Theron Tham Tzi Tjenn, 21

Topic: Should organ donation after death be mandatory?

Award: High Distinction, Open Category, 2021

Mandatory organ donation only represents the medical standpoint, while ignoring all others

In Singapore, if someone requires an organ transplant at the same time he becomes a parent, his child could complete secondary school before he receives an organ! Most transplant patients wait five to 17 agonising years for a suitable organ, a duration that will increase with Singapore’s ageing population. The desperation felt by transplant patients and their families is depicted in the Japanese medical drama Code Blue. A mother, whose son has waited years for a new heart, receives news that her child’s heart will fail in two weeks. In frustration, she cries: “Before, when I heard the wail of an ambulance siren, I prayed for the victim’s swift recovery. Now, I just hope they are not long for this world.”

Waiting for an organ brings more than mental torment to patients. It presents an economic challenge too. Compensating for the failure of an organ is a time-intensive activity. Patients requiring kidney transplants, the most demanded organ, can spend 35 hours weekly in dialysis for years. A commitment akin to a full-time job, dialysis often forces patients out of employment. Furthermore, treatments substituting organ functions are among the most expensive medical services available ^[1]. Some patients, faced with huge economic and social liability ^[2], choose to die. In a country that values human talent as its most valuable resource, shortening organ waitlists should be prioritised. Yet, national organ donation rates remain among the lowest globally, reflecting the inadequacy of present measures to cope with demand for suitable organs ^[3]. Even with the Human Organ Transplant Act (HOTA) and “LiveOn” Campaign, the number of transplantable organs remains woefully mismatched to demand. Most transplants are cornea transplants, while the transplant rate of kidneys, hearts and other vital organs are abysmal ^[4].

Clearly, more needs to be done to increase the organ transplant rate. A common idea proposed is to make organ donation mandatory. With a national death rate of 22,000 in 2020, such legislation would significantly increase the pool of suitable organs compared to 504 transplanted organs in 2018. In fact, it could clear the existing backlog of transplant patients! However, such compulsory measures are extreme. As a blanket scheme, it robs people of any choice regarding their organs after death. Such a scheme is sure to invite dissent and risks unravelling Singapore’s carefully constructed social fabric. Hence, it is likely to do more harm to Singaporean society than good. Instead, identifying the root cause of the low donation rate and utilising alternative measures to tackle these causes should be the priority.

First, identifying the main source of opposition against organ donation is necessary. In most cases, opposition comes from family members. Often too attached to dead patients, they are unable to accept patients’ deaths or doubt brain death. Hence, when doctors approach families in distraught mental states, doubts if all has been done to save loved ones are raised. These doubts give families the rationale to seek alternative medical opinions. Thus, precious time in the viable window for organ donation is lost ^[5]. Furthermore, although all major religions in Singapore support organ donation, discussing it and afterlife plans in general remain taboo topics among Singaporeans. If personal views on organ donation are not made known before death, the presumed consent of HOTA is often unable to be accepted by the family ^[6].

The refusal to accept presumed consent raises three important points against enacting mandatory organ donation. First, Singapore’s mortality is mainly attributed to the elderly ^[7]. While younger Singaporeans are more open to organ donation after death, traditional attachment to the physical body is still widespread among seniors. Moreover, many senior citizens view afterlife plans as taboo and eschew such discussion with family. Thus, the greatest opposition against mandatory organ transplants will come from seniors, they themselves the greatest contributors if organ donation becomes mandatory. Hence, current difficulties faced by doctors in obtaining presumed consent for HOTA will not be ameliorated, or worse, increase with mandatory donation.

Another point for consideration is mandatory organ donation implies there is no opting out. While reducing wait times for transplant patients is important, so is the quality of life of dying patients too. Should dying people oppose donating their organs, having to spend their final days in distress knowing their bodies will be dismembered is no way to pass away in peace! The core of organ donation is to reduce the suffering of those still living. But mandatory organ donation simply transfers the suffering of transplant patients to the dying donors. Would this not defeat the moral purpose of organ donation?

