EXEMPTED BUSINESS (Motion)

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EXEMPTED BUSINESS:

(Motion): Resolved,

That the proceedings on the business set down on the Order Paper for today be exempted at this day's sitting from the provisions of Standing Order No. 1. - [Mr Mah Bow Tan].

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HUMAN ORGAN TRANSPLANT (AMENDMENT) BILL: Debate resumed.

Mdm Halimah Yacob: Mr Speaker, Sir, the Human Organ Transplant (Amendment) Bill is an important Bill. With advances in medical science, organ transplant has become a common and effective procedure to save and enhance lives in many countries. The figures on deaths arising from failed organs are staggering.

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[Mr Deputy Speaker (Mr Chew Heng Ching) in the Chair]

5.06 pm

In Western Europe, there are 120,000 patients receiving chronic dialysis treatment. Estimates suggest that between 15% and 30% of transplantations in Europe die whilst waiting for an organ. In Singapore, as at December 2002, there were 666 people on the transplant waiting list for kidneys, 20 for livers and 7 for hearts. Between 1996 and 2002, 32 kidney failure patients and 110 liver failure patients died. The Acting Minister has also given some updated figures earlier on. In the US, it was estimated that, in the year 2000, organ transplantations had saved or enhanced the lives of more than 20,000 men, women and children.

If we can save more lives through this Bill that we are now debating, then we should support it. The amendment seeks to allow removal of organs in all situations where a person is brain dead, protect living organ donors and expand the scope of transplant to include the heart, liver and cornea. The existing law is restrictive as it allows only the kidneys from persons who died in an accident to be used for transplant. The Bill seeks to remove this and to allow transplant from other brain dead patients.

To me, this is a logical development as the existing restriction makes an unnecessary distinction between those who are brain dead because of accidents and those who are brain dead because of other illnesses, and there is no medical difference between the two. In fact, developed countries with established transplantation programmes do not make a distinction between deaths from accidents and other causes.

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However, Sir, there is a concern among some Singaporeans, which my other colleagues have also expressed, that hospitals may prematurely terminate the care of a patient in order to use his organs for transplantation purposes. Now that the scope of the Act is being expanded, it is important that we address this concern. This could be addressed by putting in place effective rules and measures to determine when a person will be considered as brain dead. In some countries, the law prescribes a procedure before a person is considered brain dead. For example, in Greece, Article 7 of their law (821) provides that a patient must be declared brain dead by three specific physicians - the patient's physician, plus a neurologist or neurosurgeon, plus an anesthesiologist. None of these three physicians are allowed to be part of the transplantation team as a safeguard against premature termination of care to the donor. The organ must also be removed by physicians specialised in this field. I would like to suggest that the Minister consider introducing such a provision in our law in view of the concerns that have been raised concerning what amounts to brain death.

It is important that hospitals adopt clear rules on this and also inform and educate the public of the system that is in place. It is even better if this is stipulated in our law as the Greek law so provides. I am certain that this will help to generate greater public confidence that the interests of donors are adequately taken care of. The Greek law is also interesting in other aspects and reflect their cultural, social, norms and ethos. Their law provides for the body of the donor to be properly dealt with. The Greek law provides that the body must not look mutilated and must be made to look as normal as possible for the family's viewing afterwards. I think such a provision in that law will reasonate with Singaporeans because, culturally,

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Singaporeans also would like to have the deceased bodies of their loved ones in one piece and not mutilated as a result of organ transplants.

Another key objective of the Bill is to regulate live organ transplants. As the Bill correctly points out, there is a need for regulations to safeguard the interests of living donors by ensuring that living organ donation meets ethical and professional standards. In this regard, Sir, I feel that the existing penalties to deter illegal buying and selling of organs in our Act may not be sufficient, particularly now that we have expanded the scope of the Act. Under section 14(2) of HOTA and new section 15A(4) of the Bill, the maximum penalty imposed on someone found guilty of entering into a contract, or arrangement to sell organs, is a fine not exceeding $10,000 or to imprisonment not exceeding one year or to both. This penalty clause has not been reviewed since 1987 and is, in my view, an insufficient deterrent. A maximum fine of $10,000 and a jail term of one year is nothing compared to the huge benefits and profits that can be reaped from organ trading. I think it is timely for the Minister, in the light of the current proposal to expand the scope of HOTA, to consider increasing the penalty to deter human organ trafficking.

