Introduction and Statistics |
(HOTA)
What is HOTA?
Who is covered by the act? AND
What are the organs covered?
When does the act kick in? How is a person certified dead? (a) have not been involved in the care or treatment of the person so certified; (b) do not belong to the team which will effect the removal of the organ from the body; (c) have not been involved in the selection of the proposed recipient; (d) will not be involved in the care of the proposed recipient of the organ; and (e) possess the prescribed postgraduate medical qualifications (if patient is being certified brain dead). What are the criteria for brain death? - Glasgow Coma Scale <5, - No corneal reflex - No pupillary reflex - No oculocephalic (“doll’s eyes”) reflex - No oculovestibular reflex - No gag/cough reflex - Iso-electric EEG - Positive apnoea test - Absence of cerebral flow - Absence of confounding conditions (e.g. hypothermia, hypoglycemia, oversedation) About opting out How to opt out Note: This section is based on my own personal medical knowledge, and in no way constitutes official MOH/hospital/transplant team policy. Who is likely to be chosen as an organ 'donor'? What conditions make organs unsuitable for transplant? - Infectious diseases (HIV/AIDS, sepsis(blood infection), TB) - Cancer - Renal disease (kidney failure) - Chronic heart disease (heart failure) - Severe systemic disease, e.g. uncontrolled diabetes - Hepatitis B carrier (unless the receipient is also positive) |
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Medical (Therapy, Education and Research) Act (MTERA) Human Organ Transplant Act 1987 Interpretation (Amendment) Act 1998 Human Organ Transplant (Amendment) Act 2004
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Reference Data used to generate the tables above #1 - Before HOTA, we could only save 5 lives a year. After HOTA, we now save a life a week. This is the reality of HOTA. HOTA is good both for the dead and the living. But we respect the wishes of those who want to opt out of HOTA. We will facilitate it. Every year, about 2,500 opt out of HOTA. The number went up soon after the SGH incident but has since come down to 80 a day. I respect the wishes of those who opted out but I worry for the poor patients on the organ waiting list.
#2a - NINETEEN people got a new lease of life, with organs from people who died of non-accidental causes, in the first four months since the wider organ laws kicked in on July 1. They received 10 kidneys, one liver and eight corneas from five people. Before the Human Organ Transplant Act was amended, organs from only accident victims could be taken for transplant without permission from the family. In these four months, only two kidneys and two corneas were taken from an accident victim. Even with the amendment, however, Singapore is still fighting a losing battle as more people are added to the waiting list each year, and the waiting time gets longer. There are now almost 700 people in need of a kidney and who face a waiting period of about seven years. Those waiting for a liver or heart die in about two years if they can't get a transplant. Last year, 22 people needed liver transplants but only two donor livers were available, and 15 people died waiting for liver transplants.
#2b - SINGAPORE: 23 patients with organ failure have benefited from the revised Human Organ Transplant Act (HOTA). The Act was amended in July this year to include all causes of death instead of deaths from accidents only. The Act was also expanded to include liver, heart and cornea as well as living donor organ transplant instead of just cadaveric donation. And in the four months since HOTA was revised, there had been six donors, five of whom died from non-accidental causes. Giving this update at the opening of Transplant Asia, Senior Minister of State for Health, Dr Balaji Sadasivan, told 500 international delegates that while the revised HOTA will save lives and reduce suffering, it will not solve the organ shortage problem. Singapore, he said, must enhance its living related donor transplant programme from the current low kidney living donor rate of 4.4 per million population, to about 20, just like in the developed countries such as the US and Norway. Dr Balaji also cited a cost-analysis argument on why the programme should be enhanced. In Singapore, the average annual cost of dialysis has been estimated to be twice that of kidney transplantation
#3 - Sixty five more people got a new lease of life, with additional organs available for transplantation under the revised Human Organ Transplant Act (HOTA). Since 1 July 2004, HOTA covers not just kidneys but also liver, heart and cornea. The opt-out organ donation law allows for organs to be removed in the event of death from all causes. In the past 12 months, there have been 19 HOTA donors, 3 of whom died of accidents and 16 of non-accidental causes. Without the revision, there would only have been 6 kidneys transplanted under HOTA from the 3 donors who died of accidents. With the revision of HOTA, an additional 31 kidneys, 5 livers, 2 hearts and 27 corneas were transplanted. This means an additional 65 people benefited from the wider organ donation law. The revised HOTA has also enhanced the living donor transplant programme. A total of 23 local patients received kidneys from living donors and 5 local patients were transplanted with livers from living donors. The Ministry will continue to work with hospitals and volunteer welfare organisations to increase the number of living donor organ transplants. Presently, there are 636 people in need of a kidney transplant, 12 for liver, 3 for heart and 11 for cornea. The Ministry would like to encourage Singaporeans to continue their support for the organ transplant programme. Their gifts of life will go a long way towards saving lives and easing the suffering of patients whose lives have been shattered by organ failure. It will also greatly reduce the waiting time for organ transplants.
#4a - In the two years since the wider organ donation law came into effect, 144 people have received the gift of life. 69 people received a new kidney, 10 people have liver transplants, 5 people got a new heart and 60 people have their sights restored. All of them have benefitted from 35 donors under the Human Organ Transplant Act (HOTA), 7 of whom died of accidents and 28 of non-accidental causes. Since July 2004, HOTA has been extended beyond kidney to include liver, heart, and cornea. It is no longer restricted to deaths due to accidents. There were on average only 13.5 cadaveric kidney transplants obtained through HOTA per year between 1988 and 30 June 2004. The change in HOTA has improved the situation and in fact has cut the waiting list for cadaveric kidney transplant by 10 per cent. In 2003, there was a peak of 673 End Stage Renal Failure (ESRD) patients on the waiting list. Currently, there are 605 patients on the waiting list. The waiting lists for the other organs are 13 for liver, 3 for heart and 18 for cornea respectively. The living donor organ transplant programme has also received much support from the public. Since 1 July 2004, 51 local patients received kidneys from living donors and 10 local patients were transplanted with livers from living donors.
#4b - About 130 people have benefited from the July 2004 revisions to widen the scope of the Human Organ Transplant Act (Hota), announced the Ministry of Health (MOH) yesterday. According to the ministry, 69 people got new kidneys and 10 got new livers. There were also five heart transplants and 46 cornea transplants. The number of patients on the waiting list for a cadaveric kidney has also seen its largest dip, down 10 per cent. They now number 605, down from 661 in 2004 and a peak of 673 in 2003. There were also 51 live kidney donations and 10 live liver donations in the two years since the amendment. In line with its efforts to ease the dependence on dialysis, MOH also announced plans to increase live organ donation rates. Foreign medical experts have been invited to review current live organ transplant initiatives. It is hoped the review will increase awareness nation-wide and provide more support for end-stage renal patients and their families. Before it was extended to livers, corneas, hearts and all causes of death, Hota covered only the procurement of kidneys from those who died in accidents. Hota also regulates living donors.
#5 - Mr Khaw Boon Wan: Sir, the first kidney transplant was carried out in Singapore in 1970. This was 37 years ago. As at the end of last year, 1,778 kidney, 83 liver, 27 heart, 7 lung and 2,356 cornea transplants have been done in Singapore. The Human Organ Transplant Act (HOTA) was enacted in 1987. So it was 20 years ago. From 1987 until the middle of 2004, 222 patients with kidney failure have benefited from cadaveric kidney transplants under HOTA, giving an average of 13 patients per year. This was an improvement as prior to HOTA, cadaveric kidney transplantation only averaged five per year. So before HOTA, only five lives were saved each year. After HOTA, it almost tripled to 13. In the middle of 2004, HOTA was amended to cover the liver, the heart and the cornea, and to include all causes of death. I took this Bill through in this House and I was glad for the full support from the House. From then until the end of last year, 103 kidney patients benefited from cadaveric transplants under the amended HOTA - an average of 41 patients per year, which is a significant increase. So before HOTA, five per year; now, 41 per year - more than an eight-fold increase. So we are saving lives, just for kidneys, almost one per week. In addition, 115 patients have benefited from 11 cadaveric livers, 10 hearts and 94 corneas. HOTA is therefore a very important policy in saving lives. Nevertheless, there remains a shortage of organs for transplantation. At the beginning of this month, there were 541 patients on the waiting list for kidney, 10 for liver, 2 for lung and 1 for heart. Each year, some patients die while waiting for an organ.
