HUMAN ORGAN TRANSPLANT BILL (As reported from Select Committee)

Order for Third Reading read. 4.36 pm

The Acting Minister for Health (Mr Yeo Cheow Tong): Mr Deputy Speaker, Sir, I beg to move, "That the Bill be now read a Third time."

Sir, the Select Committee on the Human Organ Transplant Bill received seven written submissions. The Committee heard oral representations from nine persons in respect of four of the written submissions. The Committee's Report has been circulated to Members of the House.

Sir, most of the points raised in the submissions are already catered for within the Bill as it stands. These include safeguards for the proper certification of death and arrangements for the participation of Muslims in kidney donation through the existing Medical (Therapy, Education and Research) Act.

One representation proposed the removal of lower priority for transplant for those who have registered their objection to the donation of their kidneys. The main concern was that the priority consideration will over-ride all medical considerations. This might result in a kidney being transplanted into a recipient whose tissues are not compatible with the donor's. In such a case, the end result would be subsequent organ rejection and a wasted kidney. I must therefore clarify that medical criteria are the most important criteria in the selection of a kidney recipient. The tissues of potential recipients are first matched with the donor kidneys. The recipient must also not be suffering from any other medical complications.

It is only then that priority is given to the non-objectors from the identified pool of potential recipients. The priority system is fair and will remain unchanged.

The question of the right of a person to decide on the disposal of his own body was addressed in one submission to the Select Committee. I must reiterate that this right is in no way abolished by the legislation. Every Singaporean retains his right to decide whether he wishes to donate his kidneys or not. No objector need fear that he will be counselled and coerced into changing his mind.

My Ministry will continue in its efforts to educate the public on the continuing needs and problems of kidney failure patients. These health and public education efforts will, however, be directed to Singaporeans in general and not at specific individuals.

Sir, I beg to move.

Question proposed.

Dr Aline Wong: Sir, members of my GPC are in full support of the Bill. We are very gratified indeed to see that the Ministry has taken so much trouble, proceeded with so much care and given full consideration to the feelings, values and beliefs of the different sectors of the population.

We also agree with the views of the Select Committee that the representations made actually have already been taken care of within the Bill. So we look forward to the implementation of the law which indeed represents a ray of hope for the unfortunate victims of chronic renal failure.

Here I just wish to reiterate a few points which are worth repeating as they have been repeatedly put to us by members of the public. In implementing the law, the Ministry needs to bear in mind that it has to keep up with the publicity, educating the public on the purposes of the law, and also as to the provisions for the freedom of choice of individuals who might wish to object to donate their kidneys. If the publicity on this law is not kept up, I am afraid that in due course, with the passage of time, the public may forget about the intents and purposes of the law.

It is also imperative for the Ministry to make special efforts each year to inform those who will be reaching 21 years of age of their right to choose to donate their kidney or to opt out.

Another point is that the Ministry must still try to find all kinds of methods to help the victims of chronic renal failure. Even though now many more kidneys may be available for transplants, people still hope that the Ministry will spare no effort in providing dialysis treatment on as wide a scale as possible. Even though this is expensive and only a temporary treatment, yet to those who suffer from the illness and are awaiting donors, the availability of dialysis treatment is still and is very importantly a life saving provision. So it is our opinion that the Ministry should still spare no effort in finding ways and means to help victims of kidney disease including, apart from dialysis treatment, looking at the possibility of allowing them to use Medisave for their regular treatment and their payments.

In a way, this Bill can be looked at as a Bill protecting the rights of those who object to kidney donation for personal, religious or other reasons. It is therefore crucial that every possible means must be taken to make it easy and convenient for the objectors to register their objection.

Registration forms should be made widely available through community centres, RC centres and other public places and proper acknowledgment must be made. We must not repeat the mistake made in the past where some people who pledged to donate their kidneys failed to receive the donor cards. I can speak from personal experience.

Several years back the computer was not used for registering the donors and some administrative slip-ups might have occurred. Now we must take great care with the list of objectors because the principle of the law is based on presumed consent. And even though we are now using the computer, the computer may still fail us occasionally.

The Register of Objectors must also be kept strictly confidential so that those who object need not fear stigmatization which should not occur at all.

We are very happy that the Bill has gained the general support of the Muslim community and the individual Muslims can donate their kidneys under section 3 of the Medical (Therapy Education and Research) Act. The Ministry officials should now assure the Muslim donors that the conditions as mentioned by the representatives of MUIS to the Select Committee will be scrupulously adhered to.

