HIGH COURT (ADMIRALTY JURISDICTION) (AMENDMENT) BILL

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HIGH COURT (ADMIRALTY JURISDICTION) (AMENDMENT) BILL: Order for Second Reading read.

The Senior Minister of State for Law (Assoc. Prof. Ho Peng Kee): Mr Speaker, Sir, I beg to move, "That the Bill be now read a Second time."

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This Bill amends the High Court (Admiralty Jurisdiction) Act in order to expand the current jurisdiction of the High Court in respect of shipping and maritime cases.

Sir, Singapore is one of the busiest ports in the world. We have positioned ourselves as a dispute resolution centre for maritime claims. In line with this, we established an Admiralty Court in 2002, to determine shipping and admiralty-related cases. As a maritime centre, it is important that our laws keep up-to-date with international maritime practices.

Currently, under section 4(4) of the High Court (Admiralty Jurisdiction) Act, a ship may be detained and used as security to satisfy certain claims against the owner of the ship. Such a jurisdiction is internationally accepted, and all major ports have similar legislation.

Leading shipping lawyers and members of the shipping industry have strongly recommended amending section 4(4) to also allow a ship on a demise charter to be used as security to satisfy a claim against the charterer. This is already the law in many jurisdictions, including the United Kingdom, Australia, New Zealand, Hong Kong, Malaysia, France, Italy, Greece, Netherlands and Spain. The Law Reform and Revision Division of the Attorney-General's Chambers studied the proposal and recommended its adoption. The Government has accepted the recommendation. This amendment will implement it.

A demise charter is a special type of ship hire, where the charterer is given full possession and control of the ship. The demise charterer has the power and the right to decide on the crew, the management and employment of the ship. These rights are very similar to those of an owner of the ship.

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Sir, this amendment will plug a lacuna in our maritime law. As the current law only applies to the owner of the ship, a ship owner can avoid the effect of section 4(4) by operating the same ship as a demise charterer rather than as an owner. This can be achieved by the use of a separate entity that is controlled by the owner. The separate entity will operate the ship after entering into a demise charterparty with the owner. As the separate entity does not own the ship, the ship cannot currently be detained and used as security to satisfy obligations incurred by this entity. The amendment will prevent owners from avoiding the effect of section 4(4) by this method, as the new provision will allow the ship to be detained as security for claims against the separate entity.

This amendment will prevent ship owners from insulating their ships against such detention by using a demise charter. It will also bring our law in line with international practice.

Sir, I beg to move.

Question put, and agreed to.

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

The House immediately resolved itself into a Committee on the Bill. - [Assoc. Prof. Ho Peng Kee].

Bill considered in Committee.

[Mr Speaker in the Chair]

* *The Chairman: The citation year "2003" will be changed to "2004" as indicated in the Order Paper Supplement.

Clauses 1 and 2 ordered to stand part of the Bill.

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

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

3.06 pm

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

In 1987, this House took a big step in saving lives when it enacted the Human Organ Transplant Act (HOTA) based on the concept of presumed consent. By so doing, we made it possible for the removal, for transplantation, of kidneys of those who die as a result of accidents, unless they have earlier opted out. In this way, lives are saved and useful kidneys are not wasted unnecessarily.

Singapore was not the first in the world to have adopted such an opt-out scheme for organ donation. Several European countries pioneered the laws for presumed consent.

Since then, there have been at least 20 countries in the world with organ transplant laws similar to HOTA. These countries have concluded, as we have, that an opt-out scheme is a more effective approach to ensure that organs from those who die can be used to save lives.

Separately, we have the Medical (Therapy, Education and Research) Act of 1972 to allow Singaporeans to pledge their organs, through opting-in. Between 1972 and 1987, 27,000 pledges were received. After the passing of HOTA, we have continued to encourage organ pledging. Since 1987, we have received an additional 30,000 pledges.

Of these 55,000 pledges, three became kidney donors during the last 30 years, saving six lives. This is not a big

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number. Nevertheless, we will continue to promote organ pledging as the spirit of giving, love and altruism is worth promoting.

Easing the restrictions of HOTA

Meanwhile, Singaporeans have continued to support HOTA. In the past 15 years, only 12,000 people have opted-out of HOTA.

To date, there have been 117 donors under HOTA. Together, they have saved 230 lives.

When HOTA was enacted, we deliberately kept it very restrictive. First, HOTA applies only to kidneys. Second, HOTA applies only to death from accidents. We took a very restrictive approach as we were breaking new ground and we did not want to unduly alarm Singaporeans. As Singaporeans have now become familiar with the concepts of brain death and presumed consent, I am proposing that we take the next step of easing these two restrictions so as to save a few more lives.

(a) Beyond kidney to liver, heart and cornea

First, we are proposing to expand HOTA to also cover three other organs: liver, heart and cornea.

(b) Beyond accident to other causes

**** Second, we are proposing to expand HOTA to also cover non-accidental deaths.

Living donor organ transplantation

In addition, we are proposing a third amendment to use HOTA to regulate living donor organ transplantation. In recent years, living donor organ transplantation has become accepted

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throughout the world. It is performed on a regular basis in many countries.

In Singapore, we have carried out more than 400 living donor kidney transplants (since 1976) and more than 40 living donor liver transplants (since 1996). In fact, in the past two years, there were more living donor kidney and liver transplants than transplants from cadaveric organs.

There are important medical and ethical issues to be managed for living donor organ transplantation. It is therefore necessary to regulate living donor organ transplantation to protect the interest of donors, as well as to ensure that there is no organ trading.

Key features of the amendments

Let me now go into the details of the amendments.

Inclusion of liver, heart and cornea

**** First, clauses 3, 5, 6, 7 and 11 of the Bill will extend HOTA to include liver, heart and cornea.

In 1987, kidney transplantation was the only established transplant procedure. The first heart transplant and the first liver transplant in Singapore took place only in 1990. Since then, liver transplantation and heart transplantation have become established treatment modalities. For patients with liver failure or heart failure, organ transplantation is, in fact, the only way to save their lives.

Each year, we carry out about eight cadaveric liver transplants and two heart transplants. There are currently about 20 patients on the waiting list for liver transplants and five patients on the waiting list for heart transplants. The waiting list is not long, but only because patients with end-stage liver failure or heart failure often do not survive the waiting time. Each year, about 15 people

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die while waiting for a liver and three people die while waiting for a heart.

Just two months ago, a 4-year-old girl died while waiting for a liver transplant. She had waited 31 months but in vain. Her parents wanted to donate their livers but, unfortunately, their tissues were not compatible. In the last two years of her life, she had to be hospitalised two to three times a month. She also had recurrent infections and spent the last three months of her life in hospital.

A few months back, a 41-year-old mother of two passed away while waiting for a heart transplant. She had developed heart failure after a viral infection. While waiting for a heart transplant, she had to be placed on a heart assist device to help her heart pump effectively. However, after 11 months on mechanical support, she developed a blood infection and passed away while waiting for a heart.

Every patient with organ failure clings on to the hope of receiving an organ transplant and leading a normal life. The inclusion of liver and heart under HOTA will allow

a few more of these organs to be used to save lives, instead of being wasted through cremation or burial.

