Sankaran Jagadish, 38

Topic: Will donor’s altruism be negated by advancement in transplantation in 2050?

Award: Fourth Place, Open Category, 2023

The sporting season is upon us. Mr Noah Lim¹ has just made headlines as the first gold medallist from Singapore in the SEA games held at Cambodia. In another news, Ms Jamie Yeow and Ms Galina Ivanova² won medals for Singapore at the World Transplant Games held at Perth in April this year. World transplant games is an international event promoting sport activities among organ transplant recipients. Thanks to the altruism of their donors, these two recipients went on to lead an active life post organ transplantation eventually winning medals at the games. If you would ask me if such heart-warming anecdotes of donor altruism be negated by advancement in transplantation in 2050, I will say an emphatic no.

Donor’s altruism will not be invalidated in the future by technological progress in transplantation including laboratory grown organs, xenotransplantation, and gene-editing. Here are my reasons for my prediction that even with these scientific advances, the donor's altruism will not be nullified in the future. Let me start by discussing laboratory grown organs.

Laboratory grown organs

Science and technology is advancing at a supersonic pace. Lab grown meat is now available in the market in Singapore³. Lab grown organs are the next frontier. By isolating stem cells from the patient themselves, organs are grown in the lab, thereby drastically reducing the chances of immune rejection. This is the most promising medical breakthrough of this century. Laboratory grown organs will reduce the supply-demand gap for human organs.

However, such a promising technology has limitations as well. It takes a few days for cells to grow, a few more days to assemble into a tissue and a few more days to form an organ ready to get transplanted in humans. In case, if organs are needed immediately, from a readiness point of view, organ donation is better than laboratory grown organs.

Nature has perfected the act of creating organs over millions and millions of years. In the case of laboratory grown organs, there is an optimisation step in the laboratory. A few conditions need to be tested for the isolated stem cells to identify suitable growth conditions. The degree of uncertainty in achieving success in growing organs in the lab (excluding the uncertainty due to rejection by the recipient) is higher than that of extracting an organ from a donor.

One of the other issues is the age appropriateness of the organ. In the case of transplants, the organ being harvested has been working very efficiently in the body for many years. In the case of laboratory grown organs, it remains to be tested whether the organ grown in the laboratory performs the same inside the human body too. An area of active research is to grow organs in the laboratory using 3D printing. Unlike simple structures that could be easily programmed to be printed, organs are extremely complex structures. Retaining the tissue architecture and vasculature to recapitulate the emergent properties of many of the organs are very challenging to the state-of-the-art 3D printing today.

Xenotransplantation

Xenotransplantation involves transplanting organs grown in non-human sources. One of the risks of xenotransplantation is the possible spread of zoonotic diseases. We are currently living through, perhaps, the first pandemic in our life-experience. Covid-19 is a zoonotic disease⁴ proving that animal to human transmission is a real threat. Apart from infection, restricting the size and shape of the organ while growing in the animal suitable for human transplant is still work in progress. After harvesting, given that it is from a non-human source, the risk of organ rejection is higher than that from human sources.

Gene editing

Gene editing is a technological breakthrough involving manipulation of one’s genes to create organs that are devoid of those mutations. This was awarded the Nobel prize in Chemistry in 2020⁵. This technology is applicable only if the cause of the organ degeneration is due to a genetic mutation. In the case of organ degeneration due to ageing, an accident or an injury, gene editing is not a very promising avenue to be explored and such patients are to be only considered for transplantation.

Whole body donation

Medical education is imparted to budding clinicians using cadavers and simulators. Simulators give a unique advantage to medical training since they reduce the number of cadavers needed per medical student for medical education. Whole body donation (in the form of cadavers) is the most valuable gift anyone can offer to the field of biomedicine.

However, no technology has evolved so far where an entire human body can be prepared in the laboratory. Anatomy and dissection lessons need to be taught in real-life scenarios. In such cases, operating on a complete human body provides many intangible hands-on experiences for the budding medical student. Any essay about technology is incomplete if the phrase ‘artificial intelligence’ is not mentioned. There is a possibility that AI will create real life virtual simulations where necessary practice can be done. Any virtual simulation only tends to be similar to reality but is not the reality. Would anyone be comfortable to sit in a flight if the pilot and the crew underwent training only in a simulator? It would be a similar case if medical education is imparted only on simulators without access to real human bodies.

Accessibility to new technology

It is to be noted that all the technologies described here are at their infancy. They have not reached economies of scale yet. Laboratory grown organs need a lot of reagents as starting material and they also generate a large amount of laboratory waste. The amount of reagents needed for growing lab grown organs is more than that needed to extract an organ for donation.

As a result, the high costs associated with this technology might not be accessible to all the sections of the population. Healthcare costs are increasing in all the countries in the world. In countries where the bulk of the bill is paid via insurance policies, it remains to be known if insurance companies will pay for the 3D printing and lab grown organs etc. In such cases, for families with a meagre income, a matched human donor is the greatest blessing since the cost to create the organ is not a financial burden on them. Giving a fully grown matched organ is as beneficial as giving them thousands of dollars in cash.

Disclaimer

This whole essay assumes that every human being does the right thing and does not misuse the power provided to them. Misuse of harvested organs by profit minded scientists and medical personnel is not the purview of this essay. Leaving the path of righteousness can occur to anyone and is of separate discussion. It is to be noted that if possibilities of crime are considered, all the new technologies, if fallen into the wrong hands could be abused.

Concluding thoughts

Even if we assume, science and technology evolve at the greatest pace and a scenario arises where everyone has access to stem cell technology for transplantation, the altruism of donors will not be negated. The organs harvested will be used for research purposes. Billions of scientific questions remain to be explored and every harvested organ will be put to good use by the scientific community to find answers to many remaining biomedical questions.

With sustainability in mind, everybody in this world plays their part in recycling initiatives. Before we throw any device in the bin, we check whether we could take some spare parts from it. This human behaviour is also recapitulated in organ donation which is a very noble repurposing approach.

I feel that donating tissues is the easiest way to immortalise one’s life. For instance, the cervical tissue of Henrietta Lacks grown in the form of HeLa cells in the laboratory has witnessed many passages of time and has seen many generations of researchers. Those cells have contributed to innumerable drug discovery efforts to improve the quality of human lives. Another example would be cornea donors who get a unique opportunity to view the world post-mortem through another individual.

Thanks to the advances in medical science last century, we have efficiently fought infections and improved the lifespans of humans. The advances of this century are in generating lab grown organs and gene editing. However, they will not negate the altruism of organ donors. In a nutshell, there might be multiple forms of altruistic philanthropy for a living person, organ and whole-body donations are the only forms of altruistic philanthropy post-mortem.

References

1. https://www.straitstimes.com/singapore/2-singaporean-transplant-patients-win-big-at-world-games-thanks-to-gift-of-life-from-their-husbands

2. https://www.straitstimes.com/singapore/un-report-on-safety-of-lab-grown-meats-cites-s-pore-the-only-country-selling-them-as-case-study

3. https://www.science.org/doi/10.1126/science.abn2222

4. https://www.nobelprize.org/prizes/chemistry/2020/press-release/

Disclaimer: Please note that the views and opinions expressed in the essays for the Live On Festival 2023 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