Teo Jer Rei, 21

Topic: Ways to improve organ donation rates

Award: Third Place, Open Category, 2021

Encouraging More to Give, Empowering More to Live

“Organ donation is a noble gift of life that requires courage to give, and perhaps as much courage to receive”. This is a quote from Professor Tan Chee Kiat, Director of the National Organ Transplant Unit (NOTU) in a Straits Times forum article last year. Organ donors can be classified into living donors, who can donate certain organs such as kidneys, and cadaveric donors, whose organs are procured for donation after certification of death. While a single donor could potentially save up to 7 lives, Singapore still faces a shortage of organ donors.

Low levels of organ donation can be attributed to legislative, structural and societal factors. To effectively address this issue, underlying reasons need to be understood, before coming up with suggestions to target all stakeholders involved - donors, donors’ families, medical staff, and healthcare institutions. In consideration of Singapore’s aging population, whereby an estimated one in four Singaporeans will be aged 65 and above in 2030, suggestions should also involve our seniors, while safeguarding public health amid the COVID-19 pandemic.

From a legislative perspective, there are still low levels of awareness and understanding of Singapore’s opt-out organ donation act, called the Human Organ Transplant Act (HOTA), despite it being enacted many years ago in 1987. According to a 2019 survey by Channel NewsAsia, 9 in 10 intensive care unit (ICU) physicians observed a lack of awareness and acceptance of HOTA among families. Low levels of awareness cause families to find out that a lack of objection, by default, constitutes their loved ones’ organs being donated - a choice which many are unprepared to accept.

Legislative amendments can be implemented to ensure greater awareness of HOTA among the general population. A clause under HOTA can be introduced requiring Singaporeans and Permanent Residents (PRs) to submit an acknowledgement at important life milestones, to indicate their understanding and consent to inclusion under HOTA. Currently, an introductory letter from MOH is issued to Singaporeans and PRs upon turning 21 years old, explaining the terms of HOTA, as well as an opt-out form. An acknowledgement form can be included in this introductory package, which recipients must sign off and submit.

Moving forward, with Singapore’s increasing average life expectancy, another formal acknowledgement should be required at a later juncture in life, such as at the Central Provident Fund (CPF) savings withdrawal age of 55. An acknowledgement letter from MOH can coincide with the letter sent to CPF members 6 months before their 55th
birthday, to remind and reconfirm donors of their inclusion under HOTA. Furthermore, considering the government’s digitalisation efforts to go paperless, acknowledgements can also be done online, through platforms like the HealthHub app, a one-stop health portal for Singaporeans to access health records and services. These amendments help to improve HOTA’s legitimacy through greater public awareness and ensuring that those included under HOTA understand their responsibilities. Formal acknowledgements clear up uncertainty over patients’ death wishes, serving as written proof of their inclusion under HOTA, thereby facilitating a smoother organ donation process.

Globally, the COVID-19 pandemic has reduced organ donation rates as healthcare systems focused efforts on containing the virus. With the acknowledgement from Prime Minister Lee Hsien Loong that COVID-19 is likely to become endemic in the future, structural adaptations in our healthcare system should be undertaken to facilitate safe organ donations under pandemic conditions, and protect the health of living donors.

Strict visitor policies in hospitals are required especially during times of high communal transmissions. This presents a greater emotional burden for relatives, as a lack of physical contact with their loved ones during their final moments makes it harder to come to a proper closure. It becomes more challenging for medical staff to discuss the issue of organ donation with relatives and obtain their consent, possibly causing delays in the organ donation process, and rendering the process futile as organs typically only have a 24 to 48-hour window before becoming unviable for donation.

