Mar

13

Life has just become a little more difficult for dead people in India. India’s health minister Dr. Ramadoss is advocating a new solution for India’s organ transplant woes.

Instead of the family-consent-based organ donations that are currently legal in India, the health ministry wants to introduce ‘presumed consent’, a system prevalent in many European countries, allowing for a presumtion of consent to transplant organs from from all brain-dead people. The idea is to start with corneal transplants and see how that works out. If it does, it may be extrapolated to include other organs such as kidneys, liver, etc. For people who are conscientious objectors to the idea of donating of organs in general, they will have to put that down in writing, which then will take precedence over the default presumed consent. It is thought that such presumed consents will reduce and curb the proportion of illegal organ trade, by striking at the heart of the supply-demand imbalance that is at the heart of the whole organ transplant issue.

A 10-year 22-country study by Harvard and Chicago university experts in the field, has shown that though the ‘presumed consent’ can increase the number of cadaveric organ donations and reduce the organ shortages, the presumed consent model has not been the ’silver bullet’ that can address the bigger issue.

Personally, I am opposed to the presumed consent model for several reasons:

1. Imagine what can happen after someone dies. You have this person’s family, their spouse, their kids grieving, and some stranger comes in, takes possesion of the body, removes the person’s cornea or whatever organ. Unless the family can produce a written consent signed by the party before their death, the consent will be presumed. It will be very hard, at the least terribly inhuman, for any health official to enforce the removal of an organ without the express consent of the family. So the presumed consent thus becomes secondary to family consent when the circumstances are difficult and sensitive. Then what’s the point?

2. Imagine someone you know becomes a tragic victim of a traffic accident which leaves them brain-dead. It will be several hours before the family is notified and can show up at the emergency room or the hospital. Can the health officials claim the organs of this brain-dead person and start removing say kidneys, liver, corneas, etc before the family has even seen the body? Imagine the legal ramifications if a family member is ripped apart before being seen by a mother or a child.

3. How difficult would it be for a family to come up with a written consent note that forbids an organ donation? What if a family claims that they have knowledge of such a written note, but cannot produce it at the moment. Precious time would be lost no matter what, and the dead person would become useless for any organ donation as it is.

4. How difficult would it be for rogue mafias to show up as health officials and pick up a cornea or two or a kidney or two from your loved one and then sell it somewhere else? Your close one is dead. The doorbell rings. And you ask for the person’s ID not knowing whether that ID is real or fake and whether your loved one’s organ would go to a genuinely needy person or to some rich alcoholic looking for a new liver in America or the middle east.

The whole issue boils down to this. Who owns your body after you die? Your family? Your loved ones? Or the government? The presumed consent tilts the balance to the government, making your family a lot less relevant and a lot less in charge once you die. That would be ok with me if the government and its representative entities had my complete trust and faith. Tell me folks, If I don’t trust the government when I’m alive, how the heck do you expect me to trust it when I’m dead?

The only circumstance any government could be allowed to request the reuse of dead citizen’s body parts, is if it has provided free and fair healthcare to all its citizens from cradle to grave, no questions asked, no conditions whatsoever. Then, and only then, should a government dare to claim any right over people’s corneas or kidneys or livers.


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3 Comments so far

  1. ashvini kumar on March 13, 2008 12:36 pm

    “Tell me folks, If I don’t trust the government when I’m alive, how the heck do you expect me to trust it when I’m dead?”

    Well Said…

    Looks like our government & its advisor’s have gone bonkers/lost their marbles…

    They should think all these implications & possible ways a law can be interpreted and mis-used in our country. As we are pioneers in “bending” the law and interpreting it one’s own convenience. Not to mention corruption and power abuse…

  2. Felix on June 6, 2008 4:09 pm

    I would like to know what has happened to the suggestion about the presumed consent suggested by the health Minister A. Ramadoss. Was it just a publicity stunt or is he seriously thinking in terms of changing the law of human organ donation. In cases of Post mortem it should be made mandotory that the corneas have to be enucleated and sent to an Eye bank for processing, evaluation and distribution. If this is done the wait-list for corneal transplant will come down drastically. Countries like Sri Lanka are exporting corneas because of the role played by religious leaders there. In India also we should urge the religious heads of different religions to take up this matter with their respective people.

  3. Jashwant Mehta on June 6, 2008 4:47 pm

    Note prepared by Shri Jashwant B. Mehta*

    * (Founder member & Ex-President of Eye Bank Association of India (1998-2001) Hyderabad and Chairman and Managing Trustee of Eye Bank Coordination and Research Centre, K.B. H. Haji Bachuali Eye Hospital, Parel, Mumbai 400 012 Tel no: 24162929

    M/s. Jashwant Mehta & Associates,
    B-145/146 Mittal Tower,
    Nariman Point,
    Mumbai 400 021.

    Tel Nos: 2202 8532/2283 2770 Fax:2283 5149

    Preamble

    Acute problem of corneal blindness

    The people suffering from corneal opacity (either in one eye or in both the eyes) is estimated to be not less than 2 million. Out of this, atleast 2,00,000 are estimated to be bilaterally corneally i.e. blind in both the eyes. They are obviously in need of immediate corneal transplant in atleast one eye to have their vision partially restored. Unlike other causes of blindness such as cataract, glaucoma, retina detachment etc., a large number of the corneally blind are in the young age group.

