Organ trade tenesmus in Malaysia

Malaysia is for living unrelated donors....., or not?

First it was reported that Minister of Health for Malaysia Datuk Seri Liow Tiong Lai said his Ministry was looking at improving the National Transplantation Act which was being drafted to serve as a guideline on unrelated live organ donations.

He said the new law would enable the authorities to monitor live organ donors which at present were encouraged for only family members and relatives of patients.

"We have to be careful because commercialisation of organs is a big problem. The selling and buying of organs is against human principles and not ethical," he said, adding that if non-relatives want to make live organ donations, it should be out of sincerity and not for monetary gains.

Sure sounded very much like Singapore's position a year or two ago.

Then almost in response, the Health Director General Tan Sri Dr Ismail Merican in the 4th November New Straits Times, was reported as saying, "Malaysia is against living unrelated donors donating organs because of the risk of organ trading and trafficking...... If living donation is to be carried out, it should come from genetically, legally or emotionally related donors."

Hmmmm..... a bit of tenesmus there.

Singapore, by the way passed a law allowing compensation of organ donors, effectively allowing living unrelated donors to receive compensation for donating their organs. Not sure if it is just engaging in semantics to suggest that this is essentially organ trading.

What is needed now after more than 18 months of this law, is for MOH to update us with respect to how many such unrelated living donations have been effected, and the details of such donations. One of the major concerns had been the exploitation of poor donors from neighbouring countries, and servicing of wealthy recipients who are no citizens. It would be really nice and reassuring if the MOH to tell us what the numbers are, and how we are actually monitoring/regulating the situation.

Human Organ Trade - Malaysia's position

I reproduce a report (likely won't be reported in the old ST) from the NST (New Straits Times) on a speech given by Director-General of Health Tan Sri Dr Ismail Merican on the occasion of World Health Organisation regional meeting on Guiding Principles on Human Organ Transplantation.

I don't usually have a high regard for Malaysia's politicians and bureaucrats, but here, I must take my hat off to Dr Ismail Merican for making a clear stand about this.

Malaysia opposes organ trafficking, transplant tourism & commercialism
By : Annie Freeda Cruez

Director-General of Health Tan Sri Dr Ismail Merican said yesterday: “We are against organ trafficking, transplant tourism and transplant commercialism.”

He fears that what is happening in some other countries, where human trafficking to source for organs, may occur here. He does not want the vulnerable and poor to be made to sell their organs.

He warned that commercialisation of organ, tissue and cell transplantation, and any act that might indirectly promote or lead to commercial transactions of organs, was prohibited.

“Although it has not been reported in Malaysia, we are aware that it is happening in this region. We are against it,” he told reporters at the inaugural three-day World Health Organisation regional meeting on Guiding Principles on Human Organ Transplantation at a hotel here jointly organised by the WHO and the Malaysian Society of Transplantation. It is supported by the Health Ministry.
Dr Ismail said the trade in organs was due to a persistent shortage.

The ministry, he said, was against inducing vulnerable individuals or groups such as illiterate and impoverished people, illegal immigrants, prisoners and political or economic refugees being made living donors.

“We know that countries are struggling to attain self-sufficiency in the availability of organs for transplantation. It is in this unfortunate situation that unethical market practices such as transplant tourism and human trafficking are rearing their ugly heads,” he said.

There was a need to “decapitate these ugly heads” and restore order and accountability to the practice of organ transplant and that was the reason why WHO had prepared the revised guiding principles on human organ transplantation, he said.

Worldwide, he said, there were attempts to regulate the unbridled commercialisation with various strategies, proposals and mechanisms to “introduce morals into the market”.

However, the ingenuity of regulated “organ entrepreneurs” knew no bounds, said Dr Ismail.

Separation of conjoint twins - where are our medical ethicists when you need them?

Minister of Health Khaw Boon Wan has taken an important public position (today's ST) on the past attempts and present intent to separate conjoint twins.

"THREE of the four twins joined at the head who were separated in operations here are dead, and the fourth is not in good shape.

Given this track record and the similarly dismal results overseas, Health Minister Khaw Boon Wan on Sunday suggested that doctors reconsider plans to separate yet another pair of such conjoined twins.
Indian twins Vani and Veena, five, will go under the knife at East Shore Hospital in August if the medical team involved decides to proceed with the operation.

Neurosurgeon Keith Goh, who was involved in the marathon operations here to separate the two earlier sets of twins joined at the head, has been asked by the state government of Andhra Pradesh in India to carry out the surgery.
Speaking to reporters on Sunday at a grassroots event, Mr Khaw said that doctors would likely end up harming the patients and should not attempt such operations.

He said: 'Surgeons, in some instances, have to pick one twin to die to save the other. Even those who survive would often be left with brain damage. So, to what extent is this quality of life?'

The previous surgical attempts have left many doctors and ethicists dumfounded. To many, they were mainly attempts to do heroic operations for no other reason than self glorification. The only people who would truly benefit from the operations were the surgical teams and the institutions involved.

So Mininister Khaw should be congratulated for speaking out against it.