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The whip was lifted but there was no dissension THE debate on a proposed law on human organ transplants took a rare turn yesterday when the whip was lifted, allowing PAP Members of Parliament to vote as they will and not toe the party line However, all the 12 MPs - including opposition MP Chiam See Tong - who spoke during the debate supported the move to expand the scope of the Human Organ Transplant Act (Hota). | |||
Since 1969, the People's Action Party has lifted the whip six times and, this time, it is over amending the 1987 Act, which allows only the kidneys of people who died in accidents to be taken for a transplant. Now, the Government wants to include liver, heart and cornea as well and not just from death due to accidents. The organs can come from any dead person. Living donors can offer their liver and kidney too. And as in the current Act, all Singaporeans and permanent residents, except Muslims, will be governed by it and may choose to opt out. Muslims, on the other hand, can choose to opt in. The subject is an emotional one with religious overtones and the dozen MPs, including three Muslims, raised many issues that have dogged it since the debate began two years ago. Topping the list is when would a person be deemed to be brain dead, with several MPs, reflecting the confusion of many Singaporeans, giving examples of people in a coma suddenly waking up. It's a worry likely to dominate again today when about a dozen more MPs are expected to speak as the debate continues on the Second Reading of the Human Organ Transplant (Amendment) Bill. In introducing the Bill yesterday, Acting Health Minister Khaw Boon Wan said that every year, 15 people die while waiting for a liver and three die because they can't get a heart transplant. He related how a 41-year-old mother of two died a few months back, after 11 months on mechanical support. By expanding the Act, Mr Khaw said that each year the organs of more than 20 people who die from non-accidental causes, such as uncontrollable bleeding in the brain, will not be 'wasted through cremation or burial'. The small number is because only the organs of those certified brain dead, but whose hearts are still beating with the help of machines and whose organs are not damaged by disease, can be used. The beating heart seems to be the nub of the problem for most of the MPs, who wanted to know what exactly is being 'brain dead' and if there was a risk of doctors not doing their utmost for a dying patient because of their eagerness to reap the organs to save others. Dr Lily Neo (Jalan Besar GRC) expressed the common concern when she asked: 'How does the Ministry of Health ensure that organs are not removed prematurely?' Other worries include the possible rise of organ trading, the relatively light punishment for these traders, people being coerced or driven by money to donate and the need for an extensive programme to educate the public on organ donation. Mrs Lim Hwee Hua (Marine Parade GRC) fears that by making it easier for healthy people to donate an organ to a loved one, it may open the door for organ trading. Mr Chiam See Tong (Potong Pasir) and Madam Halimah Yacob (Jurong GRC) felt the maximum punishment for organ trading, a fine of $10,000 and a year's jail, was not enough of a deterrent. Others wanted to know how coercion, fear, family pressure or even financial rewards can be ruled out as reasons for the donation. |
'In
some parts of the world, patients going into a hospital to remove an appendix,
have found later on in life that they have lost one of their kidneys.
But it's too late already. Can this happen in Singapore? I would be more
confident 30 years ago when I took up medicine. But today, I'm not so
confident.' 'A
person who procures and sells human tissue could make anywhere from $80,000
to $200,000 per body.' 'Singaporeans
and PRs turning 21 are to be informed of their coverage under Hota by
the Ministry of Health. Now, all the young people I spoke to do not recollect
receiving such notification.' 'A
maximum fine of $10,000 and a jail term of one year is nothing compared
to the huge benefits and profits that can be reaped from organ trading....
Increasing thepenalty would send a clear signal to all those who may be
tempted to resort to such crimes that they would be severely dealt with.' | ||
Mr S. Iswaran (West Coast GRC) raised the question of what constitutes 'just compensation' which the amended Act will allow a recipient to give a donor. He asked: 'If the recipient offers to compensate the living donor for loss of income during the period of convalescence after the operation, is that permissible? 'And what if the post-operative complications diminish the living donor's earning capacity permanently. Can the recipient legitimately make good on that shortfall?'
The three Muslim MPs who spoke - Mr Ahmad Khalis Abdul Ghani (Hong Kah GRC), Madam Halimah and Mr Zainudin Nordin (Bishan-Toa Payoh GRC) - explained the religious considerations of their community.
Under Islamic law, the body of a dead person belongs to the paternal next of kin, not to the person.
Still, more than 13,000 Muslims have opted in, said Mr Ahmad Khalis.
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IT WOULD appear from proceedings in the House yesterday that 16 years after the controversial Human Organ Transplant Act (Hota) came into being, Singaporeans have not really moved on that much in some respects. True, as Acting Health Minister Khaw Boon Wan said in moving an expanded version of the Act, Singaporeans have become more familiar with the notion of presumed consent and brain death. Indeed, more Singaporeans now appear to accept that presumed consent - where organs of the dead can be taken unless prior objection has been made by opting out - is necessary if the legislation is to be used to save as many lives as possible. This can be gleaned from the speeches of the dozen Members of Parliament who joined the debate. Only one, Dr Lily Neo (Jalan Besar GRC), urged a return to the pre-Hota opting-in system, a retrogressive and unhelpful call if there was one. That the other MPs, fortunately, did not make similar objections can safely be taken as their presumed consent to the idea of presumed consent. Mr Gan Kim Yong (Holland-Bukit Panjang GRC) summarised the sentiment in and outside the House thus: 'Most Singaporeans now support presumed consent.' However, in the case of brain death, familiarity does not imply peace of mind. Acquitting herself better here, Dr Neo, a general practitioner, noted that 'the worrying fact for many is whether people certified brain dead are really dead'. This was a recurring theme with MPs yesterday afternoon. One of them was Opposition MP Chiam See Tong (Potong Pasir), who had joined his People's Action Party counterparts in supporting the amendments to extend the legislation to cover liver, heart and cornea transplants and non-accidental deaths. Asking 'when is a person dead?', he pulled out the anecdote of a Taiwanese woman who came back to life some time after doctors had found no activity in her brain and pronounced her well and truly dead.
The concerns MPs reflected are twofold.
Here the rather ominous words of Dr Tan Cheng Bock (Ayer Rajah) serve as a timely warning. Nowadays, the general practitioner said, 'medicine is treated less as a profession and more as an industry'. Even the 1993 White Paper on Affordable Health Care used the term 'industry' to describe medicine, he noted. Further, with hospitals now becoming more profit-oriented, the door is even more open to abuse, he said. Thirty years ago, when he first became a doctor, he would have been confident the worst would not happen. But he was not so sure now, he added. So in one respect, society - in particular the practice of medicine and the values of some doctors - has moved on. No surprise then that many Singaporeans would be more circumspect than Mr Ahmad Khalis Abdul Ghani (Hong Kah GRC), who in noting that no complaints have been brought in relation to Hota in the last 15 years, said he believed the same would continue. Neither would others be totally stilled by the assurance of Dr Chong Weng Chiew (Tanjong Pagar GRC) that 'Singaporeans know that the precious gift of life from fellow citizens will not be abused for monetary gain nor compromise the provision of health care for potential donors'. Most doctors can be trusted. But the point is that all it takes is one rotten apple to spoil everything for all the good ones. That is why more vigilance - rather than less, as some suggest - is needed when the revised Act, with its much wider scope, becomes law. There are already safeguards in the proposed amendments, which Parliament will continue to debate today. These need to be enforced rigorously. Perhaps a channel should also be set up for relatives and loved ones of patients, as well as the general public and health-care workers, for complaints and doubts to be raised about cases. In this matter of life and death, no amount of extra is too much Tan Tarn How The Straits Times 8 Jan 2004 | |||
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Opt-In vs Opt-Out system |
(Exerpts from "In widening Act, we can't be too careful") 16 years after the controversial Human Organ Transplant Act (Hota) came into being, ..., Acting Health Minister Khaw Boon Wan said in moving an expanded version of the Act, Singaporeans have become more familiar with the notion of presumed consent and brain death. Indeed, more Singaporeans now appear to accept that presumed consent - where organs of the dead can be taken unless prior objection has been made by opting out - is necessary if the legislation is to be used to save as many lives as possible. This can be gleaned from the speeches of the dozen Members of Parliament who joined the debate. Only one, Dr Lily Neo (Jalan Besar GRC), urged a return to the pre-Hota opting-in system, a retrogressive and unhelpful call if there was one. That the other MPs, fortunately, did not make similar objections can safely be taken as their presumed consent to the idea of presumed consent. Mr Gan Kim Yong (Holland-Bukit Panjang GRC) summarised the sentiment in and outside the House thus: 'Most Singaporeans now support presumed consent.' Exerpts from Tan Tarn How The Straits Times 8 Jan 2004 |
