Neha Raja Raman, 16

School: Bendemeer Secondary School

Topic: Conservative culture a root cause of low donation rates?

Award: High Distinction, Senior Category, 2022

One hundred years ago, organ donation was merely a figment of the human imagination, a scientific miracle that was just that, a miracle. Today, we have surgeons whose speciality is organ transplants, a nod to our rapid development of medical technology. Organ donation has become a key medical procedure that many people desperately need to survive. As one of the main ways that a person can restore a semblance of their health, it makes one wonder why in Singapore, a modern, well-developed country, a means to help another human being through modern science is not a route that many opt to take, even once deceased when it does not seem to disadvantage the donor in a large capacity.

In Singapore, our government has implemented the Human Organ Transplant Act (HOTA) which ‘allows for the kidneys, heart, liver and corneas to be removed, for the purpose of transplantation, in the event of death from any cause¹ unless a Citizen or Permanent Resident 21 and above chooses to opt-out. Singapore has relatively low organ donation rates compared to other counties, with 4.41 patients per million population (pmp) for deceased kidney donations and 11.18 pmp for living kidney donations in 2019, a stark contrast to the USA’s 36.88 pmp for living kidney donations and 22.99 for deceased kidney donations, also in 2019². Moreover, in 2015, there were 334 patients on the waiting list for kidney transplantation, an unfortunately disproportionate amount to the 32 living kidney donors that year³.

In our Asian society, it is unequivocal that we are more conservative compared to our western counterparts, a possible reason for our low organ donation rates. Conservative culture can be defined as the shared belief to follow traditional values and the hesitancy to deviate from those traditions.

A form of our conservatism is the strong presence of religion in Singapore. In many religions, there is the belief that the body is sacred and must be preserved or that the soul remains in the body for a certain period of time, and to remove an organ from the body would be to disrespect it. People with this belief are a substantial number of people in Singapore, with around 83.5% affiliated with a religion⁴, that are more hesitant to pledge their organs for donations and would prefer to opt-out instead, reducing the number of possible donors and thus the rate of organ donation in Singapore.

However, a reason for such low organ donation rates can also be attributed to a more human, more visceral reason. The loss of a loved one usually evokes shock and emotional turmoil, both of which can cause a grief-stricken family to grapple when making a decision on whether to donate an organ or not. By allowing an organ to be donated from the recently deceased, they can feel that they are losing another part of their loved one, deepening their sense of loss. Such anguish results in family members of the deceased being unable to make an objective decision in regards to donating the deceased’s organ. Furthermore, the approach that medical professionals take when introducing the option of organ donation to grieving families can also deepen their sorrow. If a medical professional were to take an ill-advised approach and were to present the idea of organ donation either too quickly or too crassly, the family would not have enough time to grieve and could be so distraught that they would refuse to even hear the medical professional out. However, medical professionals are also racing against the clock as possible organs for donation remain viable only within twenty-four hours after death and are thus unable to provide the family with a lengthy amount of time to mourn or deliberate their decision.

The pressure due to the time constraint placed on the decision-making process is also amplified because of our hesitancy to discuss the topic of death as it is regarded as ‘taboo’, another form of our conservatism. Without discussions between family members in regards to donating an organ after death, family members of the deceased are left flummoxed and conflicted as they do not know what their deceased family member would want. Furthermore, some families may have the superstition that talking about death may invite it into their homes, and thus avoid the topic entirely. Dr Lee Guan Huei, medical director of liver transplantation at the National University Centre for Organ Transplantation has said that “The family is still very much involved in a patient’s medical decision, and more so when the patient can no longer make his or her own views known⁵” emphasising how the decision of organ donation can lie in the family members’ hands which highlights the importance of the deceased’s desired choice being made clear. Without the individual’s clear indication of their preference, families are left to guess, putting them in a difficult position. This lack of necessary communication may force family members of the deceased to take a safer route of refusing organ donation, thus reducing organ donation rates.