Last October, a 50-year-old lady suffered from a very bad fungal ulcer in one eye. She required a cornea transplant. Fortunately, there had been a local donor three days prior to her operation and the Singapore Eye Bank was able to provide a fresh cornea for her. Without the local donor, the eye bank would have had to depend on an imported cornea. It would have taken about five days to arrive. By then, the tissue might not be in optimal condition.

Although cornea transplantation is not life saving, it restores sight to the recipient. By increasing the local supply of corneas, we would not only reduce our

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reliance on overseas corneas but also ensure that the corneas obtained are of better quality.

The need for corneas will continue to rise as our population ages. In 1991, about 80 cornea transplants were carried out here. By 2002, the number had gone up to 200. Currently, half of the corneas are obtained from Singapore donors while the other half are obtained from the United States. However, the import of corneal tissue is not ideal. The procurement cost is getting higher. Aside from cost, overseas sources are unpredictable and the quality of the tissues is subject to external factors beyond our control. For example, it takes about five days to import a cornea. The longer preservation period would affect the quality of the cornea. The delay also precludes the availability of corneas for emergency cornea transplants.

In view of this, it is also desirable to expand HOTA to include cornea.

Inclusion of non-accidental deaths

Second, clause 4 of the Bill will extend HOTA beyond accidental deaths to non-accidental deaths.

To address the shortage of organs for transplantation, we have to ensure that cadaveric organs are not wasted. However, not all cadaveric organs are suitable for transplantation. Among all the patients who die in hospital, only a small number are suitable organ donors.

In practice, solid organs such as kidney, liver and heart will be suitable for transplant only if they are retrieved from patients who are brain dead and the underlying illness has not damaged the organs. Each year, we encounter about 40 such cases in hospitals. About one-third of these are due to accidents; the rest due to other causes.

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For the purpose of transplantation, the cause of death really makes no difference. That is why in practically all other countries with transplant laws similar to HOTA, they do not differentiate deaths into accident and non-accident causes. However, as currently enacted, our HOTA restricts its scope to only accidental deaths. Now that Singaporeans have a better understanding of the importance of organ donation, I propose to remove this artificial differentiation that has unnecessarily wasted the number of organs which could otherwise have been available for donation.

The Bill would therefore allow HOTA to cover non-accidental deaths. What are non-accidental deaths? They refer to deaths from medical conditions. Examples are deaths due to intra-cranial haemorrhage (bleeding within the brain or skull) and primary brain tumours. These are patients who have already died in the ICU (intensive care units) of hospitals but purely relying on mechanical ventilators to maintain their blood circulation and keep their organs viable for transplantation.

In the case of cornea transplantation, it only involves the removal of a thin button-sized layer from the surface of the eye. The cornea is a non-vascular tissue. It can be removed after cardiac death or brain death has occurred. There will be stringent medical criteria to ensure that only tissue that is suitable for transplantation is removed.

Regulating living donor organ transplantation

Third, clauses 3, 8 and 11 of the Bill will regulate living donor organ transplantation. In particular, a new Part IVA, comprising sections 15A to 15D, will be inserted into the principal Act.

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Living donor organ transplantation is not without risks or problems. First, it exposes an otherwise healthy individual to the risks of a major surgery. For instance, among living liver donors, one in seven may experience some post-operative complications. This could range from a need for reoperation to even death. Fortunately, we have so far not had any living donors who developed complications and died as a result of donating organs. Second, there is the risk that the donor might be under duress or coercion to donate his or her organs. Third, there is the risk of organ trading. Organ trading is repulsive and repugnant. We must strictly prohibit it.

My Ministry has therefore established strict professional guidelines on living donor organ transplantation. The guidelines stipulate that the social, psychological and emotional profile of the potential donor must be fully assessed. A full medical examination is required, and the surgical procedure, operative risks and possible long-term effects must be fully explained to the potential organ donor.

While the Ministry guidelines are comprehensive, there is currently no legislative backing for the regulation of such transplants in Singapore. This limitation should be rectified.

The Bill will expand on the current professional guidelines. The new section 15A prohibits living donor organ transplantation except where certain conditions are satisfied. All living organ donor transplants would require prior approval, in writing, from the respective Transplant Ethics Committees in the transplant hospitals.

The committee would have to be satisfied that two major professional and ethical concerns are adequately addressed. First, the donor thoroughly understands the nature and consequence

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of the medical procedures and has given his or her full informed consent. Second, there is no emotional coercion or financial inducement to donate an organ.

The Transplant Ethics Committees will make their own assessment and decision based on the available information. This includes the medical report, the psychosocial report and the case report as well as interviews with the donor and relevant parties where appropriate. This will ensure that the necessary safeguards are put in place.

The new section 15B makes provision for the appointment and functions of the Transplant Ethics Committees. There will be regulations to govern the appointment and the procedures of these committees. Every committee shall comprise at least three persons, including at least one independent medical practitioner and one lay person. The section also confers immunity from legal suit on the members of a Transplant Ethics Committee and persons acting under the direction of the committee for anything which is done in good faith by them for the purposes of exercising the committee's functions.

The new section 15C empowers the Director of Medical Services to issue directions in the event that a Transplant Ethics Committee is not discharging its functions properly.

The new section 15D provides for the Director of Medical Services to issue directions to the hospital or the Transplant Ethics Committee for the purposes of Part IVA.

Other amendments

In addition, clauses 9, 10 and 11 of the Bill provide for the insertion of relevant sections and schedules so as to empower the Director of Medical Services to compound any offence which is prescribed as compoundable, as well as to

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specify the types of living donor organ transplants which should be regulated under this Act.

Public consultation

Mr Speaker, given the sensitive nature of these amendments, the Whip has been lifted to allow Members to debate and vote on the Bill based on their religious and ethical beliefs.

On my part, we have carried out extensive public consultations on the proposed amendments and the draft Bill. We took almost one year to do this. Many feedback sessions were organised. We also proactively sought the views of professional, religious and community organisations. The text of the draft Bill was also placed on the Ministry of Health's website for public scrutiny.

The public response has been good. Singaporeans accept the need for organ donation and organ transplantation in order to save lives and to reduce the suffering of those with organ failure. The majority were in favour of the proposed amendments.

If the House supports this Bill, we will continue with the public education efforts to ensure that Singaporeans are fully aware of these amendments and of how they will be affected.

Conclusion

Sir, today, there are many Singaporeans with organ failure who face financial hardship and unnecessary death. The amendments to HOTA cannot fully solve the problem of organ shortage. However, it will go some way towards saving lives and reducing suffering. I hope this House will join me in helping to save these lives.

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Sir, I beg to move.

Question proposed.

Dr Lily Neo: Mr Speaker, Sir, I stand to speak in support of the Human Organ Transplant (Amendment) Bill.

Sir, I am a doctor, and as all doctors believe that saving more lives and reducing suffering are fundamental to our doctrine, I welcome this Bill for it will enable us to save more lives and give more quality life for many patients. However, I do have several concerns with regard to this Bill.

