Tan Jing Kai, Brian, 21

Topic: Should organ donation after death be mandatory?

Award: First Place, Open Category, 2021

Organ Donation: A Delicate Balance between Religion, Autonomy and Utilitarianism

Nations all over the world grapple with a morbidly curious problem: a deficit of human organs. Every year, hospitals struggle to match a gargantuan pool of patients to a comparatively miniscule puddle of donors. To quantify the disparity – in 2019 alone, the US witnessed just 19,000 donors to 112,000 patients on the waiting list. Singapore’s attempt to circumvent this issue materialises itself in a policy named HOTA – the Human Organ Transplant Act. Similar to a few nations in the EU, the Act automatically assumes citizens to pledge their organs upon death, with the choice to actively opt out upon reaching a certain age. With differing legislation across different governments, this calls into question the moral, social and even legal legitimacy of enabling mandatory organ donation after death.

The Importance of Donating

On a purely utilitarian principle, this debate should brook no argument. Approximately twenty people die every day, waiting for an organ transplant in the US – a number that is sadly twenty too many. Unbeknown to some of us, a single body slated for donation could potentially save multiple lives. Singapore’s HOTA includes the most common organs, such as kidneys, heart, liver and corneas, while the opt-in MTERA (Medical (Therapy, Education and Research) Act) allows for much more items for donation, such as tissues, veins, ligaments and even skin and bones. These body parts, perhaps non-essential, nonetheless play a pivotal role in allowing patients to lead healthier lives through procedures like bone grafting and tendon transfer. In a perfectly efficient world, one could in fact potentially save the lives of eight individuals, in addition to improving the quality of life of dozens more. Consequentially, increased organ donation rates would no doubt improve the utility and happiness of countless people.

Arguably, there exists a moral imperative for us to donate our organs after death. We should do so, because it is the human thing to do – to empathise with their pain, to alleviate suffering from people around us and give someone a new lease of life. Sometimes, it is easy to forget that the people on the waiting list are not just nameless statistics on a government website, but actual human beings with lives just as sophisticated and complex as us, and have families and friends just as concerned as ours. At the point in which post-mortem organ donation poses no actual harm to the donor (ostensibly for they are already dead), then the process ought to be made compulsory, for the very simple fact that it saves human lives. Indubitably, the importance of organ donation cannot be emphasised more.

The Choice of Opting Out

Taking into account the undeniable utility and benefits that organ donation brings about, it might be puzzling as to why some Singaporeans actively choose to opt out of HOTA altogether. Sometimes, these instances are publicised in legal cases, where family members had retracted the donation of the deceased’s organs, citing that the latter have no prior knowledge of their default consent – as such, deeming it as illegitimate. Often, family members might not be absolutely certain of the deceased’s position on the issue, and therefore decide on the safer alternative for them.

A large reason why such an important topic remained undiscussed among many Singaporeans until the supposed donor had passed on, could perhaps be due to the inherent taboo nature of the subject itself. Death, the greatest imaginable unknown to evoke fear and mysticism, remains one of the most socially prohibited items of discussion in our Asian society. The reluctance to answer our children’s inquisitiveness on mortality (often giving the perfunctory reply of ‘you will understand when you are older’ to their enquiries), the act of avoiding the allegedly inauspicious number four in our daily lives, or even the disinclination to draft our own wills – all point to our unwillingness on broaching the topic of death. Perhaps the mere mention of it might beget misfortune, bringing the inevitability closer than it is supposed to happen. Others might believe any mention of death, especially one’s own, would be akin to cursing themselves.

Moreover, even the definition of death might be called into question. Although the medical world considers brain death to be irreversible and absolute, many Asian cultures struggle with this definition. To many of them, organ removal under brain death might even be synonymous with euthanasia.

As such, what some might perceive to be a sensitive issue in our daily discourse naturally function as a conversational barrier against ideas like organ donation. If people do not discuss it, then the benefits and concerns of organ donation will always be equivalent to a societal black box: often side-lined to an unassuming notice one receives from the government at the age of twenty-one.

Religion and Autonomy

Possibly the most powerful argument against mandatory organ donation would be the principle of bodily autonomy. The right to governance over one’s own body without external coercion forms a piece of the bedrock that underpins the most basic of human rights accords. In fact, the importance of personal autonomy and self-ownership is so absolute that it even supersedes situations of medical necessity ^[1]. As a result, the very notion of mandatory organ donation by the state, cadaveric or otherwise, is a grave assault on an individual’s human rights.