    Limitations of awareness campaigns
    While the eye donation movement started in the country in the early 50s and there have been several campaigns undertaken from time to time for creating more awareness there are obvious limitations to get more number of eye donations merely by awareness campaigns. One may fill the pledge card for donation but the donation has to come only when the person is dead and it is only the relatives of the deceased who can donate the eyes. The human memory is generally short and so much time elapses between the decision to pledge and the actual time of death. Further, at the time of death, the scenario is gloomy and there are several other priorities for the family when the death actually takes place. All these affect the actual process of eye donation and today even after a period of 50 years since the eye donation movement started in India, the number of eye donations has touched a figure of around 18000 to 20000 per annum.

    Requirement of good quality corneas

    It may be mentioned that out of the total number of eye donations received, the good quality corneas available for transplant are still less. Even in a developed country like the USA, the corneas suitable for transplant are less than 50% of the total number of eye donations received, in our country the number is still less on account of poor health standards. The number of corneal transplants performed every year in the entire country is in the range of 15000 to 16000. Obviously, this number has to go up several fold if we are to set up a target of 15 – 20 years to eradicate corneal blindness in the country. This can only happen if the number of eye donations will be several times more than the present number. It is estimated that we require atleast 100,000 corneal transplants to be performed every year for which the no of eye donation have to match proportionately.

    The Impact of Legislation

    Many countries in the world having realized the limitations of awareness campaigns have incorporated suitable legislative measures to help procuring required number of good quality corneas suitable for transplant to combat the problem of corneal opacity and these measures have helped a great deal to achieve the purpose.

    To get an idea of the success of the legislative measures in combating the problem of corneal blindness, in the USA since the legislative measures were introduced in the mid 70s in various states, the eye banking and keratoplasty has taken up quantum jump. Thus, as against the total of 20,000 corneal transplants performed in the U.S. between 1961 and 1971, the number of transplants touched a figure of 36,900 in 1988 alone. As against the 6,000 eye donations received in 1967, the figure jumped to 83,758 in 1987. There is practically no patient wait-list as of today.

    The following 3 legislations have played an important role in solving the problem of getting the required number and quality of corneas and solving the problem of corneal blindness in several countries in the world including the Europe, U.S.A. & Asian countries such as Singapore, Philippines. Even some of the Islamic Countries have also made suitable amendments in this regards.

    1. Provision of Presumed Consent
    2. Provision of Required Request
    3. Permitting Trained Technicians to Enucleate Corneas

    I. Provision of Presumed Consent

    Of the three provisions this provision has played the most important role. It enables the removal of corneas from all the post-mortem cases i.e. medico-legal cases without any legal hassle. As the removal of cornea does not affect the post-mortem findings in almost all cases of death unlike the removal of other organs such as heart, liver or kidney (which would affect post mortem findings its removal is permitted in many countries of the world in all post mortem cases without any legal hassles. The removal of cornea or the eye ball does not result in any disfigurement of the face also. It may be also mentioned that the corneas received from these medico-legal cases constitute the most concentrated source of excellent quality tissue from relatively young donors As compared to this, the quality of corneas procured from the dead body of a person dying due to old age is generally poor as the endothelium cell count, which is vital for a successful transplant especially in the case of a penetrating graft, deteriorates as the age advances. This is more so in a developing country like ours because of the generally poor standard of health of the average citizen. The utility ratio in our country varies from 30 to 40%, whereas for corneas removed in medico legal cases this percentage varies between 60% to 70%. It may also be mentioned that with an average life expectancy going up in our country more than 50% eye donors are now over 60 years of age and the quality of Cornea generally deteriorates with advancing age. Apart from this as per the latest medical standards Corneas of donors suffering from HIV, Hepatitis, Syphilis, Septicemia & blood related Cancer are also not permissible to be utilized for transplant. All these have put severe limitations from corneas receivable from voluntary donors.

    The Indian scenario

    When the Human Organs Act was passed in the year 1994, the Eye Bank Association of India tried to get the Provision of ‘Presumed Consent’on the similar lines as has been done in the other countries including the USA. While in principal it was accepted, unfortunately the wordings of the act are not at all conducive to serve the purpose and encourage the removal of corneas from the medico-legal cases.

    II. Provision of Required Request

    Besides the inclusion of “Presumed Consent”, the “Required Request” provisions of the law enacted in the USA and many other countries have also contributed to the increase in the volume of donor material. Under these provisions, it is mandatory for the individual hospital authorities to solicit eye donation from the next-of-kin in all cases of death. A column can be introduced in the death certificate where the person/authorities concerned in charge of issuing death certificate has to confirm that request is made for eye donation.

    III. Permitting Trained Technicians to Enucleate Corneas

    The present Act empowers only a registered medical practitioner to remove a human organ including eyes for the purpose of transplantation. The provision of allowing a ‘Technician’ trained in enucleation procedure besides the regional medical practitioner in the Ophthalmic Department of a hospital or teaching institution or certified by the Eye Bank Association of India for removal of corneas for the purpose of transplantation has not been included in the Act. This provision is necessary because the removal of corneas from a dead body can be easily effected by a trained technician, while the same is not possible in case of other organs such as kidney, liver or heart. (In several countries including the U.S.A., trained technicians are permitted to remove the corneas). This will save precious time of a Registered Medical Practitioner as it is very cumbersome for the practicing medical practitioner to spend a minimum of two to three hours for attending to a call for enucleation of corneas from a dead body, in cases where the cornea is to be enucleated at the residence of the deceased. Sometimes, such calls may be received at odd hours when it is impossible for a medical practitioner to leave his practice and rush to the spot where the dead body is lying for the purpose of enucleation. In fact, it has been established that a trained technician can perform enucleation better than a family physician or a registered medical practitioner.

    It is earnestly hoped that the Central Government will seriously look into the entire issue of Organ Donation and to begin with atleast carry out necessary amendments pertaining to Cornea which is the least complicated without further delay.

    DOC NO. 1192

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