Jun 29, 2008

The Issue of Human Organ Trading in Singapore

Two Indonesian men are being prosecuted in Singapore for agreeing to sell their kidneys. This landmark case has sparked a lively discussion on whether organ trading should be legalised.
ST June 29, 2008
Should sale of organs be allowed?
Doctors and MPs give their take on organ transactions
By Shuli Sudderuddin

Organ selling should be allowed in a properly controlled system, and in fact this is long overdue, Associate Professor Lee Wei Ling, director of the National Neuroscience Institute, said yesterday.

'People are dying of organ failure. And there are people who are healthy enough to donate their organs. It is ironical that the law at present punishes the very victims it is supposed to protect,' she said.

She made this call when asked for her views on the first-ever kidneys-for-sale case, which came up in court last Friday.

Dr Lee has been championing organ selling since last year when she wrote in to The Straits Times Forum page.

She said yesterday that in Singapore, it is possible to ensure the donor is healthy enough to donate his organ without adverse medical consequences, and there is fair remuneration. Checks can be made to ensure the donor does not carry any diseases that can be transmitted to the patient through the transplanted organ.

'In other countries, the donors are at a disadvantage without knowing it, and can get exploited. Singapore is the one place that can ensure that the donor is taken care of.

'We should be proud of it. There are existing rules and regulations that are outdated and irrelevant to the current situation in Singapore. We should set out to change them and do what is right.

'Every one of us has a duty as human beings to help others. People who may potentially be saved are dying, yet we still bury our heads in the sand and allow the suffering to go on? Of course, we should not break the law. But we should change the laws when they have become irrelevant. We should ensure that the person who is selling his organs is protected, and eliminate the middleman.'

She noted the existing market for organs mediated by a middleman.

'We should set up a proper, competent system to ensure the safety of the donor and that the donor receives a fair sum of the money in exchange for his organ.'

Echoing her sentiments was Dr Lee Keen Whye, a consultant obstetrician and gynaecologist at Gleneagles Medical Centre.

'As long as there is a willing buyer and seller, why not? If the seller does not feel exploited, who are we to judge? It's more important to save lives first,' he said.

Other doctors and MPs interviewed, however, disagreed. Dr Pwee Hock Swee, renal medicine specialist at Mount Elizabeth Hospital, felt that organ transactions should be purely altruistic.

Dr Lily Neo, an MP for Jalan Besar GRC, said that kidney transplants are 'a big life- and-death operation and people should not be induced to part with a part of themselves for a financial reward'.

Dr Fatimah Lateef, an MP for Marine Parade GRC, feels that it is more important to raise the number of donors available. A price tag should not be put on human organs.

Ms Halimah Yacob, head of the Government Parliamentary Committee (GPC) for Health, was also not in favour of organ trading 'because the poor and the weak will be the ones who have to give up their organs and this will lead to them being intimidated and harassed'.
Organ trading presents a host of sensitive issues. At this point in time, I haven't yet considered all the finer points.

But from a broader perspective, I can roughly see how a system of new legal rules can be built to deal with the main ethical concerns. Thus I am inclined to agree with Dr Lee Wei Ling (who happens to be Lee Kuan Yew's daughter) that it is possible, and desirable, to legalise organ trading.

The key ethical objection is that human organ trading may lead to the exploitation of the poor and of socially disadvantaged donors who are unable to make an informed choice.

For instance, a poor, lowly-educated person may be persuaded to sell his organ to a rich patient who needs such an organ. The poor, lowly-educated person doesn't understand the health risks that he is exposing himself to. In exchange for the kidney, the rich patient pays a sum which is peanuts to him, but which seems like a lot to the poor person.

This is the paradigmatic situation that the legal rules would have to deal with, for human organ trading to be legalised in Singapore. How? These are the features of a possible legal framework that I can envisage:
1. Organ sellers should be Singaporean citizens or permanent residents. This eliminates the potential problem of ill Singaporeans regularly sourcing for organs from desperately poor people in neighbouring countries such as Indonesia and Thailand. In the long run, this avoids major diplomatic disputes from arising between Singapore and its neighbours.

2. The government needs to act as a middleman. Seller and buyer should not be allowed to know each other's identities beforehand, if at all. If Y wants to sell a kidney, Y will inform the relevant government authority. If accepted for sale, Y's kidney will be transplanted to a patient selected by the hospital according to its own priority list. This avoids the ethically difficult situation where the patient directly locates his own poor, desperate person, and exercises his own undue influence to persuade or coerce the poor person to sell his kidney.

3. In addition to medical check-ups, the potential organ seller should be given the relevant counselling and medical advice. This is to ensure that he fully understands the medical risks he will be undergoing.

4. If there is any medical reason to believe that the potential organ seller's health will be unduly affected, his sale proposal should be rejected. A panel of independent doctors will have to assess each case.

5. Organ prices should be fixed by law. The price should not be subject to any kind of bidding system, nor any system whereby richer patients can gain priority by offering to pay a higher price. The Health Ministry can regularly review and revise the applicable organ prices, if necessary.
Two key considerations should be kept in mind. Firstly, more organ transplants ultimately means that more human lives will be saved - this is the noble intention of the system.

Secondly, we are talking about the types of organ transplants where the seller will have every reasonable expectation of being able to live normally after the organ is removed. (For example, a healthy person is typically able to donate one of his two kidneys and continue to live a normal life).

113 comments:

Anonymous said...

'Legalisation' is an inevitable extension of the underground organ trade. The current message is that organ trading is prevalent, inevitable and severely disadvantages the supplier of such organs. Need to right a wrong :$

Remove the middle-man / runners. Implement systems to minimise the ugly (e.g. illicit organ/human harvesting). A win-win situation and one that will earn Singapore a place in world history with far more prominence than any Olympic medal can.

Surely, a haven for the rich and poor ...

Anonymous said...

I do believe that sg has the system to make organ selling and receiving less exploitive

Anonymous said...

the sale of internal organs may arguably be uncomortable for some, however, the sale of sperms and eggs should be legalised asap.
statistics show that a sizable portion of couples are unable to conceive, often due to defective sperms and/or eggs due to late marriages.
legalising egg/sperm sales will literally mean a lifeline for many, and it's a lot more desirable than trying to import foreigners to make up the numbers.

Anonymous said...

completely and thoroughly agree with you. Let us do what we can best do to save lives and improve the quality of life for those who require organs. At the same time, let us also mitigate the possible social and moral hazards that may come out of such a system. Strict scrutiny tests should be administered.

Lower income individuals, or those requiring a "cash fix" will probably self-select themselves into the system. I only hope that compulsive gamblers do not end up going on this path to redeem themselves of their debts.

As for a price for organs - such as a kidney. Would it not be better for a "market price" to establish itself - seeing as there will be "willing buyers" and "willing sellers" so long as it was above a minimum price level or price floor of some sorts that was revised annually to take into account inflation and other factors?

Shafted said...

It is a frightening thought that organ recipients will be determined by their financial muscle rather than medical needs and suitability.

And since MoH can harvest serfs who did not opt out, that's another profit center for the gahment...

If organs are just another commodity whose trading should be legalised like your car or house, does Mr Wang also support the gahment's legal right to forcibly acquire it in the name of "national interest/service", as is the case today with land acquisition, conscription and reservist (can mobilise civilian resources)?

Anonymous said...

Mr Wang, I do not quite understand how points 2 and 5 work. On one hand, we have buyers and sellers and the government is the middleman. On the other hand, organs are allocated on a 'priority' basis.

Q: Who is the buyer? The government? Does it mean that buyers will have priority over those who cannot afford to pay? How is the order of priority determined?

Anonymous said...

if Singaporean have to resort to selling organ for a living. Then Singapore, as a society, is doomed.

Anonymous said...

topical issue.Yes, with rising inflation in Singapore, and Govt not doing much about it (other than raising more fares and means testing) this is a good concept, as long as poor people find an alternative to killing themselves on MRT tracks and HDB flats! Fist of, what would be the price of blood per litre?
For the govt who is good at sucking blood off its citizens, we should start charging them.
Slippery slope, how many times can that poor dude donate per month?
Is it more profitable than collecting tins and selling tissue??

Mr Wang Says So said...

Anon June 29, 2008 11:20 PM:

1. The buyer pays $X for the organ.
2. The government collects the $X.
3. The government pays the $X to the seller.

Patient priority will be established the same way it is being established now. For example, suppose the hospital has 100 patients who need a kidney. One kidney then becomes available, due to a healthy person who died in an accident. How does the hospital decide which of the 100 persons gets the kidney? Presumably, it's based on a combination of considerations such as:

1. which patient was on the waiting list first;

2. medically, which patient is in most urgent need of a kidney (i.e which patient is most likely to die soonest, without a kidney transplant)

3. medically, whether the prognosis is favourable (i.e whether the patient is likely to recover, if given the kidney).

Shafted:

You said: "It is a frightening thought that organ recipients will be determined by their financial muscle rather than medical needs and suitability."

You probably misunderstood my post. See comment above.

By the way, I do agree with the idea that suitable organs can be taken from dead people and used to save other people's lives.

The "if you didn't opt out, then we take it that you have opted in" part of that system is the uncomfortable element. The better alternative would really to have required all citizens to expressly elect "yes" or "no".

Anon June 29, 2008 11:21 PM:

Under our current system, it is interesting to note that if you are very poor and very desperate, you can still donate your kidney out of the kindness of your heart;

but if you are very poor and very desperate, you cannot sell your kidney for money.

Does that make sense to you?

Mr Wang Says So said...

Anon June 30, 2008 7:19 AM:

Interesting point. Perhaps if we allowed hospitals to pay for blood, we wouldn't have the chronic problem of a shortage of blood donors.

Anonymous said...

interesting development that we see here.

will not be surprised that years down the road that organ sales will be approved and legalized.

Main reason i see so is $$$$$ MONEY.


(copied this from mr wang's post)
1. The buyer pays $X for the organ.
2. The government collects the $X.
3. The government pays the $X to the seller.

i doubt the above 3 points will happen. 3 parties have got to "WIN" in this case so that the deal can proceed. i honestly don't think that the govt will just collect $X. Trust me, this is a viable revenue generating source.

IT WILL BE APPROVED!
I DARE SAY WITHIN THE NEXT 5 YEARS?

Anonymous said...

ermm...sorry...can i side track? just wondering is there any follow up action on the BUYER? the 2 SELLEr were charged but the BUYER plays a part as well, shouldn't he be charged in court too????

Anonymous said...

Mr Wang;

Pardon me if I sound crude. If Nature destined a being for destruction or to send it elsewhere, it is time to accept fate for that being.

Making organs a market commodities simply degrade the qualities of life(healthwise) for the sellers. Though one may argue that money can improve the quality of livings for the sellers, no one can be sure that the sellers may not suffer physical, mental(feeling abnormal or weaker)and medical complications due to the sales of their organs.

Amongst husband and wife, parent and child,siblings and bosom friends, organ transfers done out of love is acceptable to me. But to commercialize organs; no, it is a sin, even to an atheist.

patriot.

Anon June 29, 2008 11:20 PM said...

Mr Wang, thanks for your reply. If someone pays, it is because he wants to 'jump queue' and get the organ, which might otherwise be meant for someone else, for himself.

If priority is based on first-come-first served, then I doubt anyone would want to pay. Organ trading will not work as a system.

Since, buyers expect to benefit from the system, the likely consequence of organ trading is that the poor will be deprived of their chance of a transplant because they will be placed further down the queue.

Anonymous said...

I think currently sperm is paid to donors, as is the vagina for a course of sexual escapade.
I think this goes in line with the govt thinking - capitalist country, where the poor will sell their organs while the millionaires will get to buy and get first priority in choiciest pieces.
Why not?

Anonymous said...

Even if you're very poor and very desperate, you would not want to sell your organs if you've a choice.

Instead of providing you more rope to hang yourself with, the government - and society at large - should be providing financial and social assistance to tide you through.

It also opens up a can of worms - where do we draw the line? If the trade of organs are legal, the same arguments could be used to legalize the sale of infants.

If you're very poor and very desperate, it may be both in the child and your best interest to sell the child. After all, if the government provides the right framework and the child is brought up in a loving foster family, the child may have a better shot at life.

And - to follow the reasoning of some of the comments above - legislating the infant trade would make it less exploitative.

We should be helping people out of their misery, instead of getting them to sell some part of themselves in order to seek some form of relief. Isn't that what a progressive society is about?

Anonymous said...

Dear Mr Wang,

1. The buyer pays $X for the organ.
2. The government collects the $X.
3. The government pays the $X to the seller.

4. GST levied on the sales.

The reality is that these has been going on. 20 yrs ago, i have knowof ppl going overseas (to india/indonesia) to get kidneys transplants. Personally and ethically, it is wrong. To effectively implement the controls will be the challege.

Regards,
DIGGO

Anonymous said...

Wang: Interesting point. Perhaps if we allowed hospitals to pay for blood, we wouldn't have the chronic problem of a shortage of blood donors.

Why this isnt done? Is it cos little money is involved? Whereas organ trade is potentially lucrative...

This govt wont do anything that is not "cost-recoverable". And to be cost recoverable, the trade has got to be more lucrative.

In this world it is possible to justify anything in the name of saving lives, do good etc and so on. The real issue is always how much money is involved. And organ trade is potentially worth a lot of money, so screw the ethics.

lobo said...

Anyone knows how long an organ can be stored before it... expires?

Anonymous said...

Paying for blood and organs will cut into profits. why pay when you can harvest for free? Singapore Inc remember? too bad if you are just an employee and not a shareholder/customer.

just for discussion sake, selling organs does not "doom" the society. Afterall, we can exploit OTHER desperately poor countries. Legaliztion means that sellers actually have a choice and get a fair "market" price and buyers get value for $$$.

