HOME OWNERSHIP AND EDUCATION SCHEMES (Relaxation of criteria)

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HOME OWNERSHIP AND EDUCATION SCHEMES:

(Relaxation of criteria): 11.

Mr Ong Ah Heng asked the Minister for Community Development and Sports in view of the unemployment situation will his Ministry consider relaxing the criteria for qualifying for the Home Ownership and Education Schemes for single parents who have two children and who possess lower than GCE 'O' level qualification.

Assoc. Prof. Dr Yaacob Ibrahim: Sir, the Home Ownership Plus Education (HOPE) scheme is not designed for Singaporeans who are unemployed. It is a programme to encourage young families with limited financial resources to keep their families small and stable by providing them with a comprehensive package of assistance. We would like the couples to keep their marriage strong so that the children can grow up in an intact family and supportive environment. We must give our young children the opportunities for them to succeed in life. The HOPE scheme replaces the Small Families Improvement Scheme (SFIS) but retains the same objectives as SFIS.

There are existing schemes that low-income single parent families can tap on to meet their various needs. Our schemes provide not just financial assistance, but also support for their children's education and development. Those who need interim relief and support can be assisted under the Interim Financial Assistance Scheme (IFAS) or the Rental and Utilities Assistance Scheme (RUAS). Under IFAS, the families receive a monthly allowance and, where necessary, grants to help them pay for the utilities and service and conservancy charges. For those living in rental flats, RUAS helps them with their monthly rental and utilities bills. Single parent families with young children can

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tap on existing pre-school assistance schemes to help them offset the cost of childcare or kindergarten education. As I have said before, there is also the Centre-Based Financial Assistance Scheme for Childcare. This scheme provides a subsidy on top of the existing Government childcare subsidy. It also provides for a one-off assistance of up to $1,000 for eligible families to meet the upfront costs of placing their children in a child care programme.

There is also the Kindergarten Fee Assistance Scheme that subsidises 75% of the monthly kindergarten fees, or up to $600 a year, whichever is lower.

Similarly, those who need help to pay for the before-and-after-school programmes for their children can tap on the Student Care Fee Assistance Scheme. This scheme supports children in non-profit Student Care Centres. For single parent families who are more at risk, the Ministry has started a programme called the Healthy Start Programme which provides early intervention through providing appropriate support to the parents to strengthen their parenting and coping skills.

Sir, we understand Mr Ong's concern over those who are affected by the unemployment situation. For this group, the Ministry has recently implemented the Work Assistance Programme (WAP). WAP, as I mentioned earlier, is designed specifically to help Singaporean families tide over a period of unemployment and, more importantly, to help the main breadwinner quickly get back to work. The programme is open to low-income families who may have lost a source of income and who are in need, and this includes single parent families. It provides both employment and short-term social assistance to the recipients.

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HUMAN ORGAN TRANSPLANT (AMENDMENT) BILL: Resumption of Debate on Question (5th January, 2004), "That the Bill be now read a Second time.". - [Acting Minister for Health].

Question again proposed.

2.37 pm

Mr Zainul Abidin Rasheed (Aljunied): Mr Speaker, Sir, thank you for allowing me to join in the debate on the Human Organ Transplant (Amendment) Bill.

Sir, yesterday, Mr Ahmad Khalis, cited an anonymous quote, asking "Is life worth living?" and answering it aptly by saying: "It depends on the liver". I know that Ahmad Khalis is no drinker. So, I suppose he means both the person and the organ.

Well, take heart too, Sir, and mind you, we will have to do it with our eyes open. Yes, Sir, make no bones about it, I do support the amendment Bill.

Sir, the Acting Minister has made his case very clear and we do need to amend the HOTA to extend it beyond "accident deaths" to include all brain deaths; beyond kidneys, to include liver, heart and cornea, and beyond "cadaveric organ donation" to also regulate living donor transplants.

We know Singapore is not alone in this. There are at least 21 countries in the world with presumed consent for organ donation. Of these, only two countries, Spain and Turkey, limit their legislation to deaths caused by accidents. None of these countries restrict the organs covered by their legislation to just kidneys.

We also know that the demand for organs for transplants exceeds supply. As of June 2003, there were 654 patients on the kidney transplant, 26 on liver and 5

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on heart transplant waiting lists here. I believe the Minister may have a more updated position. For the kidney transplant waiting list, this is an increase of 15% over 1998. As a result, the average waiting time for a kidney has increased from five years to eight years.

Sir, this is obviously not just about statistics. This means even more hardship. This is especially true for Malay/Muslims, majority of whom are now not covered under the HOTA, as some true pledgings are covered under the 1972 Medical (Therapy, Education and Research) Act. It is sad to see the faces of many residents who suffer from those ailments, and their families, who seek help at our MPS sessions, CDCs, and also at the Ramadan Tabung Amal charity.

When the North East CDC held its Talk Shop series on 26th January last year to discuss the proposed amendments, we featured four special guests connected with organ transplants. One was a heart transplant recipient, the first Malay to do so; another a Chinese gentleman who had to wait eight years for a kidney transplant; a couple who became a living-related donor and recipient, and a mother of an eight-year old boy who died of a platelet disorder (bleeding in the brain) and she decided at his deathbed to donate her only child's organs for transplant. And there, three persons benefited from this benevolent act of hers. Her boy's kidneys saved a 12-year old girl and a 17-year old boy; his liver saved a 14-year old girl, and his corneas gave sight to a 54-year old woman. All heart-wrenching stories to share, and the latter heart-warming too.

However, for our first world Singapore, one that is well-known for being very professional and organised in managing its problems, this was not just a matter of clinical tackling of the situation.

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The Government realises the sensitivities involved and has taken a step by step approach to handling the question of organ transplant, from the Medical (Therapy, Education and Research) Act (MTERA) of 1972 to HOTA in 1987, and now, further amendments only after another decade and a half. I welcome this approach.

I would therefore like to commend MOH for a careful approach in this matter. The Minister's assurance that efforts at educating the public will continue is worthy of note. Despite more than 30 years of tackling this problem, there are still serious doubts about HOTA and now its extension, in many quarters, including from religious circles and individuals who are still not convinced of the need. Yes, the majority of Singaporeans do agree, but there are still others who are troubled by it. It is good that the Act allows Singaporeans who have doubts about the system to opt out. Some 12,000 non-Muslims have done so, and this freedom to choose should continue. The educational process must also continue and I think it can and should also start as early as possible in the schools, for example.

I share the concerns raised by some of my fellow Parliamentarians, including those surrounding the definition of "brain death", professional as well as ethical considerations, and they need to be addressed. They must not be taken for granted and brushed aside easily. So are the personal, cultural and religious misgivings, but they need to be handled sensitively. One cannot under-estimate the risk of such issues being mishandled, including inadequate safeguards or the safeguards being abused. Let us ensure that there are sufficient ethical and professional safeguards to avoid the possible abuses, including sales of organs and/or wrongful removal of organs, as also cautioned by Dr Tan Cheng Bock yesterday.

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Allow me now, Sir, to turn to the question of Muslims and HOTA.

I know that the Singapore Kidney Foundation, MUIS and the Muslim Kidney Action Committee have been working very hard to get more Muslims to pledge under MTERA. While in the earlier decade, only about 42,000 people or less than 2% of the non-Muslim population pledged under MTERA, about 14,000 people among Muslims or 5% have pledged their kidneys. The Muslim effort was credible - names like Mr Ameerali Tyeabali and Mr Bokhari Razak, among others, are worth applauding - but it was never going to be enough. I had my doubts from the very beginning about the opt-in system.

I remember asking Mr T T Durai of the Singapore Kidney Foundation, why not push for HOTA for the Muslims,

years back, but he cautioned that it took Singapore 15 years to bring the Singapore population around to HOTA and that we should not rush the Muslims as it might backfire. I knew that human inertia being such and added to that, earlier misplaced religious/cultural misgivings and human comfort level being what they were, and indeed still true to some extent till today, an opt-in system would not deliver the results necessary.

Later, after another 15 years, Mr Durai himself was desperately pushing for more Muslim pledges, if not to include them under HOTA, realising how critical the situation was. It is no longer just a question of opt-in or opt-out but serious financial and health burdens inflicted on many more Malays, as about 20% of those affected by kidney failures are Malays, compared to the population ratio of 14%. Moreover, if we want to achieve a better rate of compatibility in transplants, more Malays need to agree to pledge their organs.

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Just to clarify, Sir, what Mr Chiam mentioned yesterday, organ tranplant and donation should no longer be an issue for Muslims. The Fatwa allows organ transplant and donation. This is also true for many other Muslim countries, including Saudi Arabia, Indonesia and Malaysia.

I am not a religious scholar. Such matters should be best left to them to decide. The Mufti and his Fatwa Committee in fact have been progressive in making rulings that meet the challenges of contemporary demands. While starting with a "No", following further investigations and enlightened interpretations of the Quran, the Fatwa had allowed organ donation and transplant. From kidney, the ruling now allows other organs too, like heart and liver. Even cornea, which was at first not allowed, is now possible. It is also positive in terms of stem cell research. I would like to urge MUIS and its Fatwa Committee to continue to be proactive and progressive in their search to make Islamic law more inclusive in times of need, whether in principle or in terms of emergency needs.

The condition set for waris and next-of-kin to approve, while understandable in promoting a collective sense of family responsibility and to avoid potential abuses of individual consent, should also be reviewed in the context of this urgent and pressing need to save lives. The Fatwa Committee might want to review whether it is possible to waive the need for waris in the context of emergency ( darurah ). If the concept of ' darurah' was invoked for the principle of organ donation, perhaps it could also be done for the process, ie, the opt-out system. It is after all a process. MUIS and the Fatwa Committee should consider that.

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While waiting for that, for those who are waris or potential waris and have reservations countersigning the pledge by their next-of-kin or siblings, please think of the donors' wishes. The Fatwa Committee should encourage all waris to respect the donors' wishes. This, however, I see it as only an interim position. In the longer term, it would be viable only if Muslims are included in HOTA, not as a special or exclusive component, but indeed inclusive. Muslims cannot expect to have the cake and eat it. The disadvantages of being out of the system are real and the Malay-Muslims as a community cannot afford to let this continue. The health and financial considerations are indeed very serious.

