Abigail Cheng Shi Qing, 16

School: Bukit Panjang Government High School

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

Award: Special Mention, Senior Category, 2022

Low Rates of Organ Donation In Singapore

With the advent of medical technology, the success rate of solid organ transplantation as a method of treatment for end-stage organ failure has rapidly increased. As a result, the demand for many transplantable organs has also been growing tremendously. In a bid to satisfy this demand in order to save precious lives, Singapore introduced the Human Organ Transplant Act (HOTA) in 1987. This scheme presumes consent for post-mortem organ procurement and transplantation and covers all Singaporean citizens and Permanent Residents (PR) aged 21 and above, regardless of their cause of death. Despite opting out of it being an option, it is strongly discouraged as doing so would give one lower priority for future organ transplants. Yet, even with this legislation in place, the number of deceased organ donors remains at a global low of 7 to 9 per million population each year. This may come as a shock to many, thus bringing about the question of whether Singapore’s conservative culture is truly the root of our low organ donation rates. While many might agree, I disagree as I firmly believe that Singapore’s conservative culture is not the root of our low organ donation rates.

Firstly, due to various illnesses, a significant number of people who have died in Singapore are deemed unsuitable for post-death organ donation, especially for the organs that are high in demand. In order for one’s organs to be valid for donation and transplantation after death, the organs have to be healthy, so as to ensure a good quality of life for the receiver. Yet, the leading causes of death in Singapore are illnesses which cause harm to various organs, thus making said organs unsuitable for donation. Notoriously known as the top leading cause of death in Singapore, cancer invalidates organs to be used for donation. Organs belonging to cancer survivors and victims of metastatic cancers alike are usually disallowed for transplantation, with the best interests of the potential receiver in mind. However, as of 2020, cancer made up 28.6% of local deaths. Consequently, this means that almost all of the jarring 28.6% of deceased organs are totally unsuitable for donation. Needless to say, this contributes significantly to the low organ donation rate in Singapore. Other than cancer, ischaemic and other heart diseases are some of the top leading causes of death here. Accurate as of 2020, the percentage of local deaths attributed to the cause of ischaemic heart diseases is 20.5% and as for other heart diseases, the statistics show a concerning 2.1%. The various heart diseases often mean that one’s heart is weakened, in the sense that it might not pump blood as efficiently or effectively as desired. The heart is a crucial organ for living beings due to it pumping oxygenated blood around one’s body, essentially being one of the key determinants of one’s survival. Hence, when one passes on due to heart diseases, their heart functions might likely have already been compromised to a great extent, thus making it an unsuitable organ for donation. With heart diseases being the cause of the demise of many, the hearts of many deceased are ineligible for donation. Not only do heart diseases cause the heart, an in-demand transplantation organ, to be unsuitable for donation, cancer does too, in addition to making other major organs ineligible for donation, thus giving rise to the low post-mortem organ donation rate in Singapore.

Besides, as for potential living donors, many of them are also ill-suited to donate certain organs. As a first-world country, Singapore has advanced medical equipment for the purpose of carrying out rather groundbreaking procedures like Laser-Assisted In Situ Keratomileusis (LASIK), which permanently alters the shape of one’s cornea, successfully. Often dubbed the “Myopia Capital of The World”, Singapore has a tremendously high rate of myopia, with 83 per cent of young adults being myopic and 5 percent of children being myopic by the time they have to take their Primary School Leaving Examinations (PSLE). As a result, many turn to LASIK to correct their vision and remove the daily hassle of having to wear spectacles or put on contact lenses. However, having performed LASIK or eye surgery of any kind makes one’s cornea unsuitable for donation after one’s demise. Ergo, many Singaporeans and PRs are ineligible for post-demise cornea donation. Apart from that, according to the World Bank collection of development indicators, as collated from officially recognised sources, the prevalence of diabetes in Singapore was calculated to be at a worrying 11.6%. Diabetic patients are strongly discouraged from donating their organs, especially their kidneys, as they are likely to require both kidneys in the long run, due to diabetes being an extremely common cause of chronic kidney failure. This is evident as in 2013, more than 60% of kidney failure patients who required dialysis were diabetic. Furthermore, patients diagnosed with diabetes are also disallowed from donating parts of their liver as liver grafts are exceedingly vulnerable and with diabetes increasing risk factors, they are more likely to be unsuccessful and cause detriment to the receiver. Therefore, with the bulk of Singaporeans being unsuitable as living organ donors due to various factors, like eye surgery and diabetes, it comes as no surprise that our donation rates are ever so low.

In addition, the plethora of misconceptions held by many contribute to Singapore’s low organ donation rate. One common misconception possessed is that should one be under the HOTA scheme, their doctors would not give their all in saving them, as their organs can be donated to other patients who are possibly in less dire conditions. However, this misconception is completely baseless and irrational. Under the HOTA scheme, stringent clinical criteria and processes are set in place to prevent such unfortunate situations from happening. Before any procurement of organs can take place, one must be certified brain dead. The process of certification of brain death in Singapore is an immensely strict one, requiring the approval from two independent doctors not involved in the care of the patient. Apart from that, these doctors who hold the power of decision-making in certifying whether a patient is brain dead are specialists who have had appropriate training, minimising their risk of misdiagnosing brain death. As for the neurological evidence considered by these doctors before any certification of brain death, it is based on legitimate medical evidence as well as updated knowledge from medical findings. Once a patient is diagnosed as brain dead, the death of the patient is recognised both medically and legally. Only then can the retrieval of organs begin. With these stringent processes and criteria for certification of brain death set in stone, one need not worry about their chance at a possible survival being diminished should they be in a dire state, as much care is taken in saving a patient and determining brain death, which only happens when there is irreversible brain damage. However, not many citizens and PRs know about the strict processes of post-death organ donation, which may fuel their desire to opt out of HOTA, thus causing our low organ donation rates.

Yet, many might argue that conservative culture is the root of our low organ donation rates as cultural practices and traditional religious beliefs discourage post-mortem organ donation. The Confucian idea that one’s body must be kept intact during funeral rites, coupled with the many religions propagating the idea of the sanctity of one’s body, might lead one to think that unwillingness to donate one’s organs after death stems from conservatism. However, I strongly disagree with this notion as studies have shown that rather than being a discouraging factor in one’s decision to donate their organs post-death, religion is often the motivating factor for one to do so. Based on a population-based perception study on presumed consent for organ donation done in Singapore, religion was found to be a noteworthy variable associated with willingness to assent to post-mortem organ donation. Furthermore, all races in Singapore, alongside the major religions in Singapore, namely Buddhism, Christianity, Islam, Hinduism and Taoism, support organ donation, which is perceived as a generous and benevolent deed that would go a long way in making a positive impact on someone else’s life.

All in all, I believe Singapore’s conservative culture is not the root of our low organ donation rate. Rather, it is the misconceptions many have, in addition to the various factors which make many unsuitable living or post-mortem organ donors. In order to combat this issue of low organ donation rates in Singapore, we, as a nation, need to have more conversations about it. Only through generating discussion can we spread awareness and mitigate misinformation about organ donation, which might aid in increasing our organ donation rates.

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