The Acting Minister has repeatedly given his assurance before in this House and outside that this Bill is meant for kidney donation to save lives only. Unfortunately, there is still a lingering fear among some people that this Bill is only the beginning of more types of organ donation to come. In this respect, the GPC members note that the word "organ" is defined as the kidney of a human body except for the purposes of Part IV of this Bill. In Part IV which prohibits the trading in organs and blood, the term "organ" means any organ of a human body. So to those people who fear that the Bill is only the beginning of some more things to come, Part IV does seem to confirm or support their suspicion. This is very unfortunate. It is not feasible of course to change the title of the Bill to that of, say, the Human Kidney Transplant Bill because of the presence of Part IV. But we wish to emphasize that in future if the Bill is to be extended to cover other kinds of organ transplant, every single bit of extension must be fully scrutinized and debated, just as in the case of kidney transplants. Otherwise we would be betraying the trust of the public in the verbal assurances given by the Minister.

A final word on the role of the relatives. Although the Bill is based on the principle of individual consent and hence the consent of relatives need not be obtained for the removal of the kidney. Yet the sentiment of the relatives must be handled with the greatest care. Death from accidents is sudden, violent death. The trauma suffered by relatives cannot be over-stated. So at the moment of grief and shock, we must extend every emotional and psychological support to the relatives. It has been suggested that some form of public appreciation should be extended to both the donor and his relatives. This idea is worth pursuing. It would help to spread the message that kidney donation is a magnanimous gift of life. Public recognition which brings psychological rewards is perhaps a better form of appreciation than a scheme of medical benefits extended to members of the immediate family of the donor. Whatever it is, Singaporeans will learn that kidney donation is one great form of giving and caring for other fellow human being.

Sir, we support the Bill and let us get on with it.

Dr Koh Lam Son (Telok Blangah): Sir, I welcome the Third Reading of the Human Organ Transplant Bill after the Report on the Select Committee.

Sir, this Bill must be regarded as a gift of life to Singaporeans who are dying from end stage renal failure. I am sure these Singaporeans will rejoice and I rejoice with them. In fact, all Singaporeans who do not opt out, and I believe they are the majority, should rejoice because this Bill gives them the assurance that should they be struck down by kidney disease they will have a much better chance of obtaining a donor's kidney than people living in other countries where such a legislation does not exist.

The compassion to save lives is the motivation behind the Bill and I believe this far outweighs any protestation that the Bill to own one's body after death is now not automatic. You have to fill in a form to say that. With the opting-out system, we are in fact recognizing the feelings of more Singaporeans in supporting the Bill and we also end this costly and futile task of the National Kidney Foundation in recruiting people under the present system of opting-in.

The Minister said just now that people who have opted out will not be coerced or counselled into opting in. Does that mean that the Ministry or the National Kidney Foundation will not persuade people who have opted out to withdraw? As this is a sensitive issue, I would also advise very cautious implementation of the Bill. First, there must be the widest possible publicity of the opt-out system. The benefits to relatives of donors must be highlighted and the joy of those whose lives have been saved be shown, in particular, the relatives of the deceased must be handled with tact and sensitivity. The Bill must not be seen to be forced down upon them at the moment of grief. Perhaps a trained person or trained persons should be present to explain the rules of the opt-out system and to stress on the opportunity that in their moment of grief there is also a gift of life to a dying person.

I wish to seek clarification on clause 3(1) which empowers the Minister to prescribe the criteria for determining the irreversible cessation of all functions of the brain of a person. Does this mean that in case of doubt, the Minister will have the final say? I think this may not be wise because to put a decision on life and death upon the Minister will put a tremendous burden on him. This should be made by a team of medical experts.

Finally, I refer to clause 12(1)(a) which gives priority to a person who has not opted out over one who has opted out in the selection of a proposed recipient. The Minister has said that, apart from medical criteria, the opt-out system will have priority on other criteria. But what about criteria such as the recipient's age, occupation, recipient's role in the family, role in the community? Will all this now not take precedence? As an example, will you select, say, a criminal who has not opted out or a social worker who has opted out?

Dr S. Vasoo: Sir, the Bill will give a new lease of hope to kidney disease sufferers. I am confident that Singaporeans will respond favourably to help their fellow Singaporeans who are suffering from kidney diseases and this will provide a new dawn of hope to those who are suffering from the disease.

I just want to get one clarification from the Acting Minister. It is whether appropriate procedures and rules will be worked out as to who will get the priority for kidney transplant. There are likely to be contentions and other related problems as to who would get this priority. I am wondering whether these procedures will be made known to the public.

Mr Yeo Cheow Tong: Mr Deputy Speaker, Sir, I would like to thank the three Members for their comments and the various suggestions that they have made.

