HUMAN ORGAN TRANSPLANT BILL

Order for Second Reading read. 12.22 pm

The Minister of State for Health (Mr Yeo Cheow Tong) (for the Minister for Health): Mr Speaker, Sir, I will move on behalf of my Minister. Sir, I beg to move, "That the Bill be now read a Second time."

In 1985, 218 Singaporeans died of kidney failure. Many of these people could have been saved if only there were enough cadaveric kidneys available for transplantation. The Human Organ Transplant Bill seeks to do something about this problem.

Kidney disease respects no individual and recognizes no boundaries. It strikes down men and women of all ages and of all races, the rich and the poor, the educated and the illiterate. Many are mothers and fathers of dependent children. Before their illness, they had been working and helping to look after their families.

Treatment for kidney disease is either by dialysis or by transplant. Without treatment, death is inevitable, often within two to five months.

Dialysis is not a suitable treatment for kidney failure. It has to be continued for as long as the patient lives. The patient's life is precarious. He is subject to infections and medical complications. Kidney dialysis is also disruptive. The patient has to be hooked up to a machine three times a week, six hours each time. It invariably leads to loss of employment. Consequently, the whole family is placed under tremendous stress, both emotionally and financially.

Mr Speaker, Sir, transplantation is the treatment of choice for any kidney patient. The success rate for kidney transplants is good and it continues to improve. This is due to proven transplant techniques as well as new drugs which help to reduce tissue rejection. In Singapore, our very first patient to receive a cadaveric kidney transplant is today alive and well. She received her transplant 16 years ago, in 1970. Today, she leads a normal life. All she needs to do is to take three tablets a day, and that is the biggest and most important benefit for kidney transplants. It allows the patient to go back to a normal, active and productive life. The only problem is the lack of cadaveric kidneys for transplantation. For the whole of 1985 we only had one cadaveric kidney transplant. The question is: could we have done better?

Mr Speaker, Sir, every year more than 700 people die as a result of accidents. These lives were unnecessarily lost and wasted. Many of the victims were healthy people and they were in the prime of their lives. But in these tragedies lie a rare opportunity for us to turn a negative event into a positive one. We estimate that between 40 and 45 of these 700 victims of fatal accidents would have been suitable as kidney donors. They could give life to over 80 people each year, people who would have died otherwise of kidney failure.

Recognizing this, we have been encouraging Singaporeans to pledge their kidneys for the past 14 years. The Medical (Therapy, Education and Research) Act of 1972 enables the donations to be made. Unfortunately, it has been a dismal failure. Only 27,000 pledges have been received to date. For the scheme to be successful, we need a total of 800,000 people to pledge their kidneys. But Singapore is not alone. No country in the world has succeeded with this system of active consent for kidney donation. It has been found that people just shy away from thinking about their own possible death. And surveys have shown that even those who are really willing to donate their kidneys have been apathetic about sending in their kidney pledge forms.

Mr Speaker, Sir, we have also tried seeking permission from the families of accident victims at the time of death. Unfortunately, this too has not been successful. The reasons are quite understandable. The family members would be under extreme emotional strain and anguish. It would be very difficult for them, in their moment of extreme grief, to be able to come to a rational decision. It is usually easier to say no.

Mr Speaker, Sir, the existing system has failed. Lives will continue to be lost. It is pointless and wasteful for us to continue in this futile manner.

This is a sad situation, especially since surveys have indicated that Singaporeans generally support the concept of kidney donation. It is acknowledged as a noble, a humane and an admirable act. The major religions have also acknowledged that organ donation is a very laudable act of charity. In fact, several religious leaders in Singapore have recently come out openly in support of organ donation in order to save lives.

Mr Speaker, Sir, as I have mentioned a few minutes ago, Singapore is not alone in its lack of success with the present system of active consent. Europe has also faced similar problems. Consequently, in 1976, the Council of Europe recommended to European countries to gradually modify their organ donation laws towards the presumed consent system. Following this recommendation, 14 European countries have now adopted this system of presumed consent, and they include countries such as France, Italy and Switzerland. Belgium is the latest country to adopt this system, having enacted the relevant laws only in June this year. All these countries are forward-thinking, very enlightened and progressive countries.

The Bill I am presenting this morning is also based on the concept of presumed consent. The Bill seeks to authorize the removal of only the kidneys of victims of fatal accidents for transplant in kidney failure patients. Unless the accident victim had objected to this donation in his life-time, it will be presumed that he had consented to the donation of his kidneys.

Mr Speaker, Sir, the Government is aware of the different cultural backgrounds of our people and of their sensitivities and anxieties. We have therefore put in a great deal of thought in drafting the Bill. Care has been taken to ensure that all issues raised have been addressed and that all possible safeguards and precautions have been taken.

Let me now go into the main features of the Bill.

The Bill affects only victims of fatal accidents who are citizens or permanent residents of Singapore.

Various categories of people have been exempted from this Bill. Firstly, minors under the age of 21 years of age and people of unsound mind are exempted. These people may not realize or they may not be aware of the implications of the Bill. They may not be aware that they have to opt out should they decide that they do not want to donate their kidneys.

People over 60 years of age will also be exempted from this Bill. Unfortunately, our organs do deteriorate with age. Even under our present system of active consent, people over the age of 60 years of age have not been considered for the donation of their kidneys.

Singaporeans of the Islamic faith have also been exempted under this Bill. The Islamic religion specifically prohibits organ donation under the presumed consent system. In deference to their religious teachings, the Muslims as a group have therefore been exempted. However, Islam does permit donation of kidneys if it is to save lives. Individual Muslims can therefore pledge their kidneys through the existing Medical (Therapy, Education and Research) Act.

Mr Speaker, Sir, some people have expressed their concern that this Bill will deny a person the right to decide what is to happen to his own body in the event of an accidental death. Nothing could be further from the truth. Each person under this Bill fully retains his right to decide what he wishes done with his body. If he objects to having his kidneys used for transplantation, all he has to do is to register his objection. His wishes will be respected, without question and without protest. He will be able to register his objection in a very convenient way. All he has to do is to fill in a form and send it in to the Ministry of Health. In fact, the forms will be pre-addressed and postage paid, and will be available everywhere.