But where were our local medical ethicists when you needed them? And where was the Singapore Medical Council? Why didn't they have an opinion about the surgery?

What worries me also is the fact that the past surgery had been vetted and approved by the hospital ethics committee. One could question how objective and independent they were in coming to their decision. Or were they functioning more as advocates for the surgical team?

The workings of institutional ethics committees need to be seriously audited so that the public can be confident that they will independently act in the public's interest and not just pay lip service to ethical standards, while glancing at the hospital's bottom line. These processes will have to come under greater scrutiny if we are to go down the organ trading road. So much will hinge upon our ability to do things ethically.

Human Organ Trade - a nuanced approach

A colleague once referred to Minister Khaw as the 'teflon man', referring to is ability to extricate himself from all kinds of sticky situations. I personally think that was being very unfair. I think Minister Khaw has perhaps been better than other ministers in navigating out of difficult situations mainly because of his innate abilities to be more adaptable and nuanced when dealing with difficult situations.

There is no doubt the organ trade issues are very difficult to resolve. There will be no solution that will make everyone happy. Often in this kind of situation, the 'wise' approach may be just to sit on one's hands and do nothing. But having made a commitment to move forward on this, some reasonable solution now needs to be found. Personally I am prepared to give Minister the time and space to resolve this in the most appropriate way possible.

It is however critically important that we remain vigilant and mindful of the dangers ahead. For one thing, the gap between ethical and non-ethical has become a lot more narrow than it has ever been before, and it has clearly become so much easier to drift over the line (whatever this may be). Rimbursements to payments. Residents to foreigners. This is the intrinsic danger of being on the slippery slope.

Fundamental to all of this is the strength of our ethics environment. Minister Khaw is right to point to the strength of our ethics environment. But he may perhaps have overstated the case. Our ethics environment is good but maybe not as strong as he thinks. I will post more on this issue when I have a bit more time to collect my thoughts, but I think we still have a long way to go to lay claim to having an ethics environment that is robust enough to deal with complex situations like this.

Human Organ Trade - agree or disagree?

So we are back to the Human Organ Trade debate with 2 reports in today's Straits Times. One about the Canadian-based Transplantation Society's views, and the other a reprint from the Wall Street Journal. At first glance one would be forgiven for thinking the two articles were rah-rah supporting the organ trade. certainly the headlines give that impression. One reads 'Next Step: Reward Organ Donors', and the other, 'Global Transplant Group Backs Move'.

Hmmm.... Slightly misleading, I think.

Upon closer reading the two articles are clearly disagreeing with respect to the crucial points of reimbursements and payments. The Transplantation Society makes clear their position is appropriate re-imbursements for verifiable expenses. This is totally acceptable to me. In fact, their estimated sum reimbursed in UK and Australia are relatively conservative - ~S$11,000 and S$1000 respectively. Compare this with what had been earlier floated as a balloon in Singapore - S$50,000 - $100,000. A different universe altogether.

Compare this to the other article, which essentially heartily supports going all out to get the organs. Go on, pay for the organ. Find ways to incentivize the donors. Pay the donors! Tellingly the article quotes Minister Khaw as using the phrases 'appropriate incentives' and 'reasonable payments' .

So I leave it to you to figure if the articles agree with each other, and are both similarly supportive of the organ trade.

Ultimately, Singapore, you have to decide what you want.

Human Organ Trade - Rationalizing the problem

The starting point is the easiest part. Noble intentions.

We all have sympathy for and want to find ways to help the patient with end stage renal failure, whose life can be extended (not somehow made immortal, by the way) by a timely renal transplant. The problem is there is a shortage of donors. The solution would seem pretty straightforward - encourage more living donors to come forward by making sure they don't suffer financial or personal losses by being a donor. QED.

The question is how do we reimburse the donor? The fact is no matter what scheme we come up with, it will always carry some element of exploitation. Invariably, it will be the poor and desperate who will sell their organs. Quite frankly, who else will do it? Apart from the obvious ethical difficulties here, this is a particular problem for us as Singapore is likely to be a wealthy net importer, in a socio-political hinterland of poor desperate donors. Accepting that we can never ever free ourselves from the reality of the burden of somehow being exploitative, if we go ahead with it, the question is how to do this in the least exploitative way, i.e., let's face the reality that we are being exploitative, but let's do it in a way that is as fair and reasonable as we can be. We will pay the social and ethical costs of being exploiters for the sake of our patients who are dying of renal failure, but let's try and be as fair as we can be.

Can this be done? Perhaps, ... with a complex regulatory system in place, and with difficult mathematics of computing payouts (or the more palatable term, 'reimbursements'). Can it be regulated? Clearly only with great difficulty. The Ministry of Health has been vary vague about all this, and the lack of clarity clearly troubles many people. The Ministry of Health's position essentially is ... "Trust us...."....

OK , lor.

What worries many is that once legalized, the Ministry of Health will no matter what it says now, quickly forego it's role as a regulator, and default this responsibility to local hospital review boards with different bottom lines. The payouts will be simplified to a lump sum cash payment ($50-100,000? or more?), with the possibility of variable ang pow sweeteners from grateful recipients. What about the problem of exploitation? By this time, who in pragmatic Singapore cares?

