients will benefit from these changes every year. The changes will not truly solve the problem for organ shortage but more lives will be saved. Assuming the likely passage of this Amendment Bill today, Muslims who did not opt out of HOTA will be on equal footing with other Singaporeans under HOTA, should they ever develop organ disease and need to be put on the waiting list for a transplant.

Fundamentally, there is no doubt about the urgency and relevance of this Bill. I personally feel that this is the only way to go for Muslim Singaporeans as the opt-in system has clearly not yielded the desired results with an estimate of only 16,000 pledgers out of a potential pool of 300,000 Muslims. More than $1 million has been spent on publicity and educational programmes, yet many Muslims who wanted to opt in face problems, such as getting approval from their paternal Muslim male relatives or waris . The Mufti and the Fatwa

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Committee took a cautious approach by making several incremental changes to enable more Muslims to pledge their organs, ending with a fatwa requiring any two Muslim males as witnesses. However, the number of pledgers continued to plunge to the extent that there were only 87 new pledgers in 2006. The process was clearly a stumbling block arising from many cumbersome procedures.

Mdm Deputy Speaker, Islamic jurists from Muslim countries worldwide have long declared organ donation as permissible. However, the issue of presumed consent is different from the opt-in systems that many of these countries have. The presumed consent framework overcomes all these stumbling blocks and makes the process of pledging an easier one. According to MUIS, Singapore is the first country to have a religious edict permitting Muslims to be under a presumed consent system for organ donation. Though it is a long time coming, it is nevertheless a courageous and progressive move reflecting on urgent social needs, the spirit of compassion in Islam and the flexibility in the religion which allows room for change in dire situations, especially where saving of lives is involved. I believe that the issuance of a fatwa on presumed consent will boost up public confidence in this Bill. Another critical factor is also the statement of support from other organisations, such as the Muslim Kidney Action Association (MKAC) and the Singapore Islamic Scholars and Religious Teachers Association (PERGAS). Let me also categorically state my wholehearted support for this life-saving Bill.

The critical nature involving the increasing number of Muslim patients with end stage renal disease makes it imperative that the change be made. This is an issue where religious and community leaders have to show leadership and guide the community to do what is right and

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what is needed without going against the principles of Islam. However, as this is a matter of not just the head but also the heart, it is important that the public is further prepared for such a change.

I am also happy to note that there has not been an outcry or adverse reaction to the fatwa . I hope that this is because people are more aware of the related issues and not that people are resigned to accepting what they think is fait accompli . This brings me to the point on the importance of continued public education and engagement efforts. The passing of this Bill does not signal an end to this but rather a new beginning. I believe there are three groups of people out there - those who say "yes" and support the inclusion in HOTA; the fence-sitters who say "may be" and those who say "no". I would like to urge the MOH and MUIS to continue to engage the public so that we can strengthen the belief of the group that says "yes", address the concerns of the fence-sitters who say "may be" and convince those who say "no". For this to happen effectively, I would like to suggest that HOTA ambassadors be appointed to spearhead the efforts. These ambassadors can be people from different backgrounds - people who have undergone organ transplants, professionals, Malay grassroots leaders and the elderly and housewives who strongly believe in the merits of HOTA.

I would like to highlight the importance of including two specific groups in outreach efforts - they are the Muslim religious teachers and Malay-Muslim doctors. Technical details must be explained clearly and of utmost importance is the stress on the fact that the MOH will respect the sanctity of the dead, as this is a very serious issue for the community. Apart from this, the message of prevention is also important. The public must be advised on the importance of maintaining a healthy lifestyle and how they can help

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themselves in preventing organ diseases from developing.

I would also like to urge MOH to ensure that there are qualified Malay-speaking counsellors with a good understanding of Islam who can advise families in hospitals on the organ transplant procedures when death occurs to a person who has not opted out of HOTA and has organs that are deemed fit for transplant. The language ability and knowledge of Islam will enable such counsellors to advise families with sensitivity and tact, should there be any disagreements or misunderstandings of the system of presumed consent.