As George Yeo may say ... "win-win"?

NoName

Anonymous said...

I don't see how your suggestions is related to the helping with the issue of 'exploitation of the poor and of socially disadvantaged'. At All.

Clearly, you have never been poor and desperate :(

Key words: POOR, DESPERATE

Robert L said...

Dear Mr Wang,

Organ trading is, even at best, terribly dicey even in the most open and reliable of countries with the best possible public administration.

In the hands of Singapore's administration, with our questionable judiciary, police and political leaders, it will most certainly turn into a nightmare.

That's my opinion.

yamizi said...

Sir,

How about the current policies for kidney patients who are on the waiting list? If it's their turn, do they have to pay for the kidneys in return?

If the trading is to be legalised, then should the priority be given to the 'by default list' or the list that is 'willing to pay'?

Mr Wang Says So said...

"Anyone knows how long an organ can be stored before it... expires?"

It's not a relevant consideration because demand grossly outstrips supply. In other words, people regularly die, after waiting for years in vain for a kidney.

When a kidney does become available, it is immediately transplanted. There is no question of storing the kidney indefinitely, because, as I said, the demand far outstrips the supply.

Mr Wang Says So said...

"In the hands of Singapore's administration, with our questionable judiciary, police and political leaders, it will most certainly turn into a nightmare."

I don't think so. The kind of accusations that are regularly made against the Singapore judiciary, police and political leaders generally relate accusations about how they favour the ruling party. However, the ruling party has nothing to gain from more patients dying from kidney failure.

family man said...

in an egalitarian world, the govt would put people on the queue, regardless of your income and salary, and because ALL CITIZENS are an asset to the country, the govt would pay the seller through its billion dollars reserves instead of paying for Citi shares or UBS shares. Then all the patients, rich and poor will be given a kidney transplant. But this will not happen in Singapore where only the elites can rule and get treated cos they got the money.

Mr Wang Says So said...

"I don't see how your suggestions is related to the helping with the issue of 'exploitation of the poor and of socially disadvantaged'. At All."

---

I'll give you a few simple examples.

Example 1:

One feature of my proposed system is that the government will fix the price of organs. Let's say, a kidney is fixed at $20,000 (just for example).

When a kidney becomes available, it is then transplanted into a patient with the highest priority, that is, someone who

(1) is most likely to die soon without a kidney transplant;

(2) has good chances of successful recovery, if given the transplant;

(3) has been waiting a very long time for a kidney

and

(4) is able to pay $20,000.

Now, suppose we did not have the kind of rules as I have suggested. Suppose there is no price fixing. What would happen? Something like this, perhaps:

(1) you are very likely to die soon without a kidney transplant;

(2) you have good chances of successful recovery, if given the transplant;

(3) you have been waiting a very long time for a kidney (eg 5 years);

(4) you can afford $20,000

BUT then suddenly an extremely rich patient, who's just been advised yesterday that he needs a transplant, comes along to compete for the kidney. He's ill, but not that ill, he can probably afford to wait another six months or a year without dying, but why would he risk it?

He bids $5,000,000 for the kidney, a sum he can easily afford because he's a business tycoon. Instantly he jumps ahead of you in the queue. As a matter of fact, he jumps ahead of 100 other patients who had been waiting for a kidney far longer than him.

You die. No reason, really, except that you're poorer than him.

Example 2

Without my rules in place, a kidney patient may find a very poor, very desperate person, and offer a very small sum for the man's kidney. Eg $500 (just for example). Remember, the poorer and more desperate you are, the lower the sum you'll be willing to accept.

The poor, desperate person is so desperate that he accepts the offer. He loses one kidney for $500. This seems strongly offensive to our sense of justice.

With my rules in place, the poor desperate person is assured of receiving not $500, but a standard sum fixed by law (eg $20,000).

----

Note - the figures given above are just for illustrative purposes. I actually have little idea what may constitute a fair price for a kidney. I would think that this is something that would require serious consideration by the Health Ministry.

Anonymous said...

question I would like to ask - blood donation is purely altrusitic now - I believe.

But in an emergency, when blood is needed, do the restructured hospital charge the patients for the bags of blood used? Anyone knows.
My point is, are the hospitals making money out of our donated blood? This would sound like employees of GIC / CPF / Temasek holdings, where the only people gaining from our huge reserves are these employees, not the Singaporeans.

Mr Wang Says So said...

"just for discussion sake, selling organs does not "doom" the society. Afterall, we can exploit OTHER desperately poor countries."

-- See Point 1 in my post.

Mr Wang Says So said...

"Then all the patients, rich and poor will be given a kidney transplant. But this will not happen in Singapore where only the elites can rule and get treated cos they got the money.

I think you are still missing the point. This will not happen in Singapore, whether you are rich or poor , because there are not enough kidneys.

Shafted said...

Mr Wang, one recurring point I see here is about "jumping queue" or something similar.

Say there's just a kidney available, but the person on the top of the waitlist is an odd-job labourer. There's a bright young orphan somewhere further down who is likely to reap the most "utility" (since we're all rational and cold) from the kidney, and a multi-millionaire over 60 somewhere furtherdown...

Now that I've done wasting your precious bandwidth, the only possible case of a "trade" is blindingly obvious, since only the millionaire has the cash to carry out any monetary transaction.

It's like arguing that a benevolent dictator will keep an honest gahment whose one and only priority is her people. The idea sure sounds great, but the mandarins implementing it are sure to f it up.

There are just too many loop holes screaming to be exploited. It is more efficient to start of with a sound foundation, which is to keep money out of organ donations.

Mr Wang Says So said...

Shafted:

Are the orphan and the odd job labourer put in any worse position, if organ trading were legalised?

No. They are exactly in the same position as they would have been, if organ trading were illegal.

However, the legalisation of organ trading WOULD improve the survival chances of the 60-year-old millionaire, AND the survival chances of ANY kidney patient who is able to fork out $20,000 to save his own life (eg your average 3-room or 4-room HDB owner). As a matter of fact, under my proposed system, the 60-year-old millionaire holds no advantage over the 3-room or 4-room HDB owner, just by virtue of being a millionaire.

This is what I think you're not seeing. You see the harshness in the system I have proposed, but you are not seeing that the current system already HAS that harshness.

And the root cause of that harshness is simply the fact that people fall ill, people die and we aren't always able to save them.

However, if organ trading were legalised, we would be able to save MORE of them. Because there would be more organs to go around.

This is Dr Lee Wei Ling's point too. If she can't save 10 out of 10 patients, at least she can save 5 out of 10 patients. It's better than have all 10 patients die.

Anonymous said...

Dear Wang

From my *limited* exp working with our beloved neighbours, point 1 is irrelevant if a)they get a cut and b)the sellers get a fair price and c)we (at least pretend to) show respect/gratitude/humility.

Distasteful as it is .. this is life. Lets take incremental steps. Transparency ASAP. Ideals tomorrow.

PS: I agree with points 2 to 5 but Singapore's population(i.e supply) is simply too small to have point 1.

NoName

Shafted said...

If organ trading stays illegal, I'd say the guy on top of the list gets it, else no one does. MoH and the doctors and everyone else involved should make sure the donor gets caught if he tried to sell. Even at the risk of losing that one kidney, since there might be no donors without money involved.

I admit there'll always 2 sides, but saying that you have to break some eggs to make an omelette is taking it a bit too far isn't it? The idea of saving more lives is respectable, but at ANY cost?

Being one of the few countries in modern history to practice state-sanctioned eugenics, I think that is already one omelette too many.

The mentality is not where to draw the line, but if a line should be drawn at all.

That scares me into insisting that checks and balances remains, to give me an illusion of control. Now Mr Wang wants to strip away my last shreds of safety and comfort... I am so Shafted.

Anonymous said...

Dear Mr Wang;

despite your very well argued points, I am still of the opinion that blood, sperm, body parts that will be replaced naturally are the only organs that can be harvested.

As to the commercialization of human organs, it should never be done. Donations on a willing basis is in force and this method should be adequate.

patriot.

Anonymous said...

Consider one thing. Even if they put the blood transfusion as free, it will be added or calculated in somewhere with the hospital bills. I dun think it is covered by the govt.

Philip

Mr Wang Says So said...

"Donations on a willing basis is in force and this method should be adequate."

We may have differences in opinion, but let's get the facts straight. The method is not adequate. Most people who need a kidney transplant do not get a kidney transplant, because a kidney is not available. They just die, after waiting unsuccessfully for years, for a kidney.

Anonymous said...

Wang: let's get the facts straight. The method is not adequate. Most people who need a kidney transplant do not get a kidney transplant, because a kidney is not available. They just die, after waiting unsuccessfully for years, for a kidney.

Want to point out a few things.

1. This may sound harsh, but if they die it is just too bad. The world does not owe anyone a liver. And people must realise money is not the answer to problems.

2. Whether organ trade is legalised or not, or implemented in whatever form, there will always be abuse. But to legalise it, opens up a can of worms, it is a slippery slope. You can see the same logic behind the IR or Casino. But the fear of the unknown should not deter us from exploring further. The principal behind should therefore be grounded on medical ethics instead of expediency.

3. Organ transplant is only a temporary solution not a permanent one. And abuse stems from a question of demand and supply. In the name of economics, i.e. the efficient allocation of resources (kidneys), you may say the current situation is far from ideal. But organ trade cannot be looked at solely from an economics angle, that would be too simplistic. Instead efforts should be poured towards a medical solution.

Me don't have answers. This kind of issue best to explore and discuss some more (a lot more) before jumping to a rash policy decision.

mourinho

Anonymous said...

Well, from the American experience on Prohibition on alcohol, you know what will happen next, don't you? What you don't seek to regulate, but only abolish, will simply go underground and become a more severe problem than before.

Ill Singaporeans who don't know what else to do to save their own lives will wait. Many will die.

Ill Singaporeans who do know what else to do to save their own lives will go overseas, to countries such as India or Thailand. There they will buy organs from poor Indians or Thais.

These Indians or Thais will be much more susceptible to exploitation, since there won't be any rules to protect them.

Meanwhile, the transplants done will be illegal; done under less-than-ideal conditions; perhaps by unlicensed doctors with inferior medical facilities; there is a higher chance of infection etc.

No choice lah. If you're a S'porean kidney patient about to die, it's better to try your luck in India / Thailand, than just die in Singapore. Seriously, what wouldn't you do to save your own life? You'd pay every cent you have, if that would work. What would stop you is those people who loudly protest, "No, no, this can't be allowed, the government would make a profit, I'd much rather all you sick people just lie down & die, that makes me feel happier about my own morals."

Fox said...

Mr Wang,

Many of your suggestions on how the kidney trade can be regulated have actually been implemented in Iran. In fact, I discussed this topic more than a year ago in two blog posts of mine.

Compassionately logical part 1

and

Compassionately logical part 2

lh said...

Legalization sends the message that it is permissible to do so. While demand outstrips supply and people die waiting, it seems logical, possible to set-up a system (with safeguards to reduce exploitation etc), to save at least some lives (as better than none).

But if we look from the donor perspective, who (if not poor, desperate, driven up the wall) would want to even consider giving up his/her organ for money.

legalisation (even with the best intention to save lives) may send wrong signals. While it may be a 'pity' not being able to 'save' lives, it doesn't justify that someone else is permissible to make a trade in order to do so.

if we have a price catalogue for organ, what else can't we have next? It may sound very callous- we all will die and the difference is only how and when. The longer term solution should be along the lines of encouraging more altruistic donors and...taking care of your own organs.

Mr Wang Says So said...

I just did a quick bit of Internet research. Here are the types of organs and tissues which a living person may donate for transplants:

lung, kidney, part of the liver, pancreas islet cells, bone marrow; blood; heart valve; bone; skin; small bowel

The reason is that the living person will either be able to regenerate these organs/tissues, or is quite able to continue normally with life with what's left.

If that is the medical position, I'd invite readers to explain whether they see any big difference between:

(1) giving blood; and
(2) giving a kidney

and why either act suddenly becomes wrong, if money is involved.

To me, it's like saying - "The army needs more soldiers. Young men may volunteer to serve the nation. However, they are not allowed to be paid - they have to do it for free."

It is arguably more hazardous to your life to serve 2 years of NS in a combat vocation, than it is to give up one kidney.

Furthermore, the latter directly saves a life; the former usually does not.

Mr Wang Says So said...

"Consider one thing. Even if they put the blood transfusion as free, it will be added or calculated in somewhere with the hospital bills. I dun think it is covered by the govt."

I invite you to consider what you're saying. Is this your position - human lives should not be saved, unless the government pays for all the medical costs?

Anonymous said...

Is there big difference between donating blood and kidney?

Mr Wang; I presumed you are referring to live donors and if you are, then I would like to say, no one has the ability to regenerate kidney. This is a fact.

On the other hand, blood regenerate so fast that most donors are able to donate twice or even more. Hope I am right as I do not have any medical/scientific qualification.

patriot.

Anonymous said...

Example 1:

It's the rich and relatively rich who can afford to buy organs.

Example 2:

It's almost always the poor and desperate who are going to sell their organs.

Anon June 29, 2008 11:20 PM said...

"If that is the medical position, I'd invite readers to explain whether they see any big difference between:

(1) giving blood; and
(2) giving a kidney

and why either act suddenly becomes wrong, if money is involved."

This is my POV:
1 Blood can be regenerated by the donor, a kidney cannot. Living with one kidney increases the risk of a shorter life span due to renal failure because there isn't another kidney to fall back on. Although I must qualify that I do not know whether both kidneys usually fail together or one can be healthy and unaffected by the other diseased one.