How about the recipients? We started this thinking with the noble intention to help our local Singaporean kidney failures. But by not restricting the recipients to Singaporeans, the Ministry of Health is suggesting that its real purpose, is to develop Singapore into a transplantation hub. A centre of excellence for human organ trade even. We can pay the social and ethical cost of being an organ importer and an exploiter of the poor for the sake of our renal failures, but by opening the system up to foreign recipients, the dynamics of this process will become completely changed.

The organ to the highest bidder. It will become unabashedly, a free trade in organs. How else can it be? Almost predictably, if the system works, the actual number of Singaporeans benefitting from this trade will eventually only constitute a small percentage of the overall human organ entrepot trade.

This will be the logical outcome. Good for Singapore? Yeah...but only from a commercial sense. Someone joked recently that we now at least have a dollar value for our bodily parts....

But what value, our souls?

Human Organ Trade - The ethics of 'inducements'

Since so much in the debate revolve around the problem of inducements, I wondered if we are all on the same page with respect to what 'inducements' really are.

The problem of inducement is fundamental in the consideration of its ability to compromise the 'volunteer''s (be this donating organs, tissues or participating in clinical research) independence to make an autonomous, free will decision. This is a very clear inviolable ethical position that has been internationally accepted. See Belmont Report.

The difficulty lies in the interpretation what constitutes an 'inducement'.

Our Bioethics Advisory Committee (BAC), while proudly trumpeting its Consultation Paper on egg donation, curiously surfacing just before the Organ Transplant discussion began, waffles a bit about the issue of inducements.

It says:

Para 48
"In Singapore, the general ethical framework relating to the donation of tissue (which includes eggs) for research was established by the BAC in 2002. Such donation should be outright gifts and there should be no financial incentives, although reasonable reimbursement of expenses incurred should be allowed.

This ethical requirement in relation to the donation of gametes and embryos was taken up in legislation. Under Section 13 of the Human Cloning and Other Prohibited Practices Act (Cap 131B, 2005 Rev Ed), a person is prohibited from giving or receiving valuable consideration for the supply of human eggs, or to otherwise make an offer to that effect. Valuable consideration has been defined as including “any inducement, discount or priority in the provision of a service to the person, but does not include the payment of reasonable expenses incurred by the person in connection with the supply.” Reasonable expenses include expenses relating to the collection, storage or transport of the eggs. However, the possibility of compensation for time, risk and inconvenience has not been addressed. Based on the general ethical principle of fairness, it appears that there could be circumstances where allowing reasonable compensation for time, risk and inconvenience is consistent with the existing ethical framework."

After all that, the paper concludes:

"Compensation for contributing eggs for research in an amount and manner that is fair and without inducement is likely to require the attention of ethicists, policy makers and regulators in the foreseeable future."

Yes....we all know it requires the attention of ethicists, policy makers and regulators....in the foreseeable future. And all this time I thought the ethicists were in the BAC.

The shadowy National Medical Ethics Committee, an organ of the Ministry of Health (you still can't find any information about the NMEC in MOH website!), while happily supporting the BAC, hasn't published its own comments about the problem of inducements. To find out what they think I had to korek out this information from their 2007 recommendations on Phase 1 (normal volunteers) clinical trials.

In that paper they say:

Executive Summary

"Payments for participation in Phase I trials should be commensurate with the burden of participation. However, excessive remuneration or other forms of benefit are improper if they are such as to persuade people to volunteer against their better judgment."

Yet in their recommendations they say:

"The remuneration and other benefits offered should not be such as to induce people to volunteer against their initial judgment."

I am not a person of words, and not a 'semantologist', but it seems like there is a difference between initial judgement and better judgement.

This is what I think I can understand from what our local ethics groups have been saying. I am not sure I am very clear. I guess, maybe I am a bit dense. But I will leave readers to draw their own conclusion if the ethics people are themselves are very clear about the issue. And if they are prepared to deal with the issues now that the Act has been passed. Or just look the other way?

Dr.Huang Shoou Chyuan's letter to the Straits Times

I have deep reservations about the latest legislation which allows for payment for living kidney donors.

Although Health Minister Khaw Boon Wan had categorically assured parliament that the new law did not seek to legalise organ trading, many including myself remain unconvinced.

If we truly only wanted to reimburse donors for their altruistic acts, and not let this become a backdoor for organ trading, the following safeguards should have been present:

1. Foreigners should have been excluded
Only local donors should be allowed onto this scheme as we can then monitor them within our system and either reimburse them for healthcare expenses related to the organ donation through direct payment or through lifelong medical insurance coverage. Compensation for loss of earnings and other more difficult computations can also be decided by a neutral committee.

To allow foreigners into the scheme opens a Pandora’s box as it is impossible to know what a foreign donor does with the money back home. He could literally put the whole lump sum down on some gamble and have nothing left when he needs it most.

To include foreigners is also a tacit admission that transplant medicine is big business that Singapore cannot afford to ignore.