Madam, with respect to the provisions in the Bill, I would like to seek clarification from the Minister on empowering MOH officers to conduct investigations of offences under HOTA. I would like to know what would be the differences in approach compared to having investigations done by the Police. I would also like to ask the Minister what would be done to ensure proper training of officers and what checks would be in place to prevent any abuse of power and authority by such officers. As there is a limited supply of organs obtained through cadaveric transplants, I would also like to urge the Ministry to continue to look for ways to promote live organ transplant between family members. While I am against the idea of giving monetary rewards for live organ transplants, as it may be a prelude to organ trading, I would like MOH to consider offering some incentives to encourage live organ donation amongst family members. Perhaps, a donor medal of honour could be considered for living family members who donate their organs as recognition of their sacrifice and bravery. Another possibility is to offer a fully paid life or disability insurance scheme for such donors, or to extend extra leave from

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work that would be paid for by the Government.

Madam, allow me to continue my speech in Malay:

( In Malay ): [For vernacular speech, please refer to Appendix A.] The Malay-Muslim community in Singapore is making history as the first Muslim community in the world that has a fatwa that allows a system of presumed consent for organ transplant. It is a change that should be supported because it will help save lives and increase the quality of life of some organ patients. With this system of presumed consent, Malays with organ diseases in the future do not have to wait too long if they have to be put in the organ transplant list.

It is not contradictory with the nature of Islam that emphasises compassion and gives room for changes through the process of consultation, if there is a dire situation like currently, because it involves someone's life. Apart from issuing a fatwa , the support given by PERGAS shows that what is being done is consistent with Islamic teachings.

However, I was told that there are those who are not convinced or not sure on certain issues, like declaration of brain death, how their organs will be removed, when the body will be buried and such matters. I suggest that a public awareness campaign be launched by the Ministry of Health and MUIS with the cooperation of others, especially the religious teachers and religious leaders in the community. Malay-Muslim doctors also have to play their part because they can bring a different perspective in this issue.

Mdm Deputy Speaker, there are those in the community who always raise the same issue, that is whether the organ from a Muslim body will be used by organ patients who are Muslims. I think such

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view must be changed because it is against the universal value of compassion. Many Malay organ patients have benefited from the organ donation of other races. We do not want to be seen as a community that only receives but does not give. Let the issue of assessment of suitable organ recipients be done by medical experts.

I hope the community will accept this change calmly and not emotionally. If there are those who want to be excluded from HOTA, make the decision after getting the full information about related issues, and not based on emotion and feelings. Those who want to do so must also realise that if they have organ disease in the future, the chance of getting a transplant is very low, because individuals who exclude themselves from HOTA are given less priority in the transplant list. Nobody will know what will happen in the future and the possibility of getting organ disease can happen to anyone and at any time.

With that, I like to urge the Malay-Muslim community of Singapore to give full support towards HOTA and together give support to this noble and compassionate effort.

*Cols. 189-190.

5.27 pm

Assoc. Prof. Dr Yaacob Ibrahim: Mdm Deputy Speaker, I wish to share the Muslim community's perspective and feedback on the issue of including Muslims under the Human Organ Transplant Act, or HOTA.

Outlook of Muslim Singaporeans

Muslim Singaporeans have always adopted a progressive outlook. Over the years, we have responded to the emerging needs of society while staying true to our faith. In line with our Singapore Muslim identity, the Muslim community has also adopted a balanced

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and rational approach in dealing with issues. We dialogue and consult to resolve difficult challenges.

Religious concerns

Over the years, the community has become well aware of the health challenges and suffering of patients who need organ transplants. A higher proportion of Muslims suffer from diabetes, yet very few have opted in under the Medical (Therapy, Education and Research) Act, or MTERA. Muslims are over-represented on the waiting list for organ donations. Very few Muslims who need an organ donation actually get one. And over the years, my colleagues and I have met many Muslims who are open towards donating their organs to help ease the suffering of patients but were not completely sure of the religious permissibility of organ donation. Some believed that the body had to be buried intact. Others felt that their organs were not theirs to donate, believing that, once deceased, their bodies and organs belonged to God. There were others who were uncertain whether the delay in burial resulting from organ donation was allowed.