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Relatives, hoping for miracle, wanted doctors to delay surgery for another day GRIEF-STRICKEN relatives of a brain-dead man on Tuesday begged that his organs not be taken - and then got into a tussle with hospital staff when their request was rejected. They were praying for a miracle, hoping that Mr Sim Tee Hua, 43, would awake from his coma. But the crane operator was declared brain dead at 6.20pm on Monday - four days after he collapsed at work last Thursday. The cause of death a stroke, or brain haemorrhage. When doctors at Singapore General Hospital (SGH) said on Monday that they were going to remove his organs, the family requested that they wait for 24 hours - and the doctors agreed. After that time was up, the family asked for another 24 hours, but doctors felt that a delay would make the organs unusable for transplant and went ahead with the operation. Under the Human Organ Transplant Act (Hota) amended in July 2004, kidneys, livers, hearts and corneas suitable for transplant can be removed from all Singaporeans and permanent residents upon their death - unless they have opted out. Muslims are exempted because of religious reasons. Mr Sim had not opted out of the programme, so his family was powerless to stop his organs from being removed. But they tried their best. Lianhe Wanbao reported that around 20 members of Mr Sim's family intervened when his body was being wheeled into the operating theatre at about 10.15pm on Tuesday. His mother and five other relatives went down on their knees to beg doctors to delay the operation for one more day. But when their request was denied, emotions ran high and the police were called. An aunt tried to bite a police officer in the arm. Nine police officers and about 10 hospital security staff members were involved in the three-hour confrontation before the matter was resolved peacefully and doctors performed the operation. Mr Sim's sister, Ms Shen Qiu Xia, 45, told Lianhe Wanbao 'We were actually prepared to accept that he was dead if his condition did not get better by Wednesday night. 'Although he was brain-dead, his body was still warm and my mother said that she felt he would awake from the coma.' She added that he had no previous major illnesses and that he had planned to marry a girlfriend in her 30s from China's Hainan island. A Health Ministry spokesman told The Straits Times yesterday 'Where possible, doctors will accommodate a family's request for a grace period as death is usually a difficult time for them. However, the transplant team will have to balance this with the need to save the lives of organ failure patients.' Brain death is defined as a complete and irreversible cessation of brain activity. When this happens, a person can be declared dead even if the heart continues to beat due to life support measures. The kidneys taken from Mr Sim's body were given to two patients. One, a 55-year-old man, was on the transplant waiting list for about six years. The other is a 49-year-old man who had been waiting for almost eight years. Mr Sim's corneas will be transplanted in the next few days. Largely due to the amendments to Hota, the number of patients awaiting a kidney transplant dropped from 673 in 2003 to 605 in mid-2006. In the two years to July 2006, at least 130 people have received transplants under the revised Act. Anyone who does not want his organs to be taken after his death can register with the Ministry of Health. The opt-out form can be obtained from all public hospitals and polyclinics or from the Organ Donor Registry at SGH. Tracy Sua The Straits Times 8 Feb 2007 |
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READING the article, 'Brain-dead man's kin in scuffle over op to remove organs' (ST, Feb 8), the Singapore General Hospital came across as rather unfeeling in its handling of the situation. The man's mother and five relatives kneeled and begged the doctors not to remove his kidneys and corneas, to no avail. His family was not convinced that he was really dead as his body was still warm. Yes, the hospital was carrying out the procedure under the Human Organ Transplant Act (Hota) but, surely, the matter could have been handled better. On one hand there is this family reeling from shock over the death of a loved one and, on the other hand, there is the law, in the form of surgeons and nurses bent on removing all his useable parts. Where is the compassion and humanity that are so clearly lacking? Many people are still unaware that their organs can be taken away from them unless they opt out. To avoid such heartrending confrontations. I suggest that the Ministry of Health educates Singaporeans and permanent residents that unless they opt out, under Hota their organs will be removed once they are considered brain dead. The ministry should also make opt-out forms more readily available - and also available online - so that people do not have to go hunting for this vital form in clinics and hospitals. Dr Lim Boon Hee Straits Times Forum 10 Feb 2007 THE report, 'Brain-dead man's kin in scuffle over op to remove organs' (ST, Feb 8), shows clearly that there is much to be done to educate the public on the Human Organ Transplant Act (Hota), as amended in July 2004. The public must be made aware that kidneys, livers, hearts and corneas suitable for transplant can be removed from all Singaporeans and permanent residents upon their death as defined by the Act - unless they have opted out. Hospitals and polyclinics should be in the forefront, explaining to patients Hota whenever the opportunity to do so arises. The various community institutions can also help in educating the public at the grassroots level. This will prevent the tussle the relatives of Mr Sim Tee Hua had with the hospital staff because they would have known that Hota will kick in in such circumstances and would also be aware of the window of time needed for transplants. Alternatively, hospitals can, whenever they anticipate the possibility of enforcing Hota, pre-empt any outburst by making the patient's relatives aware that the organs will be removed upon confirmation of brain death. This must be done with the utmost sensitivity. Harry Chia Kim Seng Straits Times Forum 10 Feb 2007 I refer to the report, 'Brain-dead man's kin in scuffle over op to remove organs' (ST, Feb 8). The Human Organ Transplant Act (Hota) empowers the health authorities to remove the organs if the deceased had not opted out. While the Ministry of Health regularly reminds the public of Hota and the opt-out procedure, what happens when the person suddenly dies and it is not known by his family members if he had opted out of the programme? In this situation, who can confirm the intent of the deceased? Should not the family of the deceased have a say as well? This incident is not a case of pitting the interests of the living potential beneficiaries against a dead person who no longer has any need for organs. Instead, it raises the ethical issue of the potentially conflicting duties of the health authorities to one group of the living (potential beneficiaries of the deceased's organs) and another (the next-of-kin of the deceased). Hota came about to meet the urgent needs of organ-failure patients so that they can have a chance to live. However, the health authorities also have a duty to the living who survive a person who has suddenly died. Can there be a better balance in meeting the needs of the two groups through a stipulated grace period that allows clarification in the absence of clear intent? Harry Chia Kim Seng Straits Times Forum 10 Feb 2007 THE on-going debate on organ trading appears to be a tussle between those like Prof Lee Wei Ling who espouse the utilitarian view and those whose arguments dwell more on the emotional aspects. While we think that our views on right or wrong are rational, more often than not they are based on emotional responses. The decisions we make will be coloured by shades of both cold rationality and raw emotions; different decisions are made based on where we as individuals lie on the continuum between these two extremes. The tug-of-war between utilitarianism and emotions can be illustrated in a hypothetical case study: Suppose a trolley is rolling down a track towards five people who will die unless you pull a lever that diverts it onto another track - where, unfortunately, lies one person who will die instead. The choice would be easy in this case: utilitarianism - minimising loss of life - is the right thing to do. But, what if the person standing on the other track is a loved one, like your husband or wife? We would be faced with a great dilemma as emotional aspects cloud the picture. Our behavioural impulses have been shaped by millennia of evolution, beginning with our origins in hostile, 'survival-of -the-fittest' hunter-gatherer environments where our genes have evolved to predispose us to favour our kith and kin in order to ensure our survival. Should we therefore continue to obey the moral impulses that evolved to serve what zoologist Richard Dawkins calls the 'selfish gene'? Say, if you were given a sum of money to spend on either keeping your 90-year-old father on life support or saving 10 starving African babies, which would you choose? Or, in our local context, the family of the brain-dead Sim Tee Hua ('Brain-dead man's kin in scuffle over op to remove organs'; ST, Feb 8) resisted the harvesting of his organs even though they could benefit many strangers. In the emotionally-charged debate on organ trading, we will always have dissenters and supporters who are motivated by the opposing forces of utilitarianism and visceral emotion. To come to a decision accepted by both sides will entail compromises in the weighing of the costs and benefits of the eventual decision. Maria Loh Mun Foong Straits Times Forum 10 Feb 2007 |
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I REFER to the letters by Dr Lim Boon Hee, Ms Maria Loh Mun Foong and Mr Harry Chia Kim Seng in response to the report, 'Brain-dead man's kin in scuffle over op to remove organs' (ST, Feb 8). I am in agreement with Dr Lim that the matter could have been handled better and that a situation like this would ignite a strong emotional response from kin, as indicated by Ms Loh. Perhaps it would help to appreciate and understand the behaviour of the kin of brain-dead Mr Sim Tee Hua in this incident. This is a case of sudden death, which none of his kin expected as he had no previous major illness. It was made more disturbing as he was preparing to marry his girlfriend from China. Such an incident is a psychologically traumatic experience and the behaviour of his kin would be considered a very normal reaction to an abnormal situation. In psychological parlance, it is a critical incident that would normally lead to post-traumatic stress response, with features of shock, denial, anger and yearning for normality. Like a thunderbolt from nowhere, the kin were struck with this tragic incident and it would be expected that they would be highly emotional in their response. Hence, it is understandable that the kin would hope for a recovery, and any indication of life, no matter how minuscule, would easily inspire hope for recovery. In such a situation, would it not be wiser to respond to the trauma the kin experienced than proceed with procedures prescribed by law? One wishes the hospital staff had received appropriate training in trauma response management, not just in compassionate response to such a situation but in sensitive handling of the matter as well. The kin experienced not only the primary trauma of Mr Sim's sudden death, but the stress of having to scuffle with the hospital staff and police as well. This incident must surely alert the authorities to provide training to hospital staff to err on the side of compassion and to engage in further education on the Human Organ Transplant Act. Anthony Yeo Consultant Therapist Straits Times Forum 14 Feb 2007 I COULD NOT agree more with Mr Anthony Yeo in his letter 'Knowing how to handle trauma is important' (ST Forum, Feb 14). In his letter, he rightly stressed the need for medical staff to be better trained in handling procedures leading to the removal of organs from the dead as prescribed by law. I was one of the unfortunate kin on the other side and I thought this letter can help hospital authorities understand people like us better, although it is very painful reopening our emotional wounds. I lost my youngest son, aged 16, seven years ago in Perth. It was sudden due to complications arising from bleeding in his brain. When he was declared brain dead, the hospital assigned an Asian social worker to help us cope emotionally. Way before the reality sunk in, we were asked for consent to donate his organs as there was no such law in Australia. While the ventilator was keeping my son's body alive, there were repeated requests but I turned them all down. I am not the selfish type. What hindered my decision was the way one of the doctors treated my son (after he was declared dead) - he was treated like a slab of meat! Even the interns gave me sympathetic looks over that doctor's shoulder. It was much later that I realised this doctor was handling the matter like a normal routine, hoping to get us to face the reality and just let go. But by the way it was articulated, I almost threw a punch at the doctor's nose. We never agreed to donate but authorised the hospital to shut down the apparatus and let my son go peacefully three days later. It was done only after repeated question and answer sessions were conducted (with subsequent test reports) between my family and the medical staff. I felt this procedure should have been necessary from the time of prognosis and not later. While still grieving weeks later, my eldest son and I regretted not having donated our beloved brother and son's organs that would have saved lives. We concluded that had the doctor been more polite and empathetic, we would have consented under the circumstances. But I am not implying that all medical staff behave in the same manner. While death is a common phenomenon in a hospital and medical staff may be emotionally better prepared, having seen so many lives go in their job, it is something that does not happen as often to us, the lay people. By the way, the nurse who looked after my son in the intensive care unit broke down and was sent home - she had a brother of the same age as my son. I hope that while the hospital authorities may think that they have a right to remove organs under the law, they should observe the simple courtesy of asking politely and in the most sensitive manner. It is a difficult task, but it has to be done humanely. Hwang Liang Keng Straits Times Forum 22 Feb 2007 |