2. Compensation details should be available before parliament vote

The details about mechanisms for quantifying fair compensation should be present before MP’s were asked to vote on what must have been a tough moral choice. These details must surely be the difference between the money being “compensation” rather than “profit” for the donor.

To be asked to vote for something which lacked any specifics at all might cause our parliament to be misconstrued as a “rubber-stamp” as many may consider voting for this legislation in such a way to be irresponsible and akin to writing a “blank cheque”.

I fear that Singapore’s reputation as a medical hub with a “high ethical standard” has been seriously eroded by the passing of this legislation.



Dr.Huang Shoou Chyuan

Human Organ Trade- Inconsistencies

Today's letter to Forum by Ms Boey Shee Lai, pointed to the ethical inconsistencies between Minister Khaw's approach to reimbursement and Professor Lee Wei Ling's approach to pay the poor out of their poverty. She is right. Such inconsistencies run through a large part of the discussions on this issue. The definitive distinction between reimbursement for expenses incurred and compensation/payments is extremely difficult to make in people's minds and impossible to legislate. Yet Minister Khaw seems to think it can be done. I hope he is right.

Minister also seems to think that our ethical reputation is so strong that somehow that will protect us. I am not so sure. I think perhaps he confuses lawfulness with ethics. I think we are widely regarded as being a very law abiding people. Ethical? hmmm...I am not so sure ( see 'Are we an ethical society?'). I get the feeling that our brand of ethics is a somewhat ends-justify-the-means type.

Are we able to enforce the laws against 'trading'. I seriously doubt it. The will is not there. Neither the tools. Take the recent Tang Wee Sung case. I got nothing against Mr Tang and I am happy for him that he got his kidney. But the truth is that there is a considerable amount of disquiet about how he obtained his kidney. Almost everyone I talk to felt there had been some off-the-table payment to the donor family. This cannot be proven and I am not saying this is true. But many people view it that way. The point is, if there is some truth in it, can the police act? Do they want to investigate? Did they investigate? Did the MOH investigate? Did they want to? If they did not want to, cannot investigate before the Act was passed, what assurances do we have that they will do a better job now that it has been legalized?

I am keeping all my toes and fingers crossed that Minister Khaw can do what he has promised to do, and that eventually he will do the right thing. The ball now is entirely in his court, and I hope he will keep his eye on that ball.

Human Organs - The new entrepot trade?

Singapore made it's reputation in the past upon being an entrepot trader. Buy from the region... sell to the world.

Now that we have legislated (and there was never really any doubt the Act would be passed) it is really all up to the Ministry of Health to determine how this whole thing about organ trade will develop. Yep, organ trade. Because no matter how you choose to define it, when you provide money in exchange for goods, that's trade.

I am not against appropriate compensation for organ donors. This would be fair and just. But it was never discussed if there was some other way to ensure fairness to donors. Was a 'purchase' the only way to do this? The Minister has opened a can of worms. The challenge is how to prevent it from degenerating into a free trade. By opening the system to foreign donors and foreign recipients, no matter how we want to camouflage the process, this will become an entrepot trade.

Sadly, once we go through this door, there is really no way to backtrack. I wish we had spent more time discussing this. As a society I think we will regret rushing into this.

Human Organ Trade in Singapore - at last, some discussions?

The issue has come up for discussions in Parliament. It's clear now the timing of Dr Lee Wei Ling's bemused rants. But I seriously hope that this will lead to some serious discussions about a critically important issue. The last wayang by Ministry of Health was such a rushed job, you seriously had to question what they were doing it for?

What I would like to see, and hope our Parliamentarians will raise are:

a] In depth presentation of pros and cons. Let's just not talk about the number of kidney failures and how many people will benefit. Let's have a really hard look at the ethical issues and the downsides and social impact to having a flourishing organ trade in Singapore.

b] A more honest discussions by our ethicists about the issues about to be breached by having an organ trade. Please don't hide behind august committees and issue bland politically correct, consensus documents. Let's discuss the issues openly. I must say I have been sorely disappointed by our ethicists who privately express reservations but who strive so hard to be politically correct.

c] Let the issue be clearly separated from issues of commercialized medicine. Why can't the Ministry of Health make it plain that this is not about establishing ourselves as a medical hub par excellence? If we have to do it, why open it to foreign recipients... unless we want to make their money? Society pays an ethical price in order to provide a service for our own citizens. Let's do it properly for our own citizenry, and let this not be a business/trade.

d] Let's have a clear plan on how we are actually going to implement a reimbursement/support scheme for donors. Call it whatever you want. The rose will smell the same whatever sweet name you want to call it. This is critical to the acceptability of the programme. It is not adequate to say let's approve first...and work out details later. This is just not acceptable.

The ends never justify the means. If we want to mature into a responsible civilized society, we need to give serious consideration to the hows and whys of what we are doing, and not capitulate to expedience.

Dr Lee Wei Ling's bemused ranting about living kidney donors

Dr Lee Wei Ling is back in the news with a letter to the Forum page essentially attacking doctors who are uncomfortable with the organ trade. She accused wary doctors of being afraid of being labelled professional pariahs in the international community. "....groan"

Not a very fair attack I must say. Somewhat childish, I might add. I mean, to resort to name calling just to make your point. Tsk Tsk, she should know better.

