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 There are existing rules and regulations that are outdated and irrelevant to the current situation in Singapore.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).

The Government Does Not Make Money From The ERP Increase. So Says Lim Swee Say.

Lim Swee Say claims that the government will not make any money from the ERP increase.

ST June 23, 2008
Govt doesn't make money from ERP
THE CashCard reader in labour chief Lim Swee Say's car beeps four to six times a day. This is because he passes through that many Electronic Road Pricing (ERP) gantries along busy city roads to get to and from work.

He was driving home the point that ERP exists solely to control road congestion and not to enrich government coffers or raise the cost of living for Singaporeans.

Mr Lim was responding to a question at a dialogue on why the Government was raising ERP rates by as much as $2 and adding five new gantries from July7 in a climate of rising inflation.

The new gantries along the banks of the Singapore River bring the total number of gantries islandwide to 65.

Mr Lim said Transport Minister Raymond Lim had told Parliament previously the Government does not make any money from the ERP increase.

The reason: It will collect $70 million a year from the ERP increase, but will lose $110 million due to the 15 per cent reduction in road tax from next month.

That is, in fact, a net loss of $40 million, he said.

This reminds me of what happened in early 2007. The government was discussing its plans to raise GST from 5% to 7% in July 2007.

Back then, the Finance Minister had said that even with the GST increase, the government would suffer a $700,000,000 budget deficit. In other words, the government estimated that even with the GST increase, it would collect $700,000,000 less than what it actually needed, to run the country.

Many Singaporeans were thus persuaded that the GST increase was a necessary evil.

But what happened next?

One year later, it was revealed in Parliament that the government did not have any budget deficit for the 2007/2008 financial year. Quite the opposite - it had a huge budget surplus of $6.45 billion dollars.

In other words, the government had collected $6.45 billion dollars more in taxes than what it actually needed to run the country. The people got suckered again.

For more details, refer to my old post here.

So when Lim Swee Say tells you that the government won't make any money from the ERP increase (and will in fact suffer a $40 million loss), take it with a pinch of salt. Or maybe three big tablespoons of it.

The last time round, our Finance Minister missed his Budget estimate by $7,100,000,000. In percentage terms, what makes you think Swee Say will do any better?

Wong Kan Seng's Latest Career Achievement

First, the terrorist Mas Selamat escaped from the Whitley Road Detention Centre in broad daylight.

Then two detainees at the Subordinate Courts lock-up beat up the police officer supervising them and made an escape bid, also in broad daylight.

And now, a 61-year-old retiree breaks through all the security measures at Changi Airport - without even meaning to.

ST June 24, 2008
Dad flies off using son's passport
He checks in at Changi, clears immigration and gets on Tiger Airways jet to Vietnam
By Carolyn Quek

IN HIS hurry to catch a flight at Changi Airport's Budget Terminal yesterday morning, retiree Ang Heng Soon, 61, grabbed the wrong passport and left home.

He took his 39-year-old son's passport. They had left their passports on the dining table, because the son was also flying from Changi Airport.

The father's mistake, and how he cleared all security checks at the airport and flew to Vietnam, led to a long day for both.

Even with the wrong passport, Mr Ang first checked in at the Tiger Airways counter for his flight to Ho Chi Minh City, where he was headed for a six-day holiday.

He next got past the security check by Certis Cisco officers at the entrance to the restricted passenger area.

Then he ran into problems, failing repeatedly to scan his fingerprint at the immigration Automated Clearance System.

Noticing his difficulty, an Immigration and Checkpoints Authority officer directed him to a lane for manual clearance.

There, an officer cleared him to leave Singapore, and he boarded his plane.

Mr Ang told The Straits Times he realised his mistake only during the flight.

You know what will happen next, don't you? The Little People will be punished again. You know, the Cisco guard, the lady at the airport check-in counter, and so on.