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Medical team maintained constant contact with kin WE REFER to all the Forum letters and reports in The Straits Times on the late Mr Sim Tee Hua's organ donation. We would like to express our regret at the unfortunate incident and the trauma the family went through. To our nurses, surgeons, anaesthetists and intensivists who have chosen the difficult and challenging career of saving lives, every life is precious. To all patients and their families, they give the same level of commitment and compassion. Families on the verge of losing a loved one go through emotions of deep grief, a sense of desperation and yet hope for a miracle. This is especially so when the death is untimely and the patient young and seemingly healthy. Naturally, effort is made to extend counselling and comfort to the family. We understand that the consolation of being able to save other lives through organ donation does not assuage the loss for these families. We fully sympathise with the shock and pain the family of Mr Sim went through. Our medical team had maintained constant communication with his family from the time his condition worsened on Feb 3, two days after he was hospitalised for the sudden illness. The team also informed the family about his poor prognosis, and pending the results of tests for brain death, the possibility of organ donation under the Human Organ Transplant Act (Hota). When his condition deteriorated further, the transplant coordinators from the Ministry of Health's National Organ Transplant Unit (Notu) met the family and explained again the implications of brain death and the organ donation process. The family acknowledged and accepted the information. In every organ donation situation, the process is extremely time-sensitive. Beyond a certain period, after brain death, organs may no longer be suitable, and the opportunity to save patients with organ failure lost. In Mr Sim's case, the Notu transplant coordinators readily acceded to the first request to postpone the procedure for 24 hours, after brain death. However, subsequent postponement would have jeopardised the organ recipients' chances. The Notu transplant coordinators and hospital staff who were directly involved with caring for Mr Sim were deeply affected by this unfortunate incident as they had been torn between empathising with the emotions of his inconsolable family and the need to save organ-failure patients. Nonetheless, both MOH and SGH will continue to find practical solutions to minimise the emotional distress of families and staff in such situations. Dr Arthur Chern Director (Integrated Health Services) Ministry of Health Professor Ng Han Seong Chairman, Medical Board Singapore General Hospital Strait Times Forum 23 Feb 2007 |
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Dr Lim Wee Kiak (Sembawang): Sir, I would like to ask the Minister to elaborate or provide us some details on a recent unpleasant commotion that happened between the family members of a brain-dead patient as well as the authorities in one of our public hospitals a few weeks ago. I am wondering what measures will the Ministry be taking to prevent such an occurrence in the future. Mr Khaw Boon Wan: Dr Lim works in the hospital and he knows that one of the most difficult tasks in running a hospital is to convey bad news, particularly of premature death or sudden death, to family members. But I think more difficult than this task is telling the family members that their loved one has died, the brain has died, and that the organs can be used to save a few lives and that we are going to do so. It is not the easiest of things to do. Very rarely do we have family members who come forward and say, "Yes. Please proceed." Fortunately, the vast majority of family members are understanding and they accepted the sudden death and they try to compensate for the sudden loss by knowing that, at least, the death will now be able to save a few lives. But occasionally, we do get family members who are probably traumatised by the sudden death, becoming pretty aggressive and, sometimes, even abusive. But we try our best to explain, be as patient as we can and as compassionate as we can. But the bottomline is that we need to be firm with this opting out policy and respect the wishes of the dead that they had not opted out of HOTA. HOTA was fully explained. Of course, we will continue to periodically explain it. People have a choice to opt out and if they do not opt out, we assume that they must have had no objection if, upon sudden death, to have their organs used to save lives. It will be good for them and for society at large because if you try to look it from the donor's point of view, do not forget that there are a few hundreds on the waiting list. It is often the luck of the draw. You never know which side you will be on. Will you be a possible donor or a possible recipient? If everybody opted out, then of course, the possibility of saving lives and the opportunity to do so will be reduced. The key point about our HOTA policy is that it is not compulsory organ donation. We respect the individual's decision. If they want to opt out, no question is asked and we facilitate it. And we respect that because who are we to say that it is right or wrong of them to opt in or to opt out? But we have a job to try to explain to Singaporeans as often and as thoroughly as we can to think about that, upon death, the body is otherwise useless but you can still perform a useful role to save a few lives. And it has happened a few thousand times in the last many years that we have had HOTA. But we understand that, yes, it is traumatic experience for the family and we try to be as patient and flexible as we can. In this instance, it was rather unfortunate. Of course, the sudden death was traumatising to the family but they knew that the patient had died. They did ask for more time, and often, we allow that. In this instance, the family said, "Please do not go in yet. Give us another 24 hours", so that they can perform their various Taoist rituals. The hospital was flexible and allowed them an extension but explained to them that there was a time limit, because when all the cells had died, there was nothing to talk about in terms of organ donation. Indeed, in this instance, after the 24 hours' extension was given, the liver which was useful was no longer useful. I forgot now how many people are on the liver waiting queue. We prepared the patients and they were waiting for the operation. Unfortunately, we had to go in and say, "Sorry, the liver is now useless." But the kidneys were still useful, and there were two patients being prepared next door. At the appointed time, unfortunately, the family said, "We want more time." But the organs were deteriorating, and if the hospital were to allow more time, then even the kidneys would become useless. These are the circumstances behind this incident. I do not want to go into further gory details because it may not be fair to the family. I for one can fully understand what sort of trauma they were going through. This person was only 42 years old - sudden death. It is not easy to be put in that kind of situation. Let me come back to the basic point - respect the wishes of the dead. At 42, that means he was around 21 or 22 when HOTA was introduced in this House. I remember there was widespread public debate. He was an educated man and I am sure he was fully aware of HOTA and the fact that he did not opt out means that he wanted to save lives in the event of any sudden death, and I think we should respect his wishes. In this instance, I think it is good for the family that at least two lives and a cornea transplant were able to take place. Parliament 28 Feb 2007 |
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The price of delay LIVER patients, awaiting a transplant, had been put on stand-by when crane operator Sim Tee Hua was pronounced brain-dead by Singapore General Hospital (SGH) staff on Feb 5. Hoping against hope that he would recover, his family asked hospital staff to postpone harvesting his organs for 24 hours. The doctors agreed, but the delay came at a price, Health Minister Khaw Boon Wan told Parliament yesterday. By the time the doctors looked at harvesting Mr Sim's organs on Feb 6 — in spite of a ruckus created by his family members — his liver had become unsuitable for transplant. The Health Ministry had to turn away expectant recipients. His kidneys and corneas however, could still be used. Mr Sim's organs were removed under the Human Organ Transplant Act (Hota). While Mr Khaw empathised with what the man's family members were going through, he stressed that the wishes of the dead should also be respected. Mr Khaw said: "The donor was around 21 or 22 when Hota was introduced in this House. I remember there was widespread public debate. He was an educated man. I'm sure he was fully aware of Hota and the fact that if he did not opt out, that would mean he wanted to save lives in the event of a sudden death. So we should respect his wishes." Enacted in 1987, Hota allows for the mandatory removal of kidneys if a person dies in an accident — unless the person has specifically opted out. The scheme covers all Singaporeans and Permanent Residents who are not Muslims. The Act was revised in 2004 to include the harvesting of livers, hearts and corneas and expanded to cover non-accidental deaths. From 1987 till mid-2004, there were some 13 patients a year receiving kidney donations — compared to five a year before that. Since Hota's amendment in 2004, some 41 kidney patients a year benefited from cadaveric transplants. In addition, 94 have received corneas, 11 got livers and 10 have benefited from heart transplants. Despite this, there is a shortage of organs. At the beginning of last month, there were 541 patients on the waiting list for kidney, 10 for liver, two for lung and one for heart. "Each year, some patients die while waiting for an organ," said Mr Khaw. While most families are understanding about organ donation, some become abusive. "We try our best to be compassionate, but the bottom line is we need to be firm with this opting-out policy and respect the wishes of the dead," he said. "People have a choice to opt out and if they don't, we assume that they must have no objections that upon sudden death, the organs can be used to save lives." If everybody opted out, it would become harder to save lives, he added. And if someone is firm on opting out of Hota, the Health Ministry would respect that decision. He urges Singaporeans to look on organ donation upon death in a positive way. "Upon death, the whole body is useless but you can still perform a useful role to save a few lives," he added. Asked by MP Lim Wee Kiak if more could be done to educate the public about Hota, Mr Khaw said: "You have to explain it in a recurring manner, almost like a Celebrate Organ Donation day per year… Yes, we'll do so. But our communication experts advise us that this is not the time to start. Let the emotions calm down a little bit but definitely we have to do it regularly." Tan Hui Leng TODAYonline 01 Mar 2007 |