I am nevertheless glad to see MOH agreeing to continue to work with NKF and MKAC to get more Muslims to pledge, with the waris agreeing, at the outset. Public education, Sir, must continue.

Mdm Cynthia Phua: Mr Speaker, Sir, broadening the scope of the Human Organ Transplant Act is a right move, given that this would mean more people who are ill will be able to get a second chance to lead a normal life. However, there are a few issues which should be addressed under the proposed amendment to the Act.

Ethics Committee

The new section 15B spells out the need for an Ethics Committee to oversee the removal of any organ at the hospitals. At the same time, the Bill proposes that the medical practitioner who is appointed to this Committee should not be employed or otherwise connected with the hospital. I feel that the Bill should stipulate the maximum term each member of the Committee can serve. If the same member serves on the Committee for too long a period of time, this will circumvent the spirit of the provision requiring that

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the doctor who sits on the Committee should not be connected to the hospital. One would assume that the guiding principle of having this Committee is to have people who are independent-minded, making decisions to the best interest of the public. Therefore, there should be a time limitation for the service with the hospital to avoid a situation where they become too familiar with the hospital.

Further, the Bill does not specify the case of a lay person. Who are these people who can be invited to sit on the Ethics Committee, whether or not he or she should be an employee of the hospital? I propose that the Bill should stipulate that this lay person should also be someone not connected to the hospital. The lay person should be someone with some level of maturity and standing in the community.

Healthy organs

In clause 4, amending section 5(2), the organs may be removed not just from someone who died in an accident. It is expanded to include anyone who dies from any cause of death. There is also the expansion to the Act to include three other organs besides the kidney - liver, heart and cornea. It is relevant at this point for the Minister to explain how the Ministry ensures that the organ removed from a person is a healthy organ, in the sense that the deceased is not, for example, a sufferer or a carrier of HIV. With the increasing incidence of HIV, there is the likelihood that the deceased may not be on medical record as an HIV sufferer but is, in fact, a carrier. How does the Ministry address this problem as the impact to the recipients will be greater in view of the multi-organ donations? What is the due diligence that the medical practitioner will have to observe before the organ is transplanted to a recipient?

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Is there a guideline from the Ministry for hospitals to comply with?

Definition of death

Since the scope of the Bill is broadened to include any cause of death and not due to any accident or otherwise, it is important that a new definition of when is a person considered to be dead be spelt out. Currently, two senior medical practitioners who possess appropriate post-graduate medical qualifications can certify the death of a person. This is provided: (i) they do not belong to the medical team that is involved in the organ removal; (ii) they are not involved in the care and treatment of the organ recipient; and (iii) their medical qualifications are recognised by the Ministry.

As the Bill now stands, everything is left to the opinion of the two medical practitioners. The families of the deceased would surely want to know, as a matter of fact, how is death determined. In the US, the definition apparently varies between some states. One definition is when a person experiences an irreversible cessation of spontaneous respiratory and circulatory functions. Another definition says there is an absence of spontaneous respiratory and cardiac functions, and because of the disease or condition which causes directly or indirectly these functions to cease, or because of the passage of time since these functions have ceased, attempts at resuscitation are considered hopeless and, in this event, death would have occurred at the time these functions have ceased.

We should make it clear in the Act so that there is no ambiguity in the determination of death. The next-of-kin, as you will well imagine, will be under a lot of trauma and distress when such a decision is to be taken. If the Act spells out the definition in a clear manner that a layman can understand, then the process will be less painful for the families of the

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deceased persons. And I agree with Mrs Lim Hwee Hua's comment that the concern here is not solely on principle nor legality, but the added dimension or sufficiency of safeguards. And we have also been recently reminded of the accidents resulting in the training of commandos. Additional external checks should be done on a periodic basis so that comprehensive safeguards on the process of the certification of death are constantly present.

Recognition of benefits and penalties of the Act

There are many people who do see the merits of organ donation as an act of saving lives. However, they also believe that organ donation is an altruistic act and not to be carried out through an act of law. In this view, some may choose to opt out and then opt in through MTERA, or some are already in MTERA for many years. I would like to stay that way. Can the Act recognise this spirit of altruistic act of organ donation and recognise the individual choice, since the end result is the same?

Can the Ministry clarify the benefits and penalties accorded to a person who chooses to opt out for a cornea transplant and remain in HOTA for the other three organs, and subsequently by fate requires a cornea transplant? Will he be penalised and denied of the organs? These are examples of the many questions asked by the public which the Ministry needs to elaborate.

Public education

It is important that the Government should go back to the people and get everyone to understand what the new law covers when this Bill is passed. It is important that everyone understands what are the organs that can be donated

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in the event of death. This is an important information that should be carefully explained to the people and we should make sure that it is filtered down with the correct messages. No one would want to see their loved ones lying in this condition with the thought at the back of their minds that the body they see is, in fact, devoid of the cornea, liver, heart and kidney, unless they strongly believe in the merits of the removal of the body organs to save lives. Hospitals should provide sufficient qualified counsellors to handle this highly charged state of emotive condition of the family members, especially when the donors are young. The Government should also muster the support of grassroots organisations, welfare bodies, religious bodies to help in this process. Here is the process in which once a decision is taken, the outcome is irreversible. The consequences can be very painful and traumatic as they haunt the conscience of the living for the rest of his or her life.

With these comments, I support the Bill.

Mdm Ho Geok Choo (West Coast): Sir, I rise in support of the amendment Bill. It is encouraging to note that many seriously ill people are saved each year through organ donations. At the same time it is just as depressing to note that yet many more die each year, because there are simply not enough organs donated.

HOTA will change this as more organs for transplant can be made available to those who are in need. I applaud the Government for having the moral courage to introduce these changes despite the many issues and concerns that need to be addressed and clarified. Reassurance and practical solutions to allay the fears, apprehensions and concerns of Singaporeans will need to be put in place.

Sir, I would like to raise some of these concerns focusing on five areas:

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The first area of concern is that the Bill focuses too much on the supply side of the equation. What is not surprising is the rationale that the MOH gives for the need to include liver, heart and cornea under this opt-out system. I reckon that the dire need for such organs is what prompts the Government to introduce the amendment. However, in my opinion, there is just not enough debate in this nation about the demand-management side of the equation.

We are not sure by what criteria patients who need these organs are given priorities one over the other. In the US, the authorities have developed rather elaborate contra-indications of who should get priority and who should not. There is no such set of contra-indications in Singapore or, at least, we are not sure what those contra-indications are as they are not made publicly available.

For example, I am pretty sure that a patient who is 85 years old, an invalid, and a widower would not be given the priority over, say, a patient who is a 35-year old and a breadwinner of his family. Another example would be a person who is a drug addict or a convicted criminal. How would he be placed on the priority list?

I am quite sure that hospitals in Singapore attempt to look into who best to give priority, when deciding on organ transplantation, but there are no clear and publicly available indications of who would be placed in the front of the queue. In the case of car control, the Government steps in on the demand side of things. In the case of organ transplants, the Government steps in on the supply side of things. There is nothing wrong with the approach. However, just as I feel that more can be done on the supply side of the car population, so I think that more can be done to indicate how demand of organs

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can be better managed.

As far as supply of organs is concerned, since a person who decides not to opt-out is effectively saying "yes" to donating his/her organs, the amendment should also include something about the community giving back something to the immediate family members of a deceased patient who has his/her liver, kidney, or cornea removed upon the certification of brain death. A one-off benefit could include the defraying of funeral expenses; a one year write off of income tax being owed; grants and so on. Quite obviously, there must be a cap on the amount that can be given out, but in making this gesture, the Government will be signalling that it, too, is doing something about properly managing the harvest of organs in this country.

Sir, the amendment does not include other types of organs. A few years ago, there was a successful lung transplant being carried out in Singapore. Perhaps, we could also look into other organs, and some thought ought to be given to the issue as to the maximum number of organs that can be harvested from any single deceased patient.

The second area concerns the consistent application of HOTA on the population in a secular state like Singapore. Muslim Singaporeans have been excluded from the amendment on HOTA on presumed consent unlike all other non-Muslim Singaporeans. Should Singapore, as a secular state, pass a law differentiating the various religious groups? I would have thought that we should have a law that is consistent with our secular nation state status since there is no fundamental objection, as explained by the hon. Member Mayor Zainul Abidin.

Sir, the Muslim population forms a significant number in Singapore. With the amendment on HOTA providing for Muslims to opt in, I would like to check

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with the Minister on the impact on Muslims who need organ transplants. I wonder, Sir, how many will die whilst waiting to be accorded the priority for an organ transplant. Can the Minister enlighten us as to the number of Muslims in Singapore waiting for organ transplants and what would be their priority in the queue?

The third area concerns the definitions and issues of brain death. Sir, as medical science evolves, the definition of 'death' is being expanded. Life can be prolonged artificially for the purpose of organ removal. This has raised questions as to when death takes place and does 'brain death' in all instances constitute death? Like my colleagues before me, I am concerned.

Some doctors, for example, claim that tests for 'brain-stem' death, the precondition for organ removal, can actually precipitate the condition. Understandably, there is a widespread underlying concern among the public as a whole that less effort may be put into saving the life of a patient if it is assumed that his organ can be harvested and used for transplant.

It was reported in the newspapers, sometime back, that a well known Japanese author observed that, in the interest of prolonging the lives of others for the greater good, American doctors administer heparin and phentolamine to the brain dead to keep their organs alive for transplant. The moral issue arises. Heparin prevents blood clotting within organs, whilst phentolamine widens the blood vessels so that more blood flows through the organs to keep the brain alive. These two drugs do not improve patient comfort or care but can hasten heart death. I understand that in 1997 an ethicist blew the whistle. To date, there is no consensus on the morality of using

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these two drugs. I am interested to know whether these drugs are used by our Singapore doctors and, if so, how do we deal with the dilemma.

Sir, it is important that any debate of the issue needs to take account of these reservations with the aim of providing further clarification and reassurance. It is also important that there is enough information reaching out to the public so that those affected can be reassured and make better-informed decisions. For example, for a teenager reaching the age of 18 and who now qualifies legally to make a decision on HOTA, what kind of education or information sharing is put in place to sufficiently prepare these teenagers for making an informed decision and choice with regard to HOTA?