The good minister Wong Kan Seng will strut around, point his finger and say, "Tsk tsk ... you so naughty ... you so negligent ... your pay is docked ... you are sacked ..." and then he will probably look at the TV camera and say, "Lee Kuan Yew was right - you Singaporeans are too complacent."

Someone might quietly suggest that in view of all these security lapses, perhaps the Home Affairs Minister is not doing his job very well and should resign. Whereupon Wong Kan Seng's eyes will widen slightly in surprise.

And then he'll say: "Ooh, I am sorry that this has happened. But in Singapore, sacrificing the minister for political expediency is just not right. I am very highly talented, you know. I must be - otherwise why would you be paying me a world-class salary? It will be a tragic loss for Singapore if I were to quit."

Up, Up And Away - The ERP Takes Off

Two years ago, I wrote a post entitled Money & Material Things. I mentioned then that I lived in a HDB flat, did not own a car and did not plan to.

Two years later, I still live in the same HDB flat, still do not own a car and still do not plan to. Relatives have given up asking me why Mrs Wang and I, two quite successful & established professionals, do not even aspire to move to a condo or own a humble secondhand car (Mrs Wang is a lawyer).

There are a few reasons. One is that a car is largely unnecessary to our lifestyle. Our HDB flat is two minutes away from an MRT station, which is extremely convenient. Also, the nature of our professional backgrounds means that our offices will almost certainly be in the CBD, and it is quicker for us to get to the CBD by train than by car. Furthermore CBD driving has its own problems, including higher parking costs, heavy road traffic and ERP costs.

Another reason why we don't want to own a car is that in Singapore, car ownership just makes you a rather easy victim for the government's Pay-&-Pay policies.

ST June 17, 2008
ERP charges up at 32 CBD gantries from July 7
Five more new gantries coming up along Singapore River
By Maria Almenoar

THE roads are getting pricier from July 7. Five new gantries, forming a cordon along the Singapore River Line, will go live to regulate the evening traffic flow from 6pm to 8pm, bringing the total number of gantries to 65.

In what is seen as the most extensive revision of Electronic Road Pricing (ERP) here since its implementation 10 years ago, another 32 gantries in the Central Business District (CBD), including those around Orchard Road, will also have their charges increased.

Rates are being revised mostly during the evening time slots because speeds have fallen steadily during the home-rush hours.

The Government is going to fix this by doing three things.

The biggest change is that if you pay, you will get to enjoy a smooth flowing ride - which is not always the case now.

Motorists can expect to pay as much as $1 more at existing gantries and $2 at new gantries ....

The above changes are going to cause some loud howls of protest among the public, considering the price of oil nowadays and the inflation situation. Actually, if you had plans to destabilise our society, raising fees at 32 ERP gantries would be a positive first step in the right direction.

(P.S That was just my way of saying that the Transport Minister has a very bad sense of timing. But since I do not drive, I shall not comment any further. Car-driving readers may now proceed to the comment section of my blog).

(P.P.S I invite my driver-readers to share some details of their lifestyle (for example, how often they drive, and from where to where) and also how much they spend on car-related expenses. It might be interesting for such readers to compare notes).

If A Very Sick Man Was About to Die, Wouldn't You Help To Let His Mother Know?

Apparently not. Today we look at a human interest story in the Straits Times. To summarise, a man had a stroke and would soon die. His relative tried to contact the man's mother. The Immigration and Checkpoints Authority (ICA), which is also our national issuer of NRICs, knew exactly where the man's mother lived, but refused to reveal the details.

ST June 13, 2008
One last look at prodigal son
ST helps cousin of man in coma to locate his family; son dies 15 minutes after mum leaves hospital
By Teh Joo Lin

MORE than 20 years ago, Mr William Rajasingam Kasinathan became estranged from his family. He lost touch with his mother, sister and son.

... Last week, the 53-year-old prodigal son suffered a stroke and was on his deathbed. And the search was on for his kin.