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As Sim Tee Hua lay on life support in a Singapore hospital, seven of his relatives knelt crying on the floor before the doctors, begging them not to remove his organs and give him a chance for a miracle recovery. Their desperate pleas were to no avail and after police and hospital security staff were called in to restrain them, Mr Sim, 43, was rolled away to the operating theatre to expire. "The hospital staff were running as they wheeled him out of the back door of the room," said Sim Chew Hiah, one of his sisters. "They were behaving like robbers." The previously healthy lorry driver was already brain-dead after suffering a stroke at work, followed by a cerebral haemorrhage in Singapore General Hospital. The harvesting surgeons had waited for 24 hours, but although his family still clung to hopes that he could recover, Singaporean law assumes all citizens except Muslims are willing organ donors unless they have explicitly opted out. As a way to tackle the perennial shortage of organs that all developed societies face it has proved effective - kidney transplant rates have tripled since the measure was brought in - but it is also a policy that exemplifies the authorities' paternalistic attitude towards the people. Nonetheless the spectacle of a distraught family abasing themselves in a futile attempt to win an extra day's grace for their son and brother has triggered a rare debate in the city-state, with the letters pages of its newspapers filled with comments for and against. "Tears would roll down from his eyes when we spoke to him, telling him not to give up," Mr Sim's brother Tee Yong, 49, told the New Paper. "We know that medically a brain-dead person cannot wake up. But we did not want to give up hope. All we asked for is just one more day for a miracle to happen." Justine Burley, a bio-ethicist at the National University of Singapore, said the opt-out policy on donation was "fundamentally a good idea" but allowances had to be made on a case-by-case basis and relatives' mental trauma taken into consideration. "The spectre of family members down on their knees begging the doctors is almost too much to bear from a human standpoint," she said. Singapore's media generally follow the government line, and the Today newspaper yesterday implicitly rebuked the relatives, referring to the harvest taking place "in spite of a ruckus created by his family members". In an article headlined: "Postponement killed dreams of liver transplant patients" it quoted the health minister Khaw Boon Wan telling parliament that the single 24-hour delay they had been granted rendered Mr Sim's liver unusable, although his kidneys and corneas had been transplanted. "We try our best to be compassionate, but the bottom line is we need to be firm with this opting-out policy and respect the wishes of the dead," he said. "People have a choice to opt out and if they don't, we assume that they must have no objections." Economically Singapore is a huge success, and Lee Wei Ling, a doctor and the daughter of the country's founding father Lee Kuan Yew, called for the buying and selling of organs to be legalised. "Organ trading is frowned upon and usually not allowed in countries where political correctness reigns," she wrote. "If monetary incentive makes a potential living donor more willing to save another life, what is wrong in allowing that?" Her suggestion was described as "wrong" by Alastair Campbell, the Chen Su Lan professor of medical ethics at the National University of Singapore, because of the "inevitable exploitation that would be involved". "The sellers are always going to be the desperate poor," he said, adding that "to trade the human body as some sort of material possession like a car or house" was crossing an unacceptable line. Mr Sim's parents have been offered reduced hospital fees for five years, and the family have been sent a letter thanking them for their "generous organ donation". Sebastien Berger telegraph.co.uk 3 Mar 07 |
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THE heart-breaking scenes earlier this month, when a brain-dead man's family clashed with hospital staff who wanted to harvest his organs, have had an unintended fallout. More residents now appear to be thinking about donating their organs and taking concrete steps if they don't want to. Requests for opt-out forms have gone up since the much-publicised incident at Singapore General Hospital (SGH) on Feb 6. "There has been feedback from hospitals and polyclinics that forms are running out and that there are more queries from the public," a Health Ministry spokesperson told Today. While such feedback has been anecdotal so far, an increase in the number of those opting out of organ donation is expected. In the past, many people had dragged their feet on exercising the opt-out clause under the Human Organ Transplant Act (Hota) until it was too late. Enacted in 1987, the law allows for the mandatory removal of kidneys if a person dies in an accident – unless the person has specifically opted out. The scheme covers all Singaporeans and Permanent Residents who are not Muslim. The Act was revised in 2004 to include the harvesting of livers, hearts and corneas and expanded to cover non-accidental deaths. Between then and last month, some 6,000 had opted out of Hota. The issue made headlines after a 43-year-old crane operator suffered a stroke at work and was pronounced brain-dead at SGH on Feb 5. His family, on learning that his organs might be harvested, first pleaded for a 24-hour extension in the hope that he might recover. The doctors agreed. On Feb 6, when he still had not awakened, they sought another extension. This time, the doctors decided to harvest the organs as a further delay would have rendered them unusable for transplants. The family was then involved in a scuffle with the staff. In the wake of the debate that followed, public hospitals told Today that they have seen an increase in the number of requests for the opt-out forms. Changi General Hospital, for one, ran so low on opt-out forms and information booklets that they had to ask the Health Ministry for a "top up". At National University Hospital, there have also been "a few more" walk-ins a day asking for the forms — up from almost none before the incident. At Alexandra Hospital, staff noted that more forms were being collected from the Accident and Emergency than from other departments. "The biggest problem is usually ignorance," noted chairman of the Government Parliamentary Committee for Health, Mdm Halimah Yacob. "In a way, it's a good thing that this is being discussed in the open so that in the process, the public can hopefully be more informed about the issues and understand the subject better." She suggests better public education to help Singaporeans understand brain death and actively engaging religious bodies to inform followers that organ donation would not comprise them spiritually. Spurred by the incident, 55-year-old Mr Loke Siew Meng sent in his opt-out form last week. "Why would you want to stress your family members out?" the lawyer reasoned. National Neuroscience director Associate Prof Lee Wei Ling reminds, however, that "whoever opts out, if he or she ever needs an organ, he or she goes to the bottom of the waiting list". "The only alternative is to persuade someone really altruistic to donate to you, yet it is not fair to use emotional pressure on loved ones; or go overseas to buy one with all the attendant risks." Meanwhile, Dr Patrick Kee, who works in the hospice sector, suggests setting up a select committee be to talk to distressed family members. "I think most families are reasonable and would, with some convincing from hospital staff, allow the organs to be harvested. So this would not be counter-effective for Hota implementation," he told Today. Health Minister Khaw Boon Wan is expected to address concerns about the Hota in Parliament today Tan Hui Leng TodayOnline 28 Feb 07 |
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I was surprised to read last week about the scuffle between the relatives of a brain-dead man and the Singapore General Hospital over the hospital's operation to remove the man's organs. It is possible that many people are still unaware that their organs can be taken away unless they opt out of the Human Organ Transplant Act (Hota). More awareness should be created on this, and opt-out forms must be readily available. People living in Singapore need to make many opt-out decisions. It is not unfair to say that Singapore is an opt-out city. To list just a few opt-out schemes, we have the Dependants' Protection Scheme, the Medishield, and the ElderShield. If you are not aware of them and do not opt out, then you are presumed to be in it and premiums will be automatically deducted from your account. When I found out that I was donating to the Chinese Development Assistance Council every month, I wanted to opt out of it. I was then told that the opt-out form must bear the signature and stamp of the employer — even though the deduction is made on me, not my employer. Although that is a mere $1 deduction every month, shouldn't it be a voluntary opt-in scheme instead of a compulsory opt-out scheme? I would be grateful if anyone can tell me how many more opt-out schemes there are out there. Tan Kim Minn TodayOnline Forum 14 Feb 2007 I would like to thank Dr Andy Ho 'It's time to lay to rest brain death' (ST, Feb 15) for bringing to light some facts about brain death to the general public. . Brain death was the criterion for deciding the late Mr Sim Tee Hua's death and subsequent harvesting of his organs for transplantation (ST, Feb 8) against the wishes of his family and, might I add, without his explicit expression of desire to donate them. This is allowed under Hota. I recall when Hota was first mooted, there was the assurance that the authorities would be sensitive to the feelings of the bereaved family. This was reiterated in the Health Ministry's statement: 'Where possible, doctors will accommodate a family's request for a grace period as death is usually a difficult time for them.' It would seem that this grace period is limited to 24 hours and there is a need 'to balance this with the need to save the lives of organ failure patients'. I am concerned with the way the decision was made to exercise the Hota-sanctioned harvesting of Mr Sim's organs in spite of the obvious distress of the family members. Is this a case of exercising the letter rather than the spirit of Hota? In light of all this, I have decided to opt out of having my organs removed automatically by completing the required Health Ministry form. My family members have decided to follow suit. In place of this, among ourselves as family members, we have an understanding that upon being incontrovertibly declared dead, we shall give permission for any and all organs to be harvested as may be necessary. As a family, we are wresting back the control over our persons. Do not conclude that I am insensitive to the plight of organ-failure patients. For years before Hota, I had carried an organ donor card specifying the organs to be harvested upon death. My preference is to have the privilege of giving