While feedback and surveys so far indicate willingness to move towards a system of presumed consent, we need to put in place sufficient mechanism to address the concerns of those who have not expressed support and to understand their reasons for not doing so. Only then, we can better convince those unconvinced of the cause that we are promoting.

The fourth area of concern is on the proposed regulation of living donor transplants. Here, I would like to make some observations on this issue in other countries. The HOTA Act 1989 forbids people from accepting organs from anyone not genetically related, unless it is approved by a panel of doctors. Even then, no money is allowed to change hands. The existing legislation is the same in the UK. This issue is being debated by the BMA in the UK at present. It has been proposed that the NHS is permitted to buy organs from live donors.

John Harris, Professor of Bioethics at Manchester University, argues for healthy donors to be given the right to sell

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organs. According to him, "Thousands of lives could be saved by establishing an 'ethical market' in live organs. This payment should be tax-free and donors should not lose entitlements to state benefits." In an article in the BMA Journal, he says, "This would prevent the rich using their purchasing power to exploit the market at the expense of the poor. People would not be able to use wealth to jump the queue and rich countries should not be allowed to buy organs from the poor countries."

One proposal is to only allow organ trading to take place within countries or within a bloc of countries. Legalising the sale of organs would also remove the incentive for illegal profiteering from the trade. Opponents, include Alistair Campbell, Professor of Medical Ethics at Bristol University, who argued "Our body is not a piece of property in the sense that our house is. Also the consequence of a market in human organs is inevitably exploitative, as studies from countries like India have shown." According to Campbell, "Far from improving the lot of the poor, it worsens their situation. The notion of an 'ethical market' is a myth and it will only be the most needy who are ready to sell organs."

Surveys conducted in the US have shown that only 12% of people were likely to donate an organ for a financial incentive and 5% said that they were less likely to do so. At the same time, there are indications that more people in developed countries are offering organs for sale, often via Internet. In a recent case, a British woman offered a kidney for US$200,000 so that she could purchase an apartment. Studies have indicated that, not surprisingly, it would be the poorer section of society who would be most likely to sell their organs. Also, many live donors suffer a decline in their own health. Other studies conducted in the US into commercial blood banks indicated that there were four

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times as many cases of hepatitis among paid donors, because offering payment attracted poorer and sicker donors, who sometimes lied about their health. As a result, commercial blood banks were curbed.

In all EU states, with the exception of Austria, payment for organs beyond reasonable compensation is strictly forbidden. But penalties vary from country to country and there is nothing to stop EU citizens from travelling abroad to purchase organs from live donors in countries where the practice is not illegal. Germany is the exception where it has an extra-territoriality clause which makes it illegal for a German citizen to purchase organs anywhere in the world.

Based on the above research findings, Sir, I am concerned that the issue of 'transplant tourism' is real and may catch up with Singapore. It is therefore prudent and timely, as we debate the proposed amendments to HOTA, that we also address the potential illicit trafficking of human organs more extensively. Specifically, what would be our stand with regard to the wealthy purchasing organs from living donors in developing countries? Therefore, I urge that legislation with regard to living donors and recipients needs to specifically address aspects such as definition of organ trafficking; the introduction of an extra-territoriality clause, as exists in Germany; removal of an organ by force; promise of payment or payment for an organ; participation of medical staff in the illegal transplant of an organ.

The fifth area pertains to new section 5(2) of the Amendment Bill. Sir, at this juncture, I would like to make reference to clause 4 which amends section 5(2) to allow organs to be removed from the deceased person who has died from any cause of death, and not just where the death was caused by accident or resulted from injuries caused by accident. From

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the medical perspective, the removal of organs is very much a mechanical process. We must not forget that such an act can cause intense emotion in the next-of-kin of the dead person. Although there is presumed consent, it would appear to be more humane if we could include in this clause the following "after having informed the next-of-kin and explained the procedure of the removal of organs." Even if the intent is there to touch base with the next-of-kin first, it is good to have the inclusion as a check and balance to ensure that indeed this procedure is not inadvertently left out.

Sir, on this note, I support the amendment Bill.

Mr Ang Mong Seng (Hong Kah): (In Mandarin) : Mr Speaker, Sir, I rise to support the Human Organ Transplant (Amendment) Bill.

After making a detailed study of the Bill, I would like to raise the following six points. One, the acceptance of the definition of "brain death". Advances in medical science and technology have led to a higher rate of success in human organ transplant procedures. This has brought a ray of hope to those patients whose organs are at the end-stage of the disease. The Bill would help raise the number of organs available for donation.

Surveys have shown that most Singaporeans support this Bill. However, they have also shown that there is a group of Singaporeans, especially the more conservative and elderly, who continue to have doubts and are apprehensive about the definition of "brain death". In fact, before the law was enacted in 1987, the Ministry of Health has, through the media and public forums, explained and discussed this issue and yet, 17 years later, there are still some Singaporeans who are sceptical and

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worried about the definition of "brain death" due to their lack of understanding. It does show how people look at death and how it is dealt with is still very much influenced by traditional thinking. To them, a person is still alive so long as his heart is still beating.

One reason for this could be that we have not done enough to clarify the issue to the public through adequate and proper channels. Perhaps, we need to explain the issue more and in greater detail so that people have more confidence and trust on how we deal with death and the removal of organs from the cadavers. I suggest that MOH publish and distribute pamphlets and brochures in four official languages and hold public discussions at grassroots levels to explain the issue to the people. The subject may be taught in schools too. This will help more people to have a proper understanding of the question of brain death and other details of the Bill.

Another issue I am concerned about is the health insurance coverage for the living donors. More and more Singaporeans are now covered by medical insurance. I have asked a few agents from the various insurance companies about this matter and they told me that they were not sure about the impact of an organ donation on the status of the insurance policy of the insured. In the event of a donor falling sick, an insurance company may claim that it is due to an operation involving an organ donation in the past, and hence may refuse to honour his policy and compensation on this basis. This is rather unfair to the policy holder.

I would like to know what the Minister's position on this issue is, and whether legislation will be made to provide some kind of protection to the organ donors who are covered by the medical insurance. As far as I know, unlike other donors, a donor who claims

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to be a direct relative is not subject to rigorous interviews and investigations to preclude the possibility of financial inducements. All that is needed is the provision of documents to prove his relationship and undergo a medical examination and psychological test. However, this could lead to abuse, especially when the so-called direct relatives, including uncles and aunties, come from foreign countries, such as China or India. It is difficult to verify the authenticity of the documents.

Hence, it is not easy to find out whether there is monetary inducement involved. To avoid the possibility of organ trading, I hope MOH will legislate to provide for a DNA test for the donor to prove his claim of being a relative of the recipient.

Fourthly, the punitive measures in the Bill are rather lenient. I fully agree with the Minister that we need to stop this nefarious transaction in human organs. The Bill provides for a fine of $10,000 or a jail term of not more than one year. This is peanuts to those who could reap huge profits from organ transactions. I personally feel that the illegal sale of human organs is more serious than illegal 4-D bettings. In the case of illegal 4-D bettings, an offender receives a fine of $20,000 to $200,000 and a jail term of not more than five years. Therefore, the fine should not be limited to $10,000. It should be raised to $100,000 or $200,000. This will deter trading in human organs, which may tarnish our reputation as a respectable medical centre.

Fifthly, under the new law, the age limit for a living liver donor is 55 years. On the other hand, the age limit for organs removed from a cadaver is 60 years. What surprises me is that the age limit for a living kidney donor is 65 years. When a person reaches 60 years, he is considered a senior citizen. At this stage,

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the risks and the post-operation complications are greatly increased, especially for such major operations. Our desire to help the serious kidney patients should not cause us to neglect the risks taken by the otherwise healthy donor when he donates his organs. Perhaps, we should consider lowering the age limit for living kidney donors to 55, as is the case for living liver donors, to allay the fears of those elderly people who might think they are suitable candidates for such operations.

Sixthly, the Transplant Ethics Committee's definition of "lay person". I would like the Minister to clarify what is the meaning of a "lay person" to be appointed to the committee. I am afraid that an ordinary lay person may not possess adequate medical knowledge to fully understand what is required of him when he takes part in the committee's deliberations. I agree with Dr Tan Cheng Bock that the Transplant Ethics Committee is a very vital body. It may be advisable to lay down certain criteria for the appointment of such a person, to ensure that he has the ability to exercise correct judgement in the discharge of his responsibility. When an organ transplant operation is undertaken, certain ethical problems may arise. Under the Bill, a representative can enjoy immunity from a law suit, if he is acting according to the directive from the Director of Medical Services or the Transplant Ethics Committee. If a lay person does not possess sufficient medical knowledge to fully understand the implications of his judgement, he would not be able to make valuable contributions to the Transplant Ethics Committee. Why appoint him to the Committee? I would like the Minister to clarify the points I have raised above.

I support the Bill.

Dr Mohamad Maliki Bin Osman (Sembawang): Mr Speaker, Sir, thank you for giving me the opportunity to speak on

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the proposed amendments to HOTA.

Sir, my colleagues before me have eloquently articulated the issues related to the proposed amendments - from the need to safeguard against the trading of organs in cases of living organ transplants to the ethical issues of what constitutes brain death to the procedures that doctors will have to adopt in declaring a patient for being brain dead. Some have highlighted the perennial problem of the lack of public education and the need to ensure that the public is kept aware of the developments and their individual rights and obligations. I share their concerns and I look forward to the Minister's response to these concerns in relation to the proposed amendments.

