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A round peg in a world of square holes...

Friday, February 23, 2007

"No" to being a hangar queen

Human Organ Transplant Act (HOTA)

The Human Organ Transplant Act 1987 allows for the kidneys to be removed in the event of death due to accidents for the purpose of transplantation.

All non-Muslim Singapore Citizens and Permanent Residents between the ages of 21 and 60 years are included under HOTA. They will have priority in receiving a cadaveric organ if they need one. However, they can also opt out of HOTA if they do not wish to donate their organs when they die.

On 6 January 2004, the Human Organ Transplant (Amendment) Bill was passed by Parliament to allow more Singaporeans to benefit from cadaveric organs. The amendments to HOTA were:

a. To extend HOTA beyond kidney to also include liver, heart and cornea
b. To extend HOTA beyond deaths due to accidents to all causes of death; and
c. To extend HOTA beyond cadaveric donation to also regulate living donor organ transplantation.

The revised HOTA takes effect on 1 July 2004. It is estimated that about 60-80 patients with organ failure will benefit from the additional organs each year.

FAQs here

Should we not consider relying solely on an opt-in system only, as this would respect the rights of the people?

It has consistently been shown in Singapore and other countries that relying on an opt-in system will not be sufficient to make a significant impact in meeting the needs of organ failure patients. As such MOH will continue to have both the opt-out system (HOTA) and an opt-in system (MTERA) for purposes (education and research) and organs not covered under HOTA.

Nice dodge. I don't see the question about the rights of the people being respected. In an interesting parallel, it is also part of the Nazi doctrinaire belief of the "mass man" that the primacy of the state over the rights of the individual is held sacrosanct. It is rightly so that citizens should worry when the state exercises the coercive power of its machinery to facilitate the removal of organs from an individual despite objection from the next-of-kin.

From 1973 to 1986, we conducted intensive public education campaigns, reaching religious groups, community and grassroots organisations, and educational institutions. The campaign was aimed at helping Singaporeans understand that kidney donation is acceptable and crucial to saving thousands of lives.

We did not stop there and continued with our advocacy campaign. Our efforts resulted in the passing of the Human Organ Transplant Act (HOTA), 1987, by the Parliament of Singapore. This Act presumes that non-Muslim Singaporeans and Permanent Residents between 21 and 60 (age-wise), who die in accident, have pledged to donate their kidneys upon death, unless they opt-out in their lifetime. (National Kidney Foundation (NKF))

       And we all know what a paragon of virtue the old NKF is...

       Dr. Huang Shoou Chyuan penned some thoughts about the recent brain death case at Singapore General Hospital.

       In November 1941, after viewing the Nazi propaganda film on euthanasia Ich klage an! (I accuse!), by Wolfgang Liebeneiner, Father Alfred Delp commented,

       even if all a person's organs are gone and he can no longer express himself as a human being, he still is human and there still remains a constant call toward an inner nobility and a call to love and sacrificial strength for those who live around him. If you deprive people of the ability to nurse and heal their sick, you make human beings into egotistical predators who are interested only in their own pleasant life.
(Bleistein, Roman.  Begegnung mit Alfred Delp.  Frankfurt: Verlag Josef Knecht, 1994.  23.)

       Consider two excerpts from a book review written by Ian Hacking, Whose body is it?, on Strange Harvest: Organ Transplants, Denatured Bodies and the Transformed Self, a book authored by Lesley A. Sharp, Professor of Anthropology at Barnard College and Associate Professor of Anthropology and Sociomedical Sciences at Columbia University:

       In November, when I was reading this book, I came across a letter in the Toronto Star written in response to a bland editorial against presumed consent for organ donation.

       "I resist anyway the idea that we are all a collection of usable parts, and that someone unknown to us can decide how to take us apart and redistribute us. It’s a mechanistic rather than a humanistic view . . . It is not like putting a new element in an old stove.

                                         [ . . . ]

Those who donate are usually young, healthy people who have died suddenly and unexpectedly," the mother of the four-year-old donor wrote in her letter to the Toronto Star. "The tragedy of their deaths gets overlooked in the way the debate is framed by those . . . who seem to think we are all mechanical collections of interchangeable body parts." She continues by saying, "we had two days to get used to the idea that he was dying, and to trust the hospital staff who told us so. [And to be sure that] the time of death is not being advanced because other people are waiting for the usable parts."

       On the "new" classification of death: "brain death," "as opposed to the traditional "heart death" — which often renders organs non-viable:

       How dead is brain-dead? Few of us think about the flesh and blood on the ventilator, the chest going up and down in regular breaths, the heart pumping the blood around and keeping many of the organs working and thus reusable. What seems to have disturbed Sharp most was the fact that brain-dead donors are anaesthetised before the organs are extracted. Brain-dead, and hence incapable of feeling pain: why do they need anaesthesia? There appears to be a serious amount of denial here. When Sharp first started asking that question, three organ procurement staff, two neurologists and two internists told her that she was misinformed; another physician told her to ask an anaesthetist, since he did not want to talk about it.

When she did get answers, they were various. Anaesthetists can monitor and control blood pressure by the use of various drugs; these can relax muscles so that operating is easier, and also help to prevent the abdomen collapsing at a critical moment. So the anaesthetist’s drugs make the cadaver more tractable. But, Sharp reveals, there is a lot more going on. A brain-dead body will move in a lifelike way when nerves are pinched or cut. The body, warm and looking healthy enough where it has not been injured, may seem to shrug or kick or even signal. This is very disturbing to some of the staff attending the operation. These effects are reduced almost to nothing when the cadaver is anaesthetised. And some of the people involved reflect, perhaps, that if, despite all the tests, the person is not quite dead, then at least he will be spared pain in the moments before the heart stops. All this despite the official conviction that brain-death implies no possibility of feeling pain – "pain is a cortical phenomenon."