Trafficking in human beings is a heinous crime. Trafficking in human organs is a crime of the same genre. It is equally heinous as the victims are usually the desperately poor and needy. Increasing the penalty would send a clear signal to all those who may be tempted to resort to such crimes that they would be severely dealt with.

Another concern I have, Sir, is with regard to both section 14(2) of the Act and new section 15A of the Bill and the issue here is whether they are extensive

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enough to cover all the various transactions and steps involved in organ trading. Under section 14(2), a contract or arrangement under which a person agrees for valuable consideration, whether given or to be given to himself or to another person, to the sale or supply of any organ or blood from his body or from the body of another person, whether before or after his death or the death of the other person, shall be void. It is unclear whether this provision covers all the situations involved in organ trading. For example, does it cover a broker who acts merely as the agent to bring in the organs, or procure people locally, or overseas, who are willing to sell their organs, but who himself has no direct dealings with the person seeking an organ transplant? Does it also cover those who act as the contact points, or who knowingly make the travel arrangement, or engage in other activities to support the buying and selling of human organs? In this whole process of illegal organ trading, there is a long chain and we have to ensure that we put adequate measures in place to prevent organ trading.

Organ trafficking, Sir, is a worldwide concern. In the European Union Parliament, stringent laws are being considered to penalise human organ trafficking. The proposal is for those convicted of organ trafficking to be liable to 10 years of imprisonment. Hence, I would like to urge a review of the scope of these clauses which stipulate the penalty for buying and selling organs by ensuring that they are wide enough and are severe enough to act as a deterrent.

I would also like to suggest a review of section 15 of HOTA. The use of Internet and other forms of communications, such as SMS, has become very pervasive today compared to 17 years ago when HOTA was first passed. In some countries, the Internet has become a very pervasive tool for the buying and selling of organs. A simple

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query on the Google search engine, for instance, would yield thousands of websites purporting to sell various body parts. Under section 15 of HOTA, all advertisements relating to buying or selling of organs or blood are prohibited.

Section 15, too, describes what amounts to an advertisement. It includes every form of advertising, whether in a publication, by the display of any notice or signboard, or by means of any catalogue, pricelist, letter or other documents whereby words are inscribed on any article, or by the exhibition of a photograph or a cinematograph film, or by way of words inscribed on any article or exhibition of a photograph or cinematograph film, or by way of sound recording, sound broadcasting or television or in any other way, and any reference to the issue of an advertisement shall be construed accordingly.

Perhaps, the Minister could clarify whether these new forms of communication I have cited, ie, Internet, SMS, will be covered under section 15(1) and, if not, whether he would consider amending this provision to add greater clarity to it, so as to prevent organ trading.

Sir, with the introduction of a new Part IVA under the Bill dealing with living donor organ transplants, Muslims will now be partly covered under HOTA. In this regard, the position of a Muslim living donor and that of a non-Muslim are the same, subject of course to the requirement of approval from the waris for Muslims. Muslims are now also regulated by Part IVA when it comes to living organ donations. In many countries, the use of organs from living donors has become much more important, compared to the use of organs from those who are brain dead. In 1999, there were 5.3 kidney donors per million population in the UK, 8.7 in Switzerland and 11.5 in Sweden. Norway has a very successful number of

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live kidney donations among the European countries, with 24.6 people donating their kidneys per million population in Norway in 1999.

With a clearer framework for live organ donations provided under this Bill and more public education of the benefits of live organ donations, I can foresee that, over time, living donors will become a much more important source for organ transplants in Singapore, and this will benefit everyone, regardless of their religious convictions.

Sir, the removal of organs from Muslims who have died remains the same. Muslims are still required to opt in before section 5 of HOTA, which deals with the removal of organs after death, will apply to them. There are several fatwas from the MUIS Fatwa Committee on the issue of organ donations by Muslims after death. The key point to note is that Muslims are allowed to donate their organs, subject to the approval of the waris after a person's death. A key consideration for the fatwa committee's decision is that Islam places a high premium on saving lives and gives priority to the needs of the living rather than the dead. Hence, Islam supports transplants to save lives in emergency situations. The need to require the consent of the waris is the only reason why section 5 cannot automatically apply to Muslims.