We will maintain a computerized Register of Objectors. This register will be checked in every case before any kidney is ever removed. This is to ensure that the accident victim who has passed away has not in his life-time registered his objection to his kidneys being used for donation. The register will also be kept totally confidential. Only the designated senior doctor in each hospital will have access to this register, and it will be his duty to check to ensure that the accident victim is not registered on the Register of Objectors.

Those people who do not wish to donate their kidneys will be given the grace period of six months after the Bill is passed to register their objection. During this grace period, no kidneys will be removed under this Act. After the grace period people can still send in their objections at any time. Their names should appear on the Register within 24 hours of their forms being received.

Each objector will then receive an acknowledgment card. This card will be of wallet size and it can be conveniently carried around with him. The card will confirm that his objections have been received and, secondly, that his name has been entered in the Register of Objectors.

Mr Speaker, Sir, some people have also expressed the fear that kidneys may be removed from an accident victim who has passed away before he is truly dead. This is a very natural anxiety and I would like to assure Members that this is totally unfounded. The sole responsibility of doctors is to save lives and the Bill in no way changes this. The doctors looking after the accident victims will be battling to save the lives of their patients. However, should all their efforts fail, extreme care will be exercised to ensure that the certification of death is properly carried out. To ensure that this certification of death is properly done, only experienced doctors with specialist qualifications will be allowed to certify death in these cases. And it must be done by two separate doctors.

To eliminate any conflict of interest, these two doctors will not be the ones looking after the accident victim. Neither will they be members of the transplant team, nor will they be involved in looking after kidney failure patients. The two specialists will specifically and strictly adhere to a standard and internationally-accepted protocol to check for the slightest indication of life. They will check to ensure that there are no circumstances which may give rise to a suppression of body functions and which may result in wrong certification.

All removal and transplantation of kidneys under this new law will initially be permitted only in Government hospitals. There will be no monetary considerations involved. No one will stand to gain in any way except the kidney recipient.

Mr Speaker, Sir, the kidney donation system in a way resembles an insurance system. The pool of people who consent to donate their kidneys form an insurance pool from which some kidneys may be available in the future. Like any insurance system, it is only fair that those who join are the ones who are more likely to enjoy the benefits from the system. The Bill therefore provides for those who form the pool of potential donors to have priority in receiving kidneys. It is only fair that they will have priority over people who have consciously chosen not to join the pool and not to donate their kidneys in the event of accidental death.

Any person who has objected may withdraw his objection at any time. He will then have equal priority again with the non-objectors two years from the date of his withdrawal of objection. This delay is to prevent any possible abuse of the system by persons who opt out with the intention of rejoining the pool as and when they find out that they have kidney disease.

Muslims who pledge their kidneys under the existing Medical (Therapy, Education and Research) Act during this six months' grace period will also have priority similar to non-objectors. Those who do so after the grace period will then have priority in the same manner as persons who have withdrawn their objections, and for the same reasons. This ensures consistency and fairness for everybody.

Mr Speaker, Sir, the sale or trafficking of human organs is repugnant. The Bill will prohibit the buying and selling of human organs. This section of the Bill will apply to all human organs under all circumstances and not only to kidneys. This is to correct a gap in the existing legislation in this area.

Finally, let me reiterate that much effort has been put into the drafting of this Bill to build in all possible safeguards for the protection of everyone who come under its ambit. It has been drawn up to ensure consistency and fairness. The Bill is deliberately restrictive to apply only to kidneys, and upon accidental death. It does not seek to deprive anyone of their right to decide or to take anything away from them against their will. It will not change anyone's lifestyle, nor will it take advantage of anyone's ignorance.

Mr Speaker, Sir, this Bill is motivated by the desire to save lives, lives that would otherwise be lost unnecessarily. We can do this at no cost to anybody. So let us have the willingness to accept a new idea. Let us have the courage to adopt a new approach to helping our fellow Singaporeans in need. Let us give them the gift of life.

Mr Speaker, Sir, I intend to commit this Bill to a Select Committee to give an opportunity for members of the public to present their views.

Sir, I beg to move.

Question proposed. 12.46 pm

Encik Ibrahim Othman (Tanah Merah): Mr Speaker, Sir, I rise in support of the Bill moved by the Minister of State for Health.

In supporting this Bill, I share the plight of many kidney patients who can only survive by undergoing dialysis or having a kidney transplant. During dialysis, they have to be attached to an artificial kidney machine for about six hours each time, three times a week. It is only a temporary treatment. It is time-consuming and the cost to the patient is very high.

Every year we have many new cases of end-stage kidney disease in Singapore. However, there are only a limited number of artificial kidney machines in our hospitals. Therefore, only a limited number of patients can use it at any one time. Owing to the present situation where demand far exceeds the facilities available, many kidney patients will die from lack of treatment or even without receiving treatment. As such, we have to resort to kidney transplant to enable kidney patients to lead normal lives.

This proposed Bill will allow for the kidneys of persons who die from accident to be removed for transplantation unless these persons have specifically objected to it in their life-time. Anyone else dying from all other causes, such as illnesses or old age, will not be affected.

This Bill, apart from excluding persons under 21 years of age, or who are mentally ill or retarded, old people above 60 years of age, also excludes Muslims. I am very pleased to note that the Ministry of Health has discussed this issue with the Majlis Ugama Islam Singapura (MUIS) and have excluded Muslims from this Bill. The exclusion of Muslims from this Bill is proper and good as it is in accordance with Muslim law. However, this does not mean that Muslims cannot donate their kidneys. I wish to inform my non-Muslim colleagues and friends that Muslims can donate their kidneys if it is for the purpose of saving lives. As such, Muslims may opt in and sign up as donors under the existing Medical (Therapy, Education and Research) Act of 1972.

The Ministry of Health, with the help of MUIS, must encourage as many Muslims as possible to opt in and sign up as kidney donors. The Ministry must ensure that when a Muslim opts in, the following stand by MUIS is taken into consideration:

1. The donation is confined only to the kidneys;

2. The kidneys must be transplanted immediately to a patient and not kept in an organ bank; and

3. The next-of-kin of the donor, according to hierarchy under Muslim law, must give his permission when the donor signs in. I hope the Minister of State for Health will give his assurance that all the above conditions are met before removing the kidneys of Muslims.