The resistance to the organ trade isn't about providing reimbursements. It is about designing and implementing a system whereby there can be appropriate and just compensations without allowing the system to degenerate into a crass free for all, cash for organ trade where the rich sick can exploit the poor and defenseless. Because that would be a system where wealth justifies any manner of abuse.

Think again, Dr Lee.

Prof Kesavan's letter on Organ Trade:

Well said. Well done Prof Kesavan!! Thanks for bring this back online. We should not allow this organ trade nonsense to just willy nilly drift into becoming a fait acompli. I was worried you guys didn't care.



Concerns over proposal to reimburse organ donors (ST 19/3)

THE Singapore Urological Association is a professional society representing specialist surgeons. Many of our members are directly involved in renal transplantation and the care of kidney failure and kidney transplant patients.

We commend the Ministry of Health's efforts to amend the Human Organ Transplant Act, with the intention of increasing the number of transplants.

Our association fully endorses the proposed amendments to lift the upper age limit for cadaveric donors and to allow donor-recipient paired matching as these are medically justified.

The amendment to support the welfare of living donors by allowing them to be compensated seeks to reimburse donors for expenses incurred through their altruistic act, including loss of earnings, transport costs and possible future medical expenses.

But this amendment raises the following concerns:

The proposed amendment currently before Parliament would allow for monetary payment of the donor for such costs. There is a real risk of manipulation by the indirect inclusion of financial inducements for the donor, in the guise of loss of earnings and potential medical costs, to inflate the amounts payable.

The provision for 'lump sum' compensation for potential medical expenses is problematic. The amounts of such expenses are, at best, uncertain; calculations of future health insurance premiums for the donors will be difficult.

It may be preferable to provide for such costs within Singapore's health-care framework. An example would be to issue donors with a medical benefits card that would cover related medical issues.

The ministry may also wish to consider wider medical coverage, given the potential problem of future insurability of the donor.

Having 'lump sum' compensation would be inappropriate for donors from foreign countries, as they will have no access to the Singapore health and legal systems once they return to their countries of origin. There will be little guarantee that any money paid will be used for its intended purpose. It will also negatively affect Singapore's international standing as a medical hub with high ethical standards.

We therefore recommend that the above amendment be restricted to Singaporeans and Singapore permanent residents.

The question of financial compensation for the donor remains a difficult ethical and practical issue, and should be tailored to the specific situation in Singapore. We hope these concerns are taken into consideration in the implementation of the proposed legislation.

Professor E Kesavan
President
Singapore Urological Association

Hard to swallow - Human Organ Transplantation Amendment Bill

This report (19/1) on the Human Organ Transplant Amendment Bill being introduced in Parliament slipped through with fanfare, and almost unnoticed. A bit hard to swallow. Looks like they die-die almost will push through.

SINGAPORE: Four amendment bills were introduced in Parliament on Monday. The first was the Human Organ Transplant Amendment Bill, which aims to allow compensation to altruistic living organ donors.

It will also allow paired living donor organ transplant and the extension of the cadaveric donation age to beyond 60. It also aims to increase the penalties on organ trading.

- CNA/vm

Human organ trade - fait accompli? Why am I not surprised....?

So the Ministry of Health has floated another balloon about the human organ trade issue. This time it declared it has completed a 1 month long exercise (1 month!! whoohoo...! That was a long and comprehensive exercise!) to get public opinion on the proposed amendments to HOTA (Human Organ Transplant Act).

see MOH Press Release
Details in Annex

Apparently 86 % had favoured some sort of reimbursement (fair 'nuff) and a majority suggested appropriate sums of at least S$50,000. How this figure was arrived at, we do not know. The Press Release tells us that there were 55 respondents (wow!), 9 written submissions from various oprganizations (we are not told which organizations so we can't say if these were biased opinions..!) and 162 participants surveyed at the People's Association dialogue session.

Well, I seriously question the validity of such feedback...and doubt the representativeness of these opinions. It could well represent the first steps towards understanding the full range of public opinion, but currently these are very sparse numbers and likely to only represent interest groups.

Of particular concern for me has always been the issues pertaining to the 'reimbursements' for donors. I have nothing against this per se, and I think we should adequately compensate the donor. But reimbursements really open the way to unethical practices related to a] free market trading of human organs, and b] inducements/exploitation of the poor. The MOH has been deliberately vague about these issues preferring to defer the consideration until after the law has been amended. It says, "These are operational details which the Ministry will take into account after the law has been amended.". Ho hum. Isn't it clear that because these are sticking points in the deliberations, we do need to clarify these before we amend the law? Once the law has been amended we will all just be driven down the road by operational details which may not underpinned by ethical principles.

With regards to foreigners, the MOH says, "The law will have to apply equally to all donors and patients if the transplants take place in Singapore. Otherwise, there may be double standard. If the law is amended, MOH would issue guidelines to the Hospital Transplant Ethics Committees so that they can better judge between what is reasonable compensation and what is inducement."