The Members for Changkat and Telok Blangah have suggested that the publicity drive for the Bill be kept up. I would like to assure the Members of the House that there will be an intense publicity campaign for the six months that the grace period is in force. Subsequently, every year, all Singaporeans upon reaching the age of 20 years will receive a reminder and we will also, on an annual basis, be carrying out mass-media campaigns to ensure that Singaporeans are aware of the implications.

In terms of having dialysis facilities made available, the Ministry is working with the National Kidney Foundation to assist the NKF in making dialysis facilities available in various parts of Singapore. We will also assist the NKF to purchase the consummables in bulk so that the cost of dialysis can be further reduced.

In terms of using Medisave for payment for dialysis, at the present moment the dialysis facilities that are available in the private sector are rather expensive. It costs between $2,000 and $3,000 a month. Most Medisave account holders will therefore have inadequate Medisave balances to enable them to undertake the dialysis for long. What we are looking into is having a catastrophic illness insurance system which would help bear the bulk of the dialysis cost. When this catastrophic illness insurance system comes into force, then the Medisave requirements will not be a problem.

Regarding the easy availability of forms and to ensure that the administrative mechanism for acknowledging and processing the forms is efficiently implemented, I would like to assure the Member that forms will be available in all parts of Singapore through our Ministry of Health's facilities - the OPDs, the polyclinics, hospitals - and that we have worked out a system where all the objector forms will be processed within 24 hours and that an acknowledgment form will be sent out. There will be intricate safeguards built in to ensure that there is cross-checking that the forms that are sent in have been processed. In cases where the forms may be misplaced in the mail or have gone astray in the mail, the forms will carry an advice to objectors that if they do not receive an acknowledgment form within three weeks they should telephone the Ministry so that we can look into the reasons why.

Regarding the fear that the Human Organ Transplant Bill will be broadened to include other organs, that point was brought up also in the Second Reading of the Bill. In fact, there were two schools of thought. One school of thought, as expressed by, I think, two Members, was that because of the improving medical technology regarding transplant of organs, the Ministry should also look into broadening the ambit of the Bill. The other school of thought was that we should be very cautious. I would like to remind the Member that my answer was that yes, in due course, there may be a need for other organs. But the Ministry would prefer to persuade Singaporeans on the desirability of donating those organs on their own rather than through the use of legislation. Over time as Singaporeans become more familiar and comfortable with the concept of kidney donation and when the need arises for the other organs, I am sure the level of objection will have reduced.

The Ministry will also be strengthening the crisis counselling capability of our staff. We will be training a team of counsellors whose job will be to counsel and assist the relatives in their moment of grief. This will help them overcome the intense emotions that they will be feeling and that will be the main role of the crisis counsellors.

The Member for Telok Blangah has also asked for assurances that the Ministry and the National Kidney Foundation will not persuade objectors to withdraw their objections. As I stated in my address earlier on, the Ministry will not be counselling individual objectors and the list of objectors will be kept confidential. That means nobody else will have access to information as to which person has objected. So the NKF will be in no position to counsel individuals who have objected. I would like to reassure the Member that this list is totally confidential.

Dr Koh Lam Son: May I seek a point of clarification? My point was that it would be best if you could counsel and persuade those who have opted out to withdraw their objection and to opt in.

Mr Yeo Cheow Tong: If we are going to do that, then we should publicize the list of objectors. I think we will rely on the mass media campaign that we will be carrying out, that those people who feel that it is desirable, in the interest of saving lives, not to opt out would not opt out. We hope that those people who have opted out will over a period of time be persuaded by our arguments to change their decision. In which case, we would welcome their withdrawal of their objection.

The Member for Telok Blangah has also asked about the criteria of brain death and in case of doubt will the Minister have the final say. A set of criteria will be drawn up and the actual certification of death will be carried out by a team of doctors or specialists whose job is to determine the time of death and the state of death. So it will not have to come to me at all. It will be settled at the hospital level by the specialists who are the best persons to be involved.

In terms of the priority system, the key criterion is medical suitability. Based on that we will then find out which are the potential recipients who would form the pool of potential recipients. From there, the priority system will be worked out and the final group of recipients will be identified and the other criteria will then be applied. So the other socio-economic criteria will apply at that stage.

The Member for Bo Wen has asked whether in that case the criteria for selection would be publicized. In terms of the broad criteria, ie, the broad socio-economic criteria, yes, we can make them known. But in terms of the actual details, I think those tend to be rather emotional. It is best that they be left to the team of committee members who will be charged with ensuring that the selection of the recipients is carried out equitably.

Question put, and agreed to.

Bill accordingly read a Third time and passed.