Muslim religious scholars, through many dialogues and interactions, have assured the community that saving lives is paramount in Islam.

They have clarified misconceptions over concerns, such as burial delays, for example, by explaining that Islam requires that bodies be buried as soon as possible, unless there is a good cause to delay it. Donating organs to save lives is certainly a good cause. The practice of organ transplantation, as pointed out by Mdm Halimah Yacob, is not new, even in Muslim countries. Muslim jurists and academics locally, and from the region and beyond, hold the same view, as can be seen from a seminar convened by a key Malay-Muslim community organisation, Jamiyah, as early as 1994, where they explained in

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great detail the jurisprudential perspectives on the permissibility of organ donation.

Fatwa ruling

The Fatwa Committee, chaired by the Mufti and with leaders from the Muslim religious community, agrees with these Muslim jurists. To help facilitate organ donation by Muslims, the Fatwa Committee has unanimously decided to allow the inclusion of Muslims under HOTA.

Some people, including Dr Ahmad Magad, have asked why this fatwa has only come into being now, after more than 20 years of HOTA. Madam, the fatwa institution is evolutionary in nature, and responds to changes and circumstances to meet the interests and welfare of the community. The fatwa on HOTA has evolved gradually over the last 20 years. During these years, the Fatwa Committee has continued to give the issue of organ donation careful thought and consideration, and assessed the effectiveness of each fatwa over time in meeting the needs of those suffering from organ failure.

Despite the fatwa of 2004 which sought to facilitate organ donation by removing the requirement of consent of waris or next-of-kin, the number of Muslim pledgers has not increased substantially. In fact, there were only 87 new Muslim pledgers in 2006. At the same time, there are still many patients on the waiting list. Some have passed away while waiting for an organ transplant.

Madam, allow me now to explain the process by which we gained support, leading up to the fatwa. To heighten the community's awareness of the issue, senior religious officials from MUIS met

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the community and presented to them the religious perspectives of the issue in three public dialogue sessions in July last year, and discussed the organ donation issue in the sermon during Friday prayers at mosques all over Singapore on 6th July 2007. These were reported extensively in the Malay media, such as Berita Harian , Warna and Suria , and attracted much public discussion, including several calls from the community for the authorities to amend HOTA to include Muslims. MUIS also sought the views of the asatizah community or the religious teachers. The majority were supportive, and some expressed the move as "long overdue". The overall feedback confirmed that the Muslim community was largely supportive of the pressing need for organ donation to save lives.

Islamic virtues, such as ihsan (kindness) and rahmah (compassion), require us to find solutions to problems, to actively help those in pain and save lives. These factors were key to the deliberations on the inclusion of Muslims under HOTA.

In the days following the issuance of the fatwa , MUIS informed me that they received over 50 calls, the majority of whom were supportive of the move. This finding is consistent with the feedback received during public consultation sessions and feedback received via email and telephone. Nevertheless, we do acknowledge that there is a segment, as pointed out by Dr Ahmad Magad, that is not supportive of HOTA, but we cannot afford to wait until everyone is convinced before proceeding. We respect the decision of those who wish to opt out and have made the opt-out forms easily available for them.

Public education

Madam, I would like to reassure Dr Ahmad Magad, Dr Fatimah Lateef, Mdm Halimah Yacob and Prof. Thio Li-ann that

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our public education efforts will not stop should the Bill be passed. Our efforts to help all in the community appreciate the urgency of suffering organ failure patients and understand the need for organ donation will continue, and will be intensified. MUIS is producing an information booklet to address religious matters and will continue to respond actively to all who may have queries. More public dialogues will also be held, and these dialogues will include the asatizahs and the Muslim doctors, as suggested by Dr Ahmad Magad. I also welcome Dr Ahmad's suggestion to implement a HOTA Ambassadors programme to spearhead the public education efforts. I think this is a good idea, and ask that the Ministry of Health and MUIS look into implementing it.