I feel that this opt-out scheme of HOTA is too imposing. I would have preferred just an opt-in scheme. Many have expressed disgruntlement that their body organs automatically do not belong to them after death. Although they can opt out, there is a penalty for doing so under HOTA. The explanation for the opt-out scheme has been that the opt-in scheme enacted under the Medical (Therapy, Education and Research) Act (MTERA) since 1972 drew very small donor response. My point is that, with our affluent society, it will be more civic to invite people to donate their organs rather than compelling them to do so through regulations. Is it right to base the poor response of our past record of our opt-in scheme for our decision to expand HOTA now? In the past, no concerted efforts were tried by MOH on public persuasion or public education to get donors to better promote our opt-in scheme. Could it be that the opt-in scheme has failed from the lack of effort on the part of the Ministry? Are we being seen as taking an easy way out again without even considering this implication of compulsion on the people? Is it right for us to progress as a society in this manner?

Brain death issue has been controversial. The worrying fact for many is whether people certified with "brain death" is really dead. Many reports in the media had published how "brain death"

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patients had woken up after years of being in coma. One such case was noted in Europe recently - the patient was apparently in coma for 18 years. For the loved ones of many certified brain death patients, the acceptance of brain death is heart-wrenching, especially when this is instantaneously followed by the removal of the organs of their loved ones. How does the Ministry of Health ensure that organs are not removed prematurely? I have read that in the United States, the whole brain must stop functioning

for a diagnosis of "brain death" whereas, in Britain, brain-stem death is enough. Which one are we following in Singapore?

This Bill will expand the organs for transplant to include the cornea, heart and liver. Some have questioned why corneas should be included in this Bill as cornea transplants do not save lives and corneas can be imported easily. Cornea transplants have not been affected here in the past and nobody has been deprived here of cornea transplant. The argument against including the heart is that, since not many heart transplant operations are being done here, why is there a need for that organ presently? Also, due to their religion, some have expressed that they are uncomfortable with the idea of having no hearts in their after-life and having no sight if they had their corneas removed.

This Bill will regulate the living organ transplant. May I seek clarification from the Minister on a few points here? How is his Ministry going to regulate on the criteria concerning living donors and prevent abuses with regard to the deterrent measures? How is his Ministry going to ensure that donors are not under financial inducements or emotional coercion and duress to donate their organs? Are there safeguards to protect the interests of the donors because there is a risk of death or long-term medical complications? How do we ensure that the medical costs incurred in the course or as a result of donating their organs can be

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addressed? Will those Singaporean recipients and donors who cannot afford to pay for their medical bills fall under the safety net of Medifund? How will this new proposed Bill affect foreign patients seeking organ transplant in Singapore?

Sir, Muslims have been excluded from HOTA; therefore, Muslims waiting for a kidney transplant will naturally have a very low priority. May I ask the Minister how he is going to address and help Malays who are apparently at higher risks of developing kidney disease? Kidney disease treatment, such as dialysis, is not only a costly but also a long-term liability and this will cause hardships to many Malay families. In the past, Muslims signed up as donors on finding out they had kidney failure so that they were eligible when they needed the transplant, usually several years later from the onset of kidney failure. Can they continue this practice?

Sir, I would like to urge the Ministry of Health to step up public education not only about HOTA but also to equip the public on how to prevent the need for organ transplants. As we know, the majority of kidney failure cases here have been the result of diabetes and hypertension. Therefore, healthy lifestyle promotion for prevention of disbetes and hypertension, early diagnosis of these conditions and good control of these conditions will help us reduce our need for more organ transplants. All efforts must be enhanced and monetary issues addressed, especially towards helping those who are poor to pay for their long-term medications for these chronic diseases.

Sir, may I now seek clarification on certain clauses of the Bill? Section 5(2)(f) of the Act suggests that there is no authority to remove organ if the designated officer, after making inquiries, has reason to believe that person was not of sound mind, unless the parent or guardian has consented to such removal. I understand that, legally, if a person is

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already classified as of unsound mind, a committee of estate will be appointed to take care of that person's estate. If this is the case, the consent to be sought should be from the appointed committee, instead of the parents or guardians. Therefore, should this section not be amended to include consent to be sought from the committee of the estate, if any? If the designated officer, after making inquiries, has reason to believe that the person was not of sound mind, it ought to be deemed that no authority was given. The rationale is that person would not be in a position to decide whether to object to the removal of his organ and submit the objection.

Sections 9 to 13 (Part III Registration of Objection) suggests that any person objecting to the removal of organ will be given an acknowledgement form and, if he subsequently changes his mind, another form will be given to him. In this case, there will be several forms in the hands of his next-of-kin and this may cause confusion and may lead to the next-of-kin questioning this perceived discrepancy. In this way, may I suggest that a new clause be added to state that, in the event of discrepancy, the information recorded in the register shall be final and conclusive of the election of the person.

I hope the Minister can enlighten us on the points raised.

Mr Gan Kim Yong: Mr Speaker, Sir, I rise in support of the proposed amendments to the Human Organ Transplant (Amendment) Act.

As the Acting Minister has pointed out in his speech, some 230 lives have been saved, since HOTA came into effect in 1987. Some people may feel that 230 is a small number compared to our national population of more than three million and

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that it would not make any difference. It may not have made any difference to many Singaporeans, but it certainly makes a lot of difference to the 230 lives which were saved through HOTA and to their family members. It is for this reason that we are here today to debate the proposed amendments to the Act to expand the scope so that more lives can be saved. These amendments, if approved by Parliament, will undoubtedly make a significant difference to those who are currently on the waiting list for organ transplant.

Sir, we have come a long way. Over the last 15 years, most Singaporeans have overcome the initial fears and concerns of HOTA and come to accept the principle of presumed consent on organ transplant. It is therefore timely to move to expand the scope of HOTA so that more lives could be saved. While I expect more Singaporeans to be supportive of the proposed changes, we cannot take for granted that all of them have clearly understood the implications of these changes. In my dialogue with my residents, some of them, especially the older ones, still have specific concerns. We need to address their concerns if we were to have their unequivocal support. And I would like to elaborate on some of these concerns.

Firstly, the Bill is proposing to expand HOTA to include non-accidental deaths. In particular, this will include patients who are considered to be brain dead. The intention is quite clear. We hope that this will allow more organs to become available. It has been estimated that about 24 kidneys, for example, could become available for transplant if non-accidental deaths were covered under HOTA. The motive therefore is quite obvious. However, the inclusion of non-accidental deaths in HOTA may give rise to some concerns with regard to brain death. Although the Government has clarified, on several occasions, the definition of "brain death" and has

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assured the public that adequate safeguards will be introduced to ensure that the declaration of brain death follows a set of very stringent clinical criteria, some Singaporeans are still concerned on two aspects. Firstly, whether brain death is reversible and, secondly, whether every effort will still be carried out to save the lives of brain dead patients. The question that lingers on in some people's mind is that, while a person may be certified brain dead according to medical definition, is he truly dead? Some still have the fear or hope, depending on how you look at it. Those who have been certified as brain dead may still wake up one day. And if their vital organs have been removed under HOTA, they will have no hope of recovering. This is particularly so as some have heard stories of supposedly brain dead patients miraculously returning to life.

It is important to dispel the myths of brain death and allay such fears. I am afraid that professional and medical definitions alone will not be persuasive enough, although they may be adequate as legal definitions. I think we may still need to explain in layman's terms what it means to be brain dead and why recovery is no longer possible. This is a tedious but necessary process. We must understand that sometimes such issues are not a matter of the brain, but a matter of the heart because emotions are involved. And we would need to take time to explain and to persuade.