Sir, there are great benefits for Muslims to be covered under section 5 of HOTA, as the rate of kidney failure among Muslims is much higher. So long as Muslims are excluded from the ambit of section 5, we will have less priority when it comes to organ transplants. Although dialysis is one way of dealing with the problem, it is not a better solution compared to a kidney transplant.

As I mentioned earlier, with a more favourable framework that is now in place

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for live organ donations, Muslims would also benefit. However, it is important that we continue to exhaustively explore all avenues that are currently available to save lives. I, therefore, call for on-going discussions among our Muslim religious scholars, the MUIS Fatwa Committee and the Muslim community, in consultation with key international Islamic jurists and ulamas , on how best we can maximise the use of organ donations prescribed under section 5 of HOTA. Fatwas on organ donations have actually evolved quite a bit from the original position enunciated in 1973, where kidney donations were prohibited. Since then, with tremendous developments in medical science and more is known about the risks of organ transplants, a new fatwa has allowed kidney donations, subject to the approval of the waris . Over time, taking into account the concerns and needs of the Muslim community, this is one issue we need to focus and get resolved. We need to find a way of dealing with the issue of consent from the waris .

In conclusion, Sir, I support the call made by several colleagues for an extensive public education programme. This is important as there are legal, social and ethical issues involving human organ transplants, and the public needs to be properly informed and educated to overcome major concerns which cannot be addressed by the law alone.

On this note, Sir, I support the Bill.

Dr Amy Khor Lean Suan: Mr Deputy Speaker, Sir, organ donation is an emotive issue, which may be influenced by the donor's cultural values and dearly-held religious beliefs. For some people, it concerns the wholeness of the body for the afterlife. For others, it constitutes a question of respect for the departed. But, equally important, the statistics show that

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each year a significant number of people perish because suitable donor organs cannot be found in time. From a secular perspective, the issue boils down to one of whether we should, figuratively speaking, "sacrifice" the already dead for the benefit of the dying, in order that they may have another chance at life.

It is entirely appropriate that the Ministry had embarked on an extensive public consultation and feedback programme on the proposed amendments. I am also pleased that the Whip has been lifted for this Bill, and rightly so, given the religious and perhaps ethical questions it might raise in the minds of some people. Allowing MPs to vote according to their conscience and beliefs reinforces the intention of the Bill, that it is not meant to take away an individual's rights to his own body.

But, Sir, whilst I personally support the Bill, there are three key issues which I would like to highlight and urge the Ministry to seriously consider.

Firstly, as with many of my colleagues before me, the issue refers to not just extensive but sustained, systematic public education. There are still some who advocate an opt-in rather than an opt-out system, as this would allow the rights of the people to be better respected. In an ideal world, I would agree that it would be better to have an opt-in rather than an opt-out system. This will allow Singaporeans to make an informed, conscious choice to opt in and pledge their organs, rather than, as one respondent to MOH's online feedback noted: "relying on their ignorance not to opt out".

However, in reality, not many will opt in, as they are inclined not to think about the subject of death, since it is something that they deem far away or "won't happen to me yet". For others, it is also

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something unpleasant or taboo. Or as another respondent to MOH's online feedback declared: "If it is an opt-in system, I will not opt-in, as it is too much of a hassle. While I do not mind donating my organs, it is not a priority for me." Hence, I support the present opt-out system. Indeed, I think it is a pragmatic approach.

However, once this Bill is passed in Parliament, it affects the majority of Singaporeans and PRs. Many may be oblivious to the fact that they are subject to the provisions of the Act, unless they opt-out.

Furthermore, every year, a new cohort of individuals will reach the age of 21, when they become automatically subject to the Act, unless they opt out. This group must also be educated on HOTA, so that the Act, which operates based on presumed consent, truly does not take away or diminish the individual's rights.

I strongly believe that the Government must keep up with its efforts to educate the public on the implications of the Act on a regular basis. If not, very quickly, the public may forget about the Act. There is already some evidence of this from recent public feedback regarding the Bill. The concerns over an opt-in versus opt-out system, the definition of brain death, safeguards to ensure that doctors do not prematurely diagnose brain death, and the fear that the body may be mutilated, are not new and have been debated some 16 years ago, when HOTA was first enacted.