Prof. Thio has also asked the question whether Muslims can receive from or donate organs to non-Muslims. The answer is yes. There are no restrictions in the religion, and Dr Ahmad Magad has also made the same point raised by some people within the community.

Conclusion

Madam, the inclusion of Muslims under HOTA will be a milestone in the progress of the Muslim community. I would like to thank all Members for their support to include Muslims under HOTA. As mentioned by Mr Zainudin Nordin, it reflects a positive change in the mindset of the community. It also shows how Muslims in Singapore are flexible and able to make the necessary changes for the greater good, as pointed out by Dr Fatimah.

The proposed amendment to HOTA is a blessing for the Muslim community and Singapore that will save more people suffering from organ failure. To help make this happen, I sincerely hope that few people will choose to opt out if the Bill is passed. I am pleased to note that

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feedback from our community leaders and members of the public during the consultation sessions has indicated that few people have any intention of doing so.

Madam, the amendment proposed today to include Muslims under HOTA has the support of the Muslim community. It has been a long journey, and the proposal will resolve a long-standing challenge facing the community while at the same time help strengthen the community's resolve to be a dynamic and progressive pillar of the Singaporean society.

Madam, allow me to continue my speech in Malay.

( In Malay) : [For vernacular speech, please refer to Appendix A.] Mdm Deputy Speaker, the problem faced by a patient with a failed organ is not a new issue. I am saddened by newspaper reports about patients who have to wait many years to undergo organ transplant, but have a very slim hope to receive a suitable organ. The hardship of these patients and their families is aggravated by the financial burden and physical difficulty due to their dialysis treatment, making them unable to enjoy a normal life that sometimes we take for granted.

Let us look at the experience of Mr Mohamad Nazel Ahmad. In July last year, Berita Harian brought to our attention the story of Mr Nazel, who is 44 years old with two children. He went through dialysis for 20 years. With an income of only $800 per month, his story showed the difficulty of patients facing organ failure.

A few patients are luckier. Mr Mohd Selamat Mohd Ali, who received a heart donation, had first suffered a heart attack in 1998. Luckily, he was given a new lease of life in 2001, when a Chinese family consented that the heart of their relative who passed away, be donated to

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him. Their consent at that time was by chance only because there was no long-term treatment for heart failure. Mr Mohd Selamat's experience has encouraged members of his family to pledge their organs.

The issue of organ donation is not new. However, I am happy because the Muslim community today has given solid support in this effort to overcome a challenge that we have faced for some time.

We are a progressive community and we do not hesitate to face challenges. We realise how big this challenge is and we welcome effective solutions that are introduced to overcome it. Based on this stand, and supported by advancements in the medical science technology, the MUIS Fatwa Committee has reviewed this issue and allowed the Muslim community to be included in HOTA.

I understand some of them are quite concerned about the issues of organ transplants. We are aware that Islam, in general, forbids us to do things which are against Islamic law, such as disrespecting a dead body. However, Islam allows surgery on a dead body in order to save lives, for example, for post-mortem Caesarian section on a woman who has passed away, in order to save the baby that she was carrying. This is not considered as a mistreatment of a dead body, which is forbidden in Islam. In Singapore, the Ministry of Health ensures that the surgery on the dead body is the same as the surgery on a live patient. The operated dead body is handled properly and respectfully, and the surgery is done carefully. The ethical standard on this organ transplantation will be carefully monitored and reviewed constantly.

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One other major feedback is on the delay in burial so that organ transplant can be done. I am sure that all of us have seen our family members and close friends carry out the process of burial as soon as possible. Some of us are concerned whether the delay in the burial in order to carry out organ transplantation is wrong in Islam. It is true that Islam prohibits us to delay burial without a permissible reason. However, delays done to save human lives are considered a good reason, which is permissible in Islam.