It is also natural for patients and their relatives to be concerned, given the prospects of organ harvest, whether saving the patients' organs would be given higher priority than saving the patients' lives. For example, would doctors decide to disconnect the life support system so that organs can be obtained? It is therefore necessary to reassure patients and their families that

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procedures and safeguards have been put in place to ensure that patients' interests will not be compromised when the Act is expanded.

Sir, inevitably, at the end of the day, there would still be people who choose to remain unconvinced and wish to opt out for a variety of reasons. The fact that some 12,000 people have opted out of HOTA over the last 15 years is evidence that we cannot hope to convince everyone. While we want to encourage Singaporeans to support HOTA, we must also respect the rights of any individual to opt out, if he so wishes. For this reason, I would strongly urge the Ministry to ensure that the process of opting out is kept simple and accessible, especially for the older people who may not be literate. I understand that MOH plans to inform all Singaporeans and Singapore permanent residents when they turn 21 that they will be covered under HOTA. I hope MOH will continue this practice and, for the convenience of the population, the notices should be multi-lingual.

Finally, Sir, I would like to urge the Ministry to continue its public education efforts. This is important in our efforts to reach out to Singaporeans to persuade them not to opt out of HOTA. Public education also plays an important part in our continued efforts to promote organ pledging. Communicating with the public is an on-going process and we must keep up the effort.

To summarise, Sir, my three points are: firstly, we must address the concerns of some Singaporeans on the clarity of the definition of "brain death" and assure them that patients' interests will not be compromised in favour of organ harvest. Secondly, while we want to promote HOTA, we must ensure that the opt-out process is simple and accessible. And lastly, we must continue our public education and communication efforts.

On this note, Sir, I support the Bill.

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Mr Chiam See Tong (Potong Pasir): Thank you, Sir, for allowing me to join in this debate.

Sir, I congratulate the Minister for lifting the Whip on this Bill. The provisions of this Bill do touch on religious beliefs of many Singaporeans. Therefore, it is only right that the Whip be lifted and allow Members to vote by their own conscience.

Sir, I believe that it is the moral duty of all citizens to save lives and relieve pain. Accordingly, I would rise in support of the Human Organ Transplant (Amendment) Bill which seeks to widen the scope for getting more human organs for transplanation to save lives. Formerly, the scope of procuring human organs for transplantation was only limited to getting them from persons who have died in accidents. The organ allowed to be harvested was only the kidney. But with the enactment of this Bill, the list of organs allowed to be taken from dead persons

includes the liver, heart and cornea.

In addition to the enlargement of the list of organs allowed to be harvested from deceased persons, the Bill, when it becomes law, shall allow living persons to donate their kidneys and part of their livers for transplantation to another living person. Doctors soon shall also be allowed to harvest organs from dead persons who have not died from an accident.

All in all, this Bill, when enacted, is a breakthrough in medical science in Singapore. The scope for getting organs from deceased persons shall soon be very much widened, and donations of organs from living persons shall also be allowed. Although I agree to the donations of organs by living persons, at the same time, I sincerely hope that the Minister shall satisfy himself that there are sufficient safeguards against abuse and trafficking of human organs.

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I note that the punishment under new section 15A(4) is only a $10,000 fine and a maximum of 12 months' jail and, under new section 18A, the Director can compound an offence under the Act for only $2,000. Under these kinds of seemingly light punishment, some people may think it is worthwhile to flout the law and indulge in trafficking of human organs or induce an unwilling person to sell his kidney for, say, $10,000. In turn, the trafficker may market the kidney for 10 times that price to a desperate rich man who needs a kidney transplant to save his own life.

As regards the jail sentence, normally a prisoner can get a one-third remission of his jail term. So, a person who trafficks in human organs can get off with an 8-month jail term and come out to enjoy his $100,000, less the amount he has paid to the seller of the organ. When there is evidence of trafficking in human organs in Singapore, I urge the Government to be strict on those wrongdoers, especially when a criminal offence is detected.

As regards the relationship between the donor and the donee of the human organs, it would appear that the Government still insists that there must be some kind of a close relationship between the donor and the donee of the organ. This is illustrated by the recent case of Ms Andrea De Cruz and her fiance, Mr Pierre Png. In that case, I was told that a Buddhist monk had volunteered to donate part of his liver to Ms De Cruz, but the Director of Medical Services rejected that offer on the ground that there was no close relationship between the monk and Ms De Cruz. The rationale is that where there is no close relationship in terms of family members, there is always a doubt as to whether the consent by the donor was genuine. In that case, Ms Andrea De Cruz had a happy ending, as she was saved by the donation of part of the liver by her fiance Pierre Png. In my view, in

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cases of living donors, I hope that the Director of Medical Services shall still insist on a close relationship between the donor and donee of the organ to ensure that there is genuine consent on the part of the donor of the organ. If the close relationship is comprised of a blood relative, it shall all be for the better, because the organ donated shall have a better match with the donee and the chances of rejection shall be less.

As regards the First Schedule of the Bill, it allows, in addition to the kidney, the liver, heart and cornea to be removed from a deceased person for transplantation. Since the Bill has now widened the list of organs to be extracted for transplantation from a dead person, the important question one would ask is: when is a person dead? Is a person dead when his brain is dead? Again, I would like to get the Minister's assurance that Singapore has all the know-how and the medical equipment to diagnose a person to be brain-dead. Not long ago, a Taiwanese lady was thought to be brain-dead when she was in England. But when she was rushed back to China and given treatment, she recovered, so the report goes. I hope that such incidents shall never happen in Singapore, otherwise it can be embarrassing for Singapore, which is working to be a medical hub of this region. I am informed that Singapore, like the United States of America, has acceptable standards of what constitute brain death. I believe so. But I would still like the Minister to comment on this.

This Bill raises many medical and ethical issues. For example, how can a doctor take a human organ from a donor and at the same time not explain to him that there may be a risk to his life, or that he may develop health complications later on? Or how can a doctor convince himself that a donor has really given his full consent to donate one of his organs?

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After this Bill is passed, it would appear that a doctor can legally take the organ of a deceased Muslim for transplantation when that Muslim has not opted out of the Act. Will the doctor do that, knowing that many Muslims interpret their religion as prohibiting the donation of human organs? In the case of Jehovah's Witnesses, their branch of Christianity prohibits the transfusion of blood. Does the doctor do nothing and allow a Christian of that sect to die without giving him a blood transfusion so that his much-wanted organs can be donated to sick patients who are in grave need of those organs?

I know these are difficult medical and ethical questions, but they have to be discussed openly and, hopefully, a consensus can be arrived at.

Mrs Lim Hwee Hua: Mr Speaker, Sir, I rise in support of the proposed amendments to the Human Organ Transplant Act. The reasons are compelling and I shall therefore not repeat them. I would, however, like to address the issues which have arisen from the following amendments:

(1) The inclusion of corneas and hearts;

(2) The inclusion of non-accidental deaths; and

(3) The regulation of living donor organ transplants.

In addition, when discussing the inclusion of non-accidental deaths, I would briefly revisit the issue of the determination of the moment of death, for harvesting organs, as these amendments may rekindle old perceptions and fears.