Indeed, a Select Committee was even set up to receive representations on the original Act. Yet, these same concerns have been raised in the most recent feedback sessions, showing that such concerns continue to gnaw, either because they are deep-rooted and cannot be easily overcome or, perhaps more

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likely, many of the feedback participants are not aware of the previous debates and responses.

In fact, an incident I recently encountered clearly illustrates the need for on-going education efforts to reach out to as many individuals as possible. When I told one of the senior directors of my company a few days ago that I was preparing to speak on HOTA at this Parliament sitting, he asked, "HOTA? What HOTA?" Of course, the acronym will never scale the heights of brand recognition achieved, say, by SIA, or even for that matter the PAP. Nonetheless, whether it is HOTA or the words spelt out in full, the man-in-the-street is probably - and I beg the indulgence of Mr Deputy Speaker, Sir, to use Singlish in this House - "blur like sotong".

The Acting Minister for Health noted: "I see no reason why properly explained, properly educated, why we cannot achieve this higher pledge rate." Singapore's rate of organ pledging is low compared to those of other cities outside Asia. Can it be partly because the public has not been extensively and properly educated nor continuously reminded?

It was reported in the Straits Times of 22nd February 2003 that the Ministry is to conduct regular public education programmes in partnership with community organisations. I would like to ask to what extent this has been done. I cannot recall any organisation coming forth to give the grassroots and residents in my constituency an educational talk on HOTA. Continuous public education on HOTA is not just to ensure that Singaporeans make an informed decision, in this case, "not to opt out". But, beyond this, better understanding about organ donation may also encourage more people to sign up, outside the scope of HOTA, under the Medical (Therapy, Education and Research) Act enacted in 1972.

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In its public education efforts, I would like to suggest the following areas which the Ministry could pay attention to.

Firstly, as an Asian society, Singaporeans' views are still likely to be shaped by religious or superstitious beliefs. There is thus a great need to clarify misconceptions and allay fears pertaining to this emotive subject. The Government should, therefore, work closely with the religious organisations and actively enlist their help to reassure the public that organ donation is not contrary to their religious beliefs.

Secondly, from our experience in fighting SARS and administering the NSS and ERS, the grassroots could be mobilised to educate the community about HOTA. This will be especially helpful for the senior citizens who do not read the newspapers, surf the Net or even watch current affairs programmes on TV.

Thirdly, in the previous debate on HOTA in 1987, the then Acting Minister for Health had, in response to Members' concerns, informed the House that following a 6-month intense public education campaign, every year from henceforth, all Singaporeans reaching the age of 20 years will receive a reminder concerning HOTA. I would like to ask the Minister if this practice has continued ever since and, if so, in what form the reminder takes.

Fourthly, as new cohorts will come under the Act each year, it is best to educate our young so that they will not be averse to organ donation. Moreover, they can help in bringing the message across to their parents and grandparents. An encounter a friend had on a bus illustrates this point. She overheard a young mother asking her daughter to eat - something in a cup which she was spooning and wanting to put into the child's mouth.

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The child told her mother, "No eating on the bus!". Even though the mother insisted, the child did not give in, repeating what she believed was the etiquette, over and over again, "No eating on the bus". After a few minutes, the mother got the point and did not pursue the matter.

I think this incident illustrates how important it is for us to educate our young in order to reach out to those supposedly older and wiser, and who think they know better. I would like to ask the Minister if efforts have been made to educate students from secondary schools and above on organ donation. If not, I would like to urge the MOH to work closely with the MOE and other community organisations, like the NKF, to reach out to the students who would be future donors, so that they clearly understand the motivations of the Act.

Finally, the MOH could spearhead an annual "Organ Donation Awareness Day" with welfare and community groups

such as the NKF and the CCC. This could form part of a systematic and sustained effort to educate our young, and the public in general, about the critical need for organ donation and, at the same time, allay their fears and concerns.

My second point relates to living donor organ transplants and the Transplant Ethics Committee. Of the three major amendments the Bill seeks to incorporate in HOTA, the regulations for living donor organ transplants would be considered the most significant and far-reaching.

A press report discussing whether HOTA should include more organs besides the kidney, noted that many people in fact think that HOTA includes more than kidneys. A Gleneagles Hospital consultant, liver transplant surgeon, K C Tan, was quoted as saying, "Many people, even doctors, have assumed all along that the Act refers to all organs. If

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you accept the Act, other organs should be no different from kidneys."