2 Sure, sellers have the right to choose and sell their organs for much needed cash and buyers have the right to live, but the potential indirect consequences are many. They include parents abusing their children by forcing them to sell their organs, depriving those on the queue who might otherwise get their transplant if it weren't for somebody rich who bought the available organ, middlemen profiteering, doctors ordering transplants indiscriminately just to boost their track records, etc.

Many who argued for the case have overlooked the consequences and question of ethics. Is it ethical to rob another of a chance of transplant because one can afford to buy over an organ meant for one who cannot afford to but is next on the queue?

Is it justifiable to 'give the gift of life' to many more by sacrificing a few? Does it mean those who have money have the right to rob others of their lives?

Organs and life is not a matter of only digits but human beings with feelings, families, life stories. If we see this issue as a matter of digits, we have lost sight of humanity, what it means to be human.

If for one will not be able to live peacefully for the rest of my life if I have bought an organ meant for someone else who has perished as a result of being deprived of his transplant.

I will be as good as a murderer.

Anonymous said...

Some questions and after-thought:
1) Will there still be poeple willing to donate an organ (for free), if it could be sold at a price?
2) If someone dies and the organ could be used for transplant, should the family get some monetary returns? (The family could be widowed by a young father who was the main income source. Or there could be a set of parents who had invested everything on their only child for their old age, only to have the child pass before them. They can definitely benefit from the money for the organ(s).)
3) What are the chances of a poor person, who cannot pay for an organ, to get a transplant?
4) There are no aboslute infallable system in the world. Will this organ trading issue be 'slippery slope theory' or 'false delimma' or in time, both?

Anonymous said...

I donated blood a few times but decided to discontinue because I was not sure who the blood was given to.

Many told me the blood will be transfused at no cost to recipients, I felt that was no consolation. The many oversea(paying) patients that received medical/healthcares are mainly for more serious illnesses. I suspect many of them need surgeries and operations which require much blood.

Though blood may not be billed at cost, paying patients maybe given priorities to it in relation to their overall medical needs. When such arrangements occur, I do not know if locals would be deprived of his/her turn to the blood.

As, I was unable to confirm/verify my doubt, I decided to cease donating(blood).

patriot.

Robert L said...

It appears to me that we are all being herded like sheep along a particular direction. The media got us all talking about the pain and suffering of kidney patients.

Nobody is talking about the pain and suffering of kidney donors. Why the silence? Can somebody enlighten us what the donors go through?

What are the statistics of botched operations? Or of less than 100% successful operations? Of contagion picked up in hospital stay. What are the long-term effects - how many years reduction in lifespan are experienced by those who have donated their kidneys? What drop in quality of life do they experience - are they unable to play a round of golf, run a marathon, climb Mt Everest?

If any readers are not happy with my examples, feel free to substitute your own, for example, instead of golf, think about working a 12-hour shift being reduced to working a 6-hour shift.

I don't have the answers, the media is not talking about it. All they say is about "informed consent". God knows what kind of information they provide to the donors for them to give consent.

It's only today that a reader wrote in to tell us that the so-called ethics committee is made up of two doctors and a lay person, all volunteers, who do not have the means to investigate the truth of patients' submissions. This is the dicey way the Singapore administration system works. With full collaboration from the media.

Now that the ethics committee have made a mistake, do members of that committee graciously step down and tell us that the system is not working?

All the pillars of the Singapore administration systems have crumbled. The judiciary, the police, the political leaders. That's my opinion. Just look at the illegal trade caught last week. They are punishing the poor victim, the one who would have parted with his kidney. What about the one who sought to buy it? Isn't he comparatively the greater evil?

When you catch a child prostitute selling his body to a client, who do you judge is the greater evil? The person selling his body or the one buying?

Letting Singapore run an organ-trading industry is the utmost folly.

Anonymous said...

I invite you to consider what you're saying. Is this your position - human lives should not be saved, unless the government pays for all the medical costs?

Ehh, this is not my position

But in an emergency, when blood is needed, do the restructured hospital charge the patients for the bags of blood used? Anyone knows.
My point is, are the hospitals making money out of our donated blood? This would sound like employees of GIC / CPF / Temasek holdings, where the only people gaining from our huge reserves are these employees, not the Singaporeans.

June 30, 2008 10:37 PM

Was just replying to this person

Philip

SHIMURE said...

Under current practice, if you are a regular blood donor, you get free medical assistance for the government hospitals. that is if you donate blood 4 times in 1 year.

I know cos i donate blood on a regular basis.

Perhaps if you donate kidneys or stuff like that the government could also have policies on these lines?

As for the money issue.....

Well if the government does become the middle man in such issues, it is likely that they will impose a tax on the transaction and this would in terms lead to another revenue form of the government.

What i am afraid for is not so much that people will not get money for their organs.

it is more that the right people may not get the right organs for the right time.....

Another thing is if the organ transfer failed or is rejected? the first thing which the business tycoon would sue the person whom he bought the kidney from which will lead to the donor becoming even more poor and desperate.

Random rant from random thoughts...

sorry if i am too random.

Fox said...

To Anon June 29, 2008 11:20 PM:

1 Blood can be regenerated by the donor, a kidney cannot. Living with one kidney increases the risk of a shorter life span due to renal failure because there isn't another kidney to fall back on. Although I must qualify that I do not know whether both kidneys usually fail together or one can be healthy and unaffected by the other diseased one.

No. You can live perfectly well with one kidney. There is no evidence that the risk of the shorter lifespan will increase. Taken from the University of Maryland Medical Center's FAQ:

"Death from kidney donation is extremely rare (about 3 in 10,000). Donating a kidney does not change your life expectancy nor does it increase your chance of kidney failure. The health effects of kidney donation have been and continue to be carefully studied by several research groups in the United States. This research has shown that kidney donation does not appear to put donors at any increased risk for future health problems."

Although you cannot regenerate a kidney, you can obtain another one through a kidney transplant. Even if you suffer from a kidney failure as a result of a freak injury to your remaining kidney, it is very possible for the healthcare system to take care of you by buying you another one.

2 Sure, sellers have the right to choose and sell their organs for much needed cash and buyers have the right to live, but the potential indirect consequences are many. They include parents abusing their children by forcing them to sell their organs, depriving those on the queue who might otherwise get their transplant if it weren't for somebody rich who bought the available organ, middlemen profiteering, doctors ordering transplants indiscriminately just to boost their track records, etc.

Middlemen profiteering is not possible in a public healthcare system where you cut out the middleman like in Iran.

If for one will not be able to live peacefully for the rest of my life if I have bought an organ meant for someone else who has perished as a result of being deprived of his transplant.

In the present system, you can only get your kidney from cadavers and relatives. When paid donation is allowed, the supply of kidneys increases significantly. You won't be depriving anyone of anything.

Please see

1. Compassionately Logical: Part 1
2. Compassionately Logical: Part 2

for further details. I strongly recommend that you read the provided links.

Fox said...

I should add that it is possible for poor people to have access to kidney transplants in a system where donors are paid. For example, in Singapore, kidney dialysis is very costly and beyond the reach of many poor individuals who need it. However, they do receive subsidies and financial assistance from the charitable organisations and the government to go for kidney dialysis.

Also, kidney dialysis is expensive. The cost of a kidney transplant is comparable to the cost of years of dialysis. There are vested financial interest in reducing the availability of kidney transplants.

Fox said...

To robert l,

Here are some information. Taken from http://www.umm.edu/transplant/kidney/qanda.htm

"A person can lead an active, normal life with only one kidney. Studies have shown that one kidney is sufficient to keep the body healthy. After recovering from surgery, a donor can work, drive, exercise and participate in sports, though contact sports are not recommended. A donor can continue in all types of occupations, including military duty. Also, being a donor does not impact a person’s ability to have a child."

and

"The risks of donation are similar to those involved with any major surgery, such as bleeding and infection. Death resulting from kidney donation is extremely rare. Current research indicates that kidney donation does not change life expectancy or increase a person’s risks of developing kidney disease or other health problems."

Anon June 29, 2008 11:20 PM said...

Fox,

You have misunderstood what I meant. With other factors remaining constant, who would stand a chance to live longer? A person with one or two kidney? I'd say, the latter because he has a kidney to fall back on and he does not need to depend on a transplant, which may never materialise.

I do not know about you, but it pricks my conscience, even knowing that a person has given his kidney to me for the above reason. Worse still if he has to sell his kidney, which means that he wouldn't have been really desperate for money and I am in a way exploiting his plight for my benefit.

You keep linking the case of Iran here but which other country can you cite? If Iran's system is worthy of emulation, won't there be many other countries following suit? And for what reason?

And to those who argue that since there is a black market, may as well legalise it, I'd ask, are you sure there won't be any more black markets once organ trading is legalised? After all, it is still controlled by the government and buyers, especially the very rich, cannot temper with the system for maximum benefit and expediency.

Onlooker said...

Can of worms waiting to be exposed.
Post transplant Diabetes.
Doctor ethics(Hippocrates Oath).
Dr Lee suggestion will become exploited by those with the means.

Mr Wang Says So said...

Letter from ST Forum today:

"Win-win for all, so change the law

I READ with interest of the case where Indonesian kidney patient Juliana Soh paid $27,500 to Indonesian donor Toni. She got a kidney from him. The operation was done by a well-qualified doctor.
Ms Soh is happy because now she can lead a normal life without having to go for dialysis three times a week.

Mr Toni is happy too. He got $27,500. The amount, which converts to 186 million rupiah, will help him lead a better life. Since the operation was performed by a well-qualified doctor, who will make sure he gets post-operation care, he can lead a normal, healthy life. His family are happy because they have come out of poverty. So far, everyone is happy.

Health Minister Khaw Boon Wan says that, whatever the circumstances, the law has been broken and must take its course.

I write to ask that, if the act of buying and selling a kidney, which has given a new life to Ms Soh and made Mr Toni's family financially secure, is against the law, is it not the duty of the authorities to change the law so that controlled buying and selling of organs is legal?

Thousands of patients needing kidneys will be very happy if they can find a place where they can legally buy a kidney and have the operation done under the care of experts.


B.H. Melwani"

Mr Wang Says So said...

Some info concerning liver transplants:

Typically the donor gives up only part of his liver. Livers are able to regenerate. Thus the donor's liver should grow back to full size within four to six weeks.

Mr Wang Says So said...

"Another thing is if the organ transfer failed or is rejected? the first thing which the business tycoon would sue the person whom he bought the kidney from which will lead to the donor becoming even more poor and desperate."

This is a rather simple issue which a change of law can easily address.

Anon June 29, 2008 11:20 PM said...

B.H. Melwani would do better to look beyond just one case and imagine the kind of society we would become. The Indonesian donor might be happy, but for how long? Desperate people tend to make decisions based on urgency, not long term view. Will he regret later if one of his loved ones needs a kidney and he is unable to donate?

http://news.bbc.co.uk/2/hi/programmes/this_world/6090468.stm

Thanks to Fox for the above link and the following one:

http://cjasn.asnjournals.org/cgi/content/full/1/6/1136

Believe me, I have tried to look at the Iranian model for its merits but the only merit it keeps repeating is that there is no more queue for transplant, but fails to address the ethical and social problems, and the fact that US and Canada managed to increase the number of altruistic donations without the need for organ trading.

On further scrutiny, the system is not wholly government controlled and cleans as it claims, because recipients are allowed to give rewards to donors at their discretion. Correct me if I am wrong.

Also, the government seems to be spending a huge amount of funds to provide free treatment, insurance and awards. Would that translate to 15% GST in Singapore? Would the rich who wish to buy kidneys gladly bear the cost of increase in GST for the rest?

Furthermore, would those who argue for organ trading because it saves more lives give up one of their own kidneys? After all, their main concern is to save lives.

Which country's environment would we prefer to live in? Iran? US? Canada? Which is a more gracious society?

Also, notice that the legalization of organ trading benefits the rich at the expense of the poor because there were no supply of organs at all from the rich, but increase in supply from the poor to meet demand from the rich.

Like some have suggested, it would be better to put in more efforts encouraging altruistic giving, educating people to take care of their own organs and medical research for other cures rather than degenerate into a dollar driven society.

Mr Wang Says So said...

I think that this rich/poor dichotomy is somewhat misleading.

Firstly, we don't even know what $X would be. We only know that to fix $X, we want to balance two competing concerns:

1. that $X is not so high that only the very, very rich can afford it;

and

2. that $X is not so low that the organ sellers are under-compensated.

The second thing is that your life is so precious that you would willingly pay just about any price for it.

For example, if $X is $150,000, this seems like a large sum which only the very rich can afford. However, actually many Singaporeans can afford $150,000, if their lives depended on it.

Even if you only own a humble HDB two-room flat, you could probably sell it for more than $150,000 (based on current market prices) to buy your organ. It would be a completely logical decision too. Your flat is useless to you, if you're dead.

Now, from the seller's perspective. Okay, let's imagine that you're really poor and really desperate. Say you're a Geylang prostitute with two young kids to support. You can barely afford to feed them and send them to primary school.

Then you sell your kidney for $150,000. Instantly, you can stop prostituting yourself; you can send your kids to school; food is no longer a concern; and you can hope that they will get enough education to lead a better life.

And you know from the available medical research that donating a kidney simply does not lower your life expectancy. (Whereas being a prostitute does definitely lower your life expectancy, due to AIDS).

Is selling your kidney then really such a bad idea? Is it really worse than continuing to be forced to be a prostitute?

Personally I don't think so. I think that the person must judge for herself. But naturally if organ trading is not permitted then the option never becomes available.

---

Additional note: My understanding is that:

(a) one normal kidney can do the work of two normal kidneys;

(b) where kidney failure occurs, it normally hits both kidneys anyway.