my organs rather than have them taken from me. Abridged Chia Boon Beng Straits Times Forum 17 Feb 2007 THE recent incident in which a brain-dead patient's family tried to physically obstruct the operation to harvest his organs for transplant into patients needing them has revived the discussion about brain death and even led to calls to amend the Human Organ Transplant Act (Hota) itself. Some doctors have called on the authorities to respect the feelings of the family of potential donors. Given a choice, the vast majority of families would object strongly if they thought this could prevent their loved one's organs from being removed. Even with the Hota, there is a shortage of organs forcing some desperate Singaporeans to go overseas in search of organs. The only incentive at present not to opt out is that those who opt out go to the bottom of the waiting list if they ever need an organ. Justice would not be done if these people could still opt out at the point of brain death if their family objects vigorously. For the few Singaporeans who want to go beyond the Hota and donate any organ that can be used for transplant, there is a separate organ donor form where one can specify which or all organs one wishes to pledge. This used to be a paper form which could be obtained from the Ministry of Health (MOH) in the 1990s when I did so. Perhaps it is now available on MOH's website. Dr Lee Wei Ling Straits Times Forum 22 Feb 2007 I wonder how Dr Lee Wei Ling, 'Organ transplant: Unease over last-minute opt-out' (ST Forum, Feb 22), came to the conclusion that 'given a choice, the vast majority of families would object strongly if they thought this could prevent their loved one's organs from being removed'. Has there been a comprehensive study or is it based on personal anecdotal encounters? Alternate anecdotal occurrences come to mind which show this to be a rather cynical view. She also concluded that 'justice would not be done' should there be a last-minute opt-out at point-of-brain death. Perhaps this is exactly the point of the recent incident which started this series of discussions - bereaved families are not asking for mere justice; they are asking for a modicum of sensitivity, compassion and assistance to come to the right decisions at a distressing time. Why is it so difficult to pay heed to Mr Anthony Yeo (ST, Feb 14) and Drs Patrick Kee and Wong Wee Nam (ST, Feb 17)? The personal experience of Mr Hwang Liang Keng (Online forum, Feb 22) should persuade to avoid (in the words of Drs Kee & Wong) 'turning doctors into unfeeling surgical technicians instead of compassionate surgeons'. And as I stated earlier (Online forum, Feb 17) when my family and I recently decided to opt out of Hota, it's a matter of 'wresting back the control over our persons'. We have decided on this rather than risk being (in Mr Hwang's words) 'treated like a slab of meat'. Chia Boon Beng Straits Times Forum 23 Feb 2007 WE REFER to the letter, 'Unease over last-minute opt-out' (ST, Feb 22). Dr Lee Wei Ling has made three assumptions that need to be clarified. First, that 'given a choice, the vast majority of families would object strongly if they thought this could prevent their loved one's organs from being removed'. We believe most Singaporeans are not so selfish as to object to the donation of organs of their loved ones for the benefit of others if they are convinced their loved one is truly dead with no hope of recovery. In fact, the family in the recent case did not object to organ donation but simply appealed for more time to come to terms with the sudden death of their loved one. The real issue is the compassionate management of sudden deaths and helping family members face the reality that their loved one is kept alive only artificially as he is brain dead. There is a need to educate the public on the difference between coma and brain death and the stringent criteria to define brain death. It is also important to recognise that different families cope differently when faced with such situations and sensitive and empathic communication skills are critical. Second, that 'the only incentive at present not to opt out is that those who opt out go to the bottom of the waiting list if they ever need an organ'. This is a penalty rather than an incentive. Nevertheless, we believe that ignorance or apathy, rather than the threat of going to the bottom of the waiting list, is the reason why Singaporeans do not opt out of the Human Organ Transplant Act (Hota). Even if this assumption is correct, such a penalty can then be applied to the family members should they opt out on behalf of their loved one at the point of brain death. There will then be no question that 'justice would not be done'. Third, Dr Lee had drawn attention to 'a separate organ donor form where one can specify which or all organs one wishes to pledge for the few Singaporeans who want to go beyond the Hota and donate any organ that can be used for transplant'. Amendments to Hota have already been made so organs other than the kidneys can be taken. It is therefore no longer necessary for any Singaporean to pledge his organs since the only choice is to opt out. We believe most Singaporeans are altruistic and we can appeal to their spirit of compassion. It is therefore a duty of our lawmakers to ensure that the success of the legislation on organ donation does not depend on ignorance or apathy. Dr Patrick Kee Chin Wah Dr Wong Wee Nam Straits Times Forum 24 Feb 2007 |
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I refer to the recent incident over the Human Organ Transplant Act (Hota). The implementation of Hota came about partly because the previous scheme MTERA (Medical Therapy, Education and Research Act), which goes by the opt-in scheme for those who wish to donate their organs, was not successful mainly due to ignorance and lethargy on the part of potential donors. Hence, Hota was conceived as an opt-out system whereby all non-Muslim Singapore Citizens and Permanent Residents between the age of 21 and 60 years are included under unless they opt out. The objective of the Act is good. However, the implementation of the opt-out scheme should be made easier and more transparent. Currently, the forms to opt out can be obtained from public hospitals and polyclinics or downloaded from the Internet. However, they have to be sent by post to the Organ Donor Registry. I suggest that people be allowed to submit such forms via the Internet and the Act be implemented in a way that makes opting out easier for those who wish to do so. Also, those who turn 21 may not be aware or may not remember to opt out when they are eligible to do so. Many do not even know of the existence of such an Act as it was introduced when they were young. The agency involved should consider writing to these individuals so that they can make a decision on an important matter later on. The success of Hota hinges on the legal rights of the society over the private rights of the family of the deceased. If the Act provides for the rights of the family members to object to the organ transplant, it would affect the very foundation and basis of the Act. Apart from considering the legal rights of individuals, the implementation of Hota should also be done with the utmost compassion and care for the feelings of the family of the deceased. Loke Siew Meng The Straits Times 23 Feb 2007 We refer to the Forum letter (TODAY, 23 Feb 2007) by Loke Siew Meng on the Human Organ Transplant Act (HOTA) who suggested that the Ministry should inform those who turn 21 about the Human Organ Transplant Act (HOTA) as they might not be aware or may not remember to opt-out when they are eligible. Notification letters and an information booklet on HOTA are sent to all citizens and permanent residents about 6 months before they turn 21 years of age. The booklet also contains the objection form for those who wish to register an objection. Every year about 40,000 of such letters are despatched. The Ministry will work towards achieving greater acceptance of HOTA through more public education. We welcome feedback on how we can better reach out to Singaporeans on HOTA. Bey Mui Leng (MS) Assistant Director (Media Relations) Ministry of Health 26 Feb 2007 |
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I REFER to the letter by Drs Patrick Kee and Wong Wee Nam ('Let a panel review strong objections of families'; ST, Feb 17) on the Human Organ Transplant Act (Hota), suggesting that the Ministry of Health should inform those who turn 21 about Hota as they might not be aware or may not remember to opt out when they are eligible. Notification letters and an information booklet on Hota are sent to all citizens and permanent residents about six months before they turn 21 years of age. The booklet also contains the objection form for those who wish to register an objection. Every year, about 40,000 such letters are despatched. The ministry will work towards achieving greater acceptance of Hota through more public education. We welcome feedback on how we can better reach out to Singaporeans on Hota. Bey Mui Leng (Ms) Assistant Director (Media Relations) Ministry of Health The Straits Times 28 Feb 2007 |
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Brain Death |
Abridged (Full text above) THE debate on a proposed law on human organ transplants took a rare turn yesterday when the whip was lifted, allowing PAP Members of Parliament to vote as they will and not toe the party line However, all the 12 MPs - including opposition MP Chiam See Tong - who spoke during the debate supported the move to expand the scope of the Human Organ Transplant Act (Hota). . The subject is an emotional one with religious overtones and the dozen MPs, including three Muslims, raised many issues that have dogged it since the debate began two years ago. Topping the list is when would a person be deemed to be brain dead, with several MPs, reflecting the confusion of many Singaporeans, giving examples of people in a coma suddenly waking up. It's a worry likely to dominate again today when about a dozen more MPs are expected to speak as the debate continues on the Second Reading of the Human Organ Transplant (Amendment) Bill. . The beating heart seems to be the nub of the problem for most of the MPs, who wanted to know what exactly is being 'brain dead' and if there was a risk of doctors not doing their utmost for a dying patient because of their eagerness to reap the organs to save others. Dr Lily Neo (Jalan Besar GRC) expressed the common concern when she asked: 'How does the Ministry of Health ensure that organs are not removed prematurely?' Abridged Salma Khalik The Straits Times 6 Jan 2004 | |||
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IT WOULD appear from proceedings in the House yesterday that 16 years after the controversial Human Organ Transplant Act (Hota) came into being, Singaporeans have not really moved on that much in some respects. True, as Acting Health Minister Khaw Boon Wan said in moving an expanded version of the Act, Singaporeans have become more familiar with the notion of presumed consent and brain death. . However, in the case of brain death, familiarity does not imply peace of mind. Acquitting herself better here, Dr Neo, a general practitioner, noted that 'the worrying fact for many is whether people certified brain dead are really dead'. This was a recurring theme with MPs yesterday afternoon. One of them was Opposition MP Chiam See Tong (Potong Pasir), who had joined his People's Action Party counterparts in supporting the amendments to extend the legislation to cover liver, heart and cornea transplants and non-accidental deaths. Asking 'when is a person dead?', he pulled out the anecdote of a Taiwanese woman who came back to life some time after doctors had found no activity in her brain and pronounced her well and truly dead.
