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ORGAN DONATION & TRANSPLANTATION-

Legal & Social Issues

Dr.Sunil Shroff

Managing Trustee, MOHAN Foundation, Chennai

Head of Department - Urology & Renal Transplantation,

Sri Ramachandra Medical College & Research Institution, Chennai, India

info@mohanfoundation.org

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Death is not extinguishing the light but putting out the lamp because the dawn has come

- Rabindranath Tagore

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Organ Donation – Concepts

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Types of Organ Donors

After Natural Death Living person – related to patient Living person – unrelated to patient After Brain Death

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N NOrgan Donation by a Living person

Blood

Eyes

Bone marrow

Kidneys

Portion of Liver

Portion of Lung

Portion of Pancreas

Iddham Shariram Paropkardum (This body is for the use of others) - Shankracharya

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N NOrgan Donation after Natural Death

Eyes Skin and fascia Heart Valves Bones and Tendons Cartilage Veins and Arteries Middle Ear Bones

The only thing you take with you when you're gone is what you leave behind  - John Allston

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N NOrgan Donation After Brain Death

Eyes ( 2 ) Kidneys ( 2 ) Liver ( 1 ) Lung ( 2 ) Pancreas ( 1 ) Small Intestine ( 1 ) Voice Box or Larynx( 1 ) Hand ( 2 ) Penis ( 1 )

Middle Ear Bones ( 2 ) Skin and fascia - Numerous Bone - Numerous Cartilage - Numerous Tendons - Numerous Veins - Numerous Arteries - Numerous Nerves - Numerous Fingers and Toes ( 20 )

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N NCOMMMONEST TYPE OF ORGAN DONATION IN INDIA

Blood - Living related or unrelated Eyes - After Natural Death Kidney Donation - Mostly unrelated and

sometimes related

And he will wipe out every tear from their eyes and death will be no more.

- Revelations 21:4 

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0 5,000 10,000 15,000 20,000

1998-991997-981996-97

Eye Donation

Corneas Retrieved in India 1996- 99

1998-99

1997-98

1996-97

3 million corneally blind people in India. 60% are children below the age of 12. Target retrieval of corneas by Eye bank of India is 150,000 corneas per year.

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RELIGIOUS ISSUES –

Religious Heads of a Society

ETHICAL * MORAL ISSUES

Philoshers

SOCIAL ISSUES –Social Scientists

IMMMUNOSUPPRESSIVE DRUGS – Pharmacist & Pharmaceuticals

MEDICAL ISSUES - Physicians

ORGAN REGENERATION -Basic Scinetists

ORGAN DONATION & TRANSPLANTATION

SURGICAL ISSUES - Surgeons

IMMUNOLOGICAL ISSUES –

Immunologist

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ORGAN DONATION & RELIGION

Death is just a beginning of another life                          - Upanishads

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JainismJain religious leaders consider eye donation as a sublime form of charity and stress  a powerful link between ‘daan’ (charity) and ‘moksha’ (salvation).  Highest eye donation rate in India among Jains of Gujarat.

For that which is born death is certain and for the dead, birth certain.. Therefore grieve not over that which is inevitable.

- Bhagavad Gita

HinduismReligious law does not prohibit Hindus from donating their organs, This act is an individual decision.

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CatholicismCatholics view organ donation as an act of charity, and self-sacrifice. Transplants are ethically and morally acceptable to the Vatican. Pope John Paul II

Religion & Organ Donation

ProtestantismProtestants encourage and endorse organ donation.

"We accept and believe that our Lord Jesus Christ came to give life and came to give it in abundance. Organ donations enables more abundant life, alleviates pain and suffering, and is an expression of love in the times of tragedy.”

- Rev. James W.

Rassbach

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N NReligion & Organ Donation

Jehovah’s Witnesses

Jehovah’s Witnesses do not encourage organ donation but Believe it is a matter best left to the individual’s conscience

God created man to be immortal and made him to be an image of his own eternity

- Bible, The Wisdom of Solomon

IslamIn 1983 the Muslim Religious Council initially rejected organ donation by followers of Islam, but it has reversed its position, provided donors consent in writing prior to their death. The organs of Muslim donors must be transplanted immediately and should not be stored in organ banks.