But whilst the majority surveyed are for the inclusion of more organs, there are also detractors who feel that body parts should not be treated like unwanted furniture or auto spare parts. Thus, I support the MOH's stand of adopting a cautious approach of excluding the lung under the current amendment to HOTA, even though there were requests for its inclusion, as lung transplant is not yet established.

However, MOH should constantly review the usefulness and appropriateness of including other organs such as the lung and allow for such inclusions as soon as it is deemed suitable. Perhaps, the MOH could set up an Organ Donation Advisory Committee to review the scope of organ donation in Singapore, assess existing guidelines and make recommendations to the Minister on how rules can be changed in keeping with the times.

The recent high profile incident involving actress and presenter Andrea De Cruz alerted the public to the benefits of allowing for living unrelated organ transplants under special circumstances. The incident has perhaps also made the public more receptive and aware of the need to clearly spell out the rules permitting such transplants.

This would make the regulations and conditions under which living donor organ transplants, particularly those between an unrelated donor and a recipient, more transparent and safeguard against outlawed practices, such as organ trading. In our quest to save more lives, we certainly do not want to unwittingly create possible loopholes for organ trading, and where life and death is the outcome of price bidding or the influence of the powerful, as is already happening in some countries.

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There are merits for each hospital's Transplant Ethics Committee to assess and decide on living organ transplants, such as direct and faster access to information which could spell the difference between life and death. But there is also a need to put in place measures that will ensure uniformity of standards, strict independence of the ethics committee and the pooling of expertise and resources, especially in tiny Singapore.

MOH should establish comprehensive, transparent and clear guidelines, rules and procedures for the ethics committee in order to reduce as much ambiguity as possible on the part of the ethics committee in making decisions regarding the eligibility and suitability of a living donor.

The composition of, and criteria for, appointment of the ethics committee should also be made transparent to allay public concerns regarding the neutrality, professionalism and integrity of the committee. The ethics committee should preferably comprise not just a medical doctor with no vested interest in that case, but also psychologists and trained counsellors to assess the donor's motivation for organ donation. In this regard, I agree with my earlier colleagues' comments that perhaps there should be a cap as to the number allowable in the ethics committee, as well as a maximum number of representatives from the institution itself.

My final point relates to respecting the dead. When HOTA was introduced in 1988 to cover only kidneys, there were already concerns from the public that the body may be mutilated when the kidneys are harvested. Now, as more organs are to be included, there is clearly genuine concern over the possible mutilation of the body. MOH needs to reassure the public that it fully understands and

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respects the strong emotional ties between the deceased and the family, and that the body would be treated with utmost respect.

Before harvesting the donor's organs, the family of the deceased should be informed and counselled on the procedure and what to expect to see after the surgical operation, so that there will not be any added undue concern at a time of their bereavement. I would thus like to ask the Minister to assure this House that the bereaved donor's family will be properly informed and counselled by doctors and professional counsellors before the organs are harvested.

In conclusion, Sir, I would like to note that Singaporeans largely understand the primary motivations of HOTA to save lives. Hence, many support the Act and the proposed amendments, but they also have legitimate concerns regarding the Act and the Bill, some of which I have raised, and for which the Ministry must continue to attempt to overcome.

With this, Sir, I support the Bill.

Dr Warren Lee (Sembawang): Mr Deputy Speaker, Sir, thank you for allowing me to join in the debate.

Sir, the inclusion of the liver, heart and cornea to the list of organs covered by the opt-out system or presumed consent system under Singapore law is to be welcomed. It has been long in coming, but Singapore is still one of the few countries in the world where this system exists. No doubt there are 20 countries, but we are still in the minority, happily so.

Having presumed consent legislated will reduce wasted time and opportunities, when organs which would otherwise have been able to save lives, go to waste

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because people do not understand the issues involved. Transplantation of kidneys, hearts, livers and corneas is already part of the practice of medicine for many years. For those receiving kidneys and corneas, they receive additional life to the years, whereas for those receiving hearts and livers, it is often literally the gift of life itself. But cadaveric organ donation is not only the means of obtaining human organs. In reality, the number of cadaveric transplants may never be sufficient since Singapore has a low rate of deaths among otherwise healthy citizens since we have safe roads and safe streets. Nevertheless, I see many positive effects of this law.