Sir, the PAP Women's Wing has consulted with professional women and carried out a survey amongst some 300 women activists of varying ages and from

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all walks of life. I shall be reflecting some of the feedback in my speech.

Firstly, the inclusion of corneas and hearts.

Sir, clause 3 seeks to add corneas, hearts and livers to the First Schedule in the definition of an organ. At present, a large number of corneas used for transplantation come from foreign sources and the challenges are well-known, as the Minister has already touched on. It would, therefore, be desirable to include corneas under HOTA. An equally compelling argument can be made for heart transplants.

In our survey, more than 50% of the respondents disagreed with the Chinese belief that corneas were needed in the afterlife, compared with the 32% who thought so. This appears to be more of a Chinese folklore or belief, rather than being rooted in any religious grounding. Nonetheless, some may feel uncomfortable that their loved ones, or some day, they themselves, will literally die "heartless". Hence, while this does not constitute violent objection, I would like to urge the Minister to carry out the necessary public education. The Minister may also want to allay the fears that there would be cosmetic defects in their loved ones whose corneas have been harvested.

The other concern raised revolves around the observation that cornea transplants are seldom life-saving, if at all. There is no reason in principle why we should adopt such a limited position, especially with regard to the debilitating effects of blindness. Of course, in saying this, I am not endorsing a carte blanche approval of any and every organ, the failure of which would have a similarly damaging effect on the body. It is, however, safe to say that the practice of

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cornea transplants is well established here, and there are no ethical concerns that justify precluding their inclusion.

It remains to be pointed out that those who possess strong beliefs can always have the remedy of opting out of HOTA.

Secondly, the inclusion of non-accidental deaths.

Clause 4 widens the scope for inclusion of non-accidental deaths, which refer to deaths from medical conditions. As the Minister has said, many other countries have already included both accidental and non-accidental deaths in the legislation. We would, therefore, not be the first to make such a move.

Sir, non-accidental deaths were omitted from the purview of HOTA initially to allay any initial distrust of the Act, since it was easier to accept that very little could be done to save victims of bad accidents, as opposed to patients who were terminally ill.

However, with the purview now widened to cover all deaths, the onus is on the Minister and his officials to ensure that the criteria for certifying death are stringent and that the assessors are bound strictly by criteria that ensured impartiality. I shall elaborate on the determination of death shortly.

The fear appears to be more of possible inefficient policing, than one of principle. So long as there is efficient policing, there should be no objection to extending HOTA to non-accidental deaths.

Sir, with regard to defining the moment of death, since its inception in 1987, HOTA has always been applied to brain-death cases. This is notwithstanding the amendment to the Interpretation Act in 1998 to widen the definition of death to include brain-death.

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The definition of brain-death used by Singapore is the same as that used in many developed countries, which is determined based on a well-defined standard set of clinical criteria. The point would thus appear to be moot at this late stage. However, as my colleagues Dr Neo and Mr Gan have alluded to, there is perhaps a renewed fear that with the growing breadth of HOTA, medical professionals may be less rigorous in their determinations of death, that they will be motivated by the competing prospect of potential donors. This may cause grieving families to wonder if the lives of their loved ones might have been prematurely truncated. In our survey, about half expressed such reservations.

Sir, medical professionals may be well-acquainted with the determination criteria, but the lay person, by and large, appreciates cardiac death, or when the heart stops beating, better than brain-death. Once again, our survey bears this out, with half feeling more assured with cardiac death for the harvesting of organs. I would, therefore, like to urge the Minister to carry out more public education on the stringent safeguards in place as well as provide adequate counselling for affected families. With this assurance, there should be no objection to the continued adoption of brain-death as a legal criterion of death.

Thirdly, the regulation of living donor transplants.

Sir, I note that living donor transplantation is widely accepted and performed regularly in many countries. There is currently no legislation, and it is timely to regulate such transplants. And most people are supportive of such transplants.

While the first class of transplants involving related parties is well understood and accepted, those between unrelated parties can potentially lead to organ trading, if stringent guidelines and policing are not in place.

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I note the adoption of the spirit of wanting certain proof that the donor is not motivated by financial incentives. In addition, the following considerations should be addressed:

(1) The medical risks to the donors and how to mitigate these risks;

(2) Whether there is informed consent; and

(3) Whether the donor is acting under duress.

There is a fear that legislation will not cover loopholes, such that a trade in organs will unwittingly develop. However, I note, Sir, that at present it is already illegal to pay for or trade in organs. Therefore, the proposed amendments should not raise the risk of a development of the organ-trade.

However, at the same time, there may be a need for a reasonable compensation to defray the costs and expenses of donors. In the United Kingdom, this is apparently allowed for to a certain extent.

Under the proposed section 15A for living unrelated donors, approval must be obtained from the hospital's ethics committee. The mainstay of section 15 relates to whether the donor has given informed consent, and whether

that consent is not obtained by virtue of fraud or duress.

It does not however preclude contracts which allow for the reimbursement of any expenses necessarily incurred by a person in relation to the removal of any organ or blood in accordance with the provisions of any other written law. It is debatable therefore whether this extends to loss of earnings. Some clarification by the Minister with regard to this point would be helpful.

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Finally, a suggestion to the Minister for living related organ donations. These are in principle less susceptible to abuses such as organ trading, because of the presumption of emotional ties. However, there is also the fear that donors would feel pressured or even coerced to make a donation to a relative. The current professional guidelines issued by MOH do not require the approval of the hospital's ethics committee, so long as relevant evidence of kinship is produced. The Bill does not change this position. There has been the suggestion that such donors should be made to undergo psychiatric evaluations to ensure that there is no element of coercion or pressure.

On this note, Sir, I support the amendments to HOTA.

Mr Speaker: Order. I propose to take the break now. I suspend the Sitting and will take the Chair again at 4.25 pm.

Sitting suspended accordingly at 4.02 pm until 4.25 pm.

Sitting resumed at 4.25 pm

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[Mr Speaker in the Chair]

**HUMAN ORGAN TRANSPLANT (AMENDMENT) BILL

Debate resumed.

Mr S Iswaran (West Coast): Mr Speaker, thank you for allowing me to join in this debate.

I rise in support of this Human Organ Transplant (Amendment) Bill, the intent of which is to enhance quality of life and to save lives. I think on that score, no one in this House can have any quarrels with the Bill.

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My focus however is on the method and approach that are going to be used to achieve that objective. Like all good intentions, it is the means that need to be examined in closer detail. Sir, the Bill in particular addresses the issue of living donor transplants and that is the specific aspect that I wish to focus the bulk of my comments on, as many of the preceding speakers have covered many other areas.

Sir, the Transplant Ethics Committee envisaged by this Bill must be satisfied with three matters before it gives its authorisation for the removal of a specified organ from the living donor. Firstly, a living donor has to give consent. Secondly, the consent has to be informed, in the sense that he is of sound mind, able to understand the nature and the consequences of the procedure he has to undergo. Thirdly, as the Minister puts it, there must be no emotional coercion or financial inducement. These are important considerations for the Transplant Ethics Committee because it must, in its task, be seen to be objective, having the best interest of the living donor and the recipient at heart in coming to a fair and just outcome. The fact that most of these decisions may have to be made under the pressure of time, because lives will be at stake, I think, makes this task all the more difficult.