This is why the medical studies are showing no difference in the life expectancies of people who have only one kidney; and people who have two.

---

Further additional note:

Anonymous said...

I find it ridiculous that the two aspects of the HOTA act are so contradictory.

On the one hand, monetary compensation of a donor for giving up a kidney of his own free will is illegal. Even though steps can be taken to ensure that the donor is properly counseled on the risks and consequences of the operation, just as it is already done for any medical procedure or operation here in Singapore. In the meantime, appropriate testing can be done to ensure the donor and recipient is a match, that donor is free of infectious disease that may be spread to the recipient. However, once monetary transfer from the recipient to the donor is involved, the case is deemed illegal, no questions asked.

On the other hand, the government forcibly presumes that, unless you actively make a statutory declaration otherwise, your organs are to be made available for donation. In theory, this makes for a great leap in nationwide altruism. In effect, it causes great misery for the family members of the new 'donor', who should rightfully bear responsibility for the disposal of the patient's body. Furthermore, due to the nature of events, thorough testing of the donor organs for infectious diseases cannot be carried out. This poses risks for the recipient as well.

To those who argue that organ trading is a slippery slope, that it opens a can of worms, it may be worth considering that with the current legislation we have (no other country has this presumed opt-out procedure for organ donation upon brain death, though some are thinking about it), the position we are in is really no different, and legalising organ trade is actually an improvement of the situation.

Fox said...

To Anon June 29, 2008 11:20 PM:

Believe me, I have tried to look at the Iranian model for its merits but the only merit it keeps repeating is that there is no more queue for transplant, but fails to address the ethical and social problems, and the fact that US and Canada managed to increase the number of altruistic donations without the need for organ trading.

In Iran, while most of the donors are poor (84 percent), most of the recepients also belong to the poor socioeconomic class (50.4 percent). In fact, the amazing thing is, being poor does not lower one's chances of getting a kidney transplant because the donor is paid by the government, not the recepient.

Secondly, the link to the article on the Iranian paper does discuss the ethical issues associated with paid living-unrelated kidney transpants.

In the US and Canada, there are still long waiting lists for kidney transplants. People still die from waiting for a suitable donor. Ideally, one should not have to undergo kidney dialysis before getting a kidney; as soon as one has End Stage Renal Dysfunction (ESRD), you should get a kidney transplant immediately. The longer one is on dialysis before the transplant, the less effective the transplant operation. Also, it is better to have a kidney from a living donor than a cadaveric donor.

It is very probable that we will never have enough kidneys available for transplant just from altruistic donations. Who in Singapore will give a kidney to an unrelated person? Just look at Singapore, we can't even obtain enough blood units from altruistic donation for hospital use and we have to import blood units from other countries. We have to be realistic about the social attitudes towards organ donation in Singapore.

Iran is a relevant example for Singapore because

1. It has a predominantly Muslim country and we have a large Muslim popuation.
2. Its peoples' attitude towards living-unrelated organ donation is closer to Singapore's than countries like the US.

Also, the government seems to be spending a huge amount of funds to provide free treatment, insurance and awards. Would that translate to 15% GST in Singapore? Would the rich who wish to buy kidneys gladly bear the cost of increase in GST for the rest?

Dialysis in Singapore is not free. It is expensive and the costs are largely borne by the patient with support from charitable organisations, not the government. Also, patients on dialysis have worse health than patients who have had a kidney tranplant. They are less able to support themselves. I say this to remind you that there is already a high socioeconomic cost to continuing with the current practice of keeping patients on dialysis. Whether the government pays for it is a peripheral issue.

Also, since it is medical benefit to our fellow citizens, why shouldn't we help to pay? Even if you do not wish to pay, then we could resort to a system where the main source of financial support for kidney transplants comes from regulated charitable organisations similar to the way we support dialysis.

In Iran, dialysis used to be free. I say 'used to' because there is no longer any significant need for dialysis as most patients (poor and rich) with ESRD get their kidneys as soon as they need it. Rather than channel resources to dialysis, Iran shifted its resources to support renal transplant.

Also, notice that the legalization of organ trading benefits the rich at the expense of the poor because there were no supply of organs at all from the rich, but increase in supply from the poor to meet demand from the rich.

Poor people also need and get kidneys transplants in Iran.

Like some have suggested, it would be better to put in more efforts encouraging altruistic giving, educating people to take care of their own organs and medical research for other cures rather than degenerate into a dollar driven society.

Yes, please support the assertion that it is better.

Better in terms of what?

Certainly not in terms of improving people's health.

Or in terms of overall healthcare cost.

Or in terms of relieving human suffering.

People die when there are not enough kidneys for transplants. People's health suffer and deteriorate while waiting for a kidney transplant. There are just not enough kidneys to go around from pure altruistic donation.

Furthermore, would those who argue for organ trading because it saves more lives give up one of their own kidneys?

I don't see the relevance. Would those who argue for living-unrelated altruistic donation give up one of their kidneys?

If you are poor and with ESRD in need to a kidney tranplant, I would say that you are better off in Iran than in Singapore or in the US.

Anon June 29, 2008 11:20 PM said...

May I suggest as we mull over this issue that we ask ourselves whether we are willing to donate one of our two healthy kidneys if we truly believe the donor will not suffer any loss living with only one kidney.

If our answer is yes, then there is hope for more donations by educating the public about the fact that there is no difference having one or two kidneys.

If we cannot bring ourselves to donate, or even sell for monetary reward, then we need to ask ourselves why. Do we really believe it is fine to have only one kidney or does it only apply to others, but not for us to live in that condition.

I think only altruistic donors will not regret and be truly happy living with one kidney for the rest of their lives.

My apologies for taking so much space.

Fox said...

Some info concerning liver transplants:

Typically the donor gives up only part of his liver. Livers are able to regenerate. Thus the donor's liver should grow back to full size within four to six weeks.


Mr Wang, the surgical risks of liver transplant operations are much higher. There is a 1 in 200 chance of surgical complications from liver transplant operation. Such surgeries tend to more complicated than kidney transplant operations which carry a 3 in 10000 chance of surgical complications. I would not recommend liver trading.

On the other hand, a kidney transplant operation is as safe as child birth.

Palliative care and medical research said...

My personal ethics goes with Patriot July 1, 2008 11:41 AM that “blood, sperm, body parts that will be replaced naturally are the only organs that can be harvested”.

My 2-cents worth in this long post.

(A) People die

Fox July 2, 2008 9:22 PM wrote, "People die when there are not enough kidneys for transplants".

The universal truth to being alive is to die eventually. Why is the death of a ESKD patient due to unavailability of donors more regrettable than death by other means? If one consider those on ESKD to be terminally ill, then going by the current norms of palliative care, priority should really be helping the patients come to terms with their life and impending death. If a suitable cadaver donor is available, then the patient can count it as fate intervening. By extending the life of the patient (and potentially reducing the life of the donor), does one really address the issue of the ESKD patient being not ready to die when he/she will die eventually anyway?

To anonymous July 1, 2008 2:48 PM who asked, "Seriously, what wouldn't you do to save your own life?".

It is all hypothetical, so I don't really know. My current personal value would be to choose palliative care to ease my death and focus on tying the loose-ends where possible with whatever limited time I have left. I would not choose to convince a poor desperate person to sell his kidney just to extend my life. If the donor's a cadaver, then I'll treat it as fate giving me an extension.

(B) Medical ethics vs expediency

mourinhoJuly 1, 2008 2:16 PM mentioned, “principal behind should therefore be grounded on medical ethics instead of expediency... Instead efforts should be poured towards a medical solution".

Indeed, legalisation of organ trading may become a quick-fix that may detract one from developing long-term medical solution, e.g. stem cell research for regenerating tissues. One need look no further that the current oil and environmental crisis to see a parallel. Please consider how taking a long-term view benefits to our future generations.

As anonymous July 2, 2008 4:54 PM mentioned, "Like some have suggested, it would be better to put in more efforts encouraging altruistic giving, educating people to take care of their own organs and medical research for other cures rather than degenerate into a dollar driven society".

Most of the ESKD patients are not in the state because they were born with it. Majority are there due to a lifetime of bad health habits and/or lack of access to healthcare. Wouldn't it be more effective to take preventive steps (e.g. education, supporting lifestyle changes) to address the underlying causes?

(C) Taking advantage of the poor desperate

Anon July 2, 2008 9:38 PM wrote, "If we cannot bring ourselves to donate, or even sell for monetary reward, then we need to ask ourselves why. Do we really believe it is fine to have only one kidney or does it only apply to others, but not for us to live in that condition".

Thanks for the sharp question. It brings to mind the implicit question, if we cannot accept ourselves being in the donor's situation, how can it be argued as not taking advantage of another person's misery? Why twist it into "helping the poor desperate"?

(D) Opt-out HOTA

Anon July 2, 2008 9:21 PM wrote, "the current legislation we have (no other country has this presumed opt-out procedure for organ donation upon brain death, though some are thinking about it), the position we are in is really no different, and legalising organ trade is actually an improvement of the situation".

2 wrongs don't make a right. If one disagree with the existing HOTA presumed consent for cadavers, then one should support correcting the regulation back into the opt-in scheme. To argue for legalising organ trade because it is deemed "an improvement" is not addressing the real issue.

My opinion is that the cadaver organs available from HOTA should NOT be put up for sale to the highest bidder. The current "tissue-matching and needs-based" queue should still apply to HOTA sourced organs to prevent the relatively richer from jumping the queue (be it millionaire vs HDB-flat dweller, or HDB-flat dweller vs HDB-renter). Lastly, the current HOTA system is needs to be a lot more transparent... there are insinuations flying around of dead citizen organs going to non-citizens who somehow became a priority, see also section (F) below. This lack-of-transparency hinders Singapore from becoming a reputable medical hub.

(E) Legalising because black market exist

The "since there is a black market, may as well legalise it” argument does not hold water. There are also lots of other black market like loansharks, etc, should those also be legalised because it exist?

If there are other arguments such as "can save lives" then please put those arguments forward, rather than the above.

(F) Singapore Citizenship/PRship

Just a thought that restricting both donor and recipients to Singapore Citizens or Singapore PRs may not prevent abuse, it merely raises the price higher.

Consider the common understanding that Singapore Citizenship or PRship "can be bought" with enough millions. Thus, a suitably rich foreign recipient can buy the requisite citizenship/PRship for himself to qualify himself for a legally bought organ. If a Singapore citizen's organ is not available, the donor may buy the requisite citizenship/PRship for his paid foreign donor too. Thus, the legal organ transplant can get done. If one's thinking of attracting the rich recipient as a Foreign Talent, after the transplant, the rich recipient can still move on to other countries without further contribution to Singapore. However, the newly-minted Singapore citizen/PR organ donor is left behind to depend on the Singapore healthcare.

Is that good for Singapore? How does that benefit Singapore Inc? How does that benefit the Singaporeans?

Anonymous said...

Dear Mr Wang

Sadly I have little faith in Ministar Khaw to handle the legalization of organ trading fairly.

I know what u say about the world being a reflection of yourself. Can you please try to meet up with him more often?

NoName

Fox said...

To Palliative care and medical research:

"Why is the death of a ESKD patient due to unavailability of donors more regrettable than death by other means?"

Because this unavailability is artificial and preventable? If donors are paid, then donated kidneys will become more available. The needlessness of people dying when there is a ready solution disturbs me.

I advocate paid kidney donation because

1. it is no less safer than childbirth
2. studies show that the donor does not suffer any long term health effects from donating one kidney.
3. studies also show that we can all live with one kidney.
4. kidney transplant operation is relatively simple.
5. there simply aren't enough kidneys from altruistic donations.

Points 1 and 2 are universally ignored by people who argue against kidney donation.

Let's suppose we have a universal legalized paid kidney donation system in Singapore. People who donate one of their kidneys can expect some kind of legalized state-aid to buy another one in the very very rare case their remaining kidney fails. In a system that only allows only altruistic donation, I have no such assurance. I don't even get compensated for time off to prepare my self for the pre-surgical screening and the post-surgical care.

"If a suitable cadaver donor is available, then the patient can count it as fate intervening. By extending the life of the patient (and potentially reducing the life of the donor), does one really address the issue of the ESKD patient being not ready to die when he/she will die eventually anyway?"

That is a whole another issue. There is no reducing of the life of the donor. Where is the evidence that your life will be shortened by donating one kidney, apart from the inherent risk of undergoing a surgical operation?. Kidney transplants have been around for more than 50 years and numerous studies have conducted. Which major study shows that donors suffer any health problems from donating/living with one kidney? Not a single bloody one.

"I would not choose to convince a poor desperate person to sell his kidney just to extend my life."

That is extremely condescending to poor people who perform all kinds of jobs that the average richer people shun. Poor people have their dignities too. Foreign domestic helpers wouldn't be in Singapore if not for the poverty in their home countries. Foreign construction workers wouldn't be in Singapore in the construction industry, where many die or get injured each year from workplace accidents, if not for the poverty in their home countries. I suggest you move out of your home immediately to live in a tent since your house/apartment is most likely built by poor desperate foreigners.

"Indeed, legalisation of organ trading may become a quick-fix that may detract one from developing long-term medical solution, e.g. stem cell research for regenerating tissues."

Where is the evidence that organ-trading of kidneys will detract from developing long-term medical solution? It's irresponsible to make such assertions without evidence.

In any case, why isn't paid living-unrelated kidney donation a long-term medical solution? And why do you need a long-term medical solution when you think that palliative care and helping people to come to terms with death is more important?

"Most of the ESKD patients are not in the state because they were born with it. Majority are there due to a lifetime of bad health habits and/or lack of access to healthcare. Wouldn't it be more effective to take preventive steps (e.g. education, supporting lifestyle changes) to address the underlying causes?"

