Tuesday, December 2, 2008

We should dare to blaze our own path

Dec 2, 2008

By Lee Wei Ling

CHANGES to the Human Organ Transplant Act (Hota), expected early next year, will include compensation for those who donate their kidneys to save the lives of people they do not know.

Many ethicists are against the commercialisation of kidney donations. The politically correct stance seems to be that money may be paid to the organ donor/seller, but only enough to compensate him for the financial loss he would have incurred because of the operation to remove the kidney, the higher medical insurance payments he would have to pay and the cost of regular medical check-ups. It is firmly believed that the sum of the compensation must not be so high as to constitute an inducement to sell kidneys.

The reimbursement sums have not been determined yet, but Minister of Health Khaw Boon Wan has said that they are likely to amount to tens of thousands of dollars.

I think we should have a properly regulated set-up in Singapore. We should indeed ensure that anyone willing to donate a kidney to a stranger can do so with minimal medical risk to himself, and that he understands the future risks he faces with only one kidney. I, however, do not agree with the refrain that the 'financial compensation should not be so much as to induce someone to sell his kidney'.

Let's get real: Who would willingly donate his kidney to a stranger without profiting from that act? I would not, though I have pledged all my transplantable organs to be used upon my death. Few Singaporeans, if any, will donate their kidneys even if there is a financial incentive, because few are so desperate for money.

Vagrants and beggars here are sent to homes run by the Government where they have clean pajamas, clean beds, three nutritious meals and a roof over their heads. A financial incentive may persuade the loved ones of local patients who were debating in their minds whether to donate, to do so in return for money. But most sellers will be from foreign countries, underdeveloped as well as developed.

There are many developed countries where the gap between the haves and have-nots is great. The poor in these countries would be willing to part with a kidney if the price were right. If we had a correct system in place, kidney patients from developed countries might find their own kidney sellers and both sellers and patients would come to Singapore for the transplantation because the standard of medical care here is high.

Why the rigid insistence that the remuneration for the seller should not be so high as to be an inducement to part with a kidney? To be blunt, the main reason is because there is not enough independent thinking here. A meeting in Istanbul this year of more than 150 representatives of scientific and medical bodies worldwide, with government officials, social scientists and ethicists in attendance, came out strongly against kidney trading. Singapore was a signatory to the Istanbul Declaration. Thus the reluctance to abandon the stricture against kidney sales.

The major arguments in favour of kidney sales are as follows: One, there are not enough kidneys available here for patients with end-stage renal failure, in spite of the current Hota. And two, kidney transplants are better than dialysis for such patients. Transplant recipients enjoy a 68 per cent lower long-term mortality rate than patients on the waiting list for kidneys.

The two strongest arguments against sales are that the poor might be 'exploited' and their bodies 'commodified'. The poor are more likely to sell a kidney than the rich; hence the fear that a financial inducement might override their better judgment and cause them to ignore the medical risks of uninephrectomy (the surgical excision of one kidney).

But at present, it is legal for a person to undergo uninephrectomy when donating a kidney. Why are kidney sales immoral when the only difference between donating and selling a kidney is the motive of monetary self-interest? If we oppose kidney sales because nephrectomy, or kidney removal, is dangerous, then we should also oppose kidney donations.

Moreover, our society allows the poor to take many high-risk jobs that the rich would never do, such as construction and welding. And we allow both the rich and the poor to engage in recreational activities that have much greater risk than uninephrectomy - for example, smoking and bungee jumping.

The mortality rate associated with live kidney donations is only 0.03 per cent. So the argument that kidney sellers might unwittingly endanger their health does not hold water, for the same argument would apply to kidney donors. If the seller makes an autonomous decision and, in return, receives a substantial payment that may significantly improve his and his family's quality of life, why would that constitute exploitation?

As for the 'commodification' argument, the concern seems to be that kidney sellers would, in some way, lose their human dignity and be seen as mere providers of 'spare parts'. This argument has tremendous emotional force but no data to support it. What gives us dignity is our ability to make rational decisions; and people can continue to make rational decisions with only one kidney. A person with no kidney, however, dies. What price non-commodification for a dead person?

Dr Leon Kass is an American bioethicist. He is best known as a leader in the effort to stop human embryonic stem cell and cloning research as chair of the US President's Council on Bioethics from 2002 to 2005. Yet even he has written: 'I suspect that regardless of all my arguments to the contrary, I would probably make every effort and spare no expense to obtain a suitable life-saving kidney for my child - if my own were unusable...I think I would readily sell one of my own kidneys, were its practice legal, if it were the only way to pay for a life-saving operation for my children or my wife.'

Many people can be 'holier than thou' on this matter when they themselves are not suffering from end-stage renal failure. But if this misfortune were to strike them or their loved ones, they would act differently.

Singapore has long prided itself on its ability to do what is correct even if it is not politically correct. We have led the world in many areas - CPF, Medisave, HDB, ERP, to mention just a few. Some of our policies have been the butt of jokes in other countries. But many foreign governments are now sending their officials to learn from us.

The poet Antonio Machado wrote: 'Traveller, there is no road, you make your own path as you walk.'

Singapore should do that in kidney sales, as it has done in other areas, instead of blindly following what the rest of the world is doing - wrong.

The writer is director of the National Neuroscience Institute.

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