Certain questions arise when one contemplates how the Transplant Ethics Committee is going to go about its work. The Minister said that the Committee will ensure, through various reports from psychologists, doctors and so on, that the living donor is well-briefed, understands what the impacts of his action are on himself and his long-term health before he comes to a conclusion. Sir, this notion of understanding the nature and the consequences of his action is very important in this context, because the impact of a living donor transplant is quite serious. From what I understand from friends who are in the medical profession,

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living donor kidney transplants have a mortality rate of less than 0.1%. On the other hand, living donor liver transplants have mortality rates that can range between 1-3%. When we start thinking about chances of complications, post-surgery, the probability increases significantly and as I understand it can be as high as 20-25%.

It is critical that whoever is contemplating donating his or her organ is well-briefed of the implications. This briefing must be done by individuals who are well-trained and impartial. This is the part that I am most concerned about. How will the Transplant Ethics Committee ensure that is indeed accomplished, especially when we think in terms of usually these scenarios are charged with emotions and the time pressure on the Transplant Ethics Committee will be significant?

The second element that comes up is: how will the Transplant Ethics Committee ensure that the donor is not under duress or donating pursuant to any contractual agreement or other understanding? What criteria will be used to judge what is reasonable compensation as opposed to inducement? Allow me to illustrate.

If a recipient compensates the living donor for the cost of surgery, post-surgery care and also the treatment of complications that might arise that may require long-term treatment, is that permissible under new section 15 of this Bill? If it is indeed permissible, is there a test as to what is a reasonable level of compensation? And if so, who will verify or audit to ensure that such payments are legitimate and not excessive? We can extend that argument further and Mrs Lim Hwee Hua had talked about it. If the recipient offers to compensate the living donor for loss of income during the period of convalescence after the operation has taken place, is that permissible? What if the post-operative complications diminish

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the living donor's earning capacity permanently? Can the recipient legitimately make good on that shortfall?

There is a whole range of questions we can contemplate in this regard. The Bill itself leaves these matters largely unaddressed. I suspect partly because the Ministry's thinking is that it should be addressed by either the ethics committee's deliberations or in a court of law. But my own view is that we need to have some level of debate and clarity on the intent in this House to guide the committee and any other body that needs to think and address these issues. In general, the key question we need to ask is: are there any guidelines or provisions that are in place as to how remote such expenses or payments need to be before they are deemed not to be consideration for the sale of organs?

I would also like to seek a clarification from the Minister on the applicable age of consent under this Human Organ Transplant (Amendment) Bill. Sir, under HOTA, deceased between the ages of 21 and 60 may be the subject of authorisation for the removal of any organ for transplant purposes unless they have opted out. However, under the Medical (Therapy, Education and Research) Act, anyone of sound mind above the age of 18 can pledge his organs for transplant, education or research. So, the question that begs to be asked is: what is the status of a living donor or any other donor, for example, between the ages of 18 and 21 under this Bill? Can they donate? Certainly, from a public policy perspective, if the intent is to maximise the potential pool of healthy donors, we should allow those between the ages of 18 and 21 to do so. But this matter is again not explicitly addressed, and I would appreciate a clarification from the Minister on this.

Sir, given the magnitude and range of issues that need to be contemplated and

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thought through by the Transplant Ethics Committee, it is important that we also ask the questions on how the Transplant Ethics Committees are structured, what is their composition and how they are going to go about their work. The most basic question that comes to my mind is: should the Transplant Ethics Committee be centralised or decentralised? This Bill envisages that each hospital will have its own committee. In other words, it will be decentralised. I think the key concern here is the trade-off between speed of decision making whereas a more centralised model will give us greater consistency. I think the concern with a decentralised model is: will the guidelines be applied in a consistent manner, meeting not just minimum standards but what we accept as social norms in approaching such thorny issues?

From what I know based on the readings I have done on this matter, I think the additional number of organ donations that might arise from this amendment are of the order of magnitude of a few tens in a year. If that is the case, then is this argument of concern over the speed of decision making of the ethics committee really strong enough for us to err in favour of a decentralised model? Or should we really be focusing on creating a centralised body which will respond efficiently if it is given the resources to ensure that matters such as proper counselling of the donors is done, and to build up a body of cases regarding this whole new and untested water of living donors before we, with some level of confidence, decentralise it to the hospitals? I think this is an important issue. My own preference would be to keep it centralised and then, over a period of time, once we are more comfortable with the application of the principles, to decentralise it. I would appreciate the Minister's elaboration on his thinking on this subject.

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If the plan continues to be to keep the committee decentralised, then the question that I would like to ask is: how do we ensure consistency in practice across medical institutions? Will the Ministry draw up guidelines to ensure that all these ethics committees will operate within certain well-defined boundaries?

The issue of the composition of these ethics committees also needs to be addressed more specifically. As it stands, the requirement is that the ethics committee comprises no fewer than three persons, of which one must be a lay person and the other a medical doctor not employed by or related to the hospital in question. It is a good start. But if we think about it a bit further, what this means is that we could technically have a Transplant Ethics Committee of, say, seven members, of which one is a lay person, one medical professional not linked to the institution, and then five from the institution itself. Then there is the question of how will the decisions made by this Transplant Ethics Committee appear in the eyes of the general public. I think there is a need to ensure certain caps to the size of the overall Transplant Ethics Committee if, in fact, we may say that they should be set up in each hospital. And if they are going to be set up in each hospital, then there should also be an explicit limit on the number of professionals from that particular institution being represented on that committee. I think this is not to cast any doubts on anybody's integrity. This is more about being seen to be doing the right thing as much as doing the right thing.

Finally, I have a set of questions on the issue of public education. In preparing for this debate on this Bill, I spoke to several young lawyers, doctors and professionals. And as we know, under HOTA, Singapore citizens and permanent residents turning 21 are to be informed of their coverage under HOTA by the

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Ministry of Health. All the young people I spoke to, and they are young enough to remember when they turned 21, do not recollect receiving any such notification. I would like to ask the Minister to confirm that, in fact, this is being done and that all Singaporeans and PRs will be told of their coverage under HOTA at the appropriate point in time.

A related question is with respect to foreigners who are here under permanent residence or other organisations. Are they informed and, if so, at what point upon getting PR or are there any other reminders to them? I would like to know this because I think it is, potentially, a problematic issue if our practices here vary with the norms or practices in their home countries. I think we need to be sure that foreigners coming to Singapore to live and work are well briefed of our practices under this Act.

Sir, I think a lot has been said about this. There is certainly a need to educate the public about the issue of what constitutes "brain death", since that is the key trigger for this Act to come into place for cadaveric donors. The concern I have here is that in talking to professionals and well-educated individuals, there is still a great deal of, first, uncertainty as to what is actually brain death. Is brain death reversible? Are the criteria for defining "brain death" arbitrary, and a whole host of other related questions. These sorts of questions and uncertainties act as an impediment to the effective achievement of the objective of this Bill. So, I think it is critical that the Ministry, together with its agencies, works to communicate the point clearly on what constitutes brain death and why Singaporeans should be assured that these are decisions that will be made after much thought and based on criteria that have been formulated after years of practice and assessment. I think that will go a long way in taking us closer to the objectives of this Bill.