What this means really is that if this is delegated downwards to the hospitals, the commercial interests of the hiospital will become paramount. Ethics Committees or no. The hospital ethics committees decide on how much to reimburse foreigners for organs...? Duhhh.... Imagine NUH and SGH bidding against each other for organs? This is somehow ethical?

Imagine every kidney failure in the world flocking to Singapore for their transplant (wooohoooo....big mega bucks business!), then imagine the major transplantation hospitals sending out recruitment teams to Indonesia, Bangladesh and Africa etc etc....sourcing for organs. ...

Can it ever be controlled?

I think MOH has to do a little bit more work to tell us specifically how they are going to manage this before I will go along with their scheme to turn us into the organ trading capital of the world. But the cynical me feels they die-die will push this through whether we like it or not, because it will bring in the patients for our MedicalHub.

Euthanasia here we come!

The future of regulatory oversight in Singapore - Madoff and the AVA

As if to reinforce the point, there on pg 30 of today's (Dec 21) Sunday Times is another report on the Madoff Ponzi scandal. The subtitle of the article reads: "Scandal could have been prevented of the financial system's gatekeepers had been competent and independent".

Yeah. Competence and independence.

I have no problems with the competence issue. We got lotsa smart people. It's fundamentally a problem of how they apply their smartness. Which has to do with the second attribute - independence. I have commented on this before in an earlier post.

No regulatory agency can do it's job properly if it is unclear where to focus its eyes on. How do you regulate if you are more concerned about the impact on the health of the industry you are supposed to be regulating? That's surely the role of 'the other agency'! I mean, isn't the role of the regulator to protect the consumer public against the industry's excesses?

But our regulators are invariably too concerned about not offending the industry, and not to be seen as being obstacles to the growth of the industry.

No? Well....just look at the structure of the regulatory agencies we have. They are invariably organically infused with a promotional mission. Look at how these agencies rank their performance...."Pro-Enterprise Index"? What are the parameters of these PEI? Compliance cost; Review of Rules;Transparency;Customer Responsiveness; andPro-enterprise Orientation.

Errmmm...nothing about the consumer in there. Who really cares about them?

This was what failed in the Madoff scandal. The industry was more important. This was what sowed the seeds of the current financial crisis.

And this was what lay behind the melamine hysteria.

Interestingly, on pg 12 of todays Sunday Times, there is a small article on AVA's response to the melamine thingy. Tessa Wong reports that the melamine saga cost the AVA $2 million to do 'additional laboratory tests'. Apparently, melamine was never considered a food contaminant.

Ho hum. Really? Did they not read the newspapers back in 2007, when there was this massive pet food recall in the US? Did they not connect the dots? Or were they just too concerned about their Pro-Enterprise Index ranking?

Yeah. Competence and independence. That's what we so badly need.

Is this just just one of my PMT days when I rant on aimlessly, and take potshots at aything that moves? No. We have been debating more serious issues about euthanasia and human organ trades. Much of the acceptance of of these highly controversial issues depends on our ability to trust in the regulatory competence and independence of the agencies in charge. We need to know that these agencies are focused on consumer/public protection, and not being primarily concerned with the health of the medical industry.

It's never going to work any other way. We need a major overhaul of the regulatory environment, especially those related to health and safety. We need to know that the ethical review processes are truly objective and are genuine advocates of patients and volunteers/donors (and not defenders of doctors/surgeons' and scientists' rights to exploit). We need to be assured that the regulatory agencies (AVA, HSA, Singapore Medical Council?) are true protectors of the consumer/public and not disguised promoters of the industry. And we need to have more than just verbal assurances that these august bodies are competent and independent. They need to be organically structured to have that independence of regulatory decision making.

Are these too much for a Christmas wish?

Human Organ Trade - Thank you Chris and Lay Guat!!

I reproduce for you here a letter to the Straits Times on 18 December 2008 by Dr Chris Cheng and Dr Ng Lay Guat. What a great letter from 2 wonderful transplant surgeons who are prepared to their values up front!

The thing that taints the organ transplantation programme is the prospect of it degenerating into a crass commercial trading activity. The sacrifice of ethics and human value for profit. If we want to justify the reimbursements of non-relative oran donors, then we must strip away the associations with trading and exploitation that almost invariably will accompany it.

But here are 2 transplantation surgeons who are prepared to step forward and condemn this trade, at the expense of losing professional business opportunities. Chris and Lay Guat, I take my hat off to you!

I wish there were more transplantation surgeons of their mold. But I suspect there will be few.

Here is a challenge to transplantation surgeons and the institutions that house them, to do the right thing. If you are truly concerned about the renal deaths, and wish to see more ethical live donor organ transplantations, show us how genuinely altrusitic you are. Forgo your professional fees. Waive the institutional charges. Let's not do this to fatten your wallets.

Let us see how genuine you are in your compassion for the terminally ill organ failures.