I would like to, however, focus on the issue of information sharing and public education, particularly on HOTA and the Muslim community. Sir, the issue of organ transplantation, as with many other issues, has often been said to be very sensitive to the Muslims. Dr Lily Neo yesterday and Mdm Ho today asked why the Muslims are given the choice to "opt in" when they are more vulnerable to getting kidney and other diseases - rendering them in a disadvantaged position should they be diagnosed with having such a disease. What is important to note is that, whatever the religion, the transplantation of organs requires the consent of the donor. In the case of non-Muslims, the consent is presumed, thus one is given the option to opt out if consent is not granted. In the case of Muslims, consent cannot be presumed. Islamic law stipulates that the consent must be given by the waris or the next-of-kin of the intended donor. Following the introduction of HOTA in 1987, the number of Muslims who have pledged to be donors has increased from 400 to some 14,000. This, however, as indicated by several of my colleagues,

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makes up only a small percentage of all eligible Muslim adults. I have known of Muslims who are keen to opt in to HOTA but faced resistance from their waris . I think the issue is not to secularise the issue of consent for the Muslims, as suggested by Mdm Ho earlier, but rather the challenge is for MUIS and the Muslim community to convince the waris to provide their consent without compromising the prescribed laws on consent giving. MUIS must continue to reach out to the waris to understand and address their concerns and reservations about providing consent. Certainly, the question is: what is stopping the waris from giving their consent?

This is related to a more fundamental issue of whether organ transplantation is permissible in Islam or not. The Fatwa Committee of MUIS has ruled that organ transplantation is permissible for the purpose of saving lives. This is a similar position taken by several other religions, as I understand it.

Sir, indeed, the issue involving the Muslims is one of public education. There is a belief held by many Muslims that one is created and born complete with the necessary organs and, thus, one should return to one's Creator in the same manner. This is why, despite MUIS' Fatwa Committee's ruling on the matter, many Muslims are still uncertain about their willingness to be part of HOTA.

Sir, yesterday, Mr Ahmad Khalis had outlined in detail the developments of the Islamic rulings or Fatwas with regard to organ donation. Sir, the Fatwa Committee's ruling is not unique to Singapore alone. In fact, in arriving at its ruling, the Fatwa Committee makes reference to several Islamic countries and the International Islamic Authorities, like the Islamic Fiqh Academy in Al-Azhar, the authorities in Cairo and the OIC in Jeddah.

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Sir, all over the Muslim world, the position of organ donation and transplant is similar. In Saudi Arabia, for example, the Senior Ulama Commission resolved that both living and cadaveric organ transplants are permissible on the grounds of saving lives. The Saudi Centre for Organ Transplantation prescribes specific protocols with regard to proclamation of brain death for the purpose of organ transplantation. Malaysia practises a similar opt-in system for organ donors and consent from the next-of-kin is essential before retrieval of organs. In Egypt, there is no legislation regulating organ transplants except for a 1962 law that legalises cornea transplants. Kidney transplants of related donors are allowed with written consent from the donors. In Turkey, the Directorate of Religious Affairs has approved of organ transplantation, proclaiming that the deadly diseases can be treated by people using modern medicines and techniques and remains in conformity with the demands of Islam.

Sir, I raise the above examples to highlight to the Muslim community that the Fatwa issued by MUIS' Fatwa Committee is in tandem with that of many Islamic countries. This is important to allay concerns expressed by some sectors of the community about the permissibility of organ donation and transplant in Islam. MUIS and the Muslim Kidney Action Committee (MKAC) will have to continue to educate the Muslim community on the Fatwa and address other concerns that they may have. I have heard of Muslims being concerned with who the recipients of the organs will be. Others have expressed concern about respecting the dead and the ability to fulfil funeral rites and obligations. A heightened public education campaign must be embarked on continuously to address these concerns. Sir, in such a circumstance, ignorance is not bliss.

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Sir, yesterday, Mdm Halimah highlighted that Part IVA of the proposed amendment which relates to living organ donor transplants effectively suggests that the Muslims are already in HOTA. Sir, about a year ago, my wife and I lost a dear friend to leukemia. She was diagnosed with the illness some five years before her death. At that time, we were told that a bone marrow transplant was the best option for survival. All her family members were eager to donate their bone marrow. And so were we. But there was no suitable match. We looked everywhere, including her distant relatives in India, but our efforts were in vain. She succumbed to the illness at the end of 2002.

Sir, only patients of such diseases or illnesses and their loved ones will understand the sufferings and the longing for a donor organ to come by. Many will have to suffer in silence for a long time and perhaps may perish prematurely when their hope for an organ transplant is not fulfilled. I do not think we need to personally experience a loved one to be diagnosed to have a disease or serious illness to feel for his plight. This Bill is about saving lives. This Bill is about doing what we can to improve the lives of our fellow citizens.

As a citizen, I support the Bill. As a Muslim, I call on all my fellow Muslim brothers who are waris , to consider the greater good of humanity and show their support to their family members who want to be donors. If there are still reservations, I urge them to objectively bring these reservations to MUIS and the Fatwa Committee to be answered. I hope, in due course, more Muslims will opt to come into HOTA and do our part as more responsible and caring citizens.

Sir, I support the Bill.

Mr Ong Ah Heng (Nee Soon Central): (In Mandarin) : Mr Speaker, Sir, I rise to

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support the Human Organ Transplant (Amendment) Bill.

The inclusion of the non-accidental deaths, heart, liver and cornea into our system is the most effective way to increase the number of available organs for transplantation.

In theory, an opt-in system would be more ideal and meaningful.

However, experience shows that, whether in Singapore or elsewhere, the response to opt-in for donation has been far from ideal. In fact, according to a survey by the Ministry of Health, most Singaporeans actually support organ donations, but generally do not take the trouble to make the relevant applications.

Another survey done by MOH also indicated that there is still a small number of Singaporeans who are concerned that doctors might diagnose brain death prematurely. There is a group that is uncomfortable with the definition of "brain death" because, to them, a person is dead only when his or her heart stops beating. Most young people can understand and accept the concept of brain death. They also have faith in our medical personnel. However, there are some old folks and those who are not so well-educated who seem to have difficulty accepting this definition of death and they are concerned that the donors would be pronounced dead prematurely. This is probably due to a lack of understanding of the definition.

The Ministry has responded that it would be conducting regular public education programmes in partnership with the grassroots organisations to dispel such fears so that more people would be aware of the definition of brain death. I fully support this initiative.

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We must build up the public's faith in our medical personnel. Doctors will do their utmost to save the life of every patient and will not treat their patients disrespectfully. We can also go through various channels and even use our mother tongue to let those senior citizens understand that their fear and concern are really unnecessary. As a matter of fact, once they have passed the age of 60, their organs will not be harvested under this Bill.

For those who wish to opt out for whatever reasons, I hope that the Ministry of Health will make the opt-out procedure simple and easy. We must not take away the patient's organs under any circumstances by taking advantage of the patient's ignorance or helplessness. This will be unethical and despicable.

Some Chinese people still hold dearly to very traditional beliefs, especially in funeral rites. They tend to believe that when a person dies, his body should remain whole. In my constituency's meet-the-people sessions, I have occasions to come across some residents who have just lost their relatives and they sought my help to stop the pathologists to do an autopsy on the deceased for fear that his body would be mutilated, as they want the deceased's body to remain intact. The Chinese people feel very strongly that it would be disrespectful to the deceased if his body could not remain whole and intact.

I would like to urge the Chinese people, who still hold on to these traditional beliefs, to change their mindset because with the advances in medical science, the organs of the dead now can be transplanted to save more lives.

As mentioned by some colleagues before me, recent studies in the United States have revealed that some heart or liver transplant patients suffer from kidney

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failure within a few years after the transplant, and had to go for dialysis or even kidney transplant. It seems that there is indeed a sequela to these transplant operations. Therefore, I would like to urge the Ministry to step up its efforts to conduct various educational seminars and talks to promote healthy lifestyle as preventive measures. It is very important to educate Singaporeans on how to prevent the failures of organs and to change their diet and lifestyles. In view of the fact that we have a growing ageing population, the Government needs to educate the public. Otherwise, no matter how many organs we may have to harvest, they will not be enough to meet the demand.

I agree with Members who expressed concern over the illegal trafficking of organs. I know of a number of people who actually went overseas to purchase organs for transplantation. It is useless for us to enhance the penalty in Singapore for illegal trafficking of organs as people who are in need would just go overseas to acquire organs. They are eager and prepared to spend $20,000-$30,000 to buy a kidney for transplant and prolong their lives for, say, three to five years. We cannot stop them as they just could not afford to wait so long for their turn in Singapore. They would rather spend the money, and take the risk to go overseas to purchase the much needed organ.

Mr Speaker, Sir, if this sort of thing happens to someone close to you, would you have the heart to stop him from doing so? We cannot stop people from pursuing a healthy body by going overseas to acquire an organ. Therefore, it is important for the Government to educate our people on how to keep a healthy lifestyle so that their bodies will not be so prone to disease and their organs will remain good and healthy, and there is no need to go

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for transplant to replace their failed organs.

Dr Ahmad Mohd Magad (Pasir Ris-Punggol): Mr Speaker, Sir, I rise in support of the amendment to the Human Organ Transplant Act. The proposed amendments are indeed laudable as they will open the way for more organs of the human body to be made available for life-saving transplantation to individuals suffering from organ failures. The concerns I have with respect to harvesting organs from brain-dead persons as well as transplants from living donors, have been expressed by several Members. I shall therefore not repeat these.

However, I would like to express my concerns on the implications of continuing to exclude Muslims from the provisions of HOTA. When HOTA was enacted in 1987, Muslims were excluded because in the case of Muslims, according to the Shariah (or Islamic law), it is the waris (or the inheritor), who has the right to decide what to do with the body of the deceased person and this is sacrosanct. Thus, it is not permissible to remove any organ from the cadaver without the prior consent of the waris .

Sir, as Muslims are not included in HOTA, they need to pledge or opt-in if they wish to donate their organs upon their death. This pledge is not made under HOTA but under another Act, namely, the Medical (Therapy, Education and Research) Act 1972 (MTERA). Muslims wishing to donate their organs must also ensure that their waris endorse the pledge form as part of the condition of acceptance of the pledge.

Since 1990, the Muslim Kidney Action Committee (MKAC), which is a committee appointed under the auspices of MUIS (Muslims Religious Council), spearheaded many public education campaigns with

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the support of MUIS, the National Kidney Foundation (NKF) and major Malay/Muslim organisations in Singapore to encourage Muslims to pledge their kidneys under MTERA.