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Mr Ahmad Khalis Bin Abdul Ghani (Hong Kah): Sir, this Bill does not introduce legislation on human organ transplant for the first time. It is an amendment that seeks to enlarge the scope of the present Act. Since its First Reading, the Bill had attracted or rekindled much public interest. The public debate includes matters such as the definition of "brain dead", society's values on respect for the dead, the possibility that doctors would be more concerned with harvesting the organ of a dying person than with saving his life and so on. These issues were debated when Parliament passed the original Act in 1987, but the public raised them again. While technically Parliament need not deal with such issues again, it is not wise for us to brush them aside. Such concerns are real, important and widespread. Indeed, some of my colleagues before me had raised the same issues.

One such issue is whether the Bill, if passed, implies that we lack respect for the dead. The original Act has been around for 16 years. How we respect the dead had not changed significantly. Our funeral rites have not changed much, and even if they do, it is not because of the Act. Except for a very small number, all deceased persons undergo the usual funeral rites and accorded all due respect as dictated by their beliefs and customs. This is mainly because for an organ to be considered suitable for harvesting from a cadaver, there are many conditions. So, the opportunity for transplant is small and rare. Perhaps this best explains why there have been few organ transplants from cadavers each year in spite of the Act. The figures were given by the Acting Minister for Health earlier. But it may be argued that this time the Bill includes other organs, such as the liver, the heart and includes non-accidental deaths as well. Will this open the floodgates? Will this opening up encourage less care be given to potential

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donors? Looking at our experience thus far, I personally doubt it. There are hundreds of deaths due to accidents each year, but the average number of kidney transplants under HOTA has been about 13.5 per year. I am not aware of any complaint or allegation in the past 16 years that care to a potential donor was compromised due to interest in conducting a transplant. I believe that the same culture would prevail under the new provisions.

The easing up is not drastic. But the Ministry must continuously assure the public that this remains so. I understand that it is envisaged that two doctors certifying brain death for a potential donor must not be in the transplant team or be involved in the selection and care of the recipient. This mechanism removes much of the potential for compromise of medical care to the potential donor under the Bill. Perhaps the Minister could also enlighten us on measures that would ensure that the separation of roles of doctors would be rigorously implemented.

Sir, some members of the public questioned whether we should presume consent for cadaveric human organ transplant in the first place. This is a delicate balancing act. On the upside, the Act allows for lives to be saved and lives to be lived better. Here we are not talking about superficial cosmetic changes but we speak of the difference between life and death, and the difference between a reasonably healthy life as against suffering chronic ailments. The downside is whether we compromise the rights of individuals to decide and whether we unwittingly open ourselves to abuse.

Sir, it is not right to say that those who oppose the Act in principle even today do not appreciate the good arguments for it. They do appreciate the noble intention to save lives, but they

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accord more priority to maintaining certain social norms as they understand it. Conversely, it is not right to say that those who support the Act or this Bill do not care about social norms. They do appreciate the need to uphold norms but they see the Act

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as a humane way of manifesting equally compelling values where society, as a whole, decides that some sacrifice is justifiable. These arguments, Sir, and I believe many more eloquent ones, were made when the original Act was passed. But they are as relevant and applicable today as they were then. They deal with very important issues. It is not therefore surprising that the issues raised in 1987 were raised again recently. It is incumbent that this House and the Government in due course continue to handle these concerns appropriately.

That said, Sir, I see no reason for us to review the Act as such. Indeed, as our experience has shown, there is cause for us to improve on it. The thrust of the Bill is two-fold. The first is to expand on the types of organs and to include non-accidental deaths. The second is to regulate living transplant. Over the years, we have accumulated enough knowledge and experience to have the confidence that an expanded HOTA would not be harmful but instead be helpful to society. The figures provided by the Ministry support this contention. As such, I support the expansion envisaged by the Bill. The intention is to save lives, and our experience shows that the Bill, if passed, is likely to do just that.

Currently, there is no legislation regulating living organ donor transplantation, although the Ministry of Health has issued professional guidelines to doctors and hospitals. There is thus a level of uncertainty. It is bound to cause confusion among doctors, patients and potential donors. Already, Sir, there have been news reports of people in desperate conditions offering their organs for

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money. This problem is exacerbated with great improvements in communication. If unchecked, transnational transactions in organs could raise even more difficult issues. It is therefore very useful that the legislature expresses its clear position on this issue. I think the Government has correctly identified the considerations in this regard - medical risk to the donor, genuine and informed consent, exclusion of children from being donors and motivation of the donor. The overarching concern is the ethical issue - whether it is right to mutilate one living person so as to benefit another. We say it should be permissible in genuine cases. So the Bill seeks to prescribe the conditions and processes to ensure that only genuine cases are permitted.

Sir, the final aspect that I wish to touch on is with regard to the position of the Muslim community as regards HOTA and the Bill. Presently, Muslims are excluded from the Act. They can, however, opt in. Those Muslims who opt in would qualify for the benefits under HOTA as do their non-Muslim counterparts. Such benefits include the right to receive organ donation and subsidised treatment. Those Muslims who do not opt in would not be eligible for such benefits. At the end of 2000, Muslims formed about 20% of Singaporeans who suffered from kidney failure and among new cases of end-stage renal failure each year. The MKAC (Muslim Kidney Action Committee) was then formed to encourage Muslims to opt in. After about 10 years of tireless effort and $7 million spent, the number of Muslim pledges increased 33-fold, from 400 in 1990 to 13,000 in the year 2000. However, this constituted only about 4.2% of the eligible Muslim population. Getting people to opt in proved to be no straightforward task.

The position of the Muslims, Sir, is expressed by rulings issued by the Muslim Religious Council (MUIS). In principle, the

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rulings are based on the concept that the corpse of a Muslim belongs to his estate. As such, the w aris (or the heirs) of the deceased have rights over the cadaver. Thus, nothing should be taken from the cadaver unless it is with the consent of the w aris . So even if a Muslim wishes to opt into HOTA, the Muslim person has to obtain the consent of two of his w aris . This was the position in 1987. Look in another way, the position of MUIS seems to be founded on the view that, firstly, the public interest to cure diseases has to be balanced against the rights of the w aris over a cadaver; and, secondly, that the consent of the w aris cannot be presumed by legislation, but instead such consent must be expressed in individual cases. This Bill does not change this position.

But a closer look, Sir, would show some interesting developments. In 1973, MUIS issued a ruling that if a Muslim made a will to the effect that his kidneys be donated on his demise, such a will would be considered void. However, this issue underwent not a transplant but a review in the 1980s. Based on the reinterpretation of religious principles and based on prevailing medical knowledge then, MUIS issued a new ruling to the effect that kidney transplant arising from accidental deaths, such as those envisaged by the original HOTA, was permissible. This ruling made in 1986 superseded the 1973 position. However, the 1986 ruling contained a proviso. The proviso related to the rights of the w aris which I had mentioned earlier. Thus, as regards the 1987 HOTA, MUIS advised the Government that it was better that Muslims be excluded from the HOTA but they were allowed to opt in. This advice, I reckon, was in consideration of the need to recognise the rights of the waris . It was also felt that the Muslim community at that time would be more prepared to accept the opt-in scheme rather than the main regime where consent of the w aris would be presumed.