We need to gradually get Singaporeans used to the idea that donation of body parts for the common good is a worthy objective. Increasing acceptance of the idea of donating one's organs when we are dead, and these organs are of no longer any use to us, means more will come forward to donate, not just organs or tissues after death, but organs and tissues not covered under current legislation before us. These organs and tissues include the pancreas, which can provide insulin for those with diabetes mellitus, the lungs and even the intestines. The transplantation of these other organs, while proven useful in certain situations, is still not yet widely established. Hence, I believe that this is why they are not listed in the legislation before us.

Nevertheless, if someone is known to need such an organ and a suitable donor is found, having this current HOTA legislation will make it much easier for transplant coordinators, who will be speaking to the next-of-kin regarding the presumed consent of donation of their liver, heart, cornea and kidney, to also bring up the subject of possible donation of these other organs for the saving of lives.

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The Government has consulted widely with many sectors of the population and with religious leaders on the provisions of this legislation. I am pleased to note that this amendment has wide support. Yet, we recognise that not everyone will be willing to donate organs. There are some for whom the thought of a loved one being buried or cremated less than whole would cause extreme grief due to personal or religious reasons. We have to respect this and not make it difficult for people to opt out. We need to ensure that the public are clearly aware of what their decision to opt out or opt in entails. In this, I reflect what many of my other learned colleagues have said.

At this age of 21, when a citizen is given a form to sign to make a choice of opting out of the organ donor pool, this decision is binding. While it can be subsequently revoked, and the person can decide to opt in again, it would mean that under the provisions of the Act, he or she will no longer enjoy the original degree of priority in the queue for a suitable donor organ should he or she need one in the future. This measure is probably to prevent people from making frivolous decisions or deciding to defer entry into the donor pool until it is clear to them that they themselves will be needing a donor organ.

My colleagues have spoken about the position of those in the Muslim community. But as has been pointed out, these people can also opt in. This is, therefore, fair to both groups of people, ie, those opting out and those opting in, as well as those who already, by not opting out, have presumed consent. It may be presumed that those who conscientiously object to donating their own organs will also similarly be strenuous in not wanting to receive a donor organ from another person. By the same reasoning, no one who does not want to be a potential donor should be able to benefit ahead of someone else

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who was willing to be a donor himself or herself. I hope that there will be ample opportunities for conscientious objectors to register their choice and that the provisions of the Act will be made known widely annually, perhaps during the annual volunteers week or some other similar occasions. We need to do more to ensure that not only are people aware of the issues when they sign the option form, but that it is clearly made known to the public about how and where they may be able to make the choice of opting out. Doctors and medical staff, whose responsibility it will be to speak to the next-of-kin of possible removal of donor organs in individual cases, will then face less difficulties and less misunderstanding.

In time, we hope that the population's attitude will change such that there will be more support for donation of other tissues, such as blood samples for research or cord blood and placenta of new born babies for programmes such as a public cord blood bank, which can in turn help stem cell transplants and turn this concept into a reality for more Singaporeans. Transplant medicine is a difficult but established field of medicine. It is an area which will give Singapore a niche advantage compared to other providers of medical care in the region. But to progress, our people must have more experience.

Mr Deputy Speaker, Sir, this proposed law is also important in that it gives a legal framework for the donation of human organs for transplant from living donors. Many people have spoken about this point and we realise that the procurement of donor organs from live donors for financial consideration is very much a reality in many parts of the world. Some of these take place in very dubious circumstances. I am sure we in Singapore would not want to be in any way party to such exploitative practices. We also recognise that organ transplantation is a major procedure, not only for the

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recipient, but also for the donor in the case of living donors. Many have spoken about the possibility of coercion or pressure.

To take up a point which has been raised by others about what risks are actually involved, I believe it is possible for competent authorities, such as the Ministry of Health, working with a respected body of experts, to put up on the web or in printed form, a set of information listing what are the currently accepted ranges of complications, mortality risks, possible long-term complications and such like, which will be considered to be commonly agreed upon at a given point in time, and revised from time to time. This, if given out and publicised widely, will make it possible for consent, counselling and such like to be given in a transparent way and with reduction in the risk of buyers. This will also make it easier for people to talk about what might be sufficient compensation should something go wrong. What then comes under the ambit of the law and what does not come under the ambit of the law in terms of monetary compensation could also be spelt out a bit more clearly. I believe that with this sort of clarity of information, people will be much more inclined to support the law in practice.

