HUMAN ORGAN TRANSPLANT IN SINGAPORE

HUMAN ORGAN TRANSPLANT IN SINGAPORE:

(Update on status): 2.

Dr Lim Wee Kiak asked the Minister for Health (a) if he will provide an update on the status of organ transplant in Singapore; (b) how many people have benefited from the Human Organ Transplant Act since the opt out system was introduced in 1987; and (c) whether there will be a review on the legalisation of sale of human organs by his Ministry.

Mr Khaw Boon Wan: Sir, the first kidney transplant was carried out in Singapore in 1970. This was 37 years ago. As at the end of last year, 1,778 kidney, 83 liver, 27 heart, 7 lung and 2,356 cornea transplants have been done in Singapore.

The Human Organ Transplant Act (HOTA) was enacted in 1987. So it was 20 years ago. From 1987 until the middle of 2004, 222 patients with kidney failure have benefited from cadaveric kidney transplants under HOTA, giving an average of 13 patients per year. This was an improvement as prior to HOTA, cadaveric kidney transplantation only averaged five per year. So before HOTA, only five lives were saved each year. After HOTA, it almost tripled to 13. In the middle of 2004, HOTA was amended to cover the liver, the heart and the cornea,

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and to include all causes of death. I took this Bill through in this House and I was glad for the full support from the House. From then until the end of last year, 103 kidney patients benefited from cadaveric transplants under the amended HOTA - an average of 41 patients per year, which is a significant increase. So before HOTA, five per year; now, 41 per year - more than an eight-fold increase. So we are saving lives, just for kidneys, almost one per week. In addition, 115 patients have benefited from 11 cadaveric livers, 10 hearts and 94 corneas. HOTA is therefore a very important policy in saving lives.

Nevertheless, there remains a shortage of organs for transplantation. At the beginning of this month, there were 541 patients on the waiting list for kidney, 10 for liver, 2 for lung and 1 for heart. Each year, some patients die while waiting for an organ.

Society as a whole has an interest to increase the supply of donated organs so that such premature deaths can be avoided or reduced. The question is how to achieve such an outcome. On and off, there have been suggestions that organs be traded, ie, be bought and sold, to address the issue of organ shortage. Recently, the idea has again generated much debate among Singaporeans. Some support the concept, citing the effectiveness of such a market mechanism in increasing the supply. However, even from a purely practical point of view, the matter is not so simple. Thus, we have a voluntary blood donation, but not sales of human blood, because allowing sales of human blood encourages the wrong sort of people to come forward. Furthermore, many people, in Singapore and elsewhere, instinctively find the idea of trading human organs degrading and repulsive. Organ trading is not purely an utilitarian issue, but also one that raises very difficult ethical problems. One of these is its likely impact on the poor, both as donors and recipients.

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That is why hardly any country in the world has legalised organ trading, although a grey market often exists. We will continue to monitor developments in other countries, including the feasibility of ethical trading. This is a term used by some people, thinking that trading of organs can be done in an ethical manner. But how is it going to be operationalised has yet to be seen. However, as these difficult problems are not likely to be resolved soon, the Ministry has no plan to change our rule.

Dr Lim Wee Kiak (Sembawang): Sir, I would like to ask the Minister to elaborate or provide us some details on a recent unpleasant commotion that happened between the family members of a brain-dead patient as well as the authorities in one of our public hospitals a few weeks ago. I am wondering what measures will the Ministry be taking to prevent such an occurrence in the future.

Mr Khaw Boon Wan: Dr Lim works in the hospital and he knows that one of the most difficult tasks in running a hospital is to convey bad news, particularly of premature death or sudden death, to family members. But I think more difficult than this task is telling the family members that their loved one has died, the brain has died, and that the organs can be used to save a few lives and that we are going to do so. It is not the easiest of things to do. Very rarely do we have family members who come forward and say, "Yes. Please proceed."