The concerns MPs reflected are twofold.
. Perhaps a channel should also be set up for relatives and loved ones of patients, as well as the general public and health-care workers, for complaints and doubts to be raised about cases. In this matter of life and death, no amount of extra is too much Abridged (Full text above) Tan Tarn How The Straits Times 8 Jan 2004 | |||
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Relatives, hoping for miracle, wanted doctors to delay surgery for another day (Abridged) GRIEF-STRICKEN relatives of a brain-dead man on Tuesday begged that his organs not be taken - and then got into a tussle with hospital staff when their request was rejected. They were praying for a miracle, hoping that Mr Sim Tee Hua, 43, would awake from his coma. But the crane operator was declared brain dead at 6.20pm on Monday - four days after he collapsed at work last Thursday. The cause of death a stroke, or brain haemorrhage. When doctors at Singapore General Hospital (SGH) said on Monday that they were going to remove his organs, the family requested that they wait for 24 hours - and the doctors agreed. After that time was up, the family asked for another 24 hours, but doctors felt that a delay would make the organs unusable for transplant and went ahead with the operation. . Mr Sim's sister, Ms Shen Qiu Xia, 45, told Lianhe Wanbao 'We were actually prepared to accept that he was dead if his condition did not get better by Wednesday night. 'Although he was brain-dead, his body was still warm and my mother said that she felt he would awake from the coma.' She added that he had no previous major illnesses and that he had planned to marry a girlfriend in her 30s from China's Hainan island. Abridged (Full article above) The Straits Times 8 Feb 2007 As Sim Tee Hua lay on life support in a Singapore hospital, seven of his relatives knelt crying on the floor before the doctors, begging them not to remove his organs and give him a chance for a miracle recovery. . The previously healthy lorry driver was already brain-dead after suffering a stroke at work, followed by a cerebral haemorrhage in Singapore General Hospital. The harvesting surgeons had waited for 24 hours, but although his family still clung to hopes that he could recover, Singaporean law assumes all citizens except Muslims are willing organ donors unless they have explicitly opted out. . "Tears would roll down from his eyes when we spoke to him, telling him not to give up," Mr Sim's brother Tee Yong, 49, told the New Paper. "We know that medically a brain-dead person cannot wake up. But we did not want to give up hope. All we asked for is just one more day for a miracle to happen." Abridged (Full article above) Sebastien Berger telegraph.co.uk 3 Mar 07 |
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THERE was a three-hour stand-off at the Singapore General Hospital last week when the family of a brain-dead stroke patient tried to stop doctors from harvesting his organs, as permitted under the law. Brain death is said to be the complete and irreversible cessation of brain activity, but the man's next-of-kin had noticed tears rolling down his cheeks when they spoke to him, while his elder brother said he even squeezed 'my hand when I held his'. Doctors say these are just reflexes prompted by the spinal cord, not the dead brain. Families in these situations often ask: Is my loved one really dead? This tormented ambivalence arises from the conceptual untidiness that 'brain death' entails. Up to the 1960s, death was uncontroversially deemed to have occurred when all of a person's major organ systems ceased to function. To this day, no one doubts that a cold, stiff and grey body is dead, but the brain-dead are still pink and warm. Yes, a person hanging from the gallows has lost all brain function and is quite dead. So if the brain is dead, the person must be too. Yet, if ventilated, brain-dead persons can digest food and excrete waste, heal wounds and even carry a pregnancy to full term. Thus while doctors refer to the brain- dead as 'cadaveric donors', they do not look or behave like bodies in the morgue. In the brain-dead, the crucial part that is gone is the brain stem, or the lower part of the brain that is continuous with the spinal cord. The brain stem is responsible for human alertness, arousal from sleep, breathing, blood pressure and heart rate control, and it relays information between the spinal cord and the upper parts of the brain. When the brain stem stops working, the brain cannot transmit data to the body to control the heart and lungs, say. Also, it cannot receive data from the body. The patient thus shows no reaction to stimuli, no evidence of thought or consciousness and no ability to breathe on his own. Such a patient can be kept going with life-support for up to three months, before the heart also stops, as the brain turns into mush and the heart rate centre dies. But while on a ventilator, the person still looks alive, or just asleep, so how can he be (brain) dead, family members would ask. Brain death differs, however, from the persistent vegetative state - like a Terri Schiavo - where the patient is permanently unconscious but has sleep/wake cycles: The eyes may open during the waking phase but the person remains unaware of the surroundings. In such cases, clinical testing shows that the brain stem is intact - so no ventilator is required, say - but the upper parts of the brain are totally non-functioning. In the brain-dead, by contrast, we do not know if the upper brain is completely dead. For even if we concede that the patient's consciousness is irreversibly and irretrievably lost, there is no proof that the content of his consciousness that was present (in his upper brain) is also permanently gone. That content includes a person's private thoughts, memories, plans, attitudes, etc. Since they are subjectively experienced, there is (still) no way to prove that they are now absent. If so, the whole idea of brain death may have been built upon an unproven hypothesis. It does not help matters when brain-dead persons can also make complex movements, such as placing their hands in a praying position. Then there is the Lazarus sign, which 'starts with stretching of the arms, followed by crossing or touching of the arms on the chest, and finally falling of the arms alongside the torso,', according to a report in the Journal of the American Academy of Neurology in 2000. It noted that 'these movements are more common than has been reported or believed'. In the study, 40 per cent of cases had such movements, all within the first 24 hours after diagnosis, but none after 72 hours. Sometimes, drugs to paralyse the patient are used to prevent these movements from occurring during surgery to remove the organs. There is also evidence that the upper brain continues to regulate some bodily functions, including electrolyte and hormone metabolism, which are controlled by the hypothalamus, a part within the upper brain. In some countries, where high-tech tests are used to confirm the diagnosis of brain death, significant brain function may be detected in about 20 per cent of cases. These tests include those in which brain cells actively take up radioactive drugs or produce 'evoked potentials', which are electrical potentials recorded following a stimulus, such as a sound presented through earphones. (Evoked potentials are distinct from spontaneous electrical potentials that can be recorded from the surface of the head as normal brain waves.) In some cases, even normal brain waves can be detected for up to seven days. Yes, people correctly diagnosed with brain stem failure never ever recover consciousness, but what these tests show is that some brain cells are still functional. Thus not all the brain is dead in the brain-dead - at least some of the time. If so, the very concept of brain death is not internally consistent. Moreover, equating brain death with death takes for granted that the brain is the supreme regulator or fundamental orchestrator of all body functions. It assumes that it is the brain that keeps a person's total physiology integrated. However, many experts today argue that it is unclear if there is a supreme regulator at all. The evidence is, rather, that all bodily systems need to co-equally function for life to be sustained. Since the very notion of brain death is problematic, the next-of-kin should not be told that the patient is brain dead, and thus legally dead for the purposes of organ harvesting. What should be explained instead is that his brain stem has suffered irreversible damage and that total cessation of brain function is just a matter of hours or days away and that the patient cannot be kept alive with heroic measures indefinitely. In such futile cases, consent to have life support withdrawn is sought from the next-of-kin. This is not euthanasia: It is perfectly acceptable for a person to have a doctor turn off his ventilator, which would result in his death. This is because we have the right not to have things done to our bodies against our will - lawyers call it 'battery' - even things that could keep us alive. The family is advised that life support will be unplugged in the operating theatre instead of the hospital ward. Family members say their final goodbyes outside, the patient is wheeled in and he is then unplugged. Although the heart could theoretically be resuscitated (as long as the brain has not yet completely liquefied into mush), if pulling the plug is ethically acceptable in futile cases, then not resuscitating the heart would also be acceptable. Within a few minutes, the heart stops. Some 15 seconds later, the brain begins to shut down completely, the signal that stimulates breathing goes, and cells