You can say the same about stomach cancer, lung cancer, heart conditions, etc. The majority of people with these conditions get it from a combination of bad health habits. I don't think taking preventative steps means that we should stop heart surgery, colonoscopy, etc. In any case, preventative care can be promoted in conjunction with treatment. They are not exclusive.

"Thanks for the sharp question. It brings to mind the implicit question, if we cannot accept ourselves being in the donor's situation, how can it be argued as not taking advantage of another person's misery?"

The alternative to paid living-unrelated altruistic kidney donation is unpaid living-unrelated altruistic kidney donation. OK. In that case, where are the hordes of people who advocate the latter option and have signed up to give away their kidneys for free?

"My opinion is that the cadaver organs available from HOTA should NOT be put up for sale to the highest bidder."

In the Iranian system with paid living-unrelated kidney donations, organs - living and cadaveric - are allocated on the basis of medical need. The state buys the kidneys from the donor. Poor people are not denied kidney transplants in Iran. That's the beauty of their system.

Anonymous said...

A question that comes to mind after reading the posts up to now is; if human organs are commercialized. Will the family of a deceased get 'compensated' monetarily if the deceaseds' organ(s)are compulsorily harvested? And at what price?

patriot.

Anonymous said...

Today's ST report by Ben Nadarajan was pretty upsetting. Whether it was in mitigation or a reality, it was reported that that donor is not at all healthy right now and suffering. If that is the case, ST definitely gave a very very bad spin on altruistic donation of kidney, as well as sale of kidney. Seriously, the operation was carried out in Singapore and the donor / seller is now complaining of ill health.

Anon June 29, 2008 11:20 PM said...

Fox, I do not know about others, but I have never claimed that saving lives, especially at all costs, should be a priority. I have disagreed with the quick fix from the start but that is the position of the proponents of organ trading. Saving lives seems to be an extremely noble cause until we investigate further. It is not so noble if we tout that as the supreme motivation but stop short of walking the talk. Which is why I asked to examine ourselves to see whether we would truly donate if we believe saving lives is of utmost importance and living with one kidney is absolutely fine.

It is not to embarrass anyone, but I feel that leading by example to donate a kidney is the best way to convince potential donors of your claims. Given the many doctors, medical experts and people who place so much importance on saving lives and who claim it is safe, if they each contribute one, we would have achieved two goals – increasing organ supply and progressing to a more gracious altruistic society. Isn’t that what the government encourages?

As for those who ask who is to judge whether the poor should sell his organ, especially since he appears happy, I would ask again – do they think anyone would sell his organ ‘voluntarily’? Would they themselves part with a kidney for money? Show me an example of someone who did so when he did not need the money.

It might seem cruel to let the dying go, but have we thought about how they arrived at that point in the first place? For those who abused their organs, is it ethical to expect others to make sacrifices? As for the argument that living donor organs are better than those from the deceased, is it justifiable to prolong one’s longevity at the expense of a helpless other?

Would things be different when I am at my deathbed? No, I will accept that it is time to go if there is no donor from HOTA. I support HOTA, although it can do with more transparency and checks, but not organ trading due to ethical and social problems. I am also not convinced that one kidney is just as good as two because those who claim it is have yet to walk the talk.

In Iran’s case, 80% or so of the organs came from the poor but only 50% or so went to them. The balance went to the not so poor and the rich. Incidentally, the rich did not contribute at all to the organ pool. And looking at the BBC article, the pathetic condition of the desperate advertising to sell their organs and the paltry and dwindling sums being offered to them, doesn’t it come across as the rich exploiting the poor and squeezing as much value from their money as possible? Are they really helping the poor? I do not wish this to happen in Singapore.

By the way, is Iran considered a first world country? Is the percentage of Muslims comparable to Singapore’s? Are we comparing apples to oranges?

Fox said...

"Which is why I asked to examine ourselves to see whether we would truly donate if we believe saving lives is of utmost importance and living with one kidney is absolutely fine."

I wonder if it ever occurred to you that the kidney transplant operation, like any other surgical procedure, carries the risk to complications. While I claimed that you can live fine with just one kidney, I never claimed that the transplant operation would be 100 percent safe.

The fact is, different jobs have different risks. That's why oil rig workers are paid more than oil field workers. That's why commandos in the army receive hazard allowances even though commandos live perfectly as well as other soldiers. The idea is that we compensate people properly for the risk they take.

"As for those who ask who is to judge whether the poor should sell his organ, especially since he appears happy, I would ask again – do they think anyone would sell his organ ‘voluntarily’? Would they themselves part with a kidney for money? Show me an example of someone who did so when he did not need the money."

Your house/apartment was probably built by poor foreign construction workers who did so because they needed the money. So what?

"Would things be different when I am at my deathbed? No, I will accept that it is time to go if there is no donor from HOTA."

That's your business if you object to paid living-unrelated kidney transplants. Who are you to tell others that they can't donate for money?

"In Iran’s case, 80% or so of the organs came from the poor but only 50% or so went to them. The balance went to the not so poor and the rich. Incidentally, the rich did not contribute at all to the organ pool."

So what if the rich do not their organ pool? So? The rich did not help to build the house/apartment you live in. The rich do not sign up to be grunts in the army or join the police force. The rich do not clean public toilets. The rich do not work on oil rigs. The rich do not drive taxis or buses. The rich do not work as nurses in public hospitals.

Since you consider buying services from the poor to be a bad thing, why do you live in a house/apartment? Why do you take the bus? Why do you go to hospitals? Why do you use the public toilets?

"By the way, is Iran considered a first world country?"

No. But what does it matter? How is its not being a first world country relevant to the debate?

Robert L said...

I'm sorry to see that the pro kidney-trading arguments have grown increasingly more strident and unreasonable.

I come back to post only because of a particularly ridiculous claim that has been repeated a few times, and it would be wrong not to put it right.

Quote: donating kidney is no less safer than childbirth.

That sounds absurd to me. I'm not sure how to explain it, maybe I can get through this way: "a perfectly healthy kidney donor is no less safer than a perfectly healthy woman giving birth."

That would reveal clearly why that statement is wrong. A perfectly healthy woman giving birth is clearly not at all at any risk, or it's miniscule at most.

It is clearly dishonest for the pro kidney-trading camp to compare kidney donation by a perfectly healthy person with the average risks of childbirth, which includes the healthy mothers as well as the less than healthy and the elderly. Even if you come up with the risks being equal, you are still short-changing the healthy individual by exposing him to the greater risks of the unhealthy and the elderly.

Palliative care and medical research said...

Fox: "The needlessness of people dying when there is a ready solution disturbs me".

With increasingly complexity of medical options available, extending lives is no longer always the right answer. E.g. The introduction of DNR (Do Not Resusitate) or AMD (Advanced Medical Directives). Palliative care for the dying isn't just about taking care of their physical issues, but also about facilitating their psychological and spiritual well-being while facing death. Afterall, death is a universal end to being alive and is the final step in one's life journey.

Fox, it is very clear that we start-off from different perspectives. Unlike you, I agree with anon june 29, 2008 11:20 pm that "saving lives, especially at all costs," should NOT be a priority.

Like Dr Huang, I do not agree with the current laws that allow for unrelated living-donors. It opens big a loophole for exploitation, which the current cases cited in the news illustrate.

Fox: "I don't even get compensated for time off to prepare my self for the pre-surgical screening and the post-surgical care".

If your close family member, e.g. your mom or dad, were to need a kidney, and you're found to be a good match, would you donate? When you're donating to your mom/dad, would you be asking them to compensate you for your " time off to prepare"?

From wikipedia: Altruism focuses on a motivation to help others or a want to do good without reward.

In asking for compensation, one is not quite getting the meaning of altruism. If you're willing to do it without reward because it's your mom/dad, then kudos for being an example of the norms that only related-living donors are likely to be altruistic donors.

Fox: "In that case, where are the hordes of people who advocate the latter option and have signed up to give away their kidneys for free?"

As in the above example, it is my observation of human nature that people are likely to offer to be living-donors if it means saving their loved ones' life... again assuming that the dying hasn't already lived to a ripe old age. That's why real altruistic living donors are likely to be those with close ties. Just sharing my observation, if you want the evidence, please do your own polling and research.

Fox: "The alternative to paid living-unrelated altruistic kidney donation is unpaid living-unrelated altruistic kidney donation".

No, living-unrelated altruistic kidney donation is not the only alternative. Other alternatives include cadaver donors and facing one's death (with support from palliative care). For cadaver donors from HOTA, I think the existing system is in need of more transparency.

Fox: "Points 1 and 2 are universally ignored by people who argue against kidney donation".

Ok, just to humour you. Assuming that organ trading becomes legal, would you then offer your kidney for sale if you're given $X that will buy you a lifestyle that you can only achieve after decades of your normal work-life in Singapore? Why?

Actually I read and ignored all 5 of your points because they are irrelevant when one starts from the perspective that irreplaceable human body parts are sacrosanct. Making such a sacrosanct gift amongst living-related donor-recipient is an ultimate declaration of love. What would that say of our humanity to commercialise it? Are our relatively poorer fellow humans merely Boxers to our relatively affluent piggy-lives in Animal Farm?

What happens after years down the road when the donated kidney in the recipient fail again? Does the rich recipient procure yet another organ to further extend his life? How many persons' organ is he allowed to buy before he is ready to face the reality that death comes to all?

Me: "I would not choose to convince a poor desperate person to sell his kidney just to extend my life."

Fox: "That is extremely condescending to poor people who perform all kinds of jobs that the average richer people shun".

I don't see how my refusal to take advantage of the poor by buying his sacrosanct irreplaceable body parts condescending. On the other hand, your example is not an apple-to-apple comparison. How many of these workers will go home with an irreplaceable part of their body missing due to industrial accidents? Do the Singapore laws protect these workers and punish the guilty to minimise such risks or does it just say "ok, go ahead, have a hazardous work site because these poor workers will have Workmen Compensation anyway"? Your example seems to be on a different issue to me. Perhaps we can discuss further if Mr Wang writes in future on the plight of these foreign workers?

Fox: "It's irresponsible to make such assertions without evidence".

Ha ha ha, now you sound like a member of PAP internet brigade. Read my sentence carefully, I wrote "may" which has a different meaning from "would". Will appreciate if you explain if the govt's healthcare budget has a limit? If it has a limit, then does the budget have to be allocated to multiple competing needs? In the process of allocation, will there be some "needs" that will be forgone? How is the decision made to select the needs to be met and those to be forgone? [Somehow, in this "1st-world" Singapore, there is no "freedom of information" act that would make such detailed information available for public discourse].

Fox: "The majority of people with these conditions get it from a combination of bad health habits. I don't think taking preventative steps means that we should stop heart surgery, colonoscopy, etc".

Yes, so we agree that prevention is important. No, I didn't say to "stop heart surgery, colonoscopy, etc", those are your words which suggests yet another apple-to-oranges comparison. In fact, I support organ transplant from cadaver donors and related-living donors.

You associate buying a human organ with "buying services from the poor". Like I wrote above, we start-off from different perspectives that's why I draw my line on not legalising the trade of sacrosanct irreplaceable body parts whereas you push for organ trading as "buying a service".

Anon June 29, 2008 11:20 PM said...

"While I claimed that you can live fine with just one kidney, I never claimed that the transplant operation would be 100 percent safe."

So, the bottom line is, ”It is fine for others to take the risk and for me to encourage them to take the risk. But no thanks, I will not take the risk to be a living non-related donor/seller”?
What I do not want to be done to me, it is alright to be done to others?

I have done some searching and found that high blood pressure is an enhanced risk, and so are the side-effects of taking medication for it. In addition, donors have to incur financial costs for routine checkups, can develop psychological problems, are likely to face difficulties with insurance and have to avoid activities that are traumatic for the kidney or likely to injure it. Obesity also increases the risk of kidney failure and there are donors who actually became kidney patients themselves. And they were living related or altruistic donors who received clinical advice about the risks. Imagine what it is like for those who have to give up a kidney to strangers out of necessity and desperation instead of voluntarily.

So your claim that donors can live fine with just one kidney is not accurate.

The problem with existing research is that follow-up has been mainly focused on recipients and very few studies were done for donors. That explains why there is little evidence of risks after surgery. And findings are sometimes presented in misleading manner, such as comparing health statistics of donors to those of the general population instead of healthy individuals only. The latter should be the sample for comparison because donors monitored in the studies had to pass stringent health screening, which means the less healthy should be excluded.

"The fact is, different jobs have different risks."

Kidney donation is not a job. We can tell a beggar to get a job. But what kind of person would tell him to go sell his kidney instead of giving him some money when approached? The poor fellow isn’t a kidney factory.

In the US and other first world countries, payment for the organ is considered unethical and donors are accessed for their motivations. Compensation for operation-related costs is, however, acceptable. Payment, not compensation, is involved in organ trading. Is $20,000+ a reasonable payment for a kidney and the accompanying risks, or is it blatant exploitation of the poor? Worst still in Iran, that poor chap in the BBC article had to settle for less than $4,000? Isn’t that abhorrent? Their system can’t be working very well with people scrambling to part with their kidneys almost for free, can it?

"Your house/apartment was probably built by poor foreign construction workers who did so because they needed the money. So what?"

Again, foreign construction workers do not have to part with their organs. They are doing a job. You are confusing a job with an irreversible sacrifice – giving up an organ.

"Who are you to tell others that they can't donate for money?"

I am speaking up against the ills of organs trading and exploitation of the poor. Since when have I told them what or what not to do with their organs?

"Since you consider buying services from the poor to be a bad thing, why do you live in a house/apartment?..."