I also hope that the ethics committees that would be constituted under the ambit of the law would not only do their work fairly and transparently but also in a timely fashion. Because in a lot of transplant cases, time is of the essence.

Sir, on this note, I support the Bill.

Dr Tan Cheng Bock (Ayer Rajah): Thank you, Mr Deputy Speaker, Sir, for letting me speak.

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In 1987, when the Human Organ Transplant Bill was debated in this House, many of the concerns, fears and reservations of the different racial and religious groups were addressed and many were accepted. At that time, the issue was quite focused on kidney transplant. The donors then were mainly brain dead. But today, we are moving to involve more organs - the heart, the liver and also the cornea. And we are also involving living donors. So there is a difference. Of course, this brings into question ethical and also moral issues. I believe these issues were thrashed out by the Ministry at grassroots level and I am sure they must have been addressed. But having heard Dr Amy Khor, I realise that a lot more work has got to be done by the Ministry, because many people are still not very familiar with this term "HOTA".

Sir, today, I would just focus on one issue which I thought is very important, and this is my fear, that we need a very careful monitoring of the potential commercialisation of organ transplant. With the advances in medicine, better anti-rejection drugs, better equipment and management, transplant has become less scary and more acceptable. At the same time, the practice of medicine over the years has also changed. Medicine is treated less as a profession and more as an industry. This, to me, is very sad. But, unfortunately, this seems to be the trend. In fact, in our White Paper on Health, medicine was called an industry. Therefore, like any industry, the practice has also become more business-like than medicine, unlike in the past. Thus, hospitals have to be profit-orientated and they open their doors to receive patients.

Transplant medicine can be a big money spinner for hospitals, because patients needing such transplants will find ways and means to do it. So, hospitals will want to add this field of medicine to the schedule of practices to give prestige to the hospital and also as another hospital service. When hospitals open

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their doors for transplant medicine with money as the motive, there lies the danger for abuse. In some parts of the world, patients going into the operation theatre to remove an appendix have found, later on in life, that they have lost one of their kidneys. But it is a bit too late already.

Can this happen in Singapore, you may ask? I would be more confident that this would not happen 30 years ago when I took up medicine and went into practice. But today, I am not so confident. Somebody asked me, what is so wrong for somebody to want to sell his organs? It is a buyer's and seller's market, just like buying commodities. I think it is not so simple. The potential donor may be, as many have said, under duress, coercion, inducement or promise.

We have a very large foreign worker population in Singapore, many under work permits. They come here because they need money to send to their poor families. They are a very vulnerable group and could be exploited. A foreign worker may be approached and is prepared to sell one of his kidneys under the promise of a large sum of money. He knows his life is less in danger if he does it in a Singapore hospital. So, I ask, where are the safeguards?

If we read the Bill, there is an ethics committee that is to be established in every hospital. I think it is a good safeguard. And this ethics committee has a very heavy responsibility and it has a composition of at least three members, one of them must be a doctor not practising in the hospital, and another is a lay person. This committee that is set up looks good. And they have to satisfy themselves of a whole list of concerns before agreeing to any transplant.

I have gone through this legislation. I must say it is quite water-tight. It must be so because Singaporeans must be

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assured that the transplant is carried out ethically. Like I said, the Transplant Ethics Committee is a very important committee because they have to do all the assessments and they also must have consensus before they agree to any transplant. But I notice that the representation in this Transplant Ethics Committee has got no Ministry of Health's representation. I wonder why. Maybe the Minister can let me know. It is silent on the Ministry of Health's representation.

But what puzzles me is that the outcome of the decision of the hospital ethics committee, if I had read the Bill correctly, is that it has to be subjected to the Ministry's Director's final approval. If this is so, why not set up a central ethics committee, as proposed by Mr Iswaran earlier on when he made a very excellent speech on why they should not decentralise the ethics committee at the individual hospitals but should be centralised at the Ministry of Health? I think he did it very well and I do not want to go through all his points.