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BuddhismNo written doctrine but founder of a Buddhist Temple of Chicago said: "We honor those people who donate their bodies and organs to the advancement of medical science and to saving lives.”

JudaismJudaism teaches that saving a human life takes precedence over maintaining the sanctity of the human body.

"If one is in the position to donate an organ to save another’s life it’s obligatory to do so, even if the donor never knows who the beneficiary will be,”

- Rabbi Moses Tendler

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Organ Donation Ethical Issues

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Is Living Organ donation Ethical ?

Hippocratic oath – Do no Harm Voluntarism – Decision to donate in a family

may not be voluntary Usually more woman donate than men - mother

or wife are the commonest donors

One in 1000 living donor is likely to die even in best of surgical hands!!

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Commercial Aspects of Organ Donation

Most of the social and Ethical problems in organ donation due to kidney donation

A person has a pair of kidneys and can donate one and still be healthy

Usually trafficking of organs from the poor to the rich

On e-bay the famous Internet Auction websites a Kidney was being auctioned for almost One million dollars!!!

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N NCommercial Aspects of Organ Donation

Despite Govt. authorization committee to regulate organ donation activity many instances of paid donors are reported!!

Regular kidney scandals have become part of accepted newspaper readings in India!!

Kidney in Indian society is looked upon as a commodity hence the task of popularizing the concept of organ donation can be difficult!!

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Questionable Ethics

Human Rights Violation- in China (1990) – 1670 kidneys transplanted mostly from executed criminals

Commercial Trading of Organs – in India (1990) – 1580 kidneys transplanted mostly from unrelated donors

Bizarre instances of kidneys being removed by surgeons from an innocent donor is reported from all over the world regularly

Internet may be facilitating the whole process of organ trafficking

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Detractors –Transplant Surgery and patient maintenance -expensive not suitable for India.

Transplant surgery adds a few extra years to life but takes away most of the family savings of Middle income group family

Only rich can benefit with a transplant.

No hope for Poor in this field

Kidney Tx – Rs.2 Lakhs for surgery & Rs.1 lakh / year afterwards

Heart Transplant – Rs. 5 Lakhs for Surgery & Rs.75,000 / year afterwards

Liver Tx. – Rs.10 to 15 lakhs for surgery and Rs.50,000 to 75,000/ year afterwards

Ethical isues & Cost Factors

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Detractors – Transplants benefits a few in India and the same time

and resources can be used by the doctors to instead save many other lives

Ethical issues - Is Transplant Surgery Necessary at all in India?

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Ethical issues - Is Transplant Surgery Necessary at all in India?

Evangelist – There are 150,000 Patients with Kidney failure needing

transplants The only hope for living for an Acute liver failure patient is

to undergo a transplant Heart transplant gives an almost immediate improved

quality of life to the patient The long term success of the surgery are better than some

of the cancers Transplant practice - “Cutting edge of medicine practice”-

keeps us abreast with the latest in the field of research.

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Organ donation Legal Aspects in India

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Transplantation of Human Organs Act, 1994

Aims Regulate removal, storage and

transplantation of human organs for therapeutic purposes

To prevent commercial dealings in organs

Tamil Nadu Assembly passed the Act in May 1995

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N NMain Provisions of THO Act

Concept of “Brain Stem death” accepted Only “Living related Donors” are allowed to donate

organs without legal problems For unrelated Donors - Permission from “Authority”

required prior to surgery Requires - “Regulation and Registration of hospitals”

undertaking transplantation “Punishment for any commercial dealings in organs”

1st Relative – Father / Mother / Brother / Sister / Spouse / Son/ Daughter

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N NBrain Stem Death

Definition - Stage at which all functions of the Brain Stem have permanently and irreversibly ceased

Certification – Panel of four doctors

– Two sets of tests to be carried out - minimum of six hours in between the tests

– Form No. 8 to be used for certification

Death is usually a gradual event. Nail and hair can continue to Grow even after death !!