People’s ignorance in regards to organ donation or misconceptions that they carry can also be reasons for our low organ donation rates. While the words ‘organ donation’ seem quite self-explanatory, most may not know what that truly encompasses, which can cause some hesitation in going through with an organ donation. While there is a plethora of information available online in regards to organ donation in Singapore, the majority may still remain ignorant of notable details of organ donation. For example, many are not aware of other government schemes for organ donation such as the Medical (Therapy, Education and Research) Act (MTERA) which provides anyone above the age of 18 of any nationality the option to donate all types of organs and tissues⁶. As it is not presumed consent and is an opt-in scheme, most people remain unaware of it. If awareness about such options is increased, there would be a larger pool of people who would consider donating an organ and more types of organs could be donated. Moreover, some people have the impression that organ donation can only occur between family members as there must be compatibility between the donor and the recipient. While donor-recipient compatibility is integral, many people do not realise that it is very possible to find a match for organ donation outside of one’s family. Their misconception results in them not even exploring the idea of organ donation as they believe that their chances of finding a match are slim.

In regards to living organ donation, a reason for low organ donation rates could be the fear of risks to health that could entail after donating an organ. One study showed that the fear of surgical risks, which 86.5% of participants strongly agreed or agreed to, and poorer health consequent to donation, which 87.5% strongly agreed or agreed to, were the principal reasons for not considering being a living kidney donor⁷. With these concerns, people are less inclined to go through with a living organ donation because of the possible impacts on their bodies that would disadvantage them in their daily lives. Hospital bills, having to take leave from work and difficulties in completing daily tasks could be results of organ donation, which are strong inhibitors that keep living organ donation rates low.

Another reason for low living organ donation rates could be simply apathy. With a majority of people not having a direct loved one who could benefit from an organ being donated to them, they do not have much incentive to remove an organ from their body to give to a faceless recipient. While they do recognise that they are helping someone, they are most likely hesitant to donate as they are unable to form enough of a connection with the recipient for them to go through the long, gruelling process of an organ donation. Moreover, the possibility of the recipient’s body rejecting the donated organ also adds another layer of hesitancy. The possible donor may feel that even the chance of their organ being rejected can deem all their efforts a waste and thus would not opt for organ donation.

There are many factors that contribute to the low organ donation rates in Singapore and it thus cannot be fully attributed to our conservative culture. While our conservative culture most certainly plays a role, its role is not major enough for it to be declared the root cause as there are a myriad of other factors. With so many variables that influence organ donation rates, it is very difficult to determine one sole reason as the root cause as they all can have proportionate influence. Thus, Singapore’s conservative culture is not the root cause of the country’s low organ donation rates.

References

1. Human Organ Transplant Act.” MOH, 30 June 2020, https://www.moh.gov.sg/policies-and-legislation/human-organ-transplant-act

2. IRODaT - International Registry on Organ Donation and Transplantation, https://www.irodat.org/?p=database&c=US&year=2019#data.

3. A Multiethnic Asian Perspective of Presumed Consent for Organ Donation: A Population-Based Perception Study.” Frontiers, 5 October 2021, https://www.frontiersin.org/articles/10.3389/fpubh.2021.712584/full#B8

4. Singaporean Culture — Cultural Atlas, https://culturalatlas.sbs.com.au/singaporean-culture/singaporean-culture-religion.

5. “‘Are you sure he is dead?’: Doctors struggle with families’ lack of understanding of HOTA.” CNA, 5 May 2019, https://www.channelnewsasia.com/singapore/human-organ-transplant-act-doctors-families-understanding-887136.

6. “The Medical (Therapy, Education and Research) Act (MTERA).” MOH, 30 June 2020, https://www.moh.gov.sg/policies-and-legislation/the-medical-(therapy-education-and-research)-act-(mtera).

7. Factors influencing living kidney donation in Singapore.” PubMed, https://pubmed.ncbi.nlm.nih.gov/22489450/.

Disclaimer: Please note that the views and opinions expressed in the essays for the Live On Festival 2022 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