To-date, after nearly 14 years of such effort at an expenditure estimated at $7 million (estimate provided by NKF), just over 14,500 Muslims have pledged their organs under MTERA. This represents a significant increase over the 400 Muslim pledges in 1990. However, in comparison with the number of Muslims who are eligible to pledge their organs, which is estimated to be 250,000-260,000, the current number of pledges only accounts for about 6% of the eligible Muslim population.

Sir, how do we get the vast majority of Muslims to become organ donors under MTERA? Can we continue to depend on the persuasive approach? I personally do not think so. Opting in is not a straighforward procedure for Muslims. The requirement for them to get their pledge forms endorsed by their waris is troublesome and most just do not bother to do it. Records also show that more than 12,000 Muslims had their pledge cards returned because they did not have the requisite endorsement by their respective waris . Even if the waris are not required to co-sign the pledge forms, the experience, not only in Singapore, but also in many developed countries, has shown that the persuasive approach can only achieve limited results and, at most, secure participation from between 2-5% of the population. In fact, it was in recognition of this that HOTA was introduced so that non-Muslim Singaporeans are deemed to have pledged their kidneys unless they choose to opt out.

Sir, as a Singaporean Muslim myself, and having consulted with many of my

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fellow Muslim counterparts, I can say with great conviction that it is our desire to become part of the pool of organ pledgers together with non-Muslim Singaporeans. I believe that the vast majority of Muslims want to be included in the HOTA, not because they feel disadvantaged when being left out, but because like their non-Muslim Singaporean counterparts, they too deeply feel the desire to help save lives of their fellow Singaporeans who are suffering from organ failure. The MUIS Fatwa Committee, which is responsible for ruling on points of Islamic law, has confirmed that Islam not only allows but encourages organ donations for life-saving transplantations.

Mayor Zainul Abidin Rasheed and Dr Maliki have both spoken at length earlier this afternoon about fatwa in several Muslim countries being supportive of organ transplantation although in Saudi Arabia, for example, consent from a donor is still required. Muslims are acutely aware of the plight of persons, whether Muslims or non-Muslims who are stricken with organ failures, where transplantation is their only hope of living a normal life again. They are also aware of the sufferings of kidney patients who have to endure rigorous four-hour dialysis sessions, sometimes up to three times a week, to prevent toxins from building up in their bodies. Singapore Muslims want to do their part with other Singaporeans to provide hope to such patients. Sir, during an intensive public campaign conducted by the MKAC in the year 2000, more than 56,000 Muslim Singaporeans put their signatures in support of organ donation. This represents a significant verifiable response from Muslims of their desire to be included in HOTA.

I would therefore request the Hon. Acting Minister to seriously consider the inclusion of Muslims under HOTA to make them automatic organ pledgers together

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with other Singaporeans. Sir, I would like to further propose that to overcome the issue of the sacrosanct rights of the waris over the deceased Muslim cadaver, the amendment should allow making provision that in the case of Muslims opting out of HOTA, it should mean that they are doing so not only on their own behalf, but also exercising their rights over those family members

they are a waris to. For example, assuming that Muslims are included under HOTA, if I, as a Muslim, choose to opt out, then all my family members, whom I am an immediate waris to, would be deemed to have opted out as well. However, if my unmarried son chooses to opt out while I am still alive, he does this only in an individual capacity. It should not affect me or his other siblings.

Having said this, I realise that this may not be as straightforward as it seems, but it could be further refined and developed. I thank Mdm Ho Geok Choo for questioning the exclusion of Muslims from HOTA in a Singapore which aspires equal treatment and opportunities for all. In a secular society like ours, we need to find creative ways to surmount some of these religious difficulties which I believe are matters of interpretation. There should be some give and take in order to make further progress. MUIS, as the supreme religious body for Muslims, can help facilitate this.

The inclusion of Muslims as part of the fabric of this Bill has been delayed for too long. It is timely indeed to seriously look into their inclusion in HOTA, as we deliberate this issue during this revision exercise.

Mr Speaker, Sir, I leave this House with a quotation borrowed from Mr Kofi Annan, Secretary-General of the United Nations, that he made during the 18th Singapore Lecture in February 2000, and I quote:

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"All great traditions and religions overlap when it comes to the fundamental principles of human conduct: charity, justice, compassion, mutual respect, the equality of human beings in the sight of God."

Sir, the inclusion of Muslims will benefit all of us and I urge the Ministry to take steps to consider implementing it as soon as possible.

Mr Steve Chia Kiah Hong: Thank you, Mr Speaker, Sir, for allowing me to participate in this debate. As an Opposition MP, I rise to speak in support of the Human Organ Transplant (Amendment) Bill.

As long as we are medically able and ethically persuaded, there should be no reason why an organ transplant operation should not be allowed to take place either from a willing brain dead person or from a willing living and able donor. The purpose is to save and/or improve the life of another critically and/or terminally ill patient, without which living is misery and death is most certain. However, my only two concerns for the Ministry to look into are as follows:

First, all Singaporeans are, by default, organ donors. Yet, they are not educated to understand the implications and consequences of staying put as an organ donor. Many people thought that it is okay to donate their organs when they die. But they do not realise that they would not be fully and completely dead. They are just brain dead, by medical definition. The heart is still pumping and their organs will be harvested when they are actually still breathing. If they had completely died, as their heart had stopped beating, then their organs would have been useless.

Sir, all organ donors and their families should be made aware of this fact so that

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they can better decide if they want to opt out or stay put in this programme. Not enough effort is made to explain this point to our citizens. Even I, as an MP, do not know of this distinction until the Minister explained yesterday. What more of the general public. Since this is an opt out scheme, the Health Ministry should take on this mammoth task to explain the pros and cons of staying in this programme objectively to our citizens. Otherwise, citizens whose beloved family members are in a comatose brain dead condition will feel shortchanged and cheated when the organs of their loved ones are being harvested when they have not completely and fully died. The next-of-kin of a brain dead person should also have the power to decide whether to let go of their brain dead loved ones in such circumstances or to continue sustaining the brain dead using machines, hoping and hoping for a miraculous recovery.

Secondly, living organ donors of a kidney or any part of the liver should be Singapore citizens and permanent residents only. They can donate their organs to fellow citizens and permanent residents only and without any form of contractual or monetary transactions. This is because nobody in Singapore should be so poor or be so forced into by circumstances as to have to sell their organs for a living. The second reason is to prevent the creation of a black market for organ trading in the very poor and undeveloped countries where many see selling one of their kidneys as an easy way out of abject poverty.

Sir, Singapore has a global reputation to maintain, and we must be seen to maintain our standards of moral integrity and ethical code of conduct. We must not be seen to become a centre for the illegal trading of human organs. Other than the above two concerns for the Health Ministry to address, there is no

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reason why human organ transplant, especially by willing, living and informed donors, should be prohibited by law.

Sir, I support the amendment Bill.

Dr Ong Seh Hong (Aljunied): Mr Speaker, Sir, with the amendment, many of us can play a greater part in helping those most in need of an organ donation. While I applaud the move to expand the Act to cover more organs and to include non-accidental death, I think that the amendment has not been bold enough. I would like to call for the inclusion of all Singaporeans as well as more types of organs in the Act.

Sir, as I am not a scholar on religions, I have surfed the Net to gather information and comments on the views on organ donation by various major religious systems. Not surprisingly, although with some differences, all major religions support the act of organ donation with a common view that saving life takes precedence and that the act of donating one's organ is seen as an act of charity and is accorded with great merit. From a humanitarian viewpoint, donating one's organs to save lives of fellow human beings is also of highest calling. Therefore, I would urge the Minister to consider expanding further the Bill to cover all Singaporeans regardless of race and religions. As this is an opt-out system, anyone objecting to organ donation will still be able to exercise their right to be excluded.

Sir, we should also remove the age criterion of limiting the potential cadaveric donors to those between 21 and 60 years of age, which precludes many otherwise suitable potential donors. Many of these younger and older persons who have died may still have organs that are medically suitable for transplantation. Hence, I would urge that the age limit for HOTA be removed in order to increase further the number of organs available to save lives.

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Again, for those below 21, their parents or guardians could still exercise the right for them to opt out of the system.

Secondly, I urge the Minister to consider inclusion of more types of organs in the Bill. With advancement of medical science and technology, we will be seeing more and more of different body parts being transplanted to save lives and improve the quality of life. If this amendment Bill aims to save more lives, I do not understand why the skin and lung are not included while cornea is. Skin grafting is actually a life-saving procedure for patients with severe burns while lung transplant is the only hope for those with advanced lung disease in end-stage respiratory failure. In fact, many other organs, such as pancreas, have also been transplanted. May I urge the Minister to consider including at least the lungs and skin in this amendment Bill that could be used to save many precious lives?

Thirdly, I would like to touch on the need for more public education, a point that has been alluded to by many hon. fellow Members here. With HOTA in place for more than 16 years and MTREA more than 30 years, we are still having a shortage of organs available for transplant. I think this is partly due to some public ignorance and misconception on the procedure on organ harvesting and transplantation as well as the lack of knowledge of their own religious stand on the issue.

One of the common concerns that has been brought up by other Members here is the fear that removing organs from the body of the deceased will breach the norms defined by the traditional belief relating to death and the rituals associated with death. I therefore urge the Ministry to work closely with and through the religious leaders to spread the correct message that the act of organ donations is endorsed and approved by the respective religions concerned and to

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eradicate the public's fears and misconceptions on organ donations and transplantations.

Lastly, let me touch on the performance of last religious rites for the deceased before the organs are harvested. May I urge the Minister to deal with these concerns with sensitivity and maybe to allow some form of rituals to be conducted for the deceased. Because at this dire moment before organs are removed, we should allow some religious representatives at hand to conduct the appropriate last rites for the deceased and his family. Because these religious rituals are important for the family to bid farewell to their loved ones and, in the due process, it actually helps the grieving family psychologically, spiritually and emotionally.

Sir, with these four comments, I support the Bill.

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 accordingly suspended

at 3.58 pm until 4.25 pm.

Sitting resumed at 4.25 pm

[Mr Speaker in the Chair]

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HUMAN ORGAN TRANSPLANT (AMENDMENT) BILL: Debate resumed.