On Tuesday, mother and son had a reunion of sorts - Mr Kasinathan was comatose - in the intensive care unit of Tan Tock Seng Hospital.

The frail woman gazed upon her son and looked lost as she repeatedly rose from her chair and sat down.

Fifteen minutes after the 78-year-old left the hospital, he died.

It was his cousin, Ms Prem Bir Kaur, 53, who managed to track down the old woman.

Aided by a doctor and a medical social worker, she contacted the Immigration and Checkpoints Authority (ICA), the custodian of the national registration records, in the hope of securing an address.

The hospital staff offered to furnish proof that Mr Kasinathan, a bar musician, was in a critical condition so that the ICA could try and contact his mother on Ms Kaur's behalf.

But rules forbade the ICA from revealing her whereabouts, Ms Kaur was told.

On Monday night, she called The Straits Times, which helped her locate Mr Kasinathan's mother by going down a list of possible family names in the phone directory.

When given the news that her son was gravely ill, the old woman told her daughter: 'He's still my son. Take me to see him.'

Ms Kaur is relieved mother and son got to 'meet' one last time but wonders why the ICA would not help her.

She said: 'It's not fair for him to die alone. At least I can say I've tried to fulfil his last wish.'

And why did the ICA not help to fulfil he dying man's last wish? What reason could the ICA possibly have?

An ICA spokesman told The Straits Times that the National Registration Regulations make it an offence for any public officer to disclose to anyone information from its records - on pain of jail time, a fine or both.

The exceptions are few - when it is in the public interest and with the permission of the ICA Commissioner, or for the purpose of criminal proceedings.

This was not a criminal case, so the police could not formally help either.

Dr Teo Ho Pin, who chairs the Government Parliamentary Committee for Law and Home Affairs, agreed it was important to protect the private information of people.

Recently I commented that PAP MP Teo Ho Pin is quite a clever person. After reading the above ST article, and Teo's remark as quoted in it, I feel compelled to withdraw my comment. I no longer think that Teo is very clever.

According to the law, ICA was not allowed to reveal the old lady's address to Prem Bir Kaur. However, there was a very simple solution. ICA could have contacted the old lady directly, by phone or by mail, and said:

"Dear Madam

We were informed by Tan Tock Seng Hospital that your son William Rajasingam Kasinathan is seriously ill in Ward ___. His cousin Ms Prem Bir Kaur has also contacted us about this matter. She has been trying in vain to locate you.

To safeguard your privacy, we have not given them your personal contact details. However, if you wish to know more about the matter, you can directly contact Tan Tock Seng Hospital (tel no. XXXXXXX) or Ms Prem Bir Kaur (tel no. YYYYYY) yourself."

Simple as that. As I see it, there could only have been two reasons why ICA didn't do it:

(1) ICA is just too stupid; or
(2) ICA just can't be bothered.

Either way, it just reflects very badly on the ICA.

On a separate note, isn't it really quite ironic? If you have died in hospital without signing the opt-out form, the government has the legal right to immediately cut out your organs for transplant purposes. But while you're dying in hospital, the government won't even help to let your mother know.

Thinking About Critical Thinking

A reader, AM, writes from Melbourne University to tell me that he is a final-year law student. Recently he has had to write many legal essays. AM wonders how he can learn to think more critically. Evidently he feels that his earlier education in Singapore has disadvantaged him:

"Of course at this time, being a Singaporean, I would readily point the blame finger at the government and MOE for creating a flawed system where schools do not encourage critical thinking but hard memorization and accurate application (or maybe that was just my school only). So I was just wondering, how does one develop critical thinking if the system we are in doesn't necessarily encourage it?"

Personally I am very interested in the mind. But less interested in critical thinking. While critical thinking is no doubt a useful tool, my personal adventures into the intuitive right brain (via meditation, self-hypnosis and certain other esoteric methods) have made me a little wary of the dangers of over-reliance on the logical left brain.