At the same time, when Muslims opt in, they must be given the same priority in receiving kidneys as others who come under this Human Organ Transplant Bill. They must also be given six months to opt in from the commencement of the Act. Those who reach 21 years of age should be informed or reminded about signing up as a donor. This is to ensure that more Muslims become kidney donors and will receive the same priority as others in receiving kidneys as and when they need it. Again, I urge the Minister to give his assurance to Muslims in this matter.

Sir, when this Bill becomes law, kidney patients will certainly be relieved as their hope of kidney transplants will be more easily realized. This Bill can be regarded as fair because adequate safeguards have been provided to prevent abuse. The Government should give wide publicity and explain to the people the benefits of this Bill. This will ensure that everyone fully understands the meaning of this Bill.

Finally, Sir, I support the move to refer this Bill to a Select Committee.

Dr Ang Kok Peng (Buona Vista): Mr Speaker, Sir, the House will recall that during the Budget debate in March this year, the hon. Members for Toa Payoh and Ulu Pandan eloquently expressed their concern for the sufferings of patients with chronic renal failure and suggested to the Ministry of Health to consider introducing legislation for the automatic donation of kidneys for transplant purpose by persons who die in accidents with the proviso that a person can elect not to be a donor if he so wishes.

About six months later, the Human Organ Transplant Bill was tabled in the House. Today, we have the opportunity to debate on this Bill. I am very glad that the Bill will be committed to a Select Committee so that the public representation can be considered.

This is as it should be. There are persons who are not in favour of this Bill for various reasons, personal, religious or cultural. The Bill recognizes this point. Clause 5(2) makes such a provision respecting the wishes of persons who do not want to participate in the scheme. A person can register his objection at any time before and even after the relevant law comes into force. There is therefore in essence no infringement of an individual's right.

Mr Speaker, Sir, certain quarters have expressed their fears that kidneys would be removed before a potential donor is really dead. Clause 5(3) of the Bill should allay such a fear as the death has to be certified by two medical practitioners who are neither involved in the transplant nor in the treatment of the proposed recipient and must also possess appropriate post-graduate medical qualification. A further safeguard is that the removal and transplant are only allowed in Government or gazetted hospitals.

Clause 12, in dealing with the priority of the recipients, considers those who have not registered their objection, those who have registered their objection, those who have subsequently withdrawn their registered objection, and those referred to in clause 5(2)(g). But the clause seems to be silent on persons referred to under clause 5(2) (d), ie, persons under 21 years of age who require the consent of parents or guardians before they could participate in the scheme. May I seek clarification on this point from the Minister of State?

Mr Speaker, Sir, it would be ideal indeed if legislation can be avoided and our people can be persuaded through education and public campaigns to respond adequately to the crying needs of patients for another lease of life. We have tried for 14 years to persuade people to pledge to donate their kidneys on death. So far, about 27,000 pledges have been made but this represents about 3% of our need and to-date not a single kidney has been available from these pledges for transplantation. This scheme has not worked at all and is not likely to work in the foreseeable future. An alternative must be found and hence the present Bill. Under this contracting-out legislation, we may be able to salvage 80-90 kidneys from fatal accident victims each year for saving the lives of kidney patients.

In order to make the scheme acceptable by as many people and as soon as possible, the Ministry could do well by soliciting the assistance of religious bodies and other organizations to persuade people to overcome their apprehension or reluctance to donate kidneys especially because of superstition which, as hon. Members know, is not based on rational thinking and is therefore difficult to dispel.

Mr Speaker, Sir, I am satisfied with the safeguards provided and pleased that the Bill will be committed to a Select Committee and referred to the House again. I hope that the Select Committee will not take too much time to deliberate on the matter and will make its report expeditiously, as patients are dying for lack of kidneys for transplant.

Mr Chng Hee Kok: Mr Speaker, Sir, like my colleagues before me, I rise in support of this Bill. At the same time, I welcome the intention of the Minister for Health to commit this Bill to a Select Committee.

Although this Bill, as the Minister of State has pointed out, will cost the people nothing, it has generated much interest and, in some cases, doubts and, of course, resentment. Therefore, we must redouble our efforts to explain the Bill to the people because it will be an irony if, in the process of trying to save lives, the Government loses political support or political ground.

In this respect, I have only one point to raise and this relates to clause 5(2)(e) which sets the upper limit at 60 years of age. As the Minister has already pointed out, we deteriorate with age and it is doubtful that 60-year old organs would be of much help or much good in organ transplant. But there is a more important reason. I suspect that this Bill faces more resistance from the older age group than the young.

In our society, death is not something that is a subject for humour and rationality. Because of this, as mentioned by one other Member, there is suspicion and fear. Therefore, if we can change the age group and lower it to, say, 50 years old, which I believe will make very little difference to the Bill, we may perhaps get the Bill more readily accepted by the people. To keep the limit at 60 years of age means that a lot of older citizens, who at the present moment do not understand the Bill fully, will have apprehensions and this may be exploited by those who opposes this Bill. I think by lowering this upper limit to 50 years of age, it will go some way towards getting this Bill more easily accepted.

Mr Speaker: It is exactly 1.00 pm. I suspend this sitting and will take the Chair again at 2.30 pm.

Sitting accordingly suspended at 1.00 pm until 2.30 pm. Sitting resumed at 2.30 pm

[Mr Speaker in the Chair]

Debate resumed.

Dr Koh Lip Lin: ( In Mandarin): Mr Speaker, Sir, I support the Minister of State for Health in the introduction of this Human Organ Transplant Bill. The Hon. Minister of State has given us a detailed statement on the background leading to the introduction of this Bill and he has also told us the direct and indirect benefits to the members of families of people who will be receiving the organ. This is a Bill to save lives. I believe this Bill will be supported by the great majority of the people of Singapore. Of course, there will be a minority of people who do not have a clear understanding of the Bill or the true facts of the matter or who have been misled by others, resulting in their objection to this Bill.

I would like to air my views with regard to those who object to this Bill. There may be many reasons for their objection. It may be because of their religion or their cultural background that they object to the donation of their organs after death. Some people think that they have a personal right over their own organs and they do not want to be ruled by the law. Actually, those who hold such views do not need to object to this Bill because the Bill expressly states that they could simply opt out of this scheme by registering their objection. Of course, registration may be inconvenient to these people but this small inconvenience will bring benefit to the others or the country. They should not object to this Bill just because of this small inconvenience as such objection is unreasonable.