Miss Penny Low (Pasir Ris-Punggol): Mr Speaker, Sir, thank you for allowing me to join in this debate.

Organ donation has always been a sensitive issue, and the harvesting of organs, a controversial one, whether you look at it from the medical, social or

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religious angles. However, the crux of HOTA is that of saving lives. The reality is that many patients who have a chance of recovery lost the opportunity to live or live an improved quality of life, because of the shortage of willing organ donors who no longer need them. This Bill will help increase the supply of organs for transplant in Singapore. There is a higher demand than supply for organ transplants all over the world. A similar shortage of organs for transplant in Singapore will result in Singaporeans heading for the less developed countries for organ transplant - countries where the standard of medical practice may be lower, and thus putting themselves at risk. To alleviate the suffering of this section of the Singapore society, we need to increase the availability of a greater variety of organs from a greater number of donors in Singapore.

There has been some debate whether it should be an opt-in or opt-out scheme. I thought it would be good if we take a look at the experience of the Medical (Therapy, Education and Research) Act (MTERA) which embraces the opt-in system. MTERA enables Muslims not covered by HOTA to opt into the scheme to donate their organs. MTERA also enables non-Muslims to opt into the system for organs not covered by HOTA. However, the number of donors under MTERA is not encouraging. I understand from the Organ Transplant Unit, Ministry of Health, that only some 56,000 donors (out of our entire population of about three million) have pledged their organs under MTERA. This is a very low percentage. And there is a waiting list for patients who need organ transplant. So while MTERA remains useful for the categories of people and organs not covered by HOTA, there is a need to expand the scope of HOTA to save more lives.

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The opt-out system benefits everyone within the system. The benefit to a person within the system is that he enjoys priority in the event that he needs an organ donation from another person who has passed away. In other words, the opt-out system benefits the potential donor as well. And the expansion of the system under the present Bill will benefit more potential donors.

While I support the Bill, I do have some concerns with the prescribed tests for "brain death" and the procedure for harvesting organs from the brain dead. The debate in this House and the Ministry of Health's public consultation show that a big section of the public is still concerned about the concept of "brain death". There is a need for greater public awareness of the medical procedure for determining brain death and the procedure for the removal of organs from the brain dead.

I came across some American literature that said: "Often when "brain death" is declared, not all functions of the brain cease." The remaining brain functions may include continued brain wave activity and the brain continues to produce a hormone called arginine vasopressin that keeps the body's fluid and electrolytes in balance. There is also a phenomenon where a brain dead body may still exhibit flexion and muscle stretch reflexes, resulting in movements that resemble grasping.

In a book entitled, "The Nasty Side of Organ Transplant" by Norm Barber, an Australian cardiologist Dr David Wainwright was quoted that when the dissection begins, the brain dead body does not lay dead and still like a corpse. Instead, its heart beat quickens and its "torso jerks" and "arms and legs flail about".

When I looked up the Internet for related reports, amongst others, a British

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anaesthetist, who also appeared in the Guardian newspaper dated 19th August 2000, was quoted as saying that anaesthesia is usually required for organ transplant from a brain dead body because, let me quote, "if you don't give anything at all,

the patient will start moving and wriggling around and it's impossible to do the operation. The surgeon always asked us [meaning the anaesthetist] to paralyse the patient."

The foregoing is an example of literature on the Internet or otherwise, available to our Singapore public. Such literature certainly generates unease amongst the potential donor public. Hence, I advocate that we must have more public discussions and awareness of this literature, (ii) upgrade our laws and procedure, where necessary, and (iii) differentiate our local practice from that in other countries (particularly that of the UK and Australia) wherever possible so as to dispel public unease.

As a first step, perhaps, we can try to understand the current state of affairs in UK and Australia. The UK legislation defines brain death to be the cessation of brain stem functions. This definition is less stringent than that in our own Interpretation Act (section 2A). We should distinguish between our track record and the UK experience.

The US and Australian legislation define "brain dead" to mean cessation of all brain functions. So does our Interpretation Act. However, since the 1980s, a US Presidential Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavorial Research has developed certain standards for the determination of brain death. These standards have been accepted worldwide. But a survey of these standards indicated that they test the physiological response of the body (such as its pupils and respiratory functions) to determine whether there is any sign of brain activity. The question is this: are

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these tests prescribed some 20 years ago still adequate? Does the cessation of these few brain functions mean the cessation of all brain functions?

In Singapore, the prescribed tests for brain death set out in our Interpretation Regulations in 1998 were lifted from our old Rule 3 of HOTA 1987. Both were based on the brain function tests developed in the US, 20 years ago. The pertinent question is: have there been no new advances, medical breakthroughs, or change in medical consensus since then? I understand that Singapore doctors use EEG and other confirmatory tests to determine brain death. I urge the Government to review the prescribed tests for brain death to keep pace with the medical practice in Singapore.

Apart from the prescribed tests for brain death in Singapore, I also urge the Government to review the medical procedure in organ transplant from brain dead bodies. Literature from the US, UK and Australia shows that brain dead bodies are maintained on life support systems up to, and perhaps throughout, the harvesting and organ transplant procedure. This practice keeps their organs in optimum condition for transplants. The brain dead body is not allowed to shut down its bodily functions naturally. Hence, the "torso jerks" and "arms and legs flail about" as described by some doctors in the UK and Australia.

I believe that many sections of the public will find this practice distasteful. Even if a body is brain dead (and I mean cessation of all brain functions, as defined in our Interpretation Act), many sections of the public will still expect that the brain dead body be allowed to "shut down" its bodily functions, so to speak, before the harvesting begins. We treat a motorcar with more respect. Its engine is switched off and there is more than enough time for it to cool down before its parts are

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cannibalised at the scrap yard.

We keep one minute of silence - out of respect in memory of the dead. Perhaps, we can also spare a few minutes of "shut down" time - out of respect for the body of the dead. These few minutes, as my colleague, Dr Ong Seh Hong, has pointed out, is an important ritual not just for the dead, but also for those alive. It is the crucial few minutes which allow the loved ones to grieve, bid farewell and do the necessary rituals to send the dead to another world. Whether it is social, religious or even psychological, any anthropologists and sociologists worth their salt will tell us that it is amongst one of the most important rites of passage in human history, and has great significance to those alive.

The advance of medical science should not be achieved at the expense of our human dignity. Literature in US suggests that there are medical procedures which can help preserve human organs during what is called the "warm ischemia" time. The advance of medical science should help us maintain our human dignity. With the emphasis on the biomedic and life sciences in Singapore, and in our quest to be a regional medical hub, we must be in the lead in such issues in order to be in the league.

All said, HOTA is about saving lives, and I support the Bill. But I urge the Government to review both the prescribed tests for brain death and the medical procedures for organ transplant from brain dead bodies.

The Acting Minister for Health (Mr Khaw Boon Wan): Mr Speaker, Sir, let me first thank the 22 Members who have spoken on this Bill.

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Among the speakers were two veterans in this House who also spoke on HOTA in 1987: Mr Chiam See Tong and Dr Tan Cheng Bock. I checked the Hansard proceedings of that session. Both of them were consistent in their comments and they remain strong supporters of HOTA all these years, as a way to save lives. I am cheered by the strong support given by all the Members for this Bill.

[Mdm Deputy Speaker (Mrs Lim Hwee Hua) in the Chair]

4.38 pm

I have listened carefully to all the speeches. I soaked in all your concerns and reflected on them last night. And this morning, I went through the media reports to make sure that I did not miss out on any point.

Let me now respond to each of these points. It will take a while but I hope you will bear with me. Let me begin with the most talked about issue, which is brain death. Most Members have expressed concern on this, even though it has been legislated 17 years ago. For example, Dr Lily Neo asked if the care for the patients, who are potential organ donors, would be compromised. She asked: would their organs be removed prematurely? Mr Gan Kim Yong asked if a brain dead patient would suddenly wake up from brain death. In similar vein, Mdm Ho Geok Choo asked if brain death, in all instances, constitutes death. She and Mr Chiam mentioned the recent case of Ms Tanya Liu, a popular Taiwanese newscaster, who was apparently saved from "brain death" by Prof. Ling Fung of Beijing. But it was an unfortunate misreporting by the media. I met Prof. Ling in my office here last month when she was here for a public lecture. And of course, we talked about Tanya Liu. She told me how Tanya's sheer determination and strong

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family support, and of course combined with good clinical care, contributed to her recovery. But she was never brain-dead. She was only in coma.

Yesterday, Dr Lily Neo talked about an European case, 18 years in coma, suddenly woke up. I was not aware of that European incident. But that incident probably inspired a popular Hong Kong TV drama which is currently being screened by Channel U, Hun Qian Hun Hou , "The Awakening Story". It is about a woman who was unconscious for 16 years and suddenly woke up. The trouble is that, during the 16 years, the husband had a girlfriend. So you can imagine: big complications. My wife is hooked to this nightly drama, every night at 9.00 pm. As husband and wife should do things together, I too end up following the poor woman's emotional ups and downs. But, again, this fictitious character was in coma. She was not brain dead.

Given all these sensational news reports and popular TV drama, it is not surprising that lay persons should be confused. Some would harbour doubts about what really constitutes death. Mrs Lim Hwee Hua, Mr Iswaran and Mr Gan Kim Yong therefore rightly urged that I give a clear, unambiguous explanation on brain death and, preferably, in simple layman's terms.

"Brain death" means that all functions of the brain have stopped and stopped permanently. So it is not quite like what Miss Penny Low tried to explain just now that there are certain brain activities still happening. The loss of capacity to function is permanent, it is irreversible. There is irreversible loss of the capacity for consciousness. There is irreversible loss of the capacity to breathe. So this invariably leads to the state where all other organs, including the heart, also stop functioning. So Mr Steve Chia said, "You know, brain death, the heart is still beating." No, only because the machine

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keeps it beating. And he asked whether "brain death" is completely dead. Of course. The fellow is completely dead, unfortunately. Yes, it is truly, completely, unambiguously and legally dead.

Hence, unlike coma, brain death cannot be reversed. A comatose patient, like Ms Tanya Liu was months ago, unconscious but she is alive. A brain dead is however dead, and not simply unconscious.