To overcome such barriers, doctors can pre-emptively make arrangements with relatives for them to have more time with their loved ones while observing healthcare guidelines. For instance, medical staff can arrange to grant a higher number of allowed visitors or longer visiting hours, subject to precautions such as screening family members’ travel history and local movements, and administering accurate tests like Polymerase Chain Reaction (PCR) tests and Antigen Rapid Tests (ART) prior to visits. When making such arrangements, medical social workers can also assist to guide families through a discussion about the details of the organ donation process. A session coupling the discussion of organ donation together with visiting arrangements could make families more open to cadaveric organ donation, as this discussion was initiated earlier instead of a standalone discussion conducted only after the passing of their loved ones.

Under HOTA, reimbursements are available for living donors, such as compensation for loss of income and follow-up medical care if they experience long term health issues after donation. With the ongoing global pandemic, more provisions can be explored, such as additional reimbursements of medical expenses should these donors, who are temporarily weakened after donation, become infected with COVID-19. MOH can also consider giving living donors and their immediate family members priority for COVID-19 vaccination or even a 3rd dose if recommended by healthcare guidelines, should they have not done so, to confer them better protection against the virus and reduce chances of infection before and after donation. These measures give living donors a better peace of mind by alleviating their health concerns, and can encourage more to come forward to donate.

On a societal level, Singapore’s different ethnoreligious groups share commonalities such as the idea of rebirth and the need for completeness of the body upon burial, creating an implicit bias against organ donation, even though all major religions in Singapore approve of organ donation. Additionally, topics like death are considered taboo in Asian societies, leading to a reluctance to discuss one’s death wishes with their family. A lack of discussion and clarification of beliefs result in family members being unsure of their loved ones’ death wishes, as well as whether organ donation goes against religious or cultural beliefs. Given such ambiguity, families usually act conservatively and choose not to donate their loved ones’ organs.

To address reservations towards organ donation, religious, youth and elderly groups can collaborate with healthcare institutions like NKF and MOH, to initiate discussions clarifying religious or cultural beliefs among their respective networks. In view of the COVID-19 pandemic, discussions within and across community groups can be conducted online, similar to the SG Emerging Stronger Conversation series organised last year, which collated input from Singaporeans of different backgrounds regarding national issues. These discussions help to highlight greater awareness of HOTA and encourage more to discuss organ donation decisions with their families, while simultaneously fostering community bonding. As a conclusion to these discussions, summaries such as infographics can be published, similar to the SG Together infographics created in the 4 major languages, to capture the key ideas highlighted.

To address the taboo element of discussions concerning death and organ donation, we can take reference from projects that similarly deal with taboo topics. An example is the Yellow Ribbon Project, which has succeeded in combating stigma against ex-offenders searching re-employment, building a strong support base of almost 9000 partners. A publicity strategy employed by the project is its iconic yellow ribbon pin. The public can show their support by sharing pictures of the yellow ribbon on social media, or by donning on the pin, as seen in the Parliament Sitting in March this year, where Members of Parliament (MPs) such as Minister of State for Home Affairs Muhammad Faishal Ibrahim donned the pin to demonstrate support for the cause. Building on the idea of an identifiable symbol, a donor card, used in nations like Spain, which has the highest organ donation rates worldwide, can be created and issued to donors under HOTA when they submit their acknowledgement. The card can function as a government-issued identity document (akin to an Identity Card or driving license) and may be used for verification purposes. On commemorative events like World Organ Donation Day on 13 August, retail partners can collaborate to offer discounts to those who present their donor card, as an additional incentive for these potential donors. A donor card with frequent public usage can help kickstart conversations on organ donation, as people’s curiosity are piqued when they observe others using the card.

A combination of solutions targeting the different stakeholders of organ donation can help to improve Singapore’s organ donation rates. These suggestions draw inspiration from successful case studies like Spain and other local initiatives, to form a holistic approach addressing the legislative, societal, and structural aspects of organ donation. Let’s work together as a nation to offer this Bridge of Hope, and make the gift of life available to those In Search of Hope.