The Government has given due consideration to this feedback. MUIS will work together with the Ministry of Health to overcome such concerns. We will do our best to handle this issue, especially on the aspect of respecting the deceased and expediting the burial procedure as much as possible.

The fatwa which allows organ transplantation is proof that the local Muslim community is a progressive one; a community which wants to play its part to overcome the challenges faced by Singapore; and a community which not only receives, but also gives. This fatwa portrays Singapore Muslims as a community that practises the true spirit of Islam and wants to save the lives of all human beings, regardless of their religion.

I would like to end my speech by expressing my thanks to the Muslim community for their support in the public dialogue sessions, especially those who have assisted the organ failure patients in whatever way.

I am confident that, as a community, we will show our support by choosing not to opt out of HOTA. As Muslims, all of us have a responsibility to save human life and this is the way to prove it. I also hope that all of you will be able to sit with your family and close friends, and urge those who are still doubtful, to support this noble effort to save lives.

*Cols. 191-194.

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5.43 pm

Mr Khaw Boon Wan: Mdm Deputy Speaker, let me thank Minister Yaacob Ibrahim and the Members for their strong support of this Bill.

The Muslim MPs, in particular, have gone all out to help rally support for this Bill. They have not merely stated their stand clearly in this House. They have conducted many dialogue sessions in the mosques and the community centres to help us reach out to the Muslim community to explain what HOTA is all about, how they can save lives by supporting HOTA and that HOTA is not in conflict with their religion.

My Ministry and the many patients with kidney failure are grateful for their support and their tireless efforts, and the efforts to reach out to explain and reassure will continue. As noted by all Members, it is important that we keep up the efforts to improve the public's understanding of organ donation, brain death and presumed consent. These are difficult concepts and I do not think, even with intensified efforts, we can say, "All right, at the end of this year, that's it, we do not have to do it anymore." It is not possible. We have to constantly explain and re-explain, not only because there will be new citizens or new adult Singaporeans who turn 21, but, even for existing people, it requires constant reminders.

My Ministry will work closely with MUIS and Muslim leaders on this effort. As Dr Ahmad Magad put it, we need to strengthen the belief of those who say "Yes", address the concerns of those who say "Maybe", and try to convince those who say "No". Furthermore, we will henceforth no longer need to make the distinction between Muslims and non-Muslims on HOTA. All information dissemination regarding organ donation or HOTA will continue and will appear regularly in our local media. Organ

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donation booklets and opt-out forms will continue to be couriered to every Singaporean citizen and PR when they turn 21 years old. We will continue to partner the Society of Transplantation,

the NKF, the Malay Kidney Action Association and other entities to reach out to Singaporeans on organ donation and HOTA. We will also intensify efforts to reach out to community centres, grassroots organisations, schools, students, colleges and tertiary institutions. Concepts like brain death, presumed consent and the religious implications require regular explanation and a sustained educational effort. It is time-consuming, it is costly, but it is necessary. The more effective we are in this, in easing the fears and concerns of donors and their families, the more lives we can save. Dr Ahmad Magad suggested that we rope in organ recipients, professionals, grassroots leaders and other persons who strongly believe in HOTA as our HOTA ambassadors to help us explain HOTA and to ensure buy-in. Next month, we will refresh our HOTA website to also be a repository of human stories from people whose lives have been changed after receiving the gift of life, and they will be our online HOTA ambassadors.

Meanwhile, we are gearing up to inform the Muslim community about this Bill and its implications. We are preparing 300,000 packages to be individually delivered to all the Muslim citizens and PRs aged 21 to 60. The packages will be comprehensive and easily readable. Each package will contain four things:

(1) a letter informing them that they will soon be included under HOTA unless they opt out;

(2) an information booklet on HOTA describing in detail the implications of being included under HOTA;

(3) a booklet prepared by MUIS explaining why Muslims can now be

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included under HOTA and the Islamic position on organ donation; and

(4) an opt-out form for those who wish to do so.