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N NOrgan Donor

Person may authorize removal of any human organ before his death.

Person may express his wish to donate his organs in the event of his death, through a ( Form No. 5 )

“Informed Consent” of Family is crucial to cadaver organ donation.

“Presumed Consent” – In some countries the law demands organ donation from its citizens, unless they express otherwise in writing

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N NOffences and PenaltiesCommercial dealings in organs

Imprisonment : 2 to 7 years Fines : Rs.10,000/- to Rs.20,000/-

Penalties for Doctors First Offence : Name struck off State Medical

Register for 2 years Subsequent Offence : Name struck off

permanently

Since the Act was passed there has been two criminal prosecution against doctors

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Donors• Scrapping of Sub Clause (3) , Clause 9 of

Chapter II– If any donor authorizes the removal of any of

his human organs before his death under sub-section (1) of section 3 for transplantation into the body of such recipient, not being a near relative as is specified by the donor, by reason of affection or attachment towards the recipient or for any other special reasons, such human organ shall not be removed and transplanted without the prior approval of the Authorization Committee.

Pitfalls - THO ACT

Majority of kidney transplants in the country use this clause resulting in “ legal commercialisation of

kidneys”

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Is There a solution to these Legal & Ethical Problems

Restrict the number of Live unrelated kidney transplants

Push the “Brain death organ donation” Programme forward

Make amendments in the THO Act Make punishments for offences more stringent

and effective

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Brain Death Concepts

First recognised in 1959 in Paris in Intensive care units (coma de passe )

Formally accepted as a form of death in 1968 by the ad hoc committee at Harvard

Accepted by Govt. of India in 1994 as a form of death

In Babies under one year brain death concept not applicable

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No wastage of organs if organ donation

from brain dead donors undertaken Almost 95% of organ donors in western

world originate from Brain Dead Donors Largest pool of organ Donors in the world

Brain dead Pool of Donors

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Common Causes of Brain Death

In India Road traffic Accidents the commonest cause of brain death

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Brain dead Pool of Donors in India

In any of the metropolitan city in India

There are at least on an average between 10 to 20 patients admitted in different ICUs who are

brain Dead

Even Doctors often fail to diagnose or recognise this condition!!

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Transplant Statistics

• Number of transplants done throughout the world - 5,50000

• Number of patients on transplant waiting list - 1,50000

• Number of Transplants worldwide 1997 - 37,072

Annual transplant figures are not rising. Though Waiting lists though are perpetually going up.

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N NTransplant Activity of Western World (1985 to 1992)

1985 1986 1987 1988 1990 1991 19920

5000

10000

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Kidneys - Cadaverkidneys - LivingLiver Heart

1989

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N NTOTAL TRANSPLANT ACTIVITY IN INDIA (1998 – 1999)

0

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Kidney - LivingKidneys - cadaverLiverHeart

Golden IT triangle of India Hyderabad, Chennai, Bangalore are also famous as “Kidney Bazaars” in the western world

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DON’T TAKE YOUR ORGANS TO HEAVEN FOR

HEAVEN KNOWS THEY ARE NEEDED HERE !!

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Organ Donation - Social Issues

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N NUnusual Social Situations & Dilemmnas

In certain brain death situations despite the consent of the family organ donation was not possible -

Two wives where first legal wife raised an objection to organ donation

Asking for money by family for organs Death by hanging in recently married girl Brain death in a destitute where no relatives

were available for consent

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N NProblems with Cadaver Organ Donation Programme in India

Govt. Problem

No Funding for programme

Hospital problem

No efforts to identify & maintain “Brain Dead” donors

Community Problem

No Awareness of “Brain-Death” Concept

Spain has the highest number of brain death patients going on to organ donation – 32 per million population

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N NStreamlining of THO ACT

Make it compulsory for doctors or medical social workers to ask for Organ Donation in a Brain Dead Situation

Identify doctors or senior nurses to work as Transplant Coordinators in each ICU

In Medico-legal cases it should be possible to perform Post-Mortem at same time as organ retrieval in presence of a Forensic Expert

