Sir,
We are all aware of the waiting list for kidneys, averaging 9 years, and the suffering of kidney patients undergoing dialysis while waiting for a transplant, sometimes in vain. Thus, the proposals under the Bill to increase organ supply by removing the age cap for cadaveric donors, and to facilitate living paired donations, are welcome.
The cause of the long wait is a shortage of kidneys for transplantation. Why is there such a shortage?
One reason is that the demand for kidneys is high due to the high incidence of kidney failure in Singapore.
Secondly, it seems that Singaporeans are still apprehensive about organ transplants by living donors. Last July, a local kidney specialist, Prof A Vathsala, noted that Singaporeans were reluctant to donate organs to their relatives unlike in Norway where the entire family would turn up for evaluation (ST 17/7/08). It was well-known that in Norway and Spain, supply has almost matched demand. MOH has agreed that more can be done in Singapore by way of public education to encourage donation.
Another question to ask is whether the existing HOTA has been under-performing in cadaveric transplants. Even though the current HOTA auto-includes locals as cadaveric donors, has this scheme been efficient in producing results, or has it been under-used? During the Ministry’s consultation on the Bill, suggestions were received on how to improve the current processes for cadaveric donation e.g. by salvaging more organs from trauma deaths, earlier identification of potential organ recipients, and improving organ preservation. In response, the Ministry agreed that it would continue to strengthen the process.
With the promise of more public education to encourage living donors, enhancing the efficiency and pool of cadaveric donors, and the inclusion of Muslim cadaveric donors recently, this multi-prong effort will increase supply to some extent.
Should we not wait for these moves to take effect before enacting the proposals to increase payments to living donors?
Regarding living donor payments, everyone can agree with the general principle that the donor should be reimbursed for losses connected with the donation. In this sense, the current HOTA needs to be expanded for more reimbursement to the donor. The problem is that the proposed formula in Clause 3(f) could be used for profit and even become a backdoor for organ trading.
Clause 3(f) of the Bill relaxes the threshold of what can be paid to the living donor. Under the existing HOTA, S 14(3)(a) provides that a blood or organ donor may only be reimbursed for expenses which are necessarily incurred by a person in relation to the removal of any organ or blood. However, under the proposed S 14(3)(c), organ donors may now be paid sums for “defraying or reimbursing costs or expenses which may be reasonably incurred” in relation to a wide range of items including travel, accommodation, cost of domestic or child care, loss of income and long-term medical care.
Therefore, we are now talking not just about reimbursement of expenses actually incurred but a projection of all losses including future losses. The new formula leaves room for profit. First, it builds in a factor of speculation as to future losses such as long term medical care and future income losses. The wording contemplates losses even 10 years down the road. Any such calculation will be based on assumptions and uncertainties. What will the donor’s health be like after the donation? Will his earning capacity be affected? We may budget for poor health but he may recover very well. What if he comes from a region of high unemployment? If a foreign donor says he intends to seek the best medical specialist in Singapore for his long term care, how do we ensure that he will do so?
The sum to be paid will need to be determined upfront before the donor will agree. The contract is therefore likely to provide for all possible costs, even as a lump sum payment. Minister himself has said that the amount could reach 6-figure sums.
One consequence of this is that only wealthier kidney patients are likely to be able to afford to contract for an organ. On the flip side of the coin, won’t the donors more likely be those who are poor, prepared to risk bad health for some money?
Secondly, Members have already highlighted some issues concerning foreign donors. At the Singapore Medical Association Conference in Nov on this issue, concern was raised about Singapore becoming a hub for transplantation tourism, with other countries following our bad example.
Currently, living donor transplants are regulated by hospital ethics committees who usually restrict such transplants to cases where there is a family or at least a strong emotional relationship between donor and donee. This is to reduce the likelihood of a money motive behind a proposed donation. Is the Ministry retaining this requirement of family relationship, or will it become a free-for-all where unrelated living donors can donate? If the requirement of relationship is retained, the risk of money motive is smaller but still present if false declarations of relationship are made or the relationship is remote. If unrelated donors are permitted, then the risk of organ trading in disguise is clear.
Members will recall the case of Mr Tang Wee Sung who was convicted under the Act recently. In that case, the hospital ethics committee had in fact approved the transplant relying on false declarations of family relationship and that no money had changed hands. The figure in that case was reported a 5 figure sum of about $23,000, perhaps a small sum by local standards but, apparently, sufficient to induce.
We are aware of the suffering of kidney patients and can understand their overwhelming desire to improve their lives by obtaining a kidney by whatever means possible. However, as specialists have noted, there is still scope to expand our current programme rather than to prematurely wade into controversial waters. In 2004, the World Health Organisation passed a resolution which encouraged live organ transplants but also warned of the risk of the poor and vulnerable to transplant tourism. Last Sep, the then Acting Head of the Centre for Bioethics at Monash University, Robert Sparrow, made this observation: “It is hard to see how incentives could be large enough to make a meaningful difference to rates of donation without also establishing the risk of exploitation.”
Most Singaporeans can probably accept a change to the Act to provide a more generous reimbursement of donors for losses which can be proved, based on the principle of “equity” as mentioned by Minister yesterday. However, if a secondary purpose is to increase organ supply, then whether the sum is now geared towards inducement will arise.
The current formula in Clause 3(f) is very wide and may prove to be a backdoor to organ trading. This is especially because we are surrounded by countries where money could be a real inducement.
As such, we do not believe it is wise for Parliament to approve the current provision and leave the compensation framework details to be worked out later administratively.
We are of the view that the Minister should send the Bill to Select Committee to have Clause 3(f) scrutinised independently by Members of Parliament after receiving the opinions of the general public and experts, with a view to reduce the risk of profit and exploitation. One consideration could be administering the sums under a trust, especially sums relating to future costs and losses, to be disbursed at future dates.
If the Minister does not send the Bill to Select Committee, we would abstain from supporting the Bill due to concern about the wording of the Clause.
