The gift of life -- by law

Two years ago, I received a letter from Singapore’s ministry of health. It informed me that since I had been awarded permanent residence in Singapore, I would be automatically included in the country’s Human Organ Transplant Act (Hota) scheme.

Hota was passed in 1987.
It allows for the removal of organs for transplantation from Singaporean citizens and permanent residents unless the person has previously registered an objection to the Act. It acknowledges organ shortage as a big problem in the country, and aims to increase the number of organ donors by adopting the opting-out system (presumed consent).

When Hota was passed, kidneys were the only solid organ transplanted in Singapore. In the 1990s, heart- and liver-transplant programmes were established and cornea transplants became routine operations in Singapore. With the demand for liver, heart and corneas for transplant, Singapore’s ministry of health proposed amending the law in January 2003 so that more people would benefit.

After a year of public consultations and countless forums for the general public, Singapore’s Parliament unanimously voted in January 2004 to amend Hota to include livers, hearts and corneas. It marked another milestone for organ donation in Singapore.

Singapore is one of only three countries in the world to use such an opt-out system; the other two are Spain and Denmark.

Though Hota has helped save hundreds of lives every year in Singapore, recent statistics remain alarming. Today, there are more than 600 patients waiting for an organ transplant in Singapore. Moreover, the demand for cadaveric organs for transplant continues to increase rapidly. Between 1998 and 2003, the number of people waiting for a kidney grew by almost 20% to 673 patients.

There is a similar shortage of cadaveric livers, hearts and corneas for transplant. About 15 patients die each year while waiting for a liver, and about three patients die each year while waiting for a heart. The shortage of corneas for transplant means that they have to depend on overseas sources for corneas that might not be available in times of emergency.

The situation is just as critical in South Africa. In a press release in conjunction with Organ Donor Awareness Month during August, the Organ Donor Foundation reported that there are more than 3 500 people waiting for transplants in South Africa today. The shortage of skin and bone tissue is also alarming. Approximately 35 000 people are awaiting a tissue transplant.

If we base a forecast on last year’s statistics, from these thousands, at most 5% will be able to end their wait this year. In 2005, 1 084 organ transplants were done.

Should South Africa draw on Singapore’s experience and impose an opt-out system as well?

The Organ Donor Foundation carries the tagline “Gift of Life”. Indeed, being an organ donor is equivalent to giving someone else a life, and the best gifts are those that are given sincerely, with a complete understanding of the consequences.

Samantha Volschenck, marketing coordinator at the Organ Donor Foundation, is pessimistic about the chances of such a system being implemented in South Africa. She says: “The current laws do not allow this. Switching to an opt-out system means there is the need to first change the laws.”

Fiona McCurdie, transplant coordinator at Groote Schuur hospital in Cape Town, echoes Volschenck’s sentiment.

“It is still a long way for South Africa to impose such a system. Right now, it is just not practical,” she says. “One main problem is definitely funding. To make an informed, responsible decision, people have to be first educated and informed about the details and consequences of being organ donors. We, in South Africa, don’t have such resources yet.”

There are also various ethical and cultural issues to be addressed.

The first obvious such issue is the “taking” of a dead body from a grieving family. Would it be ethically acceptable to deprive such a family of the opportunity to be with their loved one for the last moments before the body is buried or cremated?

Secondly, consider the concept of an afterlife. From my understanding of South African black tradition, death is considered a sacred event. It is not the end, but rather a journey to the ancestors’ lands. In Xhosa culture, for example, dead people are believed to live in the “other land”, taking care of the living people. The “just in case” mentality applies here. What if you need all your organs to live “normally” in the afterlife?

I would argue that South Africa is then not so different from Singapore, which is, after all, still a relatively conservative Asian society that views bodies as sacred.

Koh Keng Yong, the transplant coordinator of Singapore’s ministry of health, mentioned in a press release in June 2004 prior to the amendment of Hota, the Singaporean government took considerable care before deciding to pass the law.

The ministry’s website explains that the opt-out decision was taken because it had consistently been shown in Singapore and other countries that relying on an opt-in system would not have a significant effect on meeting the needs of organ-failure patients.

Hota also has exemption clauses. It respects those who have personal reasons not to donate organs. Muslims in Singapore, for instance, are not included in the scheme based on religious grounds. If they want to do so, they have to pledge their organs separately through an opt-in system. For the rest of the population who do not want to pledge their organs, all they have to do is to register their objections via an opt-out form, and their personal wishes will be respected.

An opt-out system may not be happening in South Africa any time soon, if at all. Brushing it off as being unthinkable, inconceivable and impossible is, however, unacceptable. Thousands of South African lives are at stake, and some may have been lost when you finish this reading this article. Unless a drastic, revolutionary approach is adapted, more will continue to be lost.

I urge the decision makers in the country to give the issue serious thought. Learn from international experience, and give an opt-out system a chance to make that real difference. Right now, right here, I cannot find a reason strong enough to justify myself opting out.

Megawati Wijaya is a postgraduate student in journalism and media studies at Rhodes University

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