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.

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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.

The Giraffe's long neck , ....or, the slippery road to hell

Ostensibly, the long neck lets the giraffe reach for the juicy leaves on the higher branches. Some people though, have pointed out that the giraffes neck is in fact too short; it can't reach far downwards enough to drink. Whatever, the fact is the giraffe has become somewhat of a biological oddity. Clumsy and conspicuous, if is really a matter of time before it becomes extinct, if not for commercial zoos and Natgeo.

But how did it become that way? This has become a bit of a biological enigma and people have spent fruitless hours debating this over absinthe and wine. An interesting discussion about this can be found here. Many believe the longer reach of the giraffe conferred some survival advantage, and each successive generation got longer and longer necks. But that's probably only half the story.

Initially there might have been some survival advantage. A minor one perhaps, but that didn't matter. That would have been OK if it had just remained that way. As usual though, things got complicated when we ladies got into the act. At some point in time, the lady giraffes decided that male giraffes with longer necks were attractive. Apparently longer is better. I mean, who wouldn't want offspring to have that critical advantage to reach for the 5C's, ....ooops, sorry, I meant higher branches.

Once that paradigm was set, each generation of lady giraffes sought partners with progressively longer necks....regardless of survival (dis)advantage. Result? A biological oddity consigned to nature's museum of dead ends.

Here was an example of the development of a slippery slope. While the original intention was sound, (long necks were good because they could better reach high branches), the paradigm got overly fixated around a false criteria - sexual and physical attractiveness.

Lesson for us? So much of our debate today is poised astride the beginnings of various slippery slopes. Many have clearly good intentions, or at least couched in language that suggest noble intentions...We save lives if there are more organs available for transplants. We are merciful if we can only euthanize away human suffering. Why let unwanted unborn kids be born into this cruel world? Commercialized medicine is good for our economy and development of medical excellence, etc....

All good stuff until the paradigm gets shifted along the way. At some point the focus of the paradigm will shift so that the ends become more important than the means. It then becomes more important that we have good economic growth, high globalized performance rankings for whatever we choose to do, that our emperors and mini-emperors have have progressively beautiful clothes to wear on the global stage.... Then our necks will become increasingly longer. Overextended. Too long to manouvre ...too short to drink, too clumsy to survive. And then we will become consigned to world's museum of social dead ends.

Tragic.

Tuberculosis - hysteria in development

There was a letter in the Straits Times talking about the problem of TB is schools and the re-emergence of multidrug resistant TB etc... This is a bit of hysteria in the making, fueled somewhat by the Ministry of Health recently announcing it had place TB on the IDA (Infectious Diseases Act) Schedule 6 bugs list.

Hysteria? Yeah....because TB isn't that much of a problem really. We already have a TB immunization programme at birth (BCG; Baccille Calmette-Guerin). This confers a certain degree of immunity throughout childhood. Its efficacy wanes as the child gets older as is variably present in adulthood. We used to re-vaccinate at about 12 years old, but apparently this practice was discontinued in 2001 because of doubtful value of the program in protecting against future TB.

Most of the TB cases are in the elderly and do not represent new infections. Rather, they are a re-activation of what is called latent TB. Most of us, regardless of our 'immune status' are exposed to TB and go around carrying TB bugs in our bodies. Mostly these are sleeping dragons that don't bother us. However, when our immunity falls, these sleeping dragons are reactivated. Common causes for a fall in immunity are HIV, cancer and the use of immuno-suppressive drugs. It is therefore highly unlikely most of us will develop active TB sitting next to a patient with active disease.

What about the multidrug resistant TB problem? It seems to be a developing problem. Like all bugs, when they are exposed to inconsistent and incomplete treatment, the TB bacteria develops resistance to the drugs used. Fortunately this seems to result in rather wimpy bugs that are not very virulent and infectious. They seem to be a problem mostly for populations with reduced immunity such as those patients with HIV.

All in all, the problem of TB is not anything to lose sleep over. The incidence in Singapore is only about 35 per 100,000, i.e. about one infection out of every 3,000. If you consider these are mostly re-activated cases....it is really not that big a problem. The age group affected is mostly elderly (peak 40-60 yrs old), but like all distributions, there is a tail, and some young people with reduced immunity may succumb to the infection.

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Regardless of the MOH recent announcement of an increase in TB....(those are only projected numbers based on only 6 months of data, and the year is not over yet)....the trend over the last 40 years is a major and consistent reduction in TB incidence with no evidence of a reversal.

Hysteria? Definitely!

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What is a curious phenomenon though is the differential ethnic risk for TB...Malay > Chinese > Indian. I can't really explain this.

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good bugs...

Many of the bugs floating around us are actually friendly bugs. Our gut is full of them. These bugs that live happily with us are generally called commensals (as in 'share the same food'). Often the balance is in favour of one over another....i.e., they make use of us more than we do them, or we make use of them more than they do us...more likely the former. These would be more exploitative relationships. The bugs on our skin and hair are very much like that. Often they are just different balances of a 'mutualistic' relationship, i.e. both derive some benefit.

The bugs that have colonized out gut are very much in that category. Mostly we don't know to what extent we benefit from their presence. Unlike the herbivores who clearly use these bugs for their large gut 'fermentation chamber' to digest stuff, we are not so inclined. Still many believe, the presence of these gut bugs do help us establish some sort of health balance.

The concept of the whole Yakult industry is based primarily on the idea of seeding the gut with friendly bugs. Occasionally the colony of bugs gets thrown off balance by overgrowth of a 'renegade' strain of bugs which have no respect for the host....That's when disease manifests.

Toilet paper, anyone?

Euthanasia #8 - an option of last resort

Euthanasia cannot be an option of first choice in any society. It is always an option of last resort. I am not a champion of euthanasia, but grudgingly recognize that it may represent a final solution to a small group of patients for which palliation has failed.

If euthanasia is to be legalized and offered as a solution, society will have to pay a high ethical/moral price.

Euthanasia, thus should only be an option only for the members of that society. It should not be part of a commercialized set of activities. I could never condone euthanasia, if offered in the context of a globalized medical hub concept. I could never ever support Singapore becoming an euthanasia capital of the world, which it will definitely be should we offer euthanasia services to non-citizens.

If you are observant you'll see the pigeon orchids (Dendrobium crumenatum; anggerek merpati) make their appearance during this time of year. They are a lovely sight, these wonderful sprays of white shy blooms. Very lightly scented, they look very much like small little pigeons in flight. You'll find them dancing in clusters, often hanging onto large branches or tree trunks.

They are really very shy, and fade quickly within a day or two. So if you don't catch them soon, you will miss them.

I really don't know what forces them into bloom. I know they have lovely showings a couple of times a year. Perhaps its the rain and strong sunshine.

I have a bunch in the garden and was very very pleasantly surprised by their presence this morning.

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?