We have done a similar exercise before, although in a more simplified fashion, when we first introduced HOTA in 1987, and again in 2004 when we amended it to include other organs. Nevertheless, it will still be a massive exercise for us. We estimate that it will take us three months, from February to June to complete it. The actual inclusion of Muslims under HOTA will then commence on 1st August 2008.

Dr Fatimah proposed that we lower the age of HOTA inclusion from 21 to 18. I have also received suggestions from the public to raise the maximum age of 60 as the organs of those dying above 60 are often also suitable for transplantation. But these proposals require further study. Let us concentrate on extending HOTA to the Muslims first as that itself is a major milestone and we want to make sure that it is implemented well, achieving results of saving lives without causing undue worries and concerns to the community. Meanwhile, those who are between 18 and 21, and who wish to make an organ pledge can do so under MTERA.

Mdm Halimah and Dr Fatimah reminded our hospitals to be extra sensitive when approaching organ donation cases and their families. They said that our hospital staff should be well-trained and have relevant communication skills so as to minimise conflicts with the distressed family members. We should also streamline the process flow to make it a little easier for the grieving families. I fully agree. We have had 20 years of such experience, but each incident is a case study for us, to learn and to refine our process. Following the SGH's incident last

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year which Mdm Halimah mentioned, and which Prof. Thio talked about too, we have now made social worker support for the donor family mandatory for every organ donation case. All such family members will receive grief counselling and emotional support. And we have also enhanced the training of the senior doctors who are responsible for giving final authorisation in organ donation cases to further equip them with crisis management skills.

Measures have been put in place to ensure that all doctors who take on this task are well-trained and retrained. We have also sought the assistance of the various religious groups to provide volunteers whom we can call upon to help address any religious concerns that may arise during the organ retrieval process. With the inclusion of Muslims under HOTA, MUIS has agreed to provide religious support to advise Muslim families on the position of Islam on organ donation and HOTA, should the need arise. Hospitals will also rope in doctors and nurses who can better communicate in Bahasa Melayu in this effort. Volunteer HOTA ambassadors are welcome to join in such hospital activities, whenever the need arises.

During the dialogues with the Muslim community, many expressed the concern that any organ transplantation should not unduly delay the release of the body to the family. We took this feedback to heart. We have tightened operational procedures and coordination between hospitals, the Police and the pathologists. We will cut out any unnecessary delay. There was also a request that hospital mortuaries should provide for what it called "washing and shrouding" facilities for the use of the family members. Our hospitals will proceed to set up such facilities in the mortuaries.

Dr Ahmad Magad spoke about living donor organ transplantation and how this

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could augment cadaveric transplantation. Since this House legislated on living organ transplantation in 2004, the number of living organ transplants has risen. There were 111 living organ transplantations last year. My Ministry encourages living organ donation. This is a viable option for many patients but cultural hindrances remain. We will step up patient and professional education efforts. We are supporting a pilot programme to counsel newly diagnosed kidney failure patients on the benefits of living kidney donation so that living donor transplant is considered ahead of dialysis. We do provide some subsidies to live organ recipients to help defray the cost of organ transplantation and long-term immuno-suppressive medication, but we should not unwittingly end up promoting the trading of organs.

The problem of organ shortage is worldwide. Not surprisingly, an international organ trade has emerged, as observed by Mdm Halimah. We should not be a party to it. The beefed-up investigative and enforcement powers in the Bill will further help keep Singapore stay clear of organ trading. Dr Ahmad Magad would like to know the difference between MOH officers conducting investigations under HOTA and the Police conducting such investigations. He has asked what would be done to ensure that MOH's enforcement officers are properly trained. We will ensure that our enforcement officers will receive the necessary training and instruction, both internally and from the Police, so that they can carry out their work professionally. In fact, some of these officers are likely to be ex-Police officers with relevant experience. They will all be closely supervised by a chain of command and be required to carry identification cards which they must produce on demand when exercising their powers. In substance, the change will not differ much from today. The key difference is that we will build up investigation and enforcement capabilities internally within

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the Ministry of Health so that we do not have to rely on the Police which has so many other responsibilities. Hopefully, this will speed up investigation and enforcement.