Mdm Ho Geok Choo commented that the definition of "brain death", and I quote her, "is still being debated within the medical profession." Actually, this is not so. The issue has already been settled quite some time ago. So I can assure both Mdm Ho and Mdm Cynthia Phua that, on this point, there is no ambiguity.

Who can determine if a person is brain dead? To certify brain death, the law requires two doctors to do so, but not just any two doctors. They must be experienced with specialist qualifications, like our Minister of State, Dr Balaji, and they must be independent: they must not be involved in the care of the patient, neither must they be involved in the care of the organ recipient.

Mdm Halimah talked about the Greek regime which requires three doctors to certify brain death. But in almost all countries, like Singapore, we stop at two. While three is more reassuring than two, two competent and independent doctors are quite sufficient for this purpose. And in practice, the entire process - if brain death were to lead to a transplant - involves many doctors, as I will explain later.

What constitutes brain death? There are stringent criteria for the certification of brain death. And these tests would clearly differentiate between a person who is brain dead and a person who is in coma. Our doctors adhere strictly to

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these internationally-accepted protocol of seven clinical steps to check

for the slightest indication of life. These clinical tests include checking to see whether there is any response to various physical stimuli such as light, touch and pain.

Dr Lily Neo asked if we follow the British or the US method of certifying brain death, suggesting that there is a difference between the two. Just now when I listened to Miss Penny Low, she also read from the Internet about US and the UK and made some comment that the UK seems to be easier, lower threshold than Singapore, again suggesting that there are differences. I am no expert. So yesterday I asked Dr Balaji. Unfortunately, he is now on the way to India or is in India. He confirmed that, and I quote him here, "Brain death diagnosis in the US, UK and Singapore is medically identical".

In the US, the definition of death is based on state laws. As pointed out by Mdm Cynthia Phua, there are 50 different states; so 50 different ways of defining the same issue. However, there is a model Bill called the Uniform Determination of Death Act (UDDA) which acts as a template for individual state laws. This Act was the result of the President's Commission on Brain Death in 1981, and this was more than 20 years ago.

Whole brain death, as defined by this UDDA, is based on three criteria:

(a) severe coma of known cause;

(b) absent brainstem function (ie, the six brainstem functions are absent): and

(c) sustained apnoea (ie, there is no breathing which is the seventh brainstem reflex).

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These three criteria are medically identical to the British criteria for brain death, based on the absence of brainstem activity, ie, the absence of the seven reflexes in a comatose patient whose diagnosis is known.

So I am a bit puzzled by Miss Penny Low's recital of what she read in the Internet, suggesting that strange things are happening about brain death definition, and so on. Unfortunately, I cannot engage her on the technicality, because I am not a doctor and I never pretend to be one. But I agree with her that so long as there is information out there on the Internet which may be misleading, people in the know have a duty to come up and debunk it. And we certainly should not in this House propagate such misinformation.

In short, the diagnosis of brain death uses strict specialised medical definitions. As I said earlier, not all doctors are authorised to certify brain death. Only qualified specialists are authorised to do so. In Singapore, they have been doing so since HOTA was first enacted 17 years ago. The current Bill does not change the way brain death certification will be carried out.

However, there are situations where the seven clinical criteria cannot be fully performed. For example, one of the tests is on the eyes to see whether there is response. When the eyes are severely damaged, we cannot perform that test. The doctors would not be able to test the response if the organs have been injured or if the patient has been sedated and the medications that depress the brain functions are still circulating in the blood. Then, some of the clinical tests could not be performed.

Each year, we encounter two or three - not many, it is a handful - such cases where organs are damaged, etc. In such

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situations, ancillary tests - like angiography - can be used to measure cerebral blood flow so that brain death can be certified. These ancillary tests are already used in many developed countries, eg, in the US. At present, however, our doctors in Singapore are not able to certify these two or three cases who are actually brain dead because our law does not specify such ancillary tests for cerebral blood flow.

My Ministry has, therefore, consulted the National Committee on Neuroscience and is working with the Ministry of Law to amend the Interpretation (Determination and Certification of Death) Regulations to include the tests for cerebral blood flow as ancillary tests to certify brain death in situations like this, where the seven clinical tests cannot all be performed. Let me stress that ancillary tests are to complement the clinical tests. They are not substitutes for the clinical criteria. If six of the seven clinical tests can be performed, then we must make sure we get 6 upon 6. The criteria for these six tests must be fully met before the doctor proceeds to carry out the ancillary tests in lieu of the seventh criterion.

The bottom line is this: no doctor will think about organ removal when there is still hope for life. The sole responsibility of doctors is to save the lives of their patients. The Bill does not change this basic responsibility in any way.

Yesterday, Dr Tan Cheng Bock - unfortunately he is not here - recalled the good old days when the medical practice was a noble profession. I am not a doctor but my career started in the Ministry of Health during that romantic era. Dr Tan lamented the slow erosion of the professional values as businessmen and administrators - he probably meant me - marched in and converted a noble profession into an industry.

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I have heard of such caricature of the medical service. I do not fully agree with this description, although I understand the basis for some of this criticism. This is not the occasion to debate this topic. But I think Dr Tan knows that I am determined to help like-minded doctors like him, with sound professional values, ensure that medical practice return to the basics, and that is, to cure and relieve suffering and certainly not to bring harm. Money is a necessary evil but if a doctor is completely motivated by money and nothing else, then I think he or she has joined the wrong profession.

I do not believe that we have in our midst doctors who would be prepared to remove organs prematurely and declare brain death when one is not indicated, so as to benefit from the few dollars of surgical fees that he could get from the donor recipient. In any case, as I would explain later, we have many safeguards to prevent such a rogue doctor from completing his transaction. This is Singapore; this is not some third world country that Dr Tan described yesterday.

Mdm Ho talked about phentolamine and heparin and asked if we use these drugs on patients who are brain dead so as to keep their organs alive. I do not know one from the other. But the doctors in the Ministry of Health assured me that they do not do so.

So the Bill does not change the concept of brain death. What is new is that it will now extend HOTA to all deaths beyond accidental deaths. As I explained earlier, it was an artificial differentiation between accidental and non-accidental deaths, not seen in other countries with HOTA-like legislation. We should now remove the artificial differentiation so as to save a few more lives. But the inclusion of non-accidental deaths will not compromise the care of patients.

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That is why we have three separate groups of doctors involved in any HOTA transplant. The first group of doctors looks after the organ recipient; the second group looks after the organ donor; and the third group is responsible for certifying brain death in the donor. Three totally different, separate, independent groups. There is, therefore, check and balance to ensure the highest ethical standard is preserved. In this way, we ensure strict compliance with the requirement that patients' interests will not be compromised in any way.

Let me now respond to the various comments on the choice of organs for HOTA.

Most Members support extending HOTA to include liver, heart and cornea. As Mrs Lim Hwee Hua puts it, the reasons are compelling. There were some Members who want us to do more, like Dr Ong Seh Hong. But a few expressed some reservations, like Dr Lily Neo, about extension to cornea and heart. Dr Ong Seh Hong and, I think, Mdm Cynthia Phua have mentioned the possible extension to things like the lungs, skin and pancreas.

For the moment, the need for skin is less urgent than for kidney, liver, heart or cornea. The skin bank has 10,000 square centimetres of skin in reserve. We actually need 40,000 square centimentres to be prepared for a national emergency. So we are not quite there yet. But we do have a bit more time to build up this reserve. For lung transplantation, it is still not fully established in Singapore. Our first case was only done in the year 2000. That is why I am reluctant to include skin or lung under HOTA. Similarly, there are many organ transplant procedures which are not yet well established. These include pancreas and intestines. Recently, Members may have read or heard of face transplantation,

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where the ethical issues are even more complex.

Such new developments offer hope to those with organ failure. However, like all new procedures, there are technical difficulties and considerable risks involved. I prefer to take a cautious approach. In any case, we should be sure of public support before we extend HOTA to any new organ. We have not raised these new organs - skin, lung - during the public consultation, and it is not my style to spring surprises on Singaporeans.

It is, therefore, better to keep these outside of HOTA for the moment. But there is nothing to stop us from pursuing these organs under the Medical (Therapy, Education and Research) Act.

In this respect, I share Dr Warren Lee's observation that attitudes towards organ donations are slowly changing. It is certainly easier now than years ago when we approached the relatives of brain dead patients to consider donating their organs of their loved ones.

My Ministry will keep a close watch on all these new modalities. I will come back to this House to update the First Schedule of the Act when it is appropriate to do so, so that we keep in line with medical advances.

Yesterday, Dr Neo expressed reservations of some Singaporeans on the extension of HOTA to include cornea. While they support the extension to liver and heart, they have some problem with cornea as this is not life-saving. Moreover, foreign corneas are available. I accept that cornea transplantation is not life-saving. But the improvement to the quality of life for someone who would otherwise go blind is tremendous. Mr Zainudin yesterday gave us a fairly good account of the misery of the blind.

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Last month, I read a local survey on what Singaporeans with serious myopia will do just to get back 20/20 vision. Many said that they were prepared to shorten their lifespan by 10% for that. I was surprised by this survey finding. But I think this gives us a sense of the value of a cornea transplant, even though it is not life-saving.

Members would know of Dr Lim Suet Wun, CEO of Tan Tock Seng Hospital. Dr Lim was one of our anti-SARS heroes. He led the team in Tan Tock Seng Hospital which played a critical role in our fight against SARS. So Dr Lim is known to most Singaporeans. But many will not know that Dr Lim was the beneficiary of cornea transplants many years ago, when I was still a colleague of his in the hospital. Without the transplants, Dr Lim would effectively be blind. His subsequent career and contribution to Singaporeans would have been quite different.

I know that there are some Singaporeans who still hesitate to pledge their corneas because of perceived religious concerns. But the religious leaders have all clarified that there are no religious obstacles to cornea donation. Part of the misunderstanding is that some people think cornea transplantation means removing the entire eye. It was so in the past, long long ago, but this is no longer the practice. Cornea is a thin layer of tissue on the surface of the eye. So it is not as if the cadavers will be disfigured.