begin to die. At this time, the patient is pronounced dead and surgeons begin immediately to remove his organs. With the family's pre-obtained consent, however, doctors would have already been running cool preservatives through the organs to reduce damage from the lack of oxygen once the plug is pulled. Without ever employing the notion of brain death, this arrangement - which uses the traditional heart-and-lung criterion to define death - would satisfy the unwritten rule that a donor be dead before his organs are harvested, where harvesting must not itself cause his death. It was, in fact, in this way that the world's first successful liver and heart transplants were carried out in the United States (1966) and South Africa (1967), respectively. The notion of brain death would only be introduced the following year by an ad hoc committee of the Harvard Medical School, explicitly to free up beds in their intensive care units and expedite organ procurement for transplantation. Their report, however, presented the already contested connection between the loss of brain function and death as if it were fact. Though there was already a large body of work on the issue, the paper made scant reference to that scientific literature. But the glow of the Harvard name - and its publication in a well-regarded journal - quickly turned hotly disputed ideas into indisputable fact. (Yes, scientific 'truth' can be socially constructed.) To this day, though most protocols that doctors use to declare someone brain dead are still based on the Harvard recommendations, the veracity of this notion of brain death is hotly contested. If nothing else, given its ethically questionable provenance, it may be high time to let brain death die. Andy Ho The Straits Times 15 Feb 2007 Reply from MOH WE REFER to the commentary by Dr Andy Ho, 'It's time to lay to rest brain death' (ST, Feb 15). We do not agree with Dr Ho's assertion that the scientific truth behind brain death was 'socially constructed' or that the medical definition of brain death is inconsistent with scientific evidence. While Dr Ho accepts the irreversibility of brain death, he recommends its abandonment and reversion to the sole cardiac-respiratory definition as death. However, this view is not supported by worldwide medical and societal consensus. The notion of brain death was first described by French neurologists in 1959 and was further examined by scientific expert bodies. The Ad Hoc Committee of the Harvard Medical School published its report in 1968 and the University of Pittsburgh published its brain-death criteria in 1969. In 1971, the Minnesota criteria were published. The first country to adopt brain death as the definition for legal death was Finland, in 1971. In 1979, the Conference of the Medical Royal Colleges and their Faculties in the United Kingdom indicated that 'brain death represents the stage at which a patient becomes truly dead'. In 1981, the experts to the US President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioural Research published guidelines on the determination of death based on neurologic criteria. When a person is declared brain dead, it does not necessarily imply death of every cell in the body, and movements are sometimes observed. After brain death, if the heart continues to beat long enough, some limb reflexes can still be observed. However, they do not indicate that the person is alive. Published evidence over the years has shown that the stoppage of the heart was the invariable outcome for brain stem dead patients but maintained on a ventilator. Over a thousand such cases have been observed. The survival rate was zero and, in most cases, the heart stopped within days. Brain death is a widely accepted condition by international medical communities. The clinical criteria used in Singapore are based on international standards of diagnosing brain stem death and were drawn up with the help of local experts. Worldwide, there has been no reported case of any brain stem dead person coming back to life. The medical diagnosis of brain death as a legal definition of death and its consequence of leading to discontinuation of futile support of some of the body functions is not a means to organ donation. It offers a definitive closure to the family of patients who have died. Dr Arthur Chern Director Integrated Health Services Division Ministry of Health Assoc Prof Thomas WK Lew Head, Department of Anaesthesiology Tan Tock Seng Hospital Straits Times 26 Feb 2007 (Also available as submitted on the MOH website) |
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FRESNO (CALIFORNIA) - A MAN whose family agreed to donate his organs for transplant upon his death was wrongly declared brain-dead by two doctors at a hospital in Fresno, California, records and interviews show. Only after the man's 26-year-old daughter and a nurse became suspicious was a third doctor, a neurosurgeon, brought in. He determined that John Foster, 47, was not brain-dead, a condition that would have cleared the way for his organs to be removed, records of the Feb 21 incident show. 'It kind of blew my mind,' said the daughter, Ms Melanie Sanchez, 'like they were waiting like vultures, waiting for someone to die so they could scoop them up.' Mr Foster, who had suffered a brain haemorrhage, died 11 days later at Community Regional Medical Centre in Fresno. By then, she said, his organs were not viable for donation. The apparent close call is the second in recent months to raise questions about the organ transplant process amid a national organ shortage. Police in San Luis Obispo County are looking into a case where a transplant surgeon may have tried to hasten the death of a 26-year-old patient last year by ordering high volumes of pain medication. Organs cannot be retrieved until a patient is declared legally dead The Straits Times 13 April 2007 (Orginally from Los Angeles Times) |
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Medical Issues |
Organ goes to husband, then she dies in probably the first such death AN ORGAN donor who died shortly after an operation to remove her kidney last week is believed to be the first donor death in almost 30 years of living-related kidney transplants. The 33-year-old woman donated one of her kidneys to her husband, who had been on dialysis for several years.
Her death may set back attempts to increase the number of living donor kidney transplants in Singapore, which already has one of the lowest rates among developed countries. Dr Balaji Sadasivan, Senior Minister of State for Health and a strong advocate of more living-related kidney transplants, said yesterday: 'I'm deeply saddened by this tragic death.' On its impact on such transplants, he said: 'This is a setback. We will have to wait for the coroner's investigations to find out what happened. 'We'll have to see why the patient died and see what we have to do to ensure that this doesn't happen again.' A post-mortem was carried out and the case is now with the coroner's court. Her 35-year-old husband, who is still in hospital after the transplant, was taken to Mandai Crematorium in an ambulance on Saturday so he could recite the rites at her funeral. One of her relatives said he hopes the man can be discharged from hospital later this week, and be able to attend the prayer sessions for his late wife this Saturday. The hospital is also conducting an internal investigation into the death. Its chief executive officer, Mr Chua Song Khim, said: 'The loss of our patient deeply saddens us. We share the family's grief at the loss of their loved one.' He said the hospital was in touch with the family and would help them during this difficult period. Singapore first carried out living-related kidney transplants in 1976 and has done over 400 to date. Last year, 52 patients received a kidney from a family member, while 32 got them from dead donors. The operation is considered very safe for both donor and recipient, with one death out of 3,000 kidney donors worldwide. A Health Ministry spokesman said that, in spite of the risk that 'serious complications can occur with any major surgery, kidney transplantation remains the best treatment option for patients with end-stage kidney failure'. Despite the opt-out kidney transplant law, which allows organs to be taken from accident victims, the waiting list grows yearly, with more than 660 on the list at the end of last year. The average waiting time is seven years for a cadaveric kidney. Last year, the Human Organ Transplant Act was expanded to allow doctors to take organs from any brain-dead patients. The amendment should increase the number of kidneys available by about 40 a year. Salma Khalik The Straits Times 24 Feb 2005 (The Straits Times, 27 Feb 2007) I would appreciate if you could forward to me if you have it. Thank you. I REFER to the report, 'Medical team not to blame for woman's death: Coroner' (ST, Feb 27). The woman died after donating a kidney to her husband. The coroner exonerated the medical team that did the transplant. It appears that the clips holding the donor's left renal artery and vein shut had slipped off, resulting in internal bleeding. I find it difficult to accept the coroner's finding. Dr T. Ravintharan, who is in private practice, was reported as saying in the article, 'Warning on clips came too late' (ST, Feb 27): 'Having done laparoscopic surgery for a long time, I've always found that a combination of using the clips and sutures is a much safer way to prevent bleeding.' It is no excuse to say that the vendor's warning came too late. Retnam Thillainathan Straits Times Forum 1 Mar 2008 |
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Organ Trading (Section Pending) |
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