Dr Fatimah reminded us about being sensitive to patient confidentiality, and we certainly would. Prof. Thio asked how section 15I relates to Article 9 of the Constitution. Certainly, the intention is that we have to be consistent with what is in the Constitution. I am not familiar with legal details to know what does that mean, but certainly, constitutional supremacy must apply here.

Dr Ahmad Magad stressed that even as we amend HOTA to help save lives, the best approach is still prevention, and I cannot agree more. Those who are predisposed to develop kidney failure should actively change their lifestyle and diet. They should start exercising regularly if they have not already done so. They should work with their family GPs, take medication diligently and test their blood sugar and cholesterol regularly. Sorry for this commercial, but it is such an important message that it is worth repeating. Each year in Singapore - and this is a sad figure - there are close to 700 patients who have amputations involving their lower limb as a result of uncontrolled diabetes. That means, every day, two patients lose part of their lower limb because of diabetes which is not well-controlled, but it is largely avoidable. Many more suffer from other complications such as heart disease, stroke and blindness. All these conditions cause unnecessary suffering and loss of productivity. Let us be proactive to reduce such miseries.

Let me thank Prof. Thio for sharing with us her insights on "legal pluralism". It is a new word for me. I learn something today. As a layman, I interpret that to mean that we take a practical approach in

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Singapore. Our laws evolved gradually and take into account that we are a multi-racial and multi-religious society; we cannot simply just apply one law for all. I thank her for giving us a very good account of how HOTA has gradually evolved over the years and, within the Muslim community, how fatwa has evolved over the years in response to the needs of the society, and as we understand the science better.

She also asked whether we could simplify opting out, for example, electronically. I believe our current system of opting out is quite simple and highly simplified, but we will always see whether we could simplify it further. Online opting out has a bit of problem because we do need witnesses to witness the opting out. She also asked how is the distribution of organs organised. For instance, can you opt out of one organ and not for the others? If so, what happens to your priority for each organ? Yes, we manage each individual organ separately as far as organ transplantation is concerned. You can opt out for a cornea or heart, but your priority in other organs which you have not opted out will be unaffected.

She also asked the question about organs being transplanted between races, ie, from Muslims to non-Muslims, or from non-Muslims to Muslims. There is a waiting list for each organ and we have an expert committee formally chaired by Prof. Goh Lee Gan to decide on the priority of distribution. The Committee has, over the years, evolved quite a scientific way of computing points for each of the objective criteria. Relying on memory, there are three important sets of criteria. One, because you want a successful transplantation, ie, to maximise the chance of a successful transplantation so that patients survive and live for a long time. Therefore, tissue matching is

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paramount. Maximum points go to those tissues which match the closest. Second, because of HOTA, those who opted out enjoy lower priority than those who do not opt out. Third is how long the patients have been on the waiting list. Those who have waited longer will have a better chance than those who are still new. So, using this system of scoring, the Committee decides on the patients' priority. Race does not come into it. The example that I gave in my Second Reading speech just now was about a Malay businessman who had a liver which came from a Chinese.

As Mdm Halimah put it, this Bill marks an important and significant change. Muslims will soon be included under HOTA. The change comes too late for some who died while waiting, but better late than never. I thank Members for joining me in this fight to save some more lives "without having even to lift a finger", as Mayor Zainudin put it.

Mdm Deputy Speaker, I beg to move.

Question put, and agreed to.

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

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

Bill considered in Committee.

[

Mr Khaw Boon Wan: ]

The Chairman: The citation year "2007" will be changed to "2008", as indicated in the Order Paper Supplement.

Clauses 1 to 8 inclusive ordered to stand part of the Bill.

Bill reported without amendment; read a Third time and passed.