The success of organ transplantation is a spectacular example of what contemporary medical science has achieved in translating advances in basic science to effective therapy for the sick and dying. Transplantation is now a well established life saving procedure for patients suffering from end-stage disease of various organs and in many countries has become a part of standard medical care. On the other hand, the success has also thrown up a unique quagmire of moral, social, ethical and legal issues which continue to come up as the science progresses rapidly.
Although there were attempts to transplant the human kidney from the early twentieth century, it was successfully transplanted in 1946 by a team lead by John Murray at the Brigham & Women's hospital in Boston. Transplantation of the liver followed in 1963 and the heart in 1967. Many other organs including the lung, pancreas and intestines are now transplanted successfully and in fact there has been a recent trend towards transplanting parts of the human body like the tongue, larynx and face purely to improve quality of life.
In the rest of the world a majority of transplants are now performed with organs removed from ‘brain dead’ or ‘deceased’ donors as they are now termed. Over the last four decades, the concept of “brain death”, a state where the brain is irreversibly damaged but the heart is beating, has been legalised and accepted in many countries as a form of death. By the end of the last century more than 50 countries had accepted “brain death” as a legal concept and enacted specific laws on organ transplantation. In the scenario of brain death, two principal forms of consent have been sought. ‘Informed consent’ which is commonly practised is based on the desire by the deceased in his or her lifetime to donate organs or the agreement by legally responsible family members to do so after “brain death”. This needs a mechanism to motivate the family to donate organs after “brain death” has been declared. “Presumed consent” grants authority to doctors to remove organs from brain dead individuals in the absence of objection, from the deceased in his or her lifetime or from surviving family members
In spite of decades of work on awareness, the need for organs far outweighs their availability and the ‘demand’ and ‘supply’ gap continues to grow. Every year more than 5,000 patients waiting for an organ die in the western world. In the east, deceased donation is still culturally not acceptable. This has pushed the medical community to look at other sources of organs and has led to ‘living’ donor transplantation of single organs like the liver where a part of the liver is removed from a close relative. Also ‘xenotransplantation’ where organs are used from other species and the creation of artificial organs have been attempted but with limited successl.
Till the earlier half of the 1990s, transplant activity in India centred around live donor kidney transplants. In fact this was also a period when ‘kidney scandals’ periodically hit the public domain in which middlemen lured individuals from the deprived sections of society to sell their kidneys for a price. When the Human Organs Transplant Act was passed by Parliament in 1994, it had a dual purpose. Besides banning trading in organs, it legalised brain death, making removal of organs from persons declared brain dead permissible. The last 15 years since the passage of the law have seen negligible activity in cadaveric donation. In many states it has been as good as a non-starter. It is against this background that the recent amendment to the 1994 Act has been made to ease the procedure of brain death recognition and to push institutions to appoint transplant co-ordinators who will motivate family members for donation.
The lack of progress in cadaver donation in India is often ascribed to ‘lack of public awareness' which is only a part of the truth. The experience of the Armed Forces medical institutions as well as the recent surge of donors in Chennai has shown that if there is a concerted effort by the state and institutions to promote organ donation and identification of brain dead donors by ICU personnel, the consent rate in India is fairly good. Perhaps this also reflects the state of health care in India where activities like organ donation are given low priority because government institutions are grappling with basic problems and private institutions don’t see such activities translating into immediate profits.
One of the unfortunate fallouts of the way healthcare has grown in India is the fact that most transplant activity, including the sporadic cadaveric transplants, takes place in the private sector. This has resulted in making an inherently cost intensive procedure even more out of reach for the common man. Incidentally, in the debate in the media about the organ trade, what was perhaps new was the public articulation by some intellectuals for a 'regulated' organ trade.
‘Regulated’ organ trade
This viewpoint is based on two arguments - since every individual is the owner of his/her body, he/she has the right to sell a part of. Also, those individuals who sell their organs do so of their free volition, thus completely ignoring the social deprivation which is the basis for this act. The other premise is that since anyway we cannot stop the organ trade we may as well legalise it as this will ensure proper medical standards and protect the donor from being duped. This is perverse logic and smacks of a quick fix approach. There is an urgent need for involvement of the entire healthcare system and civil society to see a long term stake in promoting organ donation
(The writer is a surgical gastroenterologist at Jaslok Hospital, Mumbai, with a special interest in liver transplantation.)