Gift of life from the living or the dead

In an article in The Straits Times ("Doctors have key role in organ donation"; March 9), Ms Salma Khalik wrote of the small number of kidneys that were taken from people who were brain dead and transplanted into those whose kidneys have failed.

This low retrieval rate, which amounted to a "death sentence" for many, seems egregious in the face of the existing Human Organ Transplant Act (Hota). The law mandates the removal of kidneys, heart, liver and corneas to be used for transplant when a person dies, unless the person had chosen to opt out.

One reason cited by Ms Khalik is the "lack of buy-in by other doctors, particularly those working in the intensive care unit" which possibly arose from "the fear of resistance or even anger from the family, in spite of the patient not having opted out of Hota".

The opposition and wrath are understandable. For one thing, Hota is an opt-out system where consent is presumed. Upon turning 21, a Singapore citizen or permanent resident will receive a letter from the Ministry of Health saying that he or she has come of age to be included under Hota. By way of keeping this Act in the public consciousness, the ministry informs the general public of this twice a year through the local newspapers in the four official languages. It is uncertain just how many people know about this; there is yet no comprehensive study of the extent of public awareness of this Act.

The most suitable kidney donors are usually victims of head injury or catastrophic brain haemorrhage that led to brain death, which can be problematic as relatives might find it difficult to grasp that brain death is death when the heart is still beating. And there is the matter of timing.

There is possibly no worse time to approach a grieving family in the throes of an unexpected and sudden tragedy to inform them that under the law - which they might not even be aware of - certain organs will henceforth be taken for transplant.

In these fraught situations, there are sometimes powerful undercurrents of cultural and religious taboos.

Islamic teachings emphasise the need to maintain the integrity of the body after death, and the precept that one does not own one's body precludes the right to donate any organ. (However, the fatwa issued by the Islamic Religious Council of Singapore - Muis - permits organ transplants as an act of altruism out of the "dire necessity that is to save human lives").

The traditional Chinese belief of rebirth after death is associated with fears of being reborn without an intact body. To allow body parts to be taken from an elderly relative may be tantamount to being unfilial; compounding this is the fear of offending the spirit of the recently departed.

Living donors

The only other way is to encourage donation from the living but that seems to be even more daunting in Singapore. One reason could be the misapprehension and misgivings of going under the knife and its aftermath. The findings of a local study (published in the journal, Progress In Transplantation, in 2012) found that "concerns of surgical risk and poor health after donation" were significant factors in influencing the willingness to donate.

And there is also something more viscerally disconcerting about donating a kidney than giving a portion of one's bone marrow or even liver - even though the latter carries a higher risk. Perhaps it is because the loss of a kidney is permanent, a deficit that cannot be restored, unlike the bone marrow and liver, which would regenerate and everything would be made whole again. In that calculus of self-interest is the reluctance to give away a kidney - even though one can expect to live a completely normal life with one functioning kidney. It makes one feel insecure - that "just in case and you never know" unsettling sort of thinking that makes people baulk from going forward.

Most living donors are usually relatives involved in the care of the patient and experience, at first hand, the suffering and distress. So it is understandable and even expected by others that they should be donors as they would get the gratification and relief in seeing their loved one's life saved or health improved.

There can, however, be a murkier side to that gift. It is, after all, a sacrifice for which, as writer Larissa MacFarquhar wrote in her 2009 essay in The New Yorker, "no thanks seemed adequate and reciprocation was impossible".

The donation can bind the donor and the recipient "sometimes with love, sometimes with guilt, or gratitude, or a feeling of physical union due to the presence of the organ of one in the other's body" and where that burden of gratitude could be "dreadful". Musing that there is "something tyrannical" about that gift, she quoted the bioethicist Leon Kass: "Why does the benefactor love the recipient more than the recipient loves the benefactor?" His reply: "Because the benefactor lives in the recipient, the way in which the poet lives in the poem."

She cited the case of a woman who, after donating her kidney to her brother, exerted such control over him that he moved to stay with her instead of returning to his wife. Another man was so overwhelmed by a feeling of obligation towards his donor sister that he could not bear to have contact with her.

Altruistic donors

Ms MacFarquhar also described individuals who donated a kidney to a stranger. Most of these donors view their deeds rather unsentimentally as duties and seemingly in accordance with the moral philosopher Peter Singer's general argument that if we can prevent something bad without sacrificing anything of comparable significance, we ought to do it.

Some of these donors had desisted from meeting or maintaining contact with the recipients: They did not want the recipients to feel beholden, which would for them diminish the value of the deed. For one man, the act offered the balm of redemption as he felt that it was the one good thing he had done in his otherwise-messy and wasteful life.

At one level, we laud the generosity, bravery and selflessness of the act.

At another level, it might seem baffling to most of us that an individual would subject himself to a surgical procedure to remove and hand over something precious to a complete stranger and without any expectation of material gain.

Some of the donors that Ms MacFarquhar featured drew a fair amount of flak from different quarters in the public. And in the early days of kidney transplants in the late 1960s and 70s, doctors were deeply suspicious of these altruistic donors and viewed such acts with antipathy and as being aberrant to human nature.

This somewhat-misanthropic view was at odds with research that shows that human beings are far more cooperative with one another than often believed. Based on these findings, some experts posit that our success and dominance as a species rest on this bedrock of altruism.

If truth be told, such altruistic donors could make the rest of us feel guilty, inadequate and even morally shabby for not doing what they have done. And we might resent them for making us feel this way - so we would wonder about their state of mind and impute some ulterior or selfish motives to them.

But to what extent do we want to delve into the complexities of someone's motives and for what purpose in such instances?

Perhaps the question we ought to ask is whether we would contemplate making such an unconditional and undirected donation if not in life then in death; and imagine, too, that if one day, should we be in need of a kidney to save our life, the great sense of gratitude we would feel upon receiving that gift from a stranger.

The writer is vice-chairman of the medical board (research) at the Institute of Mental Health.

This article was first published on May 16, 2015.
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