I know that there is a clause in this legislation which provides that the ethics committee could be punished if they have not done their job well. I think we should prevent this. If the ethics committee's final decision has to be approved by the Ministry's Director, then we might as well have a central ethics committee to do all the assessment. I think this will then give us the assurance that there is uniformity. There is also consistency of decisions. So I am really very concerned that this ethics committee in the hospital, which is playing such an important role, should be reviewed by the Ministry of Health. Maybe to have more control, we could make it into a central ethics committee, which I think is a much better way of managing transplants.

On that note, Sir, I want to thank you for letting me speak.

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Mr Zainudin Nordin (Bishan-Toa Payoh): Mr Deputy Speaker, Sir, I rise in total support of the mission to save lives put forward by the Ministry of Health.

The battle to save lives began in 1973 when the NKFS launched its major campaign to persuade our citizens to pledge their kidneys after death. Fourteen years later, in 1987-1988, the Human Organ Transplant Act, also known as HOTA, was passed with unanimous support. Nevertheless, we need to be constantly reminded that when we pledge our organs, we do not reduce in any way the quality of our life at all. Yet, it enables us to create miracles for others, and make a major difference even after we no longer exist. Perhaps we should understand better how organ failure patients suffer and how donation can significantly help lives and families can be preserved.

Sir, I am not trying to be morbid to describe some of the sufferings, but I think it is very important for us to understand, so that when we make the decision, it is clearer and we make the decision based on information. Patients with end-stage heart disease experience shortness of breath, swollen legs and abdomen. Their congested lungs deprive them of sleep and their general weak health may not allow them to work.

Heart failure patients may not survive beyond a year. However, by pledging our hearts when we no longer need them can end their suffering and extend their lives, because approximately 70% of patients survive for at least 10 years after receiving a transplant. These patients may be fathers or mothers with dependants to care for or young innocent children who are desperate for extra time to spend with their loved ones.

Those with liver failure are deeply jaundiced. Their abdomen swells due to excessive fluid and they often vomit blood

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and are generally weak, lethargic with little or no stamina at all. In severe cases, those with liver failure suffer from sleep disturbance, mental confusion or even slip into a coma. Donating the liver, even a portion, can do wonders. A case in point is the Andrea De Cruz case. This case, fortunately or unfortunately, has brought limelight to donor Pierre Png. This case has also brought a lot of publicity to organ transplant and donation. And we believe that after the incident, more people are aware of what organ transplant is all about and the importance of being a donor.

Some may argue that donating the cornea is not life-saving. To them, I say imagine a day in their lives when they have blurred vision or, worse still, suffer complete darkness. How would their day to day living be then? Impaired vision is extremely disruptive and will certainly change one's lifestyle drastically. Suddenly you are unable to work at your desk the way you have been doing all these years. You are unable to see the smile on your children's faces. You are deprived from simple pleasures like reading, driving or watching the sunset. You may or may not have a job to sustain you as this new disability takes hold of you. As your vision deteriorates, your independence fades away. Family members may need to take care of your daily needs. If they are unable to do so, hiring help may be required, but not all can afford it.

I am sure that we can all agree that blindness is one of the most disabling handicaps. Moreover, the procedure is rapid and subtle. Hence, donating our cornea is one of the most precious gifts we can ever bestow on another human being. Those who have cared enough to become donors have given hundreds of others a new lease of life as their vision is restored, as they are saved from a dark and colourless world. However, many

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more are waiting as the demand exceeds the supply.

Sir, I believe that there are still gaps in information and education on the organ donation scheme. Many are clueless on the medical reasons, religious positions, social impacts, safety measures and procedures. On this, I urge the Ministry of Health and other relevant bodies to enhance and improve the public education and information flow. Together with this law, extensive public education will certainly ameliorate the present situation and allow people to participate and make better informed decisions.

Recently, I had a conversation with a Malay/Muslim friend whom I casually asked, "Are you a donor?" I discovered something which was quite sad. She told me that she believed in it and she wants to be a donor but she could not convince her waris to sign the document. There are still people who are not sure of the procedures. They are still confused of what the role of the waris is. So I think there is still room for improvement. We can still do a lot of public education and explain to people about the confusion. And if there are still platforms and ways for us to do this, we should enhance it.

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Lastly, I would like to say that the act of donating one's organ is indeed an act of compassion, an act that demonstrates one's reverence for life itself, especially the life of others. Indeed, and I quote, "the true meaning of life is to plant trees under whose shade you do not expect to sit."

With this, Sir, I support the amendment Bill.