I believe that just a step before this Bill is put into implementation, the Government should step up its publicity through the mass media and other channels to educate the people so that everyone in Singapore will understand the contents of the Bill, including those who have, for religious or cultural reasons, objected to the Bill. On the other hand, there may be others who object to this Bill for political reasons. They oppose this Bill simply because they oppose the People's Action Party and so they want to take this opportunity to raise anti -government sentiments. I think that the most simple method to deal with them is to tell such people that this Bill has no particular benefit to the People's Action Party; it will only benefit the people of Singapore, particularly thousands of those who are suffering from chronic kidney diseases. At the same time, we should urge our people not to be misled by these politically motivated people.

After the implementation of this Bill, I believe there may be a small fraction of the people who would indicate that they would not want to donate their organs. I hope the Ministry of Health will step up their efforts to propagate the Bill and educate the people and show them the benefits of this law, so that those who originally object to the donation of their organs may change their mind and join in the scheme.

Finally, I would like to take this opportunity to ask the Minister of State for Health a question. The present Bill refers only to the transplant of kidneys. Is there any possibility of this Bill being extended to cover other human organs? With the improvement of medical science, I believe that transplant of other human organs may also be feasible and required to help those who are affected.

Mr Speaker, Sir, I support this Bill.

Encik Abbas Abu Amin (Pasir Panjang): ( In Malay): Mr Speaker, Sir, when this Bill is eventually passed many patients with kidney ailments will be relieved because their hope of obtaining medical treatment can be better realized. Whatever good steps are taken to save lives should receive proper support. Naturally this transplant of organs will be carried out in the best way possible as expounded by the Minister of State earlier. I consider that further and on-going information should be given so that all segments of the society will understand the issues that are involved so that they will really understand the purpose and the method of implementation.

I am relieved to hear the assurance of the Minister of State that all views with respect to culture, belief and religion have been considered even before this Bill was proposed, particularly the views of Muslims. I understand that he had discussions on the subject of organ transplant with the Singapore Muslim Religious Council (MUIS). The religious ruling committee or Jawatankuasa Fatwa has ruled that Muslims can donate their organs for emergency reasons and in accordance with terms that have been spelt out by the Member for Tanah Merah. I also understand that several Muslim countries in the Middle East have carried out organ transplants in order to save lives. But we must appreciate that the Muslim community in Singapore is not that confident about the Fatwa or religious rulings that I said earlier.

What I hope is that the Ministry of Health, with the cooperation of the Singapore Muslim Religious Council, would be able to draw up special plans to explain to all segments of Muslim society so that any doubt could be erased and thus enable the Muslim community in Singapore to make their contributions without any religious qualms. I feel that the Singapore Muslim Religious Council can help to effectively disseminate information to the Muslim community in various ways, for example, through Friday sermons, religious lectures organized by JHD or the Muslim Missionary Committee and also at mosques, forums, over radio and TV, and also not forgetting the press.

Mr Speaker, I am happy that this Bill will be further examined by the Select Committee. I hope organizations as well as individuals will come forward to give their views so that this Bill can be further streamlined as the object of this Bill is to save the lives of patients who have hitherto suffered due to a dearth of donors.

Touching on this Bill, on page 3, it is stated that this Bill exempts those who are under 21 years of age unless they have the consent of their parents or guardians. I seek elucidation from the Minister concerned as to what is the method or what explanation should be directed to this group of people, that is, those Muslims who are under 21 years of age, when this law is in force and after the six months that follow, when they will exceed the age of 21. I hope I will get an explanation on this matter so that no difficulties will arise. Thank you.

Mr Chew Heng Ching: Mr Speaker, Sir, I am in support of this Human Organ Transplant Bill. It ushers in a new era in our fight against kidney disease. It brings a sparkle of hope to the many victims of the disease. I hope the Ministry of Health and the Kidney Foundation will continue their task of persuading more and more people to opt in. I am sure my fellow Members of Parliament and the community leaders will play our part to encourage more people to opt in. In fact, the concept is so well thought out, so flexible, so humanitarian, that I am tempted to ask the Minister to consider extending the scheme perhaps at a later date, to other organs, such as the human eyes.

Sir, this Bill alone, though by far the most effective, is not enough to tackle the kidney problem which has robbed the lives of some 3,000 Singaporeans since 1970. We should continue to adopt a total approach in tackling the problem. This means making dialysis treatment more readily available and more affordable to kidney victims. We should continue with fund-raising efforts from charitable institutions and well-to-do Singaporeans to provide the necessary financial assistance to these victims. More importantly, we should also tackle the prevention side of the problem. The public at large is generally ignorant of what kidney failure is about, what causes the disease, how to minimize contracting the disease. May I urge the Ministry of Health and the Kidney Foundation to continue to place emphasis on educating the public on healthy living habits, basic health care measures, and other preventive measures in order to minimize contracting the disease.

Sir, coming back to the Bill, I have the following clarifications or suggestions to make to the Minister. One relates to the question of priority, which is that when a kidney is available from a donor, who among the potential recipients will receive the highest priority? I suppose the choice of the recipient rests with the five-member committee to be appointed by the Director of Medical Services. I want to know whether the next -of-kin of the donor has a say as to whom the kidney should be donated. What if the next-of-kin wishes the kidney to be donated to a kidney victim who happens to be a relative. Will their wishes be accommodated?

Next, I want to touch on the question of opting out card. Clause 9 of the Bill states that any person who has registered to opt out will be issued an acknowledgment in the form of a card to be carried by him to prove that his kidney should not be removed in the event of his death through accident . Well, people are careless, cards get lost, and not many people like to carry cards in their wallet. For practical reason, and perhaps as a better safeguard, it may be better to reflect a person's decision to opt out symbolically in his NRIC, in the same way as we have done for his blood group.

My next point relates to clause 10 of the Bill which states that all objections will be maintained in a central Register. I presume this is stored in a central computer linked to various hospitals. I want to know whether removals or transplants will be allowed in the event of a failure of this central computer. Are there contingency measures in the event of a computer breakdown?