I'm sure that the above statement will surprise, perhaps even upset, some people. And it is not exactly the easiest thing to explain to a general audience via a blog post. So I shall not elaborate. Not now anyway.

Back to the left brain then. Here are six questions about critical thinking:

1. What is it?
2. Who said so?
3. Why should I be interested?
4. Where can I use it?
5. When shall I use it?
6. How can I apply it?

Guess what, I am not providing the answers. I posed those six questions just to demonstrate a certain critical thinking skill. It's called asking questions. This one, specifically, is known as 5W1H.

The five W's are what, who, why, where and when, and the one H is how. 5W1H was originally conceived as a journalistic tool. Out in the field, reporters would use 5W1H as a mental checklist to generate questions and make sure they cover all the basic facts needed for their news story. Now 5W1H shows up in all sorts of other places, such as in the Six Sigma processes.

As far as AM's law school adventures are concerned, 5W1H can be applied as follows. Suppose you are reading a legal article where the good professor is expounding certain opinions. Since he writes persuasively, you feel inclined to agree. On the other hand, if you wish to consider his article more critically, you simply generate questions to consider. Such as - what is he really saying here? Who would agree with this? Who wouldn't? Why not? What is the justification for this point? Where are the examples? What are the alternative views? When would this idea fail? And so on.

You might not have expected that such a simple thing as asking questions would be so important as to merit its own special acronym "5W1H". Well, it just goes to show you that critical thinking isn't that difficult, after all. On the other hand, many of us know from our personal experiences that Singapore's teachers often implicitly discourage questions, especially if the question strays outside the confines of the school syllabus. And over the years, many Singaporeans will forget how to ask questions. So perhaps we do need to remind ourselves about 5W1H. In fact, asking good questions is probably the most important thing that an MP can do in Parliament.

Not to flog a very dead horse, but there's a useful illustration from April this year:

Mr Low Thia Khiang: "Did MHA conduct regular audits at the Whitley Road Detention Centre (WRDC) prior to the escape of Mas Selamat?"

Mr Wong Kan Seng: "The WRDC and the Gurkha Contingent guards have their respective procedures. When the detainees are in the cell block, they are watched by a significant number of guards. The ratio of guards is more than what one can see in the prison.

When they're taken to other blocks, most of those movements are in passageways that are enclosed and they're also blindfolded, to keep them from familiarising themselves with the surroundings.

The only thing that ought to have been done better is a regular system check and audit. These will now be carried out on a regular basis."

Paragraph 1 of Wong Kan Seng's answer was irrelevant to the question. Paragraph 2 of his answer was also irrelevant. Well, no, not exactly, they did serve a purpose. They distracted people.

Now, look at Low's question again. And then just focus on the only relevant part of Wong's answer:

"The only thing that ought to have been done better is a regular system check and audit. These will now be carried out on a regular basis."

What would be the most natural follow-up question you would ask?
Probably something like this:

"Did MHA ever conduct any audit at WRDC at all? If so, when?"

The question was not asked. So we will never know the answer. We do know what happened next. Various lowly MHA officers were punished for the Mas Selamat escape, while the Minister was completely unscathed. In fact, he was the one handing out punishments.

But what if the question had been asked? And what if the truthful answer was that not only was there no regular audit system, but there had been no audit at all, for many years. For example, what if the answer turned out to be something like this:

"WDRC has never been audited. Not even once, ever since I became Home Affairs Minister fourteen years ago, back in 1994. As a matter of fact, we've simply never bothered to audit any of our prisons and detention centres for security."

Under such circumstances, I think that it would be more difficult for PM Lee to assert so blithely in Parliament that it is unthinkable for Wong Kan Seng to be punished.

But then we don't know. We probably never will. The right question wasn't asked; it was never asked; Wong didn't have to answer it; and so, the political history of Singapore took a certain turn, and went on in a certain way. As I predicted quite long ago, Wong Kan Seng managed to make the Great Escape.