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There were other developments. In 1995, MUIS issued a ruling that living cornea transplant was within prescribed circumstances permissible. Earlier this year, MUIS also ruled that donation of other organs such as the liver and the heart is similarly permissible as donation of kidneys. I understand, Sir, that MUIS had also ruled that organ transplants from non-accidental deaths are, in principle, permissible. Further, MUIS recently ruled that for Muslims to opt into HOTA, it is sufficient that they obtain the consent of one w aris and one witness, as opposed to the requirement for consent of two waris in 1986.

Sir, the developments mentioned show that the Muslim community in general, and MUIS in particular, are willing to relook at stated positions. They do so in the light of advances made in medicine and the changing needs of society. But they are also careful in reinterpreting established principles so as to minimise uncertainty and confusion among the adherents. I would urge the Minister and the Minister-in-charge of Muslim Affairs as well to see whether MUIS could suitably review the position as regards how the consent of the waris has to be expressed, to see whether we could bring its position closer to that of mainstream Singapore society without undermining established principles.

I understand, Sir, that our Muslim scholars are also mindful of the view of their counterparts in other parts of the Muslim world. At the same time, I believe they are aware of the views of fellow Singaporeans with whom they interact every day. I have no doubt that Islam, like other religions, promotes the saving of lives, granted that saving lives is not at all costs. I do hope that in due course the Muslim scholars and the Muslim community would advance a solution which would enable the community to

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partake in HOTA while not undermining its principles in other areas such as the rights of the waris and respect for the deceased.

In conclusion, Sir, it seems to me, on balance, the Bill is better for Singapore. And if I may borrow a quote from an anonymous writer: "Is life worth living? It depends on the quality of the liver." I support the Bill.

Dr Chong Weng Chiew: Mr Speaker, Sir, I rise to support the Human Organ Transplant (Amendment) Bill.

The support given by most respondents at the Bill's public consultation organised by the Ministry for the past year is clear evidence that there is good trust in our health system and our doctors. Singaporeans know that the precious gift of life from fellow citizens will not be abused for monetary gain nor will it compromise the provision of healthcare for potential donors. However, having said all this, I have the following points and questions to raise.

The shortage of organs is not unique to Singapore. In a report "Human Organ and Tissue Transplantation" published by the World Health Organisation's Secretariat last year, it was noted that about 70,000 solid organs were transplanted annually worldwide. I quote, "The persistent and widening gap between patients' need for organs and the number available for transplantation" has become an international problem. The long waiting list has fuelled the growth of international black market in the trading of organs.

Nancy Scheper-Hughes, a professor of anthropology at the University of California, has written extensively on human organ trade. In an article, "The Global Traffic in Human Organs", she wrote: "In general, the flow or organs follows the modern routes of capital: ...

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from Third to First World, from poor to rich ...".

A 2002 Canadian Broadcasting Corporation programme named "Deadly Harvest - Parts for Sale" highlighted the rapidly growing tissue industry, estimated to be worth more than half a billion dollars. Apparently, a person who procures and sells human tissue could make anywhere from $80,000 to $200,000 per body. Arthur Caplan, an ethicist at the University of Pennsylvania, stated that the tissue was worth "more than diamonds, in some cases". The market for solid organs is more difficult to estimate because it is illegal in almost every country. However, international reports point to a dark and exploitative sector which is growing by leaps and bounds.

What does all this mean to Singapore? Are Singaporeans immune to the lure of organs for sale? Not at all. Although we have no official statistics, for years we have heard occasional stories of sick Singaporeans going overseas for transplants. Often, the sources of the organs are suspect, with fatal consequences for the recipient due to organ mismatches and post-operative infections. Still, some continue to take the risk. They are afraid to join the ranks of those who have died while waiting or being forced to drop from the list while still being alive, because they become too ill to remain candidates for transplant.

To address this shortage and keep organ trading at bay, the Ministry has chosen the opt-out system, which has proven worldwide to work better and effectively in increasing the number of organs compared to the opt-in system. However, with an expanding aging population, we must ask how Singapore is to cope with the never-ending needs for donors. More and more citizens will live longer, with the failure of perhaps one

or two organs later in their lives.

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Transplants would then become more and more attractive as a means of postponing the inevitable. The scarcity could never be satisfied for underlying the demand is the natural human denial and refusal of death. The Ministry needs to work with the hospitals to educate Singaporeans at risk about the pitfalls of obtaining organs from doubtful and illegal sources.

The next point I would like to raise is that the Act has specified that it does not apply to donors below 21 and over 60 years of age. Should the Ministry also specify, or at least provide some guidelines for the age of the recipients, in order to ensure that breadwinners and parents with young children receive priority?

The next point I am going to raise regards severe kidney disease as a real risk following transplantations. I came across an interesting publication in the New England Journal of Medicine in September last year. It concerns the largest study of non-kidney transplants ever conducted, that is to say, transplantation involving other organs, such as hearts and livers. It was stated that, after the operations, 16% of these patients suffered from severe chronic kidney disease. Subsequently, 33% of the group progressed to end-stage renal disease. The study involved 69,000 people in the United States who received transplants between 1990 and year 2000.

Successful transplantation is defined by the long-term survival rates and improvement in the quality of life of patients. Hence, the study underscores the importance of counselling potential recipients on the significant long-term risks of kidney failure associated with transplantation, in addition to the opportunistic infections, cancer and bone diseases. In addition, the same study found that liver transplant recipients had a prevalence of Hepatitis C of 21%, with an

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associated excess risk of chronic renal failure. In view of this new information, I would like to know if there are regulations for hospitals to provide counselling to transplant recipients and requirement for them to update counselling materials and guidelines on a regular basis.

Successful transplantation also depends on continued medical follow-up and the patients' compliance with the regimen of immunosuppressive drugs. The expense of these medications and treatments for resulting complications can be very high. I would like to ask the Minister how many patients have applied for financial assistance for such therapy, the quantum of assistance, if any, in the last three years and what financial assistance schemes are in place for this specific purpose.

Next, I would like to touch on living donor organ transplants. Currently, for living related organ donation, genetic tests to prove the relationship between donors and recipients are not required in Singapore. However, it is required in the United Kingdom. Due to the potential for financial inducements in living organ transplants, I would like to recommend that the Ministry consider making genetic tests mandatory.

For living unrelated organ donation, the Bill has provided for the appointment of a hospital's Transplant Ethics Committee to perform the evaluation. As we all know, transplantation brings money as well as prestige to the hospitals. Therefore, there is a risk, however minimal or minor it could be, that a hospital would be tempted to encourage potential recipients to recruit potential donors more aggressively or even be involved in the process itself. While the presence of a medical practitioner not employed or connected with the hospital and an independent lay person on the

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ethics committee can act as a safety check, it is definitely not foolproof. Different hospital evaluation criteria could emerge. Hence, I would like to suggest that clear, uniform and stringent regulations be laid out for all hospitals, both public and private.

We must also pay attention to the welfare of potential donors. Factors such as undue influence and family pressure can affect a donor's judgement. Are there any follow-up medical and psychological checks conducted for donors? It would be useful for the Ministry to set up a database of all living donors and conduct a study tracking their health and subsequent attitude towards the procedure. The results of this study would be useful to assist us in refining our health policy in the future.

With that, I would like to conclude my support for the Bill.

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