MUBIN SHAH (Associate Editor)

“I have been waiting for a kidney transplant for many years without success and have toyed with the idea of going overseas for a transplant but my doctors have always discouraged me. My fear is what will happen in the medium and long run. The statistics are overwhelming – some 600 patients in the queue waiting an average of nine years for a kidney.”

On July 10, 2008, a dialysis patient wrote to The Straits Times in response to the debate concerning amendments to the Human Organ Transplant Act (Cap. 131A, 2005 Rev. Ed. Sing.) [HOTA]. She is single, has 2 elderly parents, no siblings or close relatives. Her fears are not unfounded.

This issue only received the attention it deserved last year when the press comprehensively covered the controversial case, PP v Tang Wee Sung, [2008] SGDC 262. Mr Tang, a well-known business magnate, was afflicted with end-stage renal failure, and in desperation sought the services of one Mr Wang Chin Sing to procure a living donor. Mr Tang was willing to pay as much as $300,000 to the donor, Mr Sulaiman, an impoverished Indonesian man. However, it was later revealed that Mr Wang, acting as the middleman for Mr Tang and Mr Sulaiman, intended to retain 99.9% of the sum offered by Mr Tang. All 3 men were charged inter alia under Section 14(1) read with Section 14(2) of the HOTA for offences involving the sale or supply of an organ for valuable consideration.

Should we allow compensation? Who should pay?

Shortly after, the issue of receiving monetary compensation for organ donation gripped our attention. In a survey conducted by The New Paper, 70% of Singaporeans surveyed were in favour of monetary compensation for organ donations. The general consensus was that donors should receive some form of remuneration and not have to worry about future medical expenses, if any were required as a result of their altruistic act.

However, one of the main obstacles to implementing such a scheme is who would pay these donors. 43% of Singaporeans surveyed opined that the recipient and the government should co-pay the donor, but this solution is imperfect because it does not take into account patients from the lower-income group who may not be able to ‘pay’ for the donated organs. Getting the government to foot the bill solely instead, gives rise to other sets of problems, where or how is the Government going to get the money to compensate all the donors?

Several other countries have compensation schemes already in place. In Israel, an organ donor receives approximately S$5,500 from the Government, free healthcare insurance for several years, free transplant surgery, health checks and psychiatric treatment. In the Czech Republic, the donor is reimbursed for loss of income for a maximum of 92 hours and transport and meal expenses incurred during or related to the organ donation.

The new HOTA

After several rounds of rigorous debates, the Ministry of Health proposed 4 amendments to the HOTA to be implemented in stages. The 4 amendments are:

1. Removal of the upper age limit for cadaveric organ donation.
2. Paired matching for exchange of organs between living donor-recipient pairs.
3. Removing the prohibition of payment to reimburse or defray the costs or expenses of living organ donors.
4. Increasing the penalties on middlemen and syndicates that engage in organ trading.

The first 3 amendments aim to increase the pool of organ donors in Singapore and the first 2 amendments have in fact been already implemented, preceded by a large-scale mass media campaign. It is estimated that with the implementation of the first amendment, 70 more patients could benefit or be saved each year. However, no patients have benefitted from the second amendment to date.

The more controversial amendment is the third amendment, though countries such as Israel and the Czech Republic have already implemented similar compensation schemes. The issue largely is that such compensations apply (and in my opinion, fairly) to non-Singaporeans as well and there is a genuine fear that donors from poorer countries would be attracted to ‘donate’ their organs. Mr Sulaiman was willing to accept a measly sum of S$23,700 although Mr Tang himself was under the impression that S$300,000 would be fair compensation.

Plugging the loopholes

The Government’s position is that Singapore will not transform itself into an organ-trading hub. Although the new amendments allow foreigners to donate their organs, they can do so only if they satisfy the Transplant Ethics Committee (TEC) that they understand the full nature and consequence of their decision and there has been no coercion or financial inducement. In addition, the approval granted by the TEC is only valid for 60 days and there must be a 1-week cooling off period between the time the approval was granted and the actual surgery to allow the donor to reassess his decision. Supplemented by the fourth amendment, these measures aim to seal any potential loopholes that may be exploited by unscrupulous persons.

However, one issue that has been unresolved and sidestepped is the fact that any reimbursement would come from the organ recipient himself. Would a living donor be more inclined to donate his organs to a person with means to ‘compensate’ him? Should a cap be imposed on the amount of money he could receive? The legislation in place and strict guidelines followed by the TEC renders such a situation highly improbable, but we cannot rule out the desperate men willing to flout these strict rules.

Legislators were tasked with the complex responsibility of reconciling the very real problem of a shrinking pool of organ donors with the idealism of preserving the sanctity of the human body and altruistic act of organ donation. Yet these amendments underline time and again our reluctance to pursue solutions which suggest the slightest hint of welfarism. Singapore’s policy has always been to be as self-reliant as possible, but implementing a compensation scheme regulated and footed by the Government will not turn society from a state of independence to one dependent on the Government to foot their medical bills.

Perhaps not enough time has passed for us to be able to decide if these amendments have been successful and adequate at meeting the demand for organ transplants here. However, the door should still be kept open to consider adopting successful compensation schemes run by other countries where compensation is regulated and allocated by the respective governments. This ensures that no individual in need of a transplant is pressured into providing compensation to the donor.