The next point relates to clause 12(1)(b), which states that a person who has registered his objection and subsequently withdrawn his objection will enjoy the same priority as a person who has not registered any objection only after a lapse of two years. While I understand this is necessary to prevent abuse, my question is, why two years? Why not one year? Why not three years? Perhaps the Minister can enlighten us on this.

My last observation concerns persons coming of age. These are people who turn 21. This exercise to allow people to opt out or to opt in is an on-going one. Presumably facilities for people to exercise their options will be made readily available at strategic locations in a constituency. For example, the community centres or the Neighbourhood Police Posts. My concern is how is the Ministry of Health going to inform the many Singaporeans who come of age every year that they have to exercise their option at the age of 21? We do not want donation by default, through ignorance or forgetfulness. Is there a procedure for this? Perhaps the Minister may wish to consider extending clause 12(2)(a) (iii), which relates to persons who obtain permanent residence and citizenship being be given a six months' grace period to exercise their option, to those who turn 21, ie, give them a grace period of six months after they turn 21 to exercise their option.

Finally, Sir, I understand the Minister will be referring the Bill to a Select Committee. While there is a need to seek a wider audience on the Bill which affects many Singaporeans, I think it is equally important that the new law be implemented as soon as possible as there are lives to be saved. I therefore urge the Select Committee to carry out its task most diligently, most expeditiously and complete its findings as soon as possible. 2.50 pm

Mr Chiam See Tong: Mr Speaker, Sir, may I be allowed to join in this debate. May I, first of all, refer to the remarks made by the Member for Nee Soon. He said that the Opposition shall be using this particular Bill to say things against the Government. I must tell him that this is a very unbecoming thing to say. The Opposition are also human beings. They also want to save lives. I support this Bill because its purpose is to save lives. How can he go about saying irresponsible things like that?

Dr Koh Lip Lin: Point of clarification, Sir.

Mr Chiam See Tong: Please, let me have my say.

Mr Speaker: He is not giving way.

Dr Koh Lip Lin resumed his seat.

Mr Chiam See Tong: If there is any objection, it would probably be due to the controversial nature of this Bill. We are an Asian society. Superstition is rife. We have just heard from the Minister that in Europe only three countries so far have got this kind of a law. They are socially much more advanced than us. As I say, if there is going to be any objection to this Bill, it is probably due to superstition, to fear, and, I think, also suspicion of the PAP Government.

An hon. Member: You are adding fuel to rumours.

Mr Chiam See Tong: Well, I am not adding fuel to rumours. I say that if there is any objection, it is probably due to these reasons. Of course, any sensible person would support this Bill, because if they have friends who suffer from chronic renal disease they would know how not only those patients suffer, but their whole family also. In fact, I have been asked to bring up this question of whether the Government would like to put more money in dialysis machines. Because, from what I have heard, there are not enough machines at the moment to go around. Some patients have to queue up and they suffer as a result. So I would urge the Government that before they pass this Bill they can tell the public that there are enough dialysis machines for any sufferer of chronic renal disease who wants treatment on demand. I think they have to do that first before they pass this Bill. I had the opportunity to attend a chronic renal disease seminar three years back. The delegate from Israel was proud to say at that time that any patient who had a kidney disease could get a dialysis treatment on demand. I do not think we can say that of Singapore today. So I hope the Minister will look into this very important aspect of kidney disease sufferers.

The question of priority has been mentioned and we note that 15% of our population is not involved, due to their religion which, I think, we should be sensitive to. They may have strong reasons not to want to donate their organs.

The purpose of this Bill is to save lives. Let us say, we have two cases. One is a very acute kidney case, and he might die any time if he does not get a transplant. The other is a patient who can live for another six months or a year. But unfortunately for this sufferer with the acute problem, he has objected. This is a moral question of saving lives. Do you want this person to die just because he has objected? Or to give it to another person who has not objected but he has got six months more to go? I think this is a moral question which the Select Committee has got to decide. The main purpose of this Bill is to save lives. In fact, this clause on priority is in conflict with the purpose of the Bill. There will be cases like that. Of course, there will also be people who may have objected because of superstition and fear. I think we also have to safeguard these people. For various reasons we have to respect their reasons for objection. They may have fears in their minds that their objection may not be taken note of. The Minister of State says that it will be computerized. But what happens if an accident happens and there is a fear in his mind that his organs may be removed? So I think in this respect you should also protect those who have objected. I think this Bill is ahead of our time and I do not know how long this Bill is going to be considered by the Select Committee, taking into account our cultural, social and Asian background. But in any event I support this Bill.

Mr Barker: Hear! hear!

Dr Dixie Tan (Ulu Pandan): Mr Speaker, Sir, first, I should like to commend the Minister and his officials for having gone to a lot of trouble to ascertain the views and the feelings of all segments of the population in the drawing up of this Bill, and taking all these views very seriously. I think most of the points that had been brought up by various peoples and by the various groups have been incorporated into this Bill. I support this Bill wholeheartedly and totally.

I should like now to try and project a concept of the process of organ donation. Actually we should try to look at organ donation as a surgical procedure, much like operations that are being done every day in operation theatres in hospitals all over Singapore. Some people have expressed the fear that organ donation will leave a body that is hollowed out. This Bill specifically states that only kidneys are to be removed. The kidneys are two small organs located at the back of the abdomen, and surgery to remove these two kidneys will not leave any vacant space within the body.

Then I have heard some people talk of mutilation of the body. There will not be any more mutilation of the body than the result of a surgical operation, namely, there will be one more line on the surface of the body that can be seen. In fact, victims of accidents, unfortunate enough to become organ donors, will be people who have suffered much more damage, damage enough for their brains to be dead, and the likelihood is that they will be far more mutilated on account of their accident than on account of their being organ donors. I should like to really try to place this concept that this is a surgical operation, and indeed it is, because it will be done by qualified surgeons who are experienced in the removal of organs and who are experts in the reparation of the surgical wound.

One other matter. Kidney transplantation is not done for acute renal failure. It is done only for chronic renal failure. Acute renal failure is treated by other methods.

Finally, I would wish to commend this Bill to all Members. 280 deaths from chronic renal failure in one year and so many from heart attacks and so many from accidents tend to leave us cold. These are just numbers. But anyone who has known a person suffering from chronic renal disease and who has known the suffering and the anguish of this person as well as the whole family concerned will no doubt support this Bill wholeheartedly. Sir, I wish to support this Bill.