This raises the final question: is mandatory consent the right way to treat the deceased? When someone is unable to make conscious and informed decisions, such as children under 18-years-old, a guardian is appointed to oversee final decisions. Why should the deceased be presumed to have given consent to donate his organs? Instead of a mandatory decree, remaining family members should be given jurisdiction over the body, for it now lacks autonomy. When a person dies, his physical possessions are inherited by his surviving family. Likewise, his physical body should come under the possession of the family too. While donated organs can bring relief to a patient in need, we cannot discount some families’ need to be assured their deceased goes into the afterlife smoothly as per their religious or racial belief. Enacting mandatory organ donation implies prioritising the physical suffering of patients over the mental needs of surviving family members, a reasoning which is difficult to justify.

These points reveal that organ transplants cannot be viewed solely from a medical perspective. As the sole branch of medicine which requires a donor, organ donation is as much a social issue as a medical one. Enacting mandatory organ transplants focuses solely on solving the organ shortage, which is only the medical part of the issue. While more organ donors are necessary, forcing people into mandatory donation could invite dissent and would be socially and politically untenable. Rather, legislation to improve donation rates must focus on the social aspect too; namely improving communication and awareness of organ donation.

The current opt-out scheme of HOTA only contributes towards Singapore’s lack of a culture that encourages discussion of afterlife plans among family. The result is overall public apathy towards the donation of organs, leading to ignorance of the medical value of organs after death. A mandatory organ donation scheme will worsen this by removing personal autonomy with regards to organ donation. Instead of relieving people of making difficult choices, good legislation should promote discussion and encourage people to make active choices for their afterlife plans. Examples could involve coupling organ donation with common life decisions, such as granting several years of tax breaks or reduced healthcare costs for organ donors. Stronger measures like an opt-out donation scheme for when people obtain car licences or undergo surgery should be considered too. The purpose of coupling is to ensure the decision to donate organs is not thrust upon patients or families in critical periods or times of grief, thereby reducing opposition and delays in the short post-mortem window to harvest organs.

Alternatively, a softer approach of recurring decisions could be implemented. As society and people age, their views towards organ donation could change. Providing an avenue for them to make recurring choices on organ donation offers opportunities for conscious decisions regarding their organs. For example, the Ministry of Health could partner with the Immigration and Checkpoints Authority for citizens to re-affirm or commit to organ donation when they renew their passports every decade ^[8]. Instead of just passive education and awareness programmes, ensuring Singaporeans make active decisions will promote widespread discussion of afterlife plans and knowledge of their stance on organ transplant. Still, these suggestions are also enforced measures, which will have loopholes that will be exploited and opposed. Rather than absolute solutions, they should be viewed as interim steps to boost Singapore’s organ donation rate, employed in tandem with current educational measures ^[9].

To conclude, organ donation is ultimately an act of altruism. People must be willing to donate their organs to help others. Some people feel it is only right to donate our organs, but not everyone may feel the same way. Mandatory organ donation would only pander to one segment of society while invalidating others’ opinions. This is unacceptable in Singapore’s diverse society. Instead, for organ donation to increase in Singapore, fundamental values must be changed. Death must be viewed as more than an unhappy event, but one which is able to bring value to others too. Simply adopting a mandatory stand forcing Singaporeans will instead backfire on this ideal. Singaporeans cannot be made more passive! Improving organ donation rates cannot be solved simply by relying on the health or legal sphere, but through a whole-of-nation approach, where every segment of society realises and strives towards value after death too. Organ donation, is after all, as much a social issue as it is a health one.

^[1] For example, non-subsidised dialysis treatment cost between SGD$2,500 - $4,000 monthly in 2014. Meanwhile, unsubsidised treatment chronic liver disease (cirrhosis) cost up to SGD$15,000 per annum in 2004.

^[2] Many studies have also shown it is cheaper for the country and better for a kidney patient’s family to get the patient to have a transplant than to stay on dialysis.