However, this begs the question: why should aforementioned human rights matter to dead people, for they cannot possibly enjoy these rights anyway? Beyond the basic dignity that should be afforded to a dead body in the first place, desecrating dead bodies for their organs erodes the trust people have in public institutions like hospitals in handling their bodies after death. And perhaps more noticeably, the deceased often have families mourning their departure, who will inevitably be hurt and outraged if the state were to go against the wishes of their deceased family members. Hence, the concept of bodily autonomy should ostensibly be accorded to everyone, extended to past our expiration, and be rigorously upheld without exceptions unless explicitly stated otherwise.

Bodily autonomy aside, religion is another unimpeachable factor that might constitute to the reluctance in donating organs, particularly in Singapore. The general consensus among the majority of religions seems to be that organ donation is permissible. Nevertheless, religion itself is not a singular monolithic construct; it is instead made of numerous, and often differing, branches and schools. Islamic bioethical concepts of bodily autonomy are often theocentric, and not anthropocentric. As a result, many Muslims might believe that ownership of their body is not theirs, but rather, God’s. In Buddhism, the issue of spiritual consciousness residing in the body after death might lead to discrepancy among its followers. Since the soul takes time to depart from the physical body, the latter should not be disturbed when death is declared ^[2]. Furthermore, many Buddhists adopt and integrate Confucian taboos that are against the destruction of the human body. In a multi-religious, largely conservative society like Singapore, religion takes centre stage in shaping the narrative of organ donation; and therefore, should not be simply dismissed.

The Future of HOTA

Even though compulsory cadaveric organ donation should not be institutionalised due to a confluence of moral and religious reasons, this does not preclude the possibility of improving status quo. Singapore still suffers from a low rate of organ donors, despite HOTA being passed back in 1987. With technologies like artificial organs and xenotransplantation still decades away, constant refinements to HOTA are sorely needed to navigate around cultural and psychological barriers.

A critical component that might be lacking in policy is education. HOTA establishes reciprocity (where organ donors are given priority on a waiting list), a fact that many Singaporeans might not be aware of. The step forward might be increasing the national visibility of HOTA – this means exposing students to such issues in their curriculum, pollicisation of opinion segments on printed media, or even through posters on community noticeboards in lift lobbies.

On the other side of the coin, policy-specific adjustments should be considered as well. Concerns Singaporeans might harbour are the presumption of consent, as well as the contentious definition of death. Consequentially, HOTA could implement changes that require residents to acknowledge their default consent say, every ten years – similar to the duration of one’s passport validity. In the same declaration, there could perhaps be an option to exclude brain death as a prerequisite for organ transplant, and instead narrow the definition to just circulatory death ^[3].

Conclusion

As unquestionably salient as organ donation is in providing the gift of life to critically ill patients, nations nonetheless should never enforce compulsory organ donation after death on their citizens. Not only would doing so destroy the trust the public holds for the government, but it would also violate the most basic of human principles – bodily autonomy and freedom of religion. What nations should do, instead, is to systemically review and improve on existing organ donation policies, to ensure they are beneficial, equitable, and progressive.

^[1] A Pennsylvanian court ruled in favour of the defendant to refuse donation of his bone marrow, even if it would save another’s life in McFall v. Shimp (1978).

^[2] Amidism, a popular sect of Mahayana Buddhism, believes the soul should leave peacefully towards reincarnation in order for a positive rebirth.

^[3] Circulatory death refers to the irreversible cessation of the heart, resulting in circulatory failure. In some religions, circulatory death is the only true determination of death as opposed to brain death.

References

1. US Health Resources & Services Administration, available at https://www.organdonor.gov/statistics-stories/statistics/data.html (Data retrieved on 2 May 2021)

2. Donate Life America, available at https://www.donatelife.net/ (Data retrieved on 2 May 2021)

3. Jean Liu (2017), ‘Commentary: Timely to review our opt-out organ donation policy’, available at https://www.channelnewsasia.com/news/singapore/commentary-timely-to-review-our-opt-out-organ-donation-policy-9317580

4. Hedayat, K. M. (2007). “The Possibility of a Universal Declaration of Biomedical Ethics”, Journal of Medical Ethics. 33 (1): 17–20

Disclaimer: Please note that the views and opinions expressed in the essays for the Live On Festival 2021 are those of the participants and are not endorsed by the National Organ Transplant Unit (Ministry of Health).

To learn more about organ donation and organ transplantation in Singapore, please visit www.liveon.gov.sg