Dr Amy Khor and Mdm Halimah stressed the need for us to respect the dead, certainly not to mutilate or disfigure the bodies. This is something that we who work in hospitals are extremely sensitive to.

Dr Neo also asked why we are including the heart under HOTA. As not many heart transplants are done here, why is there a need to include it? Every

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life is worth saving.

There is a Chinese saying, " jiu ren yi ming, sheng zao qi ji fo tu ", that is, better to save one life than to build a seven-storey temple pagoda.

Statistically, a few lives saved a year may not be impressive. But, as pointed out by Mr Gan Kim Yong yesterday, to the individual saved, it means a difference between life and death, and to their loved ones, it means a difference between bliss and misery. So I think the criteria for inclusion should be whether the operation is now an established treatment modality, and whether there is good public support for such a move. In fact, when we began our public consultation, the heart was not included. But the public consultation led us to believe that it is timely to include the heart under HOTA. This also seems to be the conclusion of Mdm Deputy Speaker who mentioned yesterday about a dialogue between the PAP's Women Wing and the professional women.

Let me now touch on the subject of living donor organ transplant. An entire new section will now be added to the main Act. As this is something new, it is right for us to spend some time on this and to make sure that we do it right. However, living donor organ transplant is not new to Singapore. Many Members have talked about the liver transplant on Ms Andrea De Cruz. This took place before the Bill. As I have said earlier, we now do more living donor transplants than cadaveric donor transplants for kidneys and livers. And the trend continues in this direction. The trend of more living donor organ transplantation is definitive. Mdm Halimah talked about Norway's experience with it. Dr Baliji told me sometime ago that in Norway, living donor kidney transplant is the norm. Chronic kidney dialysis is the exception. There, doctors push for live donor organ transplants because they believe that the quality of life for a person on dialysis is poor. As a result, it is normal in Norway

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for a family member to donate a kidney and hospitals actively promote this practice. Norway is ahead of the curve on this matter. For us, I think the first step is to begin to regulate living donor organ transplantation.

Here, we have two key objectives. First, make sure that organ donation for money remains illegal. The Bill should not become a loophole for organ trading, as warned by Dr Amy Khor. Second, ensure that we protect our people against donating under duress. These are key abuses that Dr Neo stressed that we should guard against. To safeguard these, we need a total system approach with multiple checks and balances. An important player is the Transplant Ethics Committee. Without the committee's authorisation, no transplant can be allowed to proceed. The committee members have the responsibility of ensuring that each transplant is carried out in an ethical manner. It is a heavy responsibility as pointed out by many Members. They have to balance the interest of the donor and the interest of the recipient.

Mr Iswaran and Dr Tan Cheng Bock argued eloquently on the need for a centralised approach to this, with one national ethics committee, with Ministry of Health's participation, for the entire Singapore. In this way, we better ensure consistency of approach. On the other hand, there were Members, like Dr Amy Khor, who saw the value of a decentralised approach empowering the hospital-based Transplant Ethics Committee to take such decisions.

Actually, our proposed approach is a hybrid, ie, combining the benefits of a centralised and decentralised approach. At the national level, we have the National Medical Ethics Committee currently chaired by Dr Khoo Chong Yew.

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It was previously chaired by Professor Y Y Ong. The National Medical Ethics Committee will discuss and forge consensus on policy matters. This group of wise persons will debate and assess what is the society's norm. This will be the platform where guidelines will be formulated for consistent application amongst the hospitals. Then at the transplant hospital, we will have the hospital's Transplant Ethics Committee which will decide on individual cases of transplants pertaining to their hospital. At the individual level, a decentralised approach is appropriate.

First, the final responsibility for the care and well-being of both the donor and the recipient rests with the transplant team and the hospital. The hospital-based ethics committee will be better placed to make the detailed assessment and arrive at a correct decision. Secondly, in some instances, urgent decisions have to be made. In such situations, the hospital's ethics committee will be able to review the case and respond immediately.

Both the national and hospital ethics committee will comprise members who are wise and who are experienced with sound judgement. Given the heavy responsibility of these committees, my Ministry will ensure that only respectable persons are appointed. That is why the composition of the ethics committees has to be approved by my Ministry. We all know that ethical decisions cannot be fully codified and converted into formula or computer programmes. In fact, there will be situations where two wise persons may not agree on the same case. We should not be surprised by such outcome. My plan, therefore, is to arrange for occasional discussions amongst the various ethics committees on the cases that they have encountered. As Mr Iswaran pointed out, in this way, over time, a body of cases will be built up which will help forge the society norms towards such issues.

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Mr Ang Mong Seng asked just now how a layman, on such an ethics committee, will be able to play a role on such a medical and technical subject. But this is not a completely medical subject. When Mr Pierre Png volunteered to donate part of his liver to Ms Andrea De Cruz, the issue went beyond mere medical issues. In fact, the medical aspects were relatively straightforward. Was Pierre fit for the operation? Was he fully briefed on the impact on his health, both during surgery as well as post-surgery? But beyond these medical issues were many non-medical issues. Why did he volunteer? What was his relationship to Ms Andrea De Cruz? Were there any family or societal pressures? Laymen therefore play a crucial role in the ethics committee, and that is why we make it a requirement. There must be at least one layman. The strength of the lay person would be in considering social, ethical and non-medical issues. He or she will try to represent societal views on transplant issues.

Mdm Cynthia Phua suggested that the term of membership in the ethics committee be time-limited to avoid members becoming too familiar with the hospitals. I suppose this is akin to company auditors where we do require or encourage rotation of auditors to ensure independence. I agree with the spirit of the suggestion and we will take that into account when considering the proposed composition of the committee. But I will rather not hard-wire this into the law. The criteria should really be independence and competence. If a person is proven to be balanced and independent despite being long on the committee, I will prefer to extend this membership, instead of forcing him or her into early retirement.

Besides the structure of the committee, the Bill will also allow my Ministry to set the rules and procedures for the hospital's Transplant Ethics Committee. This is also a point stressed

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by Dr Chong Weng Chiew. In particular, we will spell out the functions, responsibilities and procedures. My sense from both the public consultation and the many speeches I have heard in this House is that Singaporeans will prefer that we take a conservative approach to live donor organ transplantation. Where donor and recipient are truly related, the concern is to guard against emotional duress. Where donor and recipient are not related, the concern is to guard against organ trading.

Dr Tan Cheng Bock rightly reminded us of the large number of foreign workers here who will be especially vulnerable and potentially a source of exploitation. When a foreign worker, whom a patient never knew, suddenly pops up, claiming to be a distant relative, the antenna of the committee members must immediately pop up too. Ethics committee decisions are by consensus and this gives veto power to every single member. That is why Dr Amy Khor and Mr Iswaran's suggestion to limit the size of the ethics committee, I think, is not necessary. In fact, a large committee will make consensus making very difficult.

I worry less about hospitals pressurising the ethics committee to allow transplants than about the pressure from the media. In any high profile case, public sympathy may often go to the patient, with less regard for the interest of the live donor, especially if he or she is a foreigner. This is a scenario which I think is likely to happen. Whatever it is, we absolutely need men and women of strong character and conviction to be in the ethics committee.

Let me now talk about the act of organ trading. We have a consensus here that it is wrong and we should continue to prohibit it. Later on, I will talk about some discussions in the West which seem to want to push the boundary on this. But for the moment, we are all clear about

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banning organ trading. The issue is how to ensure that it does not take place in Singapore. In this regard, Mr Chiam, Mdm Halimah and Mr Ang Mong Seng felt that our proposed penalty of $10,000 for such a crime does not seem right. I think Mr Ang Mong Seng suggested $100,000 or $200,000. Dr Tan Cheng Bock is worried that it might induce people to join in the trade, given the light punishment. I appreciate the sentiments.

I have not revised the quantum of the penalty because during the public consultation, it was not an issue. Nobody raised this particular point. But more importantly is that the main instrument to guard against organ trading is the overall framework that I talked about earlier. Penalty is just one element in this overall framework. In particular, the role played by doctors and the ethics committee. I agree with Mdm Halimah that organ trading and organ trafficking involve a long chain of players. Between the poor donor and the rich recipient - many hands are involved. But for a transaction to take place in Singapore, many people, including doctors, have to be involved. Organ removal and organ grafting cannot be learned from the Internet. A rogue doctor has to have the cooperation of the hospital management, the hospital ethics committee and, in some way, the Ministry of Health, and many other doctors involved in the care of the donor.

For these doctors, the penalty under HOTA, whether it is $10,000, $100,000 or even $1 million, is not a factor. Their career, reputation, oaths, ethics and responsibility to the Singapore Medical Council are the key factors. I therefore believe that there are sufficient safeguards in our overall system. That is why we have not revised the penalty quantum. Nevertheless, we will keep the feedback in mind and maintain a watchful eye.

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Mdm Ho suggested that we adopt the German practice of enacting an extra-territorial clause which makes it illegal for a German to buy organs anywhere in the world. The problem there is enforcement and gathering of evidence. But it is something new in Germany and we will watch over this German experience to see whether we should similarly follow suit.

Dr Neo asked how the Bill will affect foreign patients seeking transplants in Singapore. Some Members also asked if we will end up a transplantation hub. Mdm Ho called it - a morbid term - "transplant tourism". This is certainly not the objective of this Bill or my Ministry. Our priority is to regulate living donor organ transplantation so as to prevent organ trading. It is to ensure that there is transparency for all parties involved - the donor, the recipient, the doctors performing the transplant. It is to ensure that there is objectivity and due process in decision-making. The Bill will allow us to set up a regulated regime for living donor organ transplants where locals and foreigners coming to Singapore can be assured of high medical standards operating within clear ethical boundaries. We must not become a hub or a player in organ trading, whether consciously or inadvertently.

Dr Chong Weng Chiew suggested that a database of all living donors be set up so that their post-transplant health can be checked. I agree. The Ministry currently maintains such a database. We will work with the transplant physicians and surgeons to monitor the longer term medical and psychological outcomes of the donors.

Let me now discuss the many helpful comments made by the Malay MPs. First of all, I thank all of them for their courage and support of the Bill.

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Mdm Deputy Speaker: Order. Mr Wong wants to move an exempted business motion.

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