Fortunately, the vast majority of family members are understanding and they accepted the sudden death and they try to compensate for the sudden loss by knowing that, at least, the death will now be able to save a few lives. But occasionally, we do get family members who are probably traumatised by the sudden death, becoming pretty aggressive

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and, sometimes, even abusive. But we try our best to explain, be as patient as we can and as compassionate as we can. But the bottomline is that we need to be firm with this opting out policy and respect the wishes of the dead that they had not opted out of HOTA. HOTA was fully explained. Of course, we will continue to periodically explain it. People have a choice to opt out and if they do not opt out, we assume that they must have had no objection if, upon sudden death, to have their organs used to save lives. It will be good for them and for society at large because if you try to look it from the donor's point of view, do not forget that there are a few hundreds on the waiting list. It is often the luck of the draw. You never know which side you will be on. Will you be a possible donor or a possible recipient? If everybody opted out, then of course, the possibility of saving lives and the opportunity to do so will be reduced.

The key point about our HOTA policy is that it is not compulsory organ donation. We respect the individual's decision. If they want to opt out, no question is asked and we facilitate it. And we respect that because who are we to say that it is right or wrong of them to opt in or to opt out? But we have a job to try to explain to Singaporeans as often and as thoroughly as we can to think about that, upon death, the body is otherwise useless but you can still perform a useful role to save a few lives. And it has happened a few thousand times in the last many years that we have had HOTA.

But we understand that, yes, it is traumatic experience for the family and we try to be as patient and flexible as we can. In this instance, it was rather unfortunate. Of course, the sudden death was traumatising to the family but they knew that the patient had died. They did ask for more time, and often, we allow that. In this instance, the family said, "Please do not go in yet.

Give us another 24 hours", so that they can perform their

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various Taoist rituals. The hospital was flexible and allowed them an extension but explained to them that there was a time limit, because when all the cells had died, there was nothing to talk about in terms of organ donation. Indeed, in this instance, after the 24 hours' extension was given, the liver which was useful was no longer useful. I forgot now how many people are on the liver waiting queue. We prepared the patients and they were waiting for the operation. Unfortunately, we had to go in and say, "Sorry, the liver is now useless." But the kidneys were still useful, and there were two patients being prepared next door. At the appointed time, unfortunately, the family said, "We want more time." But the organs were deteriorating, and if the hospital were to allow more time, then even the kidneys would become useless.

These are the circumstances behind this incident. I do not want to go into further gory details because it may not be fair to the family. I for one can fully understand what sort of trauma they were going through. This person was only 42 years old - sudden death. It is not easy to be put in that kind of situation. Let me come back to the basic point - respect the wishes of the dead. At 42, that means he was around 21 or 22 when HOTA was introduced in this House. I remember there was widespread public debate. He was an educated man and I am sure he was fully aware of HOTA and the fact that he did not opt out means that he wanted to save lives in the event of any sudden death, and I think we should respect his wishes. In this instance, I think it is good for the family that at least two lives and a cornea transplant were able to take place.

We will learn from this to train our staff to be even more sensitive and compassionate in our communication process. But the bottomline is, it is a difficult task to do.

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Dr Lim Wee Kiak: Sir, I want to thank the Minister for the comprehensive explanation. I guess that the most important issue is that of public education. I am wondering whether the Ministry will consider embarking on a publicity campaign to explain the HOTA again. They will have to do it probably in a recurrent manner, almost like a "Celebrate Organ Donation Day" every year. I hope the Ministry can consider this.

Mr Khaw Boon Wan: The answer is yes. We will definitely do so. Our communication experts advise us that this is not the time to re-start. Let the emotions calm down first. But certainly we will have to do it regularly. For Singaporeans turning 21, they receive brochures on HOTA. We batch it twice a year and send out a lot of materials. I know this because my daughter received them when she turned 21. So there are programmes of that kind. But it is a morbid subject. And I know Singaporeans, the majority of them will say, "I don't want to think about it." But from this incident, let us all be wiser after this and learn from this. And bear in mind that it is your wish; we will respect it. But think about this, that upon death, the body is otherwise useless. But it is not that useless, it can still save lives. I think saving lives is still priority.