Dr Tan Cheng Bock (Ayer Rajah): Mr Speaker, Sir, I rise to support this Bill. This legislation attempts to save the lives of most of the 200-odd Singaporeans who die of end-stage kidney disease each year. And this figure continues to rise.

For the past 15 years, the Ministry of Health and the National Kidney Foundation have tried to persuade the public to donate their organs, their kidneys, and for all their effort they only received about 24,000 pledges. We need 800,000. So you can see how far short we are of that figure. It is pathetic to see many Singaporeans struck by the disease, some at the prime of their youth wasting away on the dialysis machine, while at the same time healthy kidneys are not made available to them because of prejudice and fear. This, Mr Speaker, Sir, is the size and depth of our problem. We cannot run away from this. It will be with us and it will continue to get worse.

No Singaporean must turn his back against this. We must fight prejudices and fears about organ transplant. We must persuade those who want to opt out to opt in. We must give hope to the 200-odd Singaporeans. Therefore, we must all support this legislation and convince those who oppose that there are sufficient safeguards in the Bill to prevent abuse. These safeguards have been mentioned this morning by the Minister of State for Health. One fear among Singaporeans is that doctors would simply remove the kidneys as provided by the law when the victim had not opted out before his death. I think this is an important concern. It is important because we must be aware that these kidneys will have to be taken from someone who may be dead but nevertheless has very real and meaningful relationships with people who are still alive. It is a very emotive issue and we must be very sensitive to this, and any high-handed approach will spell disaster for the Ministry of Health.

In this connection, a special team of trained counsellors should be made available in each authorized hospital to counsel and provide emotional support to the families of every potential organ donor. The team must not only be highly trained but they must be very strongly motivated and, above all, available on call at any time to handle members of the bereaved family. The potential donor's family should be screened from all unnecessary bureaucratic contacts and red-tape. In extreme cases or even in unusually resistant cases, the team should be authorized to grant an exception so that the Government would not be seen as totally insensitive and devoid of compassion or flexibility because, Mr Speaker, Sir, we must remember that while the plight of our kidney failure patients deserves our fullest sympathy and support, we must be sensitive to the relatives of the accident victims.

Another fear is that this legislation will give the Government that eventual right to all the organs of the body. There is a general concern among the people that the kidney is only the beginning of a whole gamut of organs to come. The Ministry must allay this public anxiety. I know that some of my colleagues here have requested that organs should not only refer to the kidneys but also to the other organs. But I would advise caution now. Let us go step by step. Let us win the confidence of the people before we proceed to the other organs.

In this respect, we should have a good programme to educate the public and I must say that the Ministry of Health has responded to the Feedback Unit's request for an information paper on this Human Organ Transplant Bill. This paper has been circulated to all grassroots organizations and I would like to place on record my thanks to the Ministry of Health. Mr Speaker, Sir, that paper contains questions and answers on the proposed legislation. I am not sure whether this paper has been given to the press. If not, I would suggest that it should be given to the press so that more Singaporeans can be made aware of the implications of this Bill.

Another concern by the more educated is that this legislation is an infringement of their personal rights, as what rightly belongs to them can now be taken away by the Government under this legislation. Mr Speaker, Sir, the question of the rights of the individual crops up very frequently at dialogue sessions. While we cannot deny the individual of his rights, perhaps we will have to persuade and appeal to such individuals that in our closely-knit society they should also consider the obligations to the society. It is not much to ask of them considering the amount of collective effort and sacrifices made by many other Singaporeans in the building of this country. However, the Bill is quite clear: anyone who is not happy has the right, and not only the right but also the opportunity, to object to donating away his organ.

Another area of fear is that those who object may face other forms of social disincentives. At present, those who object will have less priority in receiving kidneys. It is only fair that the people who are willing to form part of the pool of potential kidney donors should be the first ones to benefit from the pool. I think the Ministry must not resort to the introduction of disincentives other than less priority for receiving kidneys to those who opt out. The act of pledging one's organs must be seen as a conscious choice of the individual. Relentless effort to persuade must continue in addition to this legislation. We must support the Ministry of Health's six-month planned programme to inform the public of the law and its implications. A long-term plan will be the prevention of the disease through health education and improved health care at our outpatient level and the private clinics.

I am glad that the Ministry of Health did not succumb to the pressures of the National Kidney Foundation to introduce legislation much earlier. It must also listen to others. While I can understand the enthusiasm and concern of those working in the National Kidney Foundation to legislate, it must be borne in mind that the issue is not that simple. We are living in a multi-racial, multi-cultural, multi-religious society. We have deeply ingrained cultural and religious beliefs. We are Asians. Western societies may accept such legislation more readily but we must not hurry over this. Our Muslim community's views must be made known, for example, and in this respect it is good to learn that MUIS supports the concept of organ donation. We must encourage Muslims to voluntarily donate their kidneys in the manner permitted by the Islamic teaching under the Medical (Therapy, Education and Research) Act, 1972.

While there is increasing awareness of the intention of the scheme, apprehension remains especially among the less knowledgeable and the less educated. It is important that the less educated are well-informed on this. Persuasion and convincing arguments must be the way to achieve our ultimate goal. Therefore, the decision to pass this legislation to a Select Committee will give those Singaporeans a chance to speak out on matters of concern.

Mr Speaker, Sir, I hope by the Third Reading of this Bill, the Ministry of Health will incorporate whatever relevant changes needed in the Bill so that Singaporeans will be assured that this legislation is passed after considering and listening to the views of MPs, lay people and professional people. I support the Bill.

Encik Wan Hussin bin Haji Zoohri (Kampong Ubi): ( In Malay): Mr Speaker, Sir, I am joining in the debate to speak only on certain aspects of the implementation of the Bill when it is eventually passed. We all know that what has been written down will sometimes meet with some difficulties in implementation. By this, I am wondering how the Ministry will ensure without any error being made concerning the religion of a deceased person.