-----------------------------------


High price of compensating donors
By Christopher Cheng & Ng Lay Guat, For The Straits Times

EVER-LENGTHENING waiting lists for kidneys is an old problem not unique to Singapore. Almost every country in the world has a waiting list that is growing longer faster than the number of transplants done per year. The solution to this problem is of course to increase the number of transplants performed. Singapore is on the right track in encouraging live donor transplants, and the opt-out system of the Human Organ Transplant Act will increase the number of deceased donor transplants. Other measures such as raising the donor age limit and paired donor transplants can help shorten the waiting list to an extent.Compensating donors is another means the authorities have suggested to shorten the waiting list. We feel that this would be an overly zealous measure.
We do not object to reimbursing altruistic donors so they do not suffer from having only one kidney. As transplant surgeons, we have come across many families with several potential donors. The ones who finally come forward tend to fit a certain profile. We have seen many instances of sister-to-brother, wife-to-husband and sister-to-sister donations. This is not because women are more generous than men, but rather because they tend not to be the sole breadwinners in their families.
For example, we recall a young patient with end-stage renal failure who had nine siblings. We couldn't help but remark that she was, in a way, luckier than many patients with smaller families. However, the only sibling who came forward to donate was an older sister. When we examined the matter, we realised that the donor was single, whereas all the other siblings were married and were breadwinners.
The worry that their own families may suffer if they chalk up large medical bills years after donating a kidney is valid. But giving such donors a lump sum may not be the answer to their worries. Not all are shrewd fund managers. Assurance of help in the event of future medical problems relating to the donation would probably be more helpful.
Another potential problem with compensating donors is that it may turn away truly altruistic donors. Already, we are seeing potential donors delaying their decision because of pending legislation on this matter. The feeling is: 'If the patient can get a kidney by paying for it, why should I run the risks of donating my kidney?' People may also refrain from offering to donate a kidney for fear of being called greedy.
The most unacceptable effect of compensating donors is that such compensation may slip into organ trading. Some have argued that the poor have the right to decide what they can do with their bodies, and if they choose to 'commodify' their bodies so that they and their families can benefit financially, so be it!
Only people driven to desperation will consider parting with parts of their bodies. They are either in desperate need of money or in great debt. The money they might save from the organ sale may be very meagre indeed.
The Government should consider giving donors medical coverage so their fears of possible medical problems later in life might be allayed. The cost of such coverage is potentially high, but we suspect it would be affordable. This is because the criteria for selecting donors are stringent, and the people who qualify to be kidney donors tend to be fit. The possibility of their developing end-stage renal failure is very low.
A rich person with end-stage renal failure should not have the automatic right to buy spare parts from another person just because he can afford to do so. This would amount to causing bodily harm to another, not unlike in slavery.
Performing kidney transplants is a joy. Watching an end-stage renal patient recover from surgery and seeing a happy family leave the hospital is a blessing no money can buy. Legalising organ trading in Singapore will just degrade this wonderful experience into a purely commercial transaction.
Differences in opinion on this matter depend on one's point of view. For someone suffering from renal failure, almost any means to obtain a kidney would appear permissible. For those desperate enough to sell their body parts as the only available means of clearing their debts or bettering their lives, organ trading may also be considered permissible. However, from a society's standpoint, we must examine the moral implications of the new rules we are considering. We should as a community put rules in place to protect the poor, the weak or the otherwise underprivileged.
The rich already enjoy many privileges in our society. Allowing them to purchase an organ legally would be crossing a dangerous line. We are sure our system will ensure that there is an equitable, innovative and highly regulated set-up such that the donors will be protected. However, as Dr Lee Wei Ling, who is in favour of legalising organ trading, has acknowledged in these pages, it will not be the rich who will come forward to donate their organs. It will be the poor and the desperate. We have always championed the underprivileged in Singapore. Selling organs, whether the sellers be Singaporean or foreign, should not be the means to a better life.
How much is life worth? Transplanting kidneys is relatively safe but it has definite risks. While it may be acceptable to run the risks for a relatively young person to undergo a transplant from a relatively healthy donor, it will be difficult to justify a rich, aged individual suffering from renal failure (and possibly other illnesses) getting a kidney from a young individual just because both parties are willing. It will be even more difficult to extend the argument for kidney trading to live liver or cornea trading. Should we allow someone to buy a face? It is now medically possible to do face transplants. This is a slippery slope; we should not place ourselves on this slope.
Yes, Singapore has dared to blaze its own trail in many areas, as Dr Lee pointed out. Medisave, Newater and HDB - these have all proved to be the right things to do. However, organ trading is fundamentally wrong. It should not be legalised because it empowers the already powerful and exploits the vulnerable. It will not lead to a more moral, sustainable society.

The writers are consultant kidney transplant surgeons at a public general hospital in Singapore. The views expressed here are personal.

Medicine a calling and not just a career? Really??

Dr Lee Wei Ling is back n the news with a letter addressing the above issue. But she is right this time.

Medicine is a calling. Sadly for many doctors, and medical students, it has become nothing more than a career. Many doctor friends counsel their children never to take up medicine, believing that this is no longer a satisfying and fulfilling career option.