References

1. Tan Chee Kiat (Professor), “Forum: Living donor kidney transplants a good option for patients”, The Straits Times, August 20, 2020. https://www.straitstimes.com/forum/living-donor-kidney-transplants-a-good-option-for-patients ↗ (opens in new tab)

2. “Facts About Organ Donation”, Live On. https://www.liveon.gov.sg/facts.html#:~:text=FACT%205,be%20saved%20by%201%20donor ↗ (opens in new tab)

3. Helen Ko, “Commentary: It is high time for a Ministry on Ageing Issues”, Channel News Asia, August 17, 2019. https://www.channelnewsasia.com/news/commentary/ageing-issues-ministry-singapore-policy-elderly-seniors-ageing-11782364 ↗ (opens in new tab)

4. Voo Teck Chuan and Shahla Siddiqui, “Commentary: Dealing with the difficult issue of organ donation when a loved one passes on”, Channel NewsAsia, May 28, 2019. https://www.channelnewsasia.com/news/commentary/death-organ-donation-how-to-deal-with-difficulty-hota-mtera-11554440 ↗ (opens in new tab)

5. “Death and Life Expectancy”, Singapore Department of Statistics. https://www.singstat.gov.sg/find-data/search-by-theme/population/death-and-life-expectancy/visualising-data ↗ (opens in new tab)

6. “Withdrawals of CPF savings from 55”, Central Provident Fund Board. https://www.cpf.gov.sg/Members/Schemes/schemes/retirement/withdrawals-of-cpf-savings-from-55 ↗ (opens in new tab)

7. “HealthHub” Smart Nation Singapore. https://www.smartnation.gov.sg/what-is-smart-nation/initiatives/Health/healthhub ↗ (opens in new tab)

8. Lim Yan Liang, “Singapore planning for a new normal of living with Covid-19: PM Lee” ¸The Straits Times¸ May 31, 2021. https://www.straitstimes.com/singapore/singapore-planning-for-a-new-normal-of-living-with-the-virus-says-pm ↗ (opens in new tab)

9. “How to organ donate” Timeliss. https://www.timeliss.com/en/guide/medical/topics/how-to-organ-donate ↗ (opens in new tab)

10. “Living Organ Donation”, Live On. https://www.liveon.gov.sg/living-organ-donation.html ↗ (opens in new tab)

11. Williams, Jerome D.; Lan, Luh Luh; Lwin, May Oo. “Social Marketing Initiatives: National Kidney Foundation’s Organ Donation Program in Singapore”, Journal of Public Policy & Marketing, 2002. https://dr.ntu.edu.sg/bitstream/10356/80844/1/jppm%252E21%252E1%252E66%252E17613.pdf ↗ (opens in new tab)

12. “What My Family Should Know”, Live On. https://www.liveon.gov.sg/what-my-family-should-know.html ↗ (opens in new tab)

13. “Before-I-Die Campaign” NUS Yong Yoo Lin School of Medicine. https://medicine.nus.edu.sg/newsletters/issue-17/feel-the-pulse/before-i-die-campaign/#:~:text=Death%20is%20a%20taboo%20topic,can%20be%20added%20to%20life%E2%80%9D ↗ (opens in new tab)

14. “Overview” Singapore Together. https://www.singaporetogether.gov.sg/speak/ ↗ (opens in new tab)

15. Matthew Wee Yik Keong, “The Yellow Ribbon Project Singapore Reaching Out and Touching a Nation”, United Nations Asia and Far East Institute, 31 January 2020. https://www.unafei.or.jp/activities/pdf/Public_Lecture/Public_Lecture2020_Mr.Keong_Paper.pdf ↗ (opens in new tab)

16. Richelle de Wit, “How Do I Register As Organ Donor?”, Citizens Advice Bureau Spain, November 4, 2014. https://www.citizensadvice.org.es/faq/how-do-i-register-as-organ-donor/ ↗ (opens in new tab)

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 ↗ (opens in new tab)