No financial costs involved in the above recommendations

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N NOrgan Donation Awareness Programmes

Mandated Choice on Driving License about organ donation

Education at School and College Level Free Air time on Doordarshan and Private

Channels for films on Organ Donation Tax Exemption for documentaries on Organ

Donation Indirect incentives to donor families Honoring cadaver donor families

In states of Maharastra & Gujarat slogans about “Eye donation” displayed on National Highways

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N NMOHAN Foundation - Objectives

( Multi Organ Harvesting Aid Network )

Formed in 1997

Spread Message of Organ Donation

Works as a support group for Patients, Public & Physicians

Foundation subgroups –

Organ Sharing Group – INOS

Counselling unit – Manashanthi

Patient Support Group

Publishes “Indian Transplant Newsletter”

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Carry the card in the walletServes also as an emergency card

Organ Donor Cards by MOHAN Foundation

The Foundation has distributed almost 100,000 cards in India. Cards are available in English, Tamil. Hindi and Marathi

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Give Life a SECOND Give Life a SECOND Chance…Chance…Carry a Donor CardCarry a Donor Card

Organ Donor Cards by MOHAN Foundation

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HONOUR OF CADAVER ORGAN DONORS ORGANISED BY MOHAN FOUNDATION

MEMORIAL SERVICE 31ST OCT 1999 Loyola College, Chennai

Saplings Planted in Memory of cadaver Organ Donors by their family members in the Campus of Loyola College on 30th Oct 1999 - organised by MOHAN Foundation

Movie in English, Hindi and Tamil for Television ChannelsMade by MOHAN Foundation

Painting Completion on Organ Donation theme organized for schools by MOHAN Foundation in March 2002

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Formed in Nov’1999 by MOHAN Foundation Essence of INOS – “Not to Waste Any Organ” Hospital in group includes – Apollo, CMC

Vellore, Sri Ramachandra Hospital and Sundaram

Medical Foundation About 30 different organs shared between

hospitals

INOS - Initiative for organ sharing Group

UNOS in USA is the largest organization such organization and is partly funded by the government

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Counselling Unit- Manashanthi

Formed in April 2001 As a support group for emotional failure Located at Annanagar Counselling available between 10AM and 1PM Organises counselling lectures and workshops

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… When that happens don't call this my “DEATHBED”, call it my

"BED OF LIFE" and let my body be used by others to lead fuller lives 

… When that happens don't call this my “DEATHBED”, call it my

"BED OF LIFE" and let my body be used by others to lead fuller lives 

At a certain moment a doctor will determine that my brain has ceased to function and that,

for all intents and purposes, my life has stopped…

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Give my blood to the teenager who has been pulled from the

wreckage of his car, so that he might live to see his grandchildren play

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Give my eyes to a man who has never seen….SunriseA baby’s faceor Love in the eyesof a woman

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Give my kidneys to one who depends on a machine to exist from week to week

Give my heart to a person whose own heart has caused nothing but endless days of pain

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a speechless boy will shout at the crack of a bat and a deaf girl will hear the sound of rain against her window

Explore every corner of my brain, take my cells and let them grow so that someday….

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……..to find a way to make a crippled child walk

Take my bones, every muscle, every fibre and every

nerve from my body….

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If you must bury something, let it be my faults, my weaknesses and all my prejudice against my fellowmen

Burn what is left of me and scatter the ashes to the winds to help the flowers grow

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Give my sins to the devil and give my soul to God,

If you do what I have asked, ………

I WILL LIVE FOREVER

 ( The above is a Legacy of Robert N.West written in 1976 )

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N N“THANK YOU” A MOHAN FOUNDATION PRESENTATION

In my end is my beginning                     - T.S.Eliot, Four QuartetsFor further information about organ donation contact us at:

Multi Organ Harvesting Aid Network

www.mohanfoundation.orgA -113 Annanagar,

3rd Avenue, Chennai – 600102, India

Tel: 044 – 26207000info@mohanfoundation.org