Again, comparing jobs with organ donation, apples to oranges. An organ is not a service that can be given away and reproduced repeatedly.

"How is its not being a first world country relevant to the debate?"

So, you’d rather follow the path taken by Iran than that of more civilized first world countries and turn a blind eye to the exploitation of the poor and ethical/social problems that come with organ trading?

Singapore, the first-world-with- Swiss-standard-of-living organ-trading hub?

Mr Wang Says So said...

I shall just provoke some new thought with an interesting tidbit. This is just for discussion purposes:

1. We bar the poor from selling their kidneys. For example, we say that no one is allowed to sell their kidneys unless they earn at least $50,000 a year and have the income tax returns; bank statements; and pay-slips; to prove it.

2. We then allow anyone to make their own financial offer for a kidney. They may bid as low or high as they like. For example, if a very wealthy person needs a new kidney very quickly, he may choose to offer $3,000,000 for it.

3. So there is no more question of exploiting the poor. If you earn more than $50,000 per year, you're well above the poverty line.

So Anon June 29, 2008 11:20 PM, how do you feel about this?

angry doc said...

"A perfectly healthy woman giving birth is clearly not at all at any risk, or it's miniscule at most."

The actual maternal mortality rate in Singapore is in the region of 10.4 per 100,000 births in 2006, while donor mortality rate for kidney transplant (not local) has been quoted at 0.03%, or 30 per 100,000.

In 2006, 4 maternal deaths were registered in Singapore.

The number of people awaiting transplant in Singapore is the the region of 600. If all 600 receive a transplant in a single year, the number of donor deaths would be more or less 0.18, depending on whether our local donor mortality rate is higher or lower than the quoted 0.03%. However, after 5 years only 92% of the transplanted kideneys will still be functioning well (local statistic).

Studies have shown that donors do not have shorter lifespans compared to the average population, or may live longer, but as pointed out this is due to the fact that donors are screened and deemed healthy to begin with.

In Iran, donors receive life-long health insurance from the government.

Those are some facts and figures which I think are helpful for this discussion. Of course, if one holds to the idea that body organs are sacrosanct and should only be donated in death or out of altruism, one doesn't need any figures.

Robert L said...

To: "angry doc" - thank you for the mortality data, it's much appreciated.

However, the point I'm making is that mortality data is gathered from an entire population which include perfectly healthy individuals as well as less than healthy individuals. It does not take much intelligence to deduce that nearly all those deaths would have come from individuals who are less than perfectly healthy. Thus if we can get data that's limited to perfectly healthy individuals, then the mortality rate of childbirth for this group must logically be miniscule.

Without the required proper data, perhaps we can do a mental exercise and imagine that out of every ten deaths from childbirth, 9 would be those who are less than healthy and 1 would be of a perfectly healthy individual. Then from your data of 10.4 per 100,000 - we can estimate the mortality rate for a perfectly healthy individual to be 1.04 per 100,000.

And compare it with 30 per 100,000 for kidney donors. (On the basis that individuals who are not perfectly healthy would not be permitted to proceed with the donation.)

Fox said...

"That would reveal clearly why that statement is wrong. A perfectly healthy woman giving birth is clearly not at all at any risk, or it's miniscule at most."

This is just plain untrue. Without ready access to modern medical care, childbirth is as dangerous as hell even for a perfectly healthy woman. More so for repeated births. I suggest you look up statistics for maternal mortality rates in developing countries.

Fox said...

"Ha ha ha, now you sound like a member of PAP internet brigade. Read my sentence carefully, I wrote "may" which has a different meaning from "would". Will appreciate if you explain if the govt's healthcare budget has a limit? If it has a limit, then does the budget have to be allocated to multiple competing needs? In the process of allocation, will there be some "needs" that will be forgone?"

It is cheaper to have as many transplants as possible (provided that both the recipient and donor are fit enough).

Actually, the full cost of dialysis over several years is much greater than that of a transplant. Unsubsidised dialysis costs at least $2000 per month. The average kidney patient in Singapore waits for 7 years before getting a kidney. During that 7 years, the total dialysis fees will amount to $168,000. It's a moot point whether the government or the patient pays for it or there are subsidies from VWOs. Someone somewhere has to pay for it. We have that 7 years of waiting simply because there simply aren't enough kidneys to go around from cadavers or related donors.

Indeed, if we can cut the waiting time, then total cost to society of providing dialysis for the patient is reduced. It is cheaper to society just to have immediate transplants. You save lives and you save money.

Fox said...

Mr Wang:

"1. We bar the poor from selling their kidneys. For example, we say that no one is allowed to sell their kidneys unless they earn at least $50,000 a year and have the income tax returns; bank statements; and pay-slips; to prove it.

No, Mr Wang. That will never work. Rich people who buy kidneys are wicked people, according to the moral brigade. Rather, we should impose an income cap on kidney recipients.

I suggest that only people who make less than $30,000 per annum be eligible for kidney tranplants. Basically, since only poor people will sell their kidneys, which the government will buy, it is only right that other poor people get it. If these poor people cannot afford the kidney transplant, we can subsidise them fully or partially.

For those who are worried about the exploitation of the poor by the rich, are you happy now?

What the hell. We'll still save more lives that way.

angry doc said...

"Without the required proper data, perhaps we can do a mental exercise and imagine that out of every ten deaths from childbirth, 9 would be those who are less than healthy and 1 would be of a perfectly healthy individual."

We know that certain medical conditions put certain pregnancies at high risk, but the two major causes of maternal mortality - eclampsia and pulmonary embolism - can and does affect women with no pre-existing medical history.

Perhaps it is possible to calculate retrospectively the mortality rates in women who would have passed as kidney donors vs those who would not, but since we do not restrict women from getting pregnant, this data will not be readily available but will require much digging.

In other words, I don't have the data to say whether it is 1 in 10 or 9 in 10.

Nevertheless, even if we assume all maternal mortality to be from healthy women, the rate is still much lower than donor mortality. It is also worth noting that Singapore has one of the lowest maternal mortality rates in the world.

Fox said...

To Robert L:

"
Without the required proper data, perhaps we can do a mental exercise and imagine that out of every ten deaths from childbirth, 9 would be those who are less than healthy and 1 would be of a perfectly healthy individual. Then from your data of 10.4 per 100,000 - we can estimate the mortality rate for a perfectly healthy individual to be 1.04 per 100,000.

And compare it with 30 per 100,000 for kidney donors. (On the basis that individuals who are not perfectly healthy would not be permitted to proceed with the donation.)"


1. Kidney donors are not screened for perfect health. They are screened for risk factors (heart condition, kidney failure, cancer, etc). Hence, your assumption that only perfectly healthy individuals are permitted to donate does not hold.

2. The median age of a living donor in developed countries is 51. What is the median age of a child-bearing mother?

3. Pregnancy is self-selective. Obviously, less healthy individuals have a lower chance of carrying the baby to full term or even getting pregnant at all.

In any case, what material difference is there between 99.97 and 99.99 percent survival rates? Whatever difference there is pales in comparison to the figure that only 5 to 10 percent of people with kidney failures in Singapore will live to obtain a kidney transplant.

Or even the number that 97 percent 5-year survival rate for patients who received living-donor kidneys vs. 92 percent for cadaveric kidneys.

Robert L said...

To Fox -
it's between 99.970 and 99.999

Anon June 29, 2008 11:20 PM said...

Mr Wang and Fox,

Interesting proposals but my gut feel is they won't solve the problem either of socio-ethics or shortening the queue. Or it going to be a humongous task to plug loopholes in the system.

Mr Wang: If we draw a line using income cap, people with high income will not sell. We've have seen that it is the poor and desperate who need the money who will sell. Even in Singapore, people will buy but think twice about selling. So it is not likely to help to enlarge the organ pool.

Then it also brings to question the rationale "who is to tell potential donors what to do with their organs?" If I am above the cap but want to sell for charity, how? For more children's education, how?

And what should be the cap? What about overseas donors, if they are allowed? What about 'altruistic' not related donors?

Also, income figures can be easily manipulated. I do not have that much confidence in our civil service to do a good job at screening and being transparent about it.

Fox's proposal, I tend to agree more with (only technically, not morally), but we are now discriminating against the rich for being rich. And, it probably won't work because there will be an underground market still. So what is the point of legalizing?

My preliminary thoughts, not done thinking about the implications and plausibility.

I still think other measures such as HOTA, encouraging related donors and medical research should take priority over organ trading.

Pallative care's point about being prepared to die is also worth thinking about, IMO.

Anonymous said...

"I still think other measures such as HOTA, encouraging related donors and medical research should take priority over organ trading.

Pallative care's point about being prepared to die is also worth thinking about, IMO."



But none of these things are mutually exclusive. Legalising organ trading doesn't mean that there will be no more palliative care; or that scientists will stop doing medical research; or that altruistic donations by relatives will come to an end.

To me, all these "considerations" for not legalising organ trading are just red herrings, false reasons, thrown out by people who are against organ trading, but aren't actually able to articulate why they have such objections.

Fox said...

To Anon June 29, 2008 11:20 PM:

"Fox's proposal, I tend to agree more with (only technically, not morally), but we are now discriminating against the rich for being rich. And, it probably won't work because there will be an underground market still. So what is the point of legalizing?"

TO SAVE PEOPLE'S LIVES!!!! If we can make one more kidney available, it means one more life saved. Isn't that obvious?

None of the 'problems' you proffered are inherent in a policy of paid living-unrelated kidney donation.

By the way, donating your kidney to your family member is not altruism. It's a gift, but it is not altruism. I will personally be embarrassed to call myself altruistic for giving money to my family members or relations. On the other hand, giving money or help to strangers without expecting anything in return is universally recognized as altruism.

To those who advocate altruistic-only donations:

And let's suppose you have have end stage kidney failure and need a transplant and none of your family members can donate a kidney for medical reasons. A living donor gives you a kidney. Are you really comfortable with the situation that he/she underwent the discomfort of a surgery, sacrificed one of his/her kidneys for you, saved your life and you are not repaying him with anything at all within your means?

I would feel very ashamed if I were such a recipient.

palliative care and medical research said said...

To anon at July 7, 2008 9:43 AM: "But none of these things are mutually exclusive. ... To me, all these "considerations" for not legalising organ trading are just red herrings, false reasons, thrown out by people who are against organ trading, but aren't actually able to articulate why they have such objections".

That's your perspective. I wrote earlier on July 4, 2008 11:02 PM that I start "from the perspective that irreplaceable human body parts are sacrosanct". Unless and until the body parts proposed for legalised sale can be regenerated by the donor, I'm against legalising organ trading. Whether the other options are mutually exclusive or not are irrelevant based on the sacrosanct irreplaceable body parts stand. If the concept of "sacrosanct irreplaceable body parts" is somehow not acceptable as an articulate objection to you, then that's just the limitations to your mind.

The options that you called "red herrings" are put there for those in the pro-legalisation camp to open their minds to other options instead of focusing on saving lives at all costs and losing the big picture as a result.

Angrydoc understood that when he wrote on July 5, 2008 9:27 AM, "Of course, if one holds to the idea that body organs are sacrosanct and should only be donated in death or out of altruism, one doesn't need any figures".

Both you and Fox seem to enjoy reading selectively and answering based only on the numbers game. Difficult long-term impact questions are ignored. Why?

----------------
Some examples of long-term impact questions from me:

What happens after years down the road when the donated kidney in the recipient fail again? Does the rich recipient procure yet another organ to further extend his life? How many persons' organ is he allowed to buy before he is ready to face the reality that death comes to all?

Assuming that organ trading becomes legal, would you then offer your kidney for sale if you're given $X that will buy you a lifestyle that you can only achieve after decades of your normal work-life in Singapore? Why?

Just a thought that restricting both donor and recipients to Singapore Citizens or Singapore PRs may not prevent abuse, it merely raises the price higher.

Consider the common understanding that Singapore Citizenship or PRship "can be bought" with enough millions. Thus, a suitably rich foreign recipient can buy the requisite citizenship/PRship for himself to qualify himself for a legally bought organ. If a Singapore citizen's organ is not available, the donor may buy the requisite citizenship/PRship for his paid foreign donor too. Thus, the legal organ transplant can get done. If one's thinking of attracting the rich recipient as a Foreign Talent, after the transplant, the rich recipient can still move on to other countries without further contribution to Singapore. However, the newly-minted Singapore citizen/PR organ donor is left behind to depend on the Singapore healthcare.

Is that good for Singapore? How does that benefit Singapore Inc? How does that benefit the Singaporeans?
----------------

Sorry, Mr Wang, for cut-and-paste and taking up your precious blog space.

palliative care and medical research said said...

Fox at July 7, 2008 10:55 AM: "A living donor gives you a kidney. Are you really comfortable with the situation that he/she underwent the discomfort of a surgery, sacrificed one of his/her kidneys for you, saved your life and you are not repaying him with anything at all within your means?"

Just take a look at the 2 cases that surfaced in the news. One of the recipient reported to be a director of CK Tangs, and yet all that was offered to the living donor is a miserly less than $30K, or 16 years of paid-labour based on donor's potential Indonesian wages. Would you call that repaying the donor "with anything at all" within the donor's means? I wouldn't. One wonders if the recipient even offered to pay the donor's legal fees and court fines.

Fox at July 7, 2008 10:55 AM: "I would feel very ashamed if I were such a recipient".

Yes, unfortunately there is already a known case of such a recipient. Do you think you can expect more of such "shameful recipients" (by your standards) if organ trading is legalised?

