Wednesday, January 14, 2009

Approach kidney donations logically

Jan 14, 2009

By Lee Wei Ling

A MONTH-LONG exercise to ascertain the Singapore public's views on proposed amendments to the Human Organ Transplant Act (Hota) has come to an end.

In releasing the findings, the Health Ministry said 86 per cent of the respondents were in favour of some form of payment to living organ donors and that a majority felt that a reasonable sum for such payments would go beyond $50,000.

Money would be needed by living donors to cover their direct expenses such as transport, and indirect expenses such as the loss of time and earnings and future medical expenses.

Many details of the proposed scheme remain unsettled though, such as how much money would be enough for compensation and how this money should be given out.

Some have expressed the concern that the proposed amendments to Hota could be used to exploit the poor and result in organ trading, especially after a few recent high-profile cases that centred on organ trading. Respondents to the Ministry of Health survey, wary of possible organ trading, were keen on increasing penalties for organ trading syndicates and middlemen.

I never cease to be amused by 'the holier than thou' attitude taken by some who are simply participating in a philosophic debate compared to the person who is willing to exchange one of his kidneys for cash and the patient who needs a new healthy kidney to keep him going.

A few weeks ago, for instance, Drs Christopher Cheng and Ng Lay Guat argued in these pages that it would be unethical to pay enough for a kidney such that monetary gain becomes the main driving force for selling/donating an organ. What would be wrong in doing so?

Just as students enter medical school for a variety of reasons - not necessarily all altruistic - so, too, people who agree to trade their healthy kidney for money do so for a variety of reasons. Our responsibility in such a situation is to ensure that the donor/seller is not exploited.

A study in the United States in 2004 showed that if the donor/seller is paid US$100,000 (S$150,000), the cost to the health-care system would be financially neutral. This is because, after receiving a new kidney, the patient/recipient will reduce the cost of medical care for his kidney disease by about US$100,000.

So long as the donor/seller feels he has received enough to make it worth his while to undertake the risk and inconvenience of having his healthy kidney harvested, who else has a right to tell him such an act is unethical? Indeed, as Drs Cheng and Ng themselves noted, in cases where patients receive kidneys from family members, it is more often than not a woman - an unmarried one moreover - who 'volunteers' to donate. I strongly suspect psychological coercion plays a role here and I fail to see why psychological coercion should not be more repugnant than financial coercion.

Drs Cheng and Ng further warned of the 'steep slippery slope' of organ trading. They wrote that if we legalised kidney trading, that would open the door to live liver trading, trading in cornea, or even heart or face trading. This is a totally ridiculous assertion.

It is only because kidney transplant has a low enough risk of morbidity and mortality that it is considered acceptable for living unrelated donors to donate their kidneys. Liver resection for transplant into a recipient carries a much higher risk. And as for heart and face transplants, the donor/seller must obviously be dead. So this kind of 'steep slippery slope' argument is a non sequitur.

Selling of body parts has always been an emotional issue, especially when the body part is taken from a living person. But many debates and controversies in medicine also arouse much heat and emotion. At the end of the day, medical specialists need to explain to the public the facts involved in an unemotional manner in order to get the public to come to a logical conclusion which is best for both patients and societies.

The debate on selling/donating kidneys has been more associated with sound and fury than with logic. I think logic is the best way to answer the questions raised in the donating or selling of kidneys.

My conclusion is that the donor/seller should get a minimum of $50,000 - possibly more, up to a maximum of $150,000. Who should pay this sum and how the money should be paid up should be as flexible as possible.

Why should the government intervene in a transaction between two consenting adults as long as it has ensured that neither will be harmed in the process?

Financial markets worldwide would require much regulation over the next few years. In kidney trading, I think, leaving the pertinent individuals to negotiate the price between themselves is the better way forward.

The writer is director of the National Neuroscience Institute. Think-Tank is a weekly column rotated among eight leading figures in Singapore's research and tertiary institutions.

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