This Bill exempts Muslims. But we know that in the context of Singapore with its multi-religious people, it is not necessary for a particular religion to be embraced by only one community. For instance, Islam is the religion of many ethnic groups. As such, when a person dies in such a situation, I would like to know from the Minister of State how is he going to ascertain the religion of a deceased person. If he were to refer only to the victim's identity card, I find that there is no column in a person's identity card to state his religion. Only his race is stated. As such, I would like to draw the attention of the Ministry concerned to the need to rule out any mistakes, as far as possible, in this respect. Although this is a small matter, if mistakes occur, the risks or consequences are unpleasant. I would merely like to remind the Ministry to exercise caution and to find ways to ascertain an accident victim's religion because if he is a Muslim he will be automatically exempted from the Bill.

Dr S. Vasoo (Bo Wen): Mr Speaker, Sir, I rise to support the Bill. The Bill will provide a new lease of life for kidney disease sufferers. At the same time, no amount of dialysis is going to help kidney disease sufferers. It is only momentary. But the Bill will in the long run provide a long-term solution to the problems of kidney disease sufferers.

I have a number of points to raise in connection with the Bill. One is that there is some public concern about the extent the Bill is going to cover . The concern is about whether the Bill is going to stop with the kidneys or whether it will extend to cover other organs in the near future. This is basically the misconception some sectors are having and I think it is essential for the Ministry to erase this public misconception.

The second point that I would like to raise is the time span allowed. Six months' grace is a rather short period because there are a lot of Singaporeans who are less-informed and who may not know exactly the implications of the Bill. I think it is essential that, with the passage of time, one needs to allow the Bill to be well publicized so that more Singaporeans will become aware of the implications of this Bill. I think the more they know about this Bill and what it means to volunteer support for those in need, the Bill will receive the best support it can have.

The third area is whether this Bill will be subsequently reviewed because in time to come with less accidental deaths, cadavers would be less in time to come and there will be insufficient kidneys available, and whether there will be subsequent review to cover adequately to meet those who are suffering from kidney diseases.

The final area one needs to look at is to provide sufficient support for the bereaved families, particularly, as they are suffering from grief and therefore they should be supported when their beloved ones have suffered death. And I think the Ministry whilst implementing this scheme should provide a good system of crisis counselling to help breaved families through so that they can become more supportive of the organ donation scheme. It will help them find relief and eventually give the best support to the scheme itself.

On that note, thank you, Sir.

Mr Heng Chiang Meng (Jalan Kayu): Mr Speaker, I would like to say that life is a gift of God. Anybody who does anything to extend the gift, in fact, is helping him or her, as the case may be. I would also like to say that anybody against such an organ or kidney donation plan is perhaps denying life itself. Listening to the comments and the arguments in support of the Bill, I find it strange that one very important issue has been missed out.

All these arguments are very rational arguments, very logical arguments. The objective of this Bill, Mr Speaker, Sir, of course, is very logical, that is, to save lives. But unfortunately the decision whether one wishes to donate the organs or not is not a rational issue. It is an emotive issue. It is an issue to be found in superstitions the fear of the unknown. Again, unfortunately, when people look for answers in this area, they do not look towards the Government. For issues of this sort, touching on religion, on culture and social values, most of them look towards their religious leaders. It is in this realm and in this area that I think we have to focus our attention.

Over the past months we have heard various religious leaders of all denominations coming out in support of this proposal. Mr Speaker, Sir, I would like to appeal to all of them to say it loud and clear in their churches, in their temples and in their mosques to ask their people and their congregation to support this Bill.

Mr Yeo Cheow Tong: Mr Speaker, Sir, I would like to thank the many Members who have spoken in support of the Bill. As I intend to refer this Bill to the Select Committee, I will therefore only reply to the broad points and not go into the detailed drafting of the Bill as this would be the job of the Select Committee to look into.

Several of our Muslim MPs have spoken on various aspects relating to the Muslim community. My officers and I myself have been in discussion with the MUIS leaders on the various aspects of this Bill. I am very happy that MUIS has come out in support of the Bill. They have come out in support of the concept of organ donation, except that for Muslims it must be an active consent system which is covered under our present Medical (Therapy, Education and Research) Act.

Arising from our discussions, we have agreed that the pledge form for kidney donation under this Medical (Therapy, Education and Research) Act will be redesigned to take into consideration the points brought up by MUIS and which have also been covered by the Member for Tanah Merah, that is, that the donation will be only for kidneys, that it will be for immediate transplant, and that the next-of-kin must give his or her permission at the same time when the individual signs his consent form. This will be done. The forms will be ready very shortly and we hope MUIS and the various religious leaders of the Islamic faith will help us to bring them to the ground and explain to their congregation, the Muslim congregation, about the various aspects of kidney donation and how to go about it.

In terms of those people who reach 21 years of age, how do we keep them informed every year? What the Ministry will do is to continue with its publicity programme on an annual basis. We will use the various media, newspaper advertisements, the TV, to keep our population continuously informed, so that those teenagers, when they get to the age of 21, will then be fully aware of the implications of the Bill. Hopefully, through the publicity programme, by the time they get to the age of 21 they will be sufficiently informed about the higher objectives of the Bill so that they would agree to donate their kidneys and therefore not have to register their objection.

Various Members have also talked about the need to better inform members of the public. The Member for Ayer Rajah has mentioned about the questionnaire which we had sent to the Feedback Unit and which has been distributed to the various grassroots organizations. Yes, the Ministry will continue with the publicity programme. In fact, only yesterday we took up a full-page advertisement in the newspapers to explain certain aspects of the Bill. This publicity programme will continue for the next six to eight months to ensure that members of the public will know over a period of time the major aspects of the Bill, what are the objectives, what are the problems facing the kidney failure patients, so that they will be totally knowledgeable of what we are talking about.

The Ministry will also be sending out flyers through the mail to every family. PUB has agreed to support us in in that respect. We will be sending out together with the PUB bills in the future flyers that will contain questions and answers to the major aspects of the Bill. So in this way every family will have such information delivered to their home. Therefore, this will enable us to reach every home in Singapore directly with the information. And, again, this will be continued periodically to ensure that Singaporeans know about this. 3.25 pm

[Mr Deputy Speaker in the Chair]

Mr Yeo Cheow Tong: The Members for Nee Soon and Kaki Bukit have brought up the question of whether the Bill could be perhaps expanded to cover other organs. At the same time the Member for Ayer Rajah and another Member just now have also cautioned the Ministry against expanding coverage too rapidly. The Ministry will be adopting a very cautious approach towards legislation. First and foremost, we have to convince Singaporeans that the donation of organs to save other people is a good act, it is a humanitarian act, and it is an act which they should all support. So I think the process of persuasion and convincing must first be put in place. And over a period of time when more people become familiarized with the fact that, yes, organ donation is taking place, then perhaps they will also be very willing to donate other organs as well. At the present moment, there is no need for the donations of other organs, for example, the heart, liver, and all that. There is no need for that yet because no such are being have been carried out. With the progress of medical science, in the future we may go into those areas if there is a need for such transplants. But we would try the persuasion approach before we resort to legislation.