Just to point out that the your hypothetical scenario cuts both ways depending on the "gratefulness" of the recipient. In living-related cases, the "gratefulness" level is likely to be higher as the donation is often seen as an act of love. But in the living-unrelated cases, or even the living-unrelated "sell-me-your-organ-as-a-service" cases ... I don't know because I don't have the numbers, but the above CK Tang director serves as an example.

As you've noted before, hypothetically if I'm in the same situation where there are no related-living or cadaver donors available, I would refuse to take advantage of the poor by buying his sacrosanct irreplaceable body parts. Thus the above is moot to me, but still thanks for exercising my brains. :-)

Anon June 29, 2008 11:20 PM said...

Altruism involves sacrifice, and giving a kidney without anything in return is altruistic, regardless of who the recipient is.

I would be very grateful to an altruistic donor but returning that kindness with $$$ is an insult to an altruistic giver. Studies have shown that altruistic donors actually enjoy psychological rewards and feel better about themselves, sometimes even more important, because they feel they have made a difference, a great difference. That is why I believe in related altruistic giving. Unrelated giving may also be altruistic, but unlikely, therefore my reservations.

I will thank my donor in other forms, like cultivating a caring relationship with his family, helping him find a job, taking care of the kidney he gave me etc. It does not have to be money all the time.

As I have explained in earlier posts, saving lives is noble, but not always, depending on the motives.

I agree that all alternatives can run concurrently, but having seen the difficulties in implementing fair and ethical system for organ trading and the social implications, the vast amount of resources and likely outcomes, I feel it is more worth the while to concentrate on encouraging related donations, educating the public to take care of their organs, research, HOTA - the existing efforts which, to me, not much effort has been put into.

My reasons are:
1 I suspect many of the cases are due to organ abuse than ageing or accidents, that is, patients are responsible to the state they are in. If that is the case, we would be encouraging more abuse if people know the can more easily obtain a replacement. We might then be putting ourselves in a 'slippery slope' scenario. Ok, I know Fox doesn't like slippery slopes.

2 As I have suspected, while Singaporeans are receptive to receiving, even buying an organ, they are not as willing to part with it. I may be slammed for sitting on a high horse, but I need to say this - it is a very selfish attitude. This attitude will worsen if we allow it to breed through materialism, that everything can be bought with money, the ugly Singaporean will become uglier, and the poor become more desperate and helpless because we will come to a point where nobody cares for anyone else in a 'me first' society.

I would even support priority given to patients who have not abused their organs to be fair to them.

One may say life is unfair, so we may as well accept fact that we will always have the poor. But if we accept that life is unfair, then we should also accept that some of us will be destined to die from kidney failure. If we think those against organ trading is robbing our loved ones of their lives, then we should volunteer to part with our organs.

If life is unfair and we should accept it, then we should stop complaining about the rich benefiting from government policies and inflation and not being able to vote etc.

And it is too presumptuous to assert that those opposing organ trading are "armchair moralists" who have not been through similar or worse situations than kidney patients or who do not walk the talk. People who say that think they are the only ones who are suffering and the rest have an obligation to solve their problem, to the extent of expecting others to sacrifice for them, and in the same breath claim that life is unfair and it should be accepted. They are contradicting themselves.

The gist is, we need to tackle the problem at the roots.

Organ trading is a quick fix that may solve the symptoms, but not without repurcussions. That's how I look at it and came to my conclusions. Just like the abuse of our environment, if we do not change our attitudes and way of life, no matter how many remedies there are, we will still face a crisis and/or repercussions.

I think we have come to a saturation point. I have said all I needed to and given feedback when asked.

Anon June 29, 2008 11:20 PM said...

Smoking, alcohol and drugs increase the risk of kidney failure.

http://www.medicalnewstoday.com/articles/11516.php

http://www.aakp.org/aakp-library/Alcohol-consumption/

http://www.kidney.org/atoz/atozItem.cfm?id=44

TL77 said...

I think that to date no one has quite been able to refute the willing buyer willing seller argument.

The case for organ selling does hold some merit on the grounds that it will increase supply.

The challenges will probably be
1. how to determine who is a willing seller
2. since such legalization will constitute an intangible cost to becoming a dollar driven society, whether this intangible cost will be considered prohibitively large.

It is probably a judgement call that may change with the mindset of the citizenry. In the ideal situation, a parallel to this would be the case of claiming a cut of charity proceeds, which is already quite prevalent in our society.

Anonymous said...

"Altruism involves sacrifice, and giving a kidney without anything in return is altruistic, regardless of who the recipient is.

I would be very grateful to an altruistic donor but returning that kindness with $$$ is an insult to an altruistic giver."


That is a rather ridiculous argument. Anyone who would feel so insulted can always choose not to sell his organ, or not to donate it at all.

By analogy, the medical profession is also a noble one, similarly concerned with saving lives. But what would you say that it is an insult for doctors to receive payment for their services?

Anonymous said...

"Organ trading is a quick fix that may solve the symptoms, but not without repurcussions."

Your problem is that up to now, you are unable to give any clear explanation of what you think the repercussions are.

- You talk about palliative care. But that is an irrelevant point. Palliative care can go on, regardless of whether organ trading is legalised or not.

- You talk about altruistic donations. But that is an irrelevant point. People can continue to make altruistic donations, regardless of whether organ trading is legalised or not.

- You talk about the importance of people accepting death. Sure, if we can't do anything for them. But if we can save their lives, why not save their lives? If we go by your kind of reasoning, we might as well shut down the A&E ward in every hospital.

- You complain about the price of organs. Okay, then propose some rules to fix the price. Isn't hat rather obvious.

- You say that some people abuse their organs. Okay, then propose some rules on how people who abuse through organs will have lower priority for buying organs. Again, isn't that obvious.

Etc etc.

Fox said...

I apologize for spelling out the obvious but there is an obvious penalty for people who do not take care of their bodies. It's called poor health.

To palliative care:

""from the perspective that irreplaceable human body parts are sacrosanct"

Human eggs are not sacrosanct even though female humans are born with a finite number of eggs. You can't replace a human egg.

That's also why we harvest organs from the dead. If organs are really sacrosanct, you shouldn't even be even thinking about getting kidneys from cadavers.

Look how silly your assumption is. I'm sure the goalposts are going to be shifted in another post where you will claim that rule only applies to live humans. But ask yourself again, before you post again, why are the organs of the dead not sacrosanct? Why this special privilege for the living?

"What happens after years down the road when the donated kidney in the recipient fail again?"

You're not reading whatever I and others have said. In a system where organs are sold to the government, priority for organ transplant is based on medical reasons.

This problem is not even inherent to a paid living-unrelated kidney transplant system. When people have a second kidney failure in the current system, they are screened for medical suitability before put back on the waiting list. 20 percent of cadaveric kidneys fail within 5 years anyway.

"Assuming that organ trading becomes legal, would you then offer your kidney for sale if you're given $X that will buy you a lifestyle that you can only achieve after decades of your normal work-life in Singapore? Why?"

Actually, I'm more than willing to sell my kidney provided that

(1) Kidney trade is legal. This is to ensure that in the case that one of my family members or friends need one and I have only one remaining kidney, I can buy another one for them.
(2) A lot of money and adequate health insurance for the rest of my life.

"Just a thought that restricting both donor and recipients to Singapore Citizens or Singapore PRs may not prevent abuse, it merely raises the price higher."

Of course. You can have other safeguards. All kidney transplants in Singapore have to be screened by an ethics committee. If the donor get his citizenship only 2 weeks before the operation, isn't it a tad suspicious?

"However, the newly-minted Singapore citizen/PR organ donor is left behind to depend on the Singapore healthcare."

Yah. And the immigration service is all staffed by idiots.

"Just take a look at the 2 cases that surfaced in the news. One of the recipient reported to be a director of CK Tangs, and yet all that was offered to the living donor is a miserly less than $30K, or 16 years of paid-labour based on donor's potential Indonesian wages. Would you call that repaying the donor "with anything at all" within the donor's means? I wouldn't. One wonders if the recipient even offered to pay the donor's legal fees and court fines."

I said with anything, not everything.

"Altruism involves sacrifice, and giving a kidney without anything in return is altruistic, regardless of who the recipient is."

Don't be stupid, lah. Giving something to your family members is obviously in your interest. All the rich people who bequeath their wealth to their kids are not being altruistic. We call those who give their money to charities altruistic, not those who give money to their relatives.

"1 I suspect many of the cases are due to organ abuse than ageing or accidents, that is, patients are responsible to the state they are in. If that is the case, we would be encouraging more abuse if people know the can more easily obtain a replacement. We might then be putting ourselves in a 'slippery slope' scenario. Ok, I know Fox doesn't like slippery slopes.

There are two problems with that.

(1) Not everyone has control over their health. Not everyone can take care of themselves. Some people, especially the poor, just don't have the time or the knowledge to take care of their health. By the way, diabetes, a leading cause of kidney failure, is more prevalent in the lower socio-economic classes in the United States than amongst rich people. Great. Now, you want to penalize the poor!

(2) Why even bother to have subsidized healthcare? You're only encouraging people to get fall ill. You sound just like that island-state government that says that we shouldn't have social welfare because it will encourage people to be jobless and lazy.

Palliative care and medical research said...

Fox: "Human eggs are not sacrosanct even though female humans are born with a finite number of eggs. You can't replace a human egg".

You're right, egg is not replaceable. Fact: An egg (occyte) that is not fertilised is naturally expelled from the body. Can you say the same of kidneys?

Fox: "That's also why we harvest organs from the dead. If organs are really sacrosanct, you shouldn't even be even thinking about getting kidneys from cadavers".

Fox: "Why this special privilege for the living?"

IMHO irreplaceable organs are sacrosanct, be it in a dead or living person.

It is my observation that most cultures do respect the bodies of the dead. Doesn't that implies some kind of sacrosanctity? How many would mind if the healthcare professionals treat the bodies of their recently deceased relatives as a piece of meat?

Btw, not everyone agree with HOTA in its current opt-out form where "we harvest organs from the dead" without their explicit consent (i.e. opt-in while alive) and the next-of-kin cannot intervene. IMHO, it lacks respect for both the deceased and the relatives left behind. Healthcare professionals even become accused of body snatching when saving a life at all costs.

By changing HOTA back to opt-in, it'll be like the deceased giving an altruistic donation of their organs (having declared their intentions/willingness to do so while alive and competent). Albeit that the donation is done only after they've passed away and therefore 100% sure that they won't be using the organ. I have no objections to altruistic donation by those dead/alive. See my earlier post on why for the living altruistic donation, it is likely to be only from related donor-recipient.

Fox: "In a system where organs are sold to the government, priority for organ transplant is based on medical reasons".

IMHO, how can you be so sure of that? Even HOTA as it stands now lacks transparency. The NKF-fiasco is a good example that even when starting out with good intentions, without transparency, things may go wrong.

Fox: "Actually, I'm more than willing to sell my kidney provided that
(1) Kidney trade is legal. This is to ensure that in the case that one of my family members or friends need one and I have only one remaining kidney, I can buy another one for them.
(2) A lot of money and adequate health insurance for the rest of my life".

Good that you walk the talk. Btw, how much is "a lot of money"? Is 16 years of your work-pay based on your expected Singaporean salary enough? What exactly is "adequate health insurance for the rest of my life"? What are the difficulties to ensure that the above 2 conditions are met for all potential organ sellers? What are the costs of meeting these conditions? Any other safeguards/conditions that need to be implemented? Would legalised organ trading still be feasible after taking all that into account?

Fox: "Of course. You can have other safeguards. All kidney transplants in Singapore have to be screened by an ethics committee. If the donor get his citizenship only 2 weeks before the operation, isn't it a tad suspicious?"

Implementation details such as these should also be openly discussed for the pro-legalisation camp to support their agenda. As often quoted, the devil is in the details. Singapore's medical-hub reputation is at stake here. Kudos to Mr Wang for writing this blog entry to open up issues for discussion.

Fox: "Yah. And the immigration service is all staffed by idiots".

http://www.mrbrownshow.com/2008/06/30
/the-mrbrown-show-speedy-clearance/

http://www.mrbrownshow.com/2008/06/16
/the-mrbrown-show-the-great-escape-2/

http://www.mrbrownshow.com/2008/03/24
/the-mrbrown-show-you-are-so-champion/

Fox: "I said with anything, not everything."

Hypothetically that you're a legal organ buyer. What would you be offering when you claimed that you are willing to pay the donor "with anything at all". Less than 30K or 16 years of paid-labour based on donor's potential Indonesian wages = "anything at all"? "Sell-me-your-organ-as-a-service" exploitation does not come into mind?

Just to throw a spanner into the works. Is saving a life at all costs so important in our Singapore society? If so, what's capital punishment which takes away lives doing here?

As tl77 said: "It is probably a judgement call that may change with the mindset of the citizenry".

Fox said...

No system is foolproof. There is no 100 percent guarantee that there will be no abuses within the system - be it one with altruistic unpaid living-related kidney donation or with paid-living unrelated kidney donations. There is no need to throw out the proverbial baby with the bathwater simply because abuses can occur during the implementation.

Most of the objections you proffer are NOT inherent to the system of paid living-unrelated kidney donations. Take for example, the current case for Mr Tang who stands accused of trying to pay for a kidney transplant that was reported in the media. One patient, Juliana Soh, got her kidney by lying that the donor was a distant relative from Indonesia. Obviously, the current system failed in this one instance. Going by the conditions you impose, in which a policy cannot be implemented if abuses cannot be 100 percent prevented, does it mean that the policy of living-related kidney transplant should be scrapped immediately?

There are problems even with living-related donations. For example, relatives can be emotionally coerced to donate their kidneys. Why haven't you considered emotional coercion? It is also possible that money gifts are offered to living-related donors. Are you absolutely sure that no financial incentives are offered to living-related donors? I am sure that you aren't. Why do you then insist that we have to be absolutely sure that living-unrelated donors do not receive any financial incentives before allowing them to donate? You have to be consistent.