       Is the anesthesia for the benefit of the brain dead patient/donor (who should not, the harvesters assure us, feel any pain), or for the surgeons, so that the body doesn't twitch and move when they are removing perfectly viable organs from a still-living body?

       This question reminds me of historical practice hundreds of years ago in New England: when an individual is suspected as a witch, he or she is placed in a barrel lined with long, sharp nails on the inside. The barrel is then rolled down a high hill. At the bottom of the hill, the barrel is re-opened. If the individual is alive, he or she is confirmed as a witch and burnt at the stake. If he or she is dead, the suspect is declared innocent and given a proper Christian burial. This method of examination was often used by the governing authorities on troublesome individuals or political opponents. Whether the individual is a witch is irrelevant as, in the case of either outcome, he or she is out of the picture.

       The same can be said for the utilitarians, it doesn't matter what the anesthesia is for, so long as they get their organs.

       Individuals wishing to opt-out will need to make a trip to the nearest polyclinic or government hospital to obtain a booklet. Alternatively, they may choose to download a PDF form from the Ministry of Health website.

       "Presumed consent" (i.e. "opt-out") is a policy I have strong reservations about. (As a bonus, consider Tan An Qi's use of the phrase in another area.) This is not the only opt-out policy implemented (not by a long shot); there are also the Dependent Protection Scheme (DPS), Medishield, Eldershield, et cetera. All employed individuals of Chinese ethnicity are also automatically included in the Chinese Development Assistance Council (CDAC) donation scheme where SGD$1 is deducted from their monthly paycheck. It also operates on the "opt-out" method, but throws additional obstacles in the way of those objecting. Those wishing to opt-out are not only required to obtain a form on their own initiative, but the form must bear the stamp and signature of their employer. Now, that would necessitate justifying to your employer why you refuse to donate a paltry sum of SGD$1 a month from your paycheck to an association directing the development of the Chinese community. If your employer is a Chinese chauvinist, good luck. And since it is a small sum, most people let it go. Apathy wins again.

       There also appears to be no centralized registry or website where all the opt-out schemes are listed. Instead, the onus is on the concerned individual to hunt down all the opt-out schemes he or she is automatically enrolled in and fulfill all the procedures in order to opt-out.

       To put it in another way, the opt-out scheme can be said to be symptomatic of a populace accustomed to being mollycoddled from cradle to grave. Create a little inconvenience, put a little obstacle in their way, and the sheeple will trot in the direction the authorities desire.

       Personally, I will sooner donate money to the DNRC than anything that has to do with a demographic notorious for being crass, materialistic, Machiavellian, environmentally destructive, racially chauvinistic, and merrily and remorselessly eating countless species to extinction.

       Oh, yes, happy Chinese New Year.

2 weeks later

Potential organ donor was wrongly declared brain-dead.

Man's heart revives just as doctors were preparing to remove his organs for transplant.


Anonymous Anonymous said...

And if you need a transplant are you going to turn down the organ and llay there and die?

Just wondering if you're putting your life where your righteous indignation is.

April 12, 2007 10:31 AM  
Blogger -ben said...

Edited comment.

1.) I do not consider self-preservation a fair trade for humanity. Preservation of the self should not — is not — a Machiavellian act. There exist instances where allowing oneself to perish, rather than surrendering one's values or perpetuating evil, represents the higher choice. Say, I break into your house, hold a gun to your head, and tell you if you do not kill your mother, I will kill you. Will you do it? Or will you practice "righteous indignation?"

2.) Whether I require an organ or not is irrelevant to the disturbing issues of presumed consent (and subsequent unilateral amendment of HOTA) and the state's use of coercive power to harness human organs from helpless patients.

3.) Do you know the queue numbers for each of the 4 organs covered under HOTA and how many organs are available for transplant each year?

What is the use of having "higher priority" for transplants when you are, say, number 48,000 and only 100 organs are available a year?

The "penalty" of being shifted to a lower priority on the transplant list for objecting to HOTA thus seems not much of a penalty at all.

More importantly, the waiting list is not made public. Names of people waiting for transplants and their queue numbers are not in the public domain. The process is not transparent. What is there to stop the rich and/or powerful from cutting in line? And how would the public know if it happened?

Where did Mr. Sim's organs go to? Who received it? A Myanmar junta official who just happened to be visiting Singapore for an undisclosed medical procedure then? Who knows? We are just supposed to have good faith in the process? If good faith works so well, then why the heavy reliance on signed contracts, collateral, sworn affidavits, et cetera in the business and legal world? One must ponder.

We are counseled that the revelation of the recipient's identity may lead to harassment or demand for monetary compensation from the donor's family. But this is ludicrous; Singapore has ample laws to deter blackmail. All we are told is to have good faith that this closeted process is not abused. And we have seen how much good faith works in the NKF saga.

Just wondering if you're putting your life where your righteous indignation is

I put my life on the line for a lot less. Join me for a trimix dive sometime.

I cannot and do not sanction the murder of an innocent human being for the purpose of extending another individual's life. The act is even more troubling when the state becomes an accomplice in the exercise of coercive force to facilitate murder and harvest of organs from a living body.

Nothing should have stood in the way of Mr. Sim's family seeking a 3rd, 4th, 5th, 6th, 7th, ad infinitum medical opinion on his medical condition. They should have been allowed to transfer him to any hospital, in or outside Singapore.

You may want to read this report and reconsider your faith in the abilities (and true motivations) of the two SGH doctors:

Potential organ donor was wrongly declared brain-dead.

Last but not least, it is not so much "righteous indignation" as moral rectitude.

April 13, 2007 3:42 AM  

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