The Member for Pasir Panjang has also raised the point about what happens to those Muslims who reach the age of 21 during the grace period. How will they stand in terms of priority? Well, if they reach 21 during this grace period, they will still be covered by the grace period. Therefore, they need not fear losing out on priority should they opt in after the age of 21 during this grace period.

The Member for Kaki Bukit came out with a long list of questions. I will try to answer them wherever I can. He brought up the point that we should try and educate the public on healthy living to try to prevent kidney failure. We know what causes kidney failure. But medical science has still not really ascertained what leads to those causes. For example, we know that there is a connection between high blood pressure and kidney failure, between diabetes and kidney failure. We also know that certain infections of the body will result in the release of toxins which when they pass through the kidneys would end up in gradually damaging the kidneys. So this is the direct impact on the kidney functions which we know about. And our health fairs have been concentrating very heavily on getting members of the public to take care of their health, to watch their blood pressure, try to cut down their intake of salt and all the other substances which lead to hypertension and high blood pressure, and also to encourage them to go for a check for diabetes. So all these are on-going programmes which we will continue to emphasise, and they would definitely help in the long term to reduce or at least check the spread of kidney diseases.

In terms of the pledge cards being lost and the suggestion that we should indicate it on the NRIC, ie, the identity card, we have discussed this with the various Government departments. We feel that that card is only an acknowledgment card. The important thing is that all the names are being captured on the computer, and we are not depending on whether or not a person has that card on him when he dies. We are actually relying more on the computer and that is a more guaranteed way. So we will make sure that every person who dies in an accident and whose kidneys may be considered suitable, that all those names would be checked carefully against our Register of Objectors to make sure that they have not objected in their life-time.

The Member has also asked another question: what happens if the computer fails? That is not an unlikely scenario. It could be due to power failure. It could be due to anything. I would like to assure Members that if the computer system does fail, during the period that the computer is down we will err on the side of safety, in the sense that we will not in that case carry out any removal of kidneys under this Act. This is to ensure that during such unforeseen circumstances things are under control and that we do not make any mistake.

Various Members have also talked about the impact of superstitions in Singapore; the impact on members of the public would be a reluctance to donate their kidneys. Yes, we realize that there is a group of people who may be strongly influenced by superstitions. That is why we are working hard to better inform the public. We would also be encouraging the various religious leaders to be more open in their support. And taking up on the Member for Jalan Kayu, I hope also that they will come out and adopt a high profile in terms of explaining the stands of the various religions on this issue.

The Member for Potong Pasir has been having problems all along with his figures. Today he is no different. He said that I had in my opening address stated that there were only three countries that have to date adopted this system of presumed consent. This is where he is mistaken, unfortunately. I stated that there were 14 countries in Europe. And I gave four examples, not three. I gave three examples, plus Belgium, which is the latest country to adopt this system. The European position is quite interesting because most of the countries in Europe that have adopted this system of presumed consent are countries that have a strong belief in personal rights, strong belief in the democratic processes, strong belief in protecting the individual as far as intervention by the State is concerned. Yet these very conservative countries in terms of personal rights have been the pace setters in terms of enacting laws that allow presumed consent. In that respect they have been very progressive. So I would like to correct the Member for Potong Pasir. There are not three but fourteen countries that have adopted this system to date.

The Member for Potong Pasir has given a very simplistic example of one person who has agreed to donate and another person who has not agreed to donate. I think it is a very simplistic example. The key thing is that we have got to persuade and convince as many people as possible to be potential donors. Then the pool of potential donors can expand. The reverse will be back to where we are today - 27,000 people who have agreed to donate will result very very certainly in over 200 kidney failure patients every year dying with this disease. So I think we have to be sure as to what is its objective. And the system of priority is in no way unfair to those people who have chosen not to be members of the pool. So we must get our thoughts very clear on that.

The Member has also requested for dialysis on demand before passing this Bill, although he said that he is in support of this Bill. This issue of dialysis upon demand has been brought up in this House before and I have given the reasons why, ie, dialysis is a very very expensive process and it is not really a suitable method for treating kidney failure. The best method for treating kidney failure is to obtain a replacement kidney for him, and that is a permanent remedy rather than a temporary remedy which will just totally destroy a person's quality of life as well as that of his family.

I would like to thank the Member for Ulu Pandan also for her comments on the medical and surgical aspects of transplants. I am sure Members of the House would have appreciated her explanation.

There have also been calls for trained counsellors to counsel families of those accident victims who have died and who have donated their kidneys. Yes, we have a team of what we call "kidney persuaders" at the moment stationed in each hospital. Their job goes further than just persuading families of accident victims to allow the kidneys to be donated. It goes further than that in terms that they also counsel the family on their present grief. But the programme will be reviewed to see how we can expand that further.

The Member for Kampong Ubi has also asked how do we recognize Muslims. After all people from other races have also become Muslims. Well, there are a few methods that we use. One is, of course, to look at the identity card to see whether that name is a Muslim name, whether there is an alias there. But that is not always available. What we will have to depend upon will be the feedback from the immediate family members who are there at the hospital, at the bedside of the victim. We will have to depend upon them to advise us because there is no other way for us to seek the information otherwise. And I am sure members of the family and their friends who are there would, when asked by the hospital staff, definitely be able to confirm whether or not the victim is or is not a Muslim.

I think I have covered most of the major points brought up by Members of the House. Once again, I would like to thank everybody for their very useful comments.

Question put, and agreed to.

Bill accordingly read a Second time.

Resolved,

That the Human Organ Transplant Bill be committed to a Select Committee consisting of Mr Speaker as Chairman and seven Members to be nominated by the Committee of Selection. - [Mr Yeo Cheow Tong].