People can also get married to become 'related'. There are no objections to spousal donation in the current system. Obviously, these abuses are minimized (but not completely eliminated) because donors are screened by an ethics committee. That was, incidentally, how one of the Indonesian donors were detected. What makes you think such an ethics committee will be any less effective in living-unrelated kidney transplant cases?

"You're right, egg is not replaceable. Fact: An egg (occyte) that is not fertilised is naturally expelled from the body. Can you say the same of kidneys?"

As predicted, you have shifted the goalposts. Your original objection was that we cannot take irreplaceable body parts out of people because they are sacrosanct. You used the very word 'irreplaceable'. Now, obviously, you've come up with the argument that something is 'irreplaceable' is not a sufficient condition to object to the removal of irreplaceable human parts.

"Just to throw a spanner into the works. Is saving a life at all costs so important in our Singapore society? If so, what's capital punishment which takes away lives doing here?"

I am vehemently against capital punishment in Singapore, though not the principle of capital punishment.

Are you really serious about comparing kidney failure patients with convicted murderers?

interpreting sg said...

i suggest that the benefiter(normally the buyer) signs a lifetime bond which pays a lump apprecaition sum plus a monthly remuneration to the donor(the seller).

1) the seller(normally poor) can ensure a lifetime of monthly income, as compensation to their inability to do strenuous work.

technically, the life of the seller is saved.

2) the buyer(usually freaking rich)’s life is owed by the donor and his wealth should be shared with his savior. for every month he is alive, he owes his life to the seller, thus the justification of a monthly remuneration.

a win-win situation :D

palliative care and medical research said...

To Fox:

Did I write "100 percent guarantee"? Those are your words. If you can't get the gist of the part of my message which leads you to jump into conclusion of putting "100 percent guarantee" into my mouth, that's just a sad reflection of your unwillingness or inability to understand.

Fox in earlier post: "That's also why we harvest organs from the dead. If organs are really sacrosanct, you shouldn't even be even thinking about getting kidneys from cadavers.
Look how silly your assumption is. I'm sure the goalposts are going to be shifted in another post where you will claim that rule only applies to live humans".

Fox in most recent post: "As predicted, you have shifted the goalposts. Your original objection was that we cannot take irreplaceable body parts out of people because they are sacrosanct".

Go ahead, read your 2 posts above. The shift is yours in your assumptions about my beliefs. Did I write "rule only applies to live humans" or "cannot take irreplaceable body parts out of people because they are sacrosanct" (under all circumstances as implied)? Nope, those are all your words, your implications and your assumptions.

I wrote "irreplaceable organs are sacrosanct, be it in a dead or living person", "making such a sacrosanct gift amongst living-related donor-recipient is an ultimate declaration of love" and "by changing HOTA back to opt-in, it'll be like the deceased giving an altruistic donation of their organs (having declared their intentions/willingness to do so while alive and competent). Albeit that the donation is done only after they've passed away and therefore 100% sure that they won't be using the organ".

Fox: "Are you really serious about comparing kidney failure patients with convicted murderers?"

You are the one who wrote: "The needlessness of people dying when there is a ready solution disturbs me". Think of your principle behind that statement of yours. Only you know if your principle which generated that statement applies equally to "kidney failure patients with convicted murderers". Hope you're using the words "convicted murderers" only symbolically, because capital punishment is not only for "murder", nor is "murder" the offence that contributed to the most capital punishment cases.
http://en.wikipedia.org/wiki
/Capital_punishment_in_Singapore

Fox, you're the one who wrote: "Human eggs are not sacrosanct even though female humans are born with a finite number of eggs. You can't replace a human egg."

I already agreed on your technical correctness of egg being irreplaceable. I wrote: "You're right, egg is not replaceable. Fact: An egg (occyte) that is not fertilised is naturally expelled from the body. Can you say the same of kidneys?". My reply is to point out the fact that until menopause arrives, a woman's body expels the old unfertilised egg (occyte) and develops a newly matured egg (occyte) each cycle, so functionally speaking a female in her reproductive years has a "new" egg every cycle, but do your body dispose of an unused kidney and re-generate a new kidney naturally? I would expect someone with basic reading skills and common bio knowledge to understand the difference.

Fox, I tired of your selective (mis-)interpretation, your rudeness (which I ignore and try to avoid quoting) and your habit of putting words into others' mouth. Looks like further debate with you will only reap more of the above habits of yours. I will not debate with you on this further.

Robert L said...

Copied from Straits Times 10 July (yesterday):

NEW YORK - James Levine will have a kidney removed in surgery this week, causing the conductor to miss the remainder of the Boston Symphony Orchestra's Tanglewood season.

His kidney is being removed because of a cyst that is causing discomfort.

(I have been a fan of Levine since his Chicago Symphony days.)

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

So goes another myth that having both kidneys do not serve any purpose. Good thing for Levine that the cyst occurs in one kidney and he has another to fall back on.

So far, we have been bombarded with a string of myths:

- The risks are the same as childbirth
- You lead a normal life after kidney donation
- Lifespan is not affected
- You don't need two kidneys

I wonder what motivate individuals to make such incredibly false claims?

Anonymous said...

Dear Mr Wang

I've been a reader of your blog for a while now and appreciate the views that you presented. Food for thoughts indeed. I do have a question here which I hope you can give some insight. If we have HOTA, why are we still short for organs for transplant? How many organs are acquired for transplant via HOTA?

Fox said...

To Robert L:

"So goes another myth that having both kidneys do not serve any purpose. Good thing for Levine that the cyst occurs in one kidney and he has another to fall back on."

No one said that both kidneys do not serve any purpose.

If Levine had Polycystic kidney disease, he would have been contraindicated for kidney donation anyway since the disease is hereditary and people with such conditions are usually excluded from donation.

"- The risks are the same as childbirth"

Yes, they are. The 0.03 percent donor mortality of kidney donation operations is taken from the US study in 2001 of 10,000 operations. The corresponding figure for maternal mortality in America in 2000 is 0.017 percent. These numbers are comparable.


"- You lead a normal life after kidney donation"

You CAN lead a normal life after kidney donation subjected to certain restrictions. Obviously contact sports are out.

"- Lifespan is not affected"

Where is the proof that lifespan is affected?

"I wonder what motivate individuals to make such incredibly false claims?"

Of course, you do realize that the ranks of these motivated individuals include renal transplant surgeons, nephrologists, etc.

Fox said...

To Anon July 11, 2008 5:13 PM:

"If we have HOTA, why are we still short for organs for transplant?"

You usually need organs from fairly healthy adults, such as people who die from automobile or work accidents. They also have to die in hospital for organ transplantation to occur. The very low fatality rate from traffic accidents in Singapore reduces the organ donor pool.

The vast majority of people in Singapore will die of age-related ailments under more fortunate and comforting conditions. Their organs are usually not suitable for donation.

Robert L said...

Well, since Mr fox has not resorted to insults in his latest post, I will address his points.

- The risks are the same as childbirth
We have dealt with this before. Mortality rates quoted for childbirth are for the general population. All females, including kidney patients, diabetics, whatever, are eligible for childbirth.
In contrast, kidney donors have already been screened from many ailments, they are mostly healthy. To compare these two mortality rates would be disingenuous.

- You lead a normal life after kidney donation
"... subject to certain restrictions. ... contact sports are out." Need I say more?
Okay, more then. In most cases, donors have to take medication for long periods of their life to suppress something, not sure what. So what else are they not telling us? The fact that mainstream media has kept this from us must surely set off our alarm bells?

- Lifespan is not affected
Official studies have indicated that kidney donors are not any worse than the population average. This is the same flaw as in the fatality rates of childbirth. Comparing a healthy group who have had one of their kidneys removed, with the health of the general population. The general population includes those with kidney disease, heart disease, cancer, AIDs and so on.
Why don't they do the same study with a control group who have been screened and cleared for kidney donation, but who did not donate but kept their two healthy kidneys? That's a rhetorical question, obviously that's not possible, I raised it only to show the obvious that those donors should have lived longer if they had not donated.

I wonder what motivate individuals to make such incredibly false claims?
[fox said: "Of course, you do realize that the ranks of these motivated individuals include renal transplant surgeons, nephrologists, etc."]

Too true, and it remains to be seen if these individuals are entirely without guilt in the two illegal cases that came to light at Mt E Hospital.
Plus, I wonder if other observers are, like me, disappointed that even now, those members of the ethics committee do not step down and admit that their committee had no effective means to fulfill their duty, when it's obvious to any of us observing how their mistake occurred.

Fox said...

"We have dealt with this before. Mortality rates quoted for childbirth are for the general population. All females, including kidney patients, diabetics, whatever, are eligible for childbirth.

No. I've said this before: pregnancy is self-selective for health and age. For example, no women above the age of 45 can undergo childbirth. Almost all Singaporean women who are pregnant are between 18 and 44. Allow me to suggest that people in this age group are healthier than the rest of the population since they are far less likely to be have hypertension, diabetes, cancer, etc. Also, many types of medications are contraindicated for pregnancy. This means that people who are taking such medications are usually advised not to get pregnant. You can exclude such individuals from the pool of people who can get pregnant. People with pre-existing conditions (anaemia, hypertension, etc) that might lead to birth complications are usually discouraged from pregnancy.

Come on, trying reading what I've written before.

"In most cases, donors have to take medication for long periods of their life to suppress something, not sure what."

Recipients have to take to take immunosuppressants, not donors. Donors don't have to take any long term medication.

"That's a rhetorical question, obviously that's not possible, I raised it only to show the obvious that those donors should have lived longer if they had not donated."

That is not 'obvious' to anyone. Yes, there is no direct evidence that donor lifespan is not reduced compared to non-donors in the same health condition. However, there is also no evidence for the opposite.

Anonymous said...

To Anon July 11, 2008 5:13 PM:

"If we have HOTA, why are we still short for organs for transplant?"

I am not sure how true this is but I heard only Changi Prison is equiped with the equipment to keep the body functioning after a person is dead. Organs of convicts who get the death sentence are harvest. Apparently hospitals in Singapore do not have the capability. So whatever the reason a person dies at the hospital, the only viable organ to be transplanted is the cornea. So my point is while having HOTA is good for the nation, serves no purpose if there is no infrastucture to implement it well.

yh said...

Mr Wang,

I do not agree with you. However complete the legal framework, organ trading IS an exploitation of the poor and desperate. If someone (geylang prostitute) is so desperate that she has to sell her organs, we probably should do something to help her (send her daughters to school for free), not take away her kidney!

The fact that exploitation of the poor (by making them do dangerous or dirty job for little pay) is already prevalent in our society does not make it right.

Since 'the seller will have every reasonable expectation of being able to live normally', how much will it cost to buy your kidney? I won't sell mine for any amount of money and i think we can safely assume that neither would you. Only the most desperate can be expected to be involved. Why not set up a system for them to sell their children or their children's kidneys to exploit them a little more?

I wonder how many on the organ waiting list are in their health predicament due to an unhealthy lifestyle. Do they all deserve a second chance?

I think there are good reasons why iran is the only country that has legalized organ trading.

Anonymous said...

According to renal doctor, although a donor may not regenerate a new kidney, the remaining kidney will grow in size by 20% to 30% to compensate for a loss of a kidney. If I recall correctly, a kidney donor had died after a kidney transplant in Singapore. It was due to internal bleeding when a "clip" had come off after operations.

If kidney trading is legalised, there is a need to ensure that the donor is not exploited. He must be a willing donor and not one forced by someone else - other family members or loan sharks. Besides the donor's consent, consents should also be obtained from his parents and spouse. They have the right to object to the trade.

In addition, they should be given medical insurance and priority for transplant when their remaining kidney fails.

Government should stop passing the buck. Today they do not subsidise a single cent for kidney dialysis. Unlike other donations, any donations to NKF and KDF, there is no dollar-to-dollar match by the government. Now, they are considering to pass the responsibility of financial compensation to the donor to a third party - a voluntary welfare organisation or religious body.

Worse still, they will be considering to withhold the compensation in the donor's CPF account. If the donor is not desperate, why will he bother to offer to give up an organ?

Anonymous said...

If I recall correctly, a harvested organ has to be transplanted within 48 hours.

Anonymous said...

What if a poor person is in need of a organ???

Axie said...

Question: In this case if we were to be poor does this mean that we have no right to live on?

Reason: People whom is in the waiting list are most probably be those whom is poor. For those whom is wealthy enough would have the privilege to get a organ to save their life first as they could easily afford that huge sum of money. That put the less wealthy people at great disadvantage.

w. ling said...

come on. you guys have been talking on this topic for so long and this system has not been legalised? i strongly approved that this should be legalised! try putting yourself in those people who need organs's shoe.. you're dying. but you are still in the waiting list, and there are hundreds of people queuing in front of you. what can you do? wait to die?

of course till then you will hope someone will sell their organs to you right?? and it doesn't mean you are going to cut queue in order to save yourself..

if this system is legalised soon, people will starts to sell their organs, and get a fair sum as a compensation to them.. and the waiting list will be shorten down like so much faster!

and! transplant is like some much better than dialysis.. imagine looking at your family member going for eg. kidney dialysis for some hrs.. how much pain they have to suffer? of course, a transplant is always better than dialysis isn't it? if not why people queue for transplant?

since people are willing to sell. and buy.. yup, why not legalise right :)

w. ling said...

and and, i think, if a poor person is in need of a organ, i believe the hospital could subsidy? based on how much they earn? :) and i think this system should be like... queue in the waiting list too? since they are people selling, i'm sure people gets cured alot lot faster.