This shift in our value system has been due largely to the national push for commercialized medicine. This strategy, articulated in the late 70's at the very highest level of our government, steered us smack down this road...at full speed. Medicine was to be one of the major pillars of our economic growth. But we can't really deny the economic sense this strategy made. It is just that the philosophy was totally wrong. It was another nudge that increasing turns us into little more than mere economic digits.

Can our lives...can doctoring be denominated just in terms of a dollar value?

But there are broader implications, and associations of this very materialistic philosophy that we need to be aware of, and concerned about. This has far wider implications.

a] The commercialization of medicine, and the strategy of establishing us as a medical hub, is in itself not necessarily wrong, but it has caused every doctor to begin to evaluate his/herself in terms of the dollar value of their contributions. There are few who are strong enough, and clear enough about their personal value system to withstand this constant and very public pressure to excel in dollar terms.

b] Medical education, is increasing being subverted by this intense pressure for our students, not to become good caring doctors, but famous award winning clinician researchers. Nobel prize anyone? I mean...do you really want your family physician to be a Nobel prize laureate? Yet the medical school is increasingly diverting must needed teaching resources into research laboratories, and losing valuable educator positions to scientists with long credentials but cannot teach.

Good teachers are increasingly belittled as dinosaurs, and new staff who care little for students clamour for attention and public acclaim. *sigh*

Who are their role models? No more the humble GP who gives his life to serve the community, but the attention grabbing stem cell clinical researcher.

c] The gradual corruption of the medical ethos will be seen in the the increasing pressures to 'bend' morality and ethics to serve mammon. Observe the increasing pressure to push the medical profession into serving the organ trade, ....and euthanasia perhaps...?

What can we do to stem the slide? Precious little, I am afraid. Another example of the slippery road to self destruction? Perhaps.

Dr Lee Wei Ling, will you be our flag bearer to reclaim the noble values in doctoring?

Euthanasia #7 - are we missing the point??

Well, it looks like we're jumping right back into the euthanasia debate. The Straits Times carried a Saturday special report on the issue, and Sandra Davie posted something in her blog...

The debate is important to have....but sadly it is beginning to sound tired,...kinda like a broken record that does not go anywhere.

People's positions get hardened around extreme and unrealistic positions. There are deliberate obfuscations so that it seems like everyone is playing in their own soccer fields. There is a general confusion about the AMD which is unfortunate as it is in a totally different playing field. Then there is the almost deliberate blurring of the line between murder and euthanasia, as if it is something done with the patient's full and informed consent. Sadly, after a protracted period of these confused meandering, the government will step in and proclaim that there is enough public debate, and that adequate public opinion has been sought, then proceed to implement its agenda.

How sad. How tragic.


I believe, if the discussions are to be meaningful:

a] The topics and definitions need to be carefully and clearly circumscribed. We need to deal with each problem clearly and specifically.

b] The main points of contention must be clearly identified and dealt with. In this regard, I see one of the major sticking points is the apprehension that the essentially noble idea, will eventually be abused, and extended to less noble ends. In the ST report, bioethicist Margaret Sommerville pointed out this 'slippery slope'. She says, "Once euthanasia is legalized, its availability expands.". She is right.

The government, and proponents of euthanasia must therefore spell out how this creeping availability, and extensions of the application of the euthanasia principle, can be managed and controlled.

c] The government must make more effort to manage the perception that this is somehow linked with the commercialization of health care. Why now?? It didn't help that this was brought up almost in the same breath as the organ trade issue. The public should be rightly concerned that euthanasia is only being surfaced now as an alternative medical option, just when there is this massive national push to establish Singapore as a 'grandmother of all medical hubs'.

If legalized, euthanasia should never ever be part of any activity associated with commercialized medicine. And it should never be offered to anyone who is a non citizen.

Human organ trade - ...and so it begins...

It was easy to contemplate reimbursing kidney donors. It just made sense to do so. Just as it did legitimizing the process.

Now when the discussion and dialogues begin it is starting to look pretty scary.

Minister Khaw Boon Wan was reported in today's Straits Times, as having said at the first HOTA dialogue session with some 300 grassroot leaders, that Singaporeans and foreigners should receive the same reimbursements. Far'nuff, I thought. Except that this is probably the first clear indication that we were clearly going to be purchasing organs from overseas, that we were not going to limit this reimbusement for organ donors thing to just a Singapore activity. Viva la Singapore Medical Hub!!

What was also worrying for me was the almost unanimous voice that supported the organ trade lobby. The reimbursements, far from originally proposed that it was only to cover costs of medical procedures and associated costs for time etc, would be in the tune of $50,000-$100,000.

Whoa....!

This was human organ trade getting into full swing. Let's not bother about those airy-fairy ideas of inducements and exploitation. If we need those organs, just go ahead and buy them off those poor sods for whom $100,000 would represent several lifetimes of income.

I hope that Minister Khaw will consider (and I trust he will because I believe he is at the core, a good and ethical person) that the opinios solicited at his dialogue do not represent the universe of opinions and are heavily biased towards the recipients position as many of those represented there will have friends, relatives and constituents who are potentially recipients of the donated kidney. There are no voices there that effectively represent the potential donors, and the populations from whom the potential donors will come from if the great kidney sale extends to the international community.