^[3] Singapore had a deceased organ donation rate of 6.6 organ donors per million(pmp) in 2017, significantly lower than the world leader, Spain, at 46.6 pmp.

^[4] After the launch of the “Live-On” Campaign in 2008, the annual organ donation rates improved by 25% (174 from 2004 - 2007 to 220 from 2008 - 2015). However, the donation rates of vital organs such as kidneys, hearts and livers dropped to 58 in 2015 from 69 in 2006. The majority of organ transplants are cornea transplants, comprising up to 88% of transplant operations.

^[5] A mere 55 minutes after circulatory death, or when the heart stops pumping, is the harvestable window for most vital organs. After this duration, they become unviable.

^[6] Channel News Asia reported that although many Singaporeans may personally opt to donate their organs, they are also less likely to be willing to donate their family members’ organs, further complicating the issue.

^[7] Singapore’s Age-Specific Death Rate is below 10 per 1000 residents for every 5-year age interval of citizens below 69 years old. However, once above 70, the death rate increases significantly for each consecutive 5-year age interval.

^[8] This resembles the proposal raised by Associate Professor Daniel Goh of the Worker’s Party in 2016, where he called for the Ministry of Health (MoH) to review the opt-out model of HOTA and instead consider a “mandated choice” policy, where people are forced to make decisions regarding organ donation when they interact with the government.

^[9] Existing efforts include expanding the training of more healthcare professionals on organ donation and working with doctors to raise patients’ awareness in living organ transplant as a treatment option.

References

1. Ministry of Health, News Highlights. (2016, August 18). Increasing Singapore’s Organ Transplant Rate [Press release]. https://www.moh.gov.sg/news-highlights/details/increasing-singapore%27s-organ-transplant-rate

2. Khalik, S. (2016, January 19). Some kidney patients refuse treatment and choose to die. The Straits Times. https://www.straitstimes.com/singapore/some-kidney-patients-refuse-treatment-and-choose-to-die

3. Singapore Department of Statistics, Death and Life Expectancy - Visualising Data. (2020). https://www.singstat.gov.sg/find-data/search-by-theme/population/death-and-life-expectancy/visualising-data

4. Tai, J. (2016, May 23). Organ donations remain low despite changes to law. The Straits Times. https://www.straitstimes.com/singapore/organ-donations-remain-low-despite-changes-to-law

5. Organ Donation in Singapore (under HOTA, or For Science). (n.d.). SingaporeLegalAdvice.Com. Retrieved May 5, 2021, from https://singaporelegaladvice.com/law-articles/organ-donation-in-singapore/

6. Organ Donation - Facts Live On - Support Organ Donation [online]. Retrieved May 08 2021, from https://www.liveon.sg/content/moh_liveon/en/organdonation/facts.html

7. Kwek TK, Lew TW, Tan HL, Kong S. The transplantable organ shortage in Singapore: has implementation of presumed consent in organ donation made a difference? Ann Acad Med Singapore 2009; 38:346-8.

8. YaghoubiFard, S., Goudarzi, R., Etminan, A., Baneshi, M., Barouni, M., & Jafari Sirizi, M. (2016). Cost-effectiveness analysis of dialysis and kidney transplant in patients with renal impairment using disability adjusted life years in Iran. Medical journal of the Islamic Republic of Iran, 30, 390.

9. McMaster P, Vadeyar H. Spain model: world leaders in organ donation. Liver Transpl 2000; 6:501-3. http://dx.doi.org/10.1053/jlts.2000.0060501 PMid:10915176

10. Li, Shu Chuen & Ong, Siew & Ong, Sien & Lim, Seng & Yeoh, Khay & Kwong, Kai & Lee, Vivian & Lee, Winnie & Lau, Joseph & Wong, Ian & Kung, Nelson & Leung, Wai & Chan, Henry & Chan, Francis K.L. & Lee, Kenneth. (2004). A Cost Comparison of Management of Chronic Hepatitis B and Its Associated Complications in Hong Kong and Singapore. Journal of clinical gastroenterology. 38. S136-43. 10.1097/00004836-200411003-00004.

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