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Organs for transplantation: the Singapore experience.

A modern, 250-square-mile Southeast Asian city-state of 2.7 million people, Singapore's experience in vital organ transplants began with its first successful kidney transplant in 1970. Its program made another major stride with the first heart and liver transplants in 1990. Currently there are plans to do pancreas and heart-lung procedures.

Despite a good record of successful renal transplants, Singapore's program was unreliable because locally procured cadaver kidneys were not only constantly in short supply, but also the small numbers that were available fluctuated wildly. Its voluntary donor system could only provide for an annual average of three transplants between 1970 and 1976. None was available for 1977, 1979, 1980, and 1981; two for 1978, six for 1982, seven for 1983, fourteen for 1984, and only one for 1985. [1] A fourteen-year effort on the part of the National Kidney Foundation (NKF) to recruit voluntary pledges acquired only some 27,000 pledges, far below the estimated 800,000 needed to yield a fair chance of meeting transplant needs.

To improve the reliability of its organ supply, Singapore adopted a strategy that employs presumed and voluntary consent. In June 1987 the parliament enacted the Human organ Transplant Act (HOTA). This law presumes that all mentally competent citizens or permanent residents between the ages of twenty-one and sixty who are victims of fatal accidents are kidney donors unless they have registered prior dissent. No familial consent is required. Organs from the mentally incapacitated and minors may be removed only with consent from their families or legal representatives.

Muslims, who form a large minority of Singapore's population, are automatically considered objectors to HOTA on religious grounds. But they could voluntarily pledge under the 1972 Medical (Therapy, Education, and Research) Act. This act also empowers individuals to sign voluntary donor cards in the event of death from other causes, and permits next of kin to give consent for the removal of organs from their loved ones.

The table opposite shows the effectiveness of this Singaporean strategy on its cadaver renal transplant program from 1986 to 1990. [2]

The figures show that the combined strategy not only provided a steadier supply of kidneys, but also increased significantly the number of transplants, with the total for 1990 more than two-and-a-half times the total for 1987. Although HOTA failed to meet its original target of ninety organs a year, it contributed substantially to the increase, accounting for more than two-thirds of the organs transplanted in 1988 and more than half for both 1989 and 1990. But the real figures for voluntary consent would be higher if HOTa had not been enacted. Some families of fatal accident victims would probably have consented to donate the organs of the deceased if they had been approached in time. Even with such increases there are currently about 230 kidney patients on the waiting list, still close to the earlier annual average of about 200.

Improving the Organ

Procurement System

Singapore's renal procurement strategy could be further improved if the voluntary system were more effectively promoted among Muslims and routine inquiry instituted. In an effort to encourage Muslims to sign voluntary cards, a Muslim Kidney Action Committee was recently set up to educate fellow believers on the compatibility between Islamic beliefs and organ donation. To date, only 379 of the country's approximately 400,000 Muslims have made voluntary pledges. This poor response is partly due to the discrepancy between the 1972 act and Muslim custom. The former accepts female next of kin as witnesses while the latter accepts only the male next of kin. This discrepancy invalidated many Muslim donor cards witnessed by women. Muslim authorities could perhaps remedy this situation by making provisions to accept the validity of voluntary cards witnessed by female next of kin.

A current private hospital practice is to notify the transplant coordinator of potential donors who are dying from causes other than fatal trauma and who have not made any voluntary pledges. The next of kin are then tactfully approached for consent to post mortem removal of their loved one's organs. But such notification is dependent on the private initiative of individual doctors and nurses. Chief transplant coordinator Peter Soh said some families miss the chance to donate the organs of their loved ones because Mr. Soh has not been notified that the potential donor exists. Perhaps routine inquiry could be instituted as an official policy for hospitals so that the burden of
Year HOTA Pledge Total
1986 - 15 15
(HOTA not enacted)
1987 - 16 16
(HOTA not implemented)
1988 16 7 23
1989 15 11 26

providng for the community's organ needs falls on hospital institutions and health professionals, not on the private initiative of individual doctors or nurses.

Enacting HOTA

In general, the procedure employed for HOTA's passage is commendable. When the idea was first mooted, the government and the NKF made a year-long effort to promote public awareness and understanding of the policy. Parliament read, debated, and revised the proposal in a series of sessions. Besides emphasizing HOTA's compassionate aim, the public was informed in particular that in the absence of explicit dissent from the policy, consent to donate one's kidneys is presumed. The extensive coverage in the multilingual local media of these proceedings evoked a lively public debate on the morality of such policy, especially in the Forum section of the English press. The Singapore Law Society also organized public gatherings to discuss the moral and legal aspects of the policy. Furthermore, a special Select Committee was formed to receive reactions to the proposal from individuals and representatives of religious, medical, and other professional bodies. Suggestions for improvements and proper safeguards to allay public fear of abuses were carefully considered for incorporation into HOTA before the legislation was finally promulgated.

Such efforts to educate the public, the encouragement of free public exchange of views on the moral and legal issues of the impending policy, and the openness to suggestions for improved legislation to safeguard human freedom and dignity are ethically praiseworthy. They show the desire to accomplish HOTA's compassionate purpose is a manner that respects human freedom and dignity, and that does not exploit public ignorance. Given Singapore's administrative efficiency, affluence, small land area, highly literate population, and easy access to the media, communicating public awareness of such policy is a relatively easy task.

Implementing the Legislation

Upon HOTA's official promulgation, objectors were given six months to register their dissent from the policy before its full implementation. Objections could be made with relaive ease by completing an "Objection to Kidney Removal" card, which is available at all government and restructured hospitals, polyclinics, and maternal and child health clinics. Even with widespread media publicity and educational efforts, the major question still remaining is whether consent to donate could be presumed of every competent adult in the absence of explicit dissent.

The question is generally side-stepped by the current practice of asking the consent of donors' families whenever possible, even though the law does not require it. As a result, however, some families, particularly those of the Chinese-educated, have professed total ignorance of HOTA and objected to the removal of organs from the deceased.

But future generations will be adequately informed of HOTA. The Ministry of Health is currently notifying all citizens and permanent residents attaining the age of twnty-one that they are presumed to consent to HOTA's policy if they do not explicitly object. Dissenters would fill in the accompanying objection card and return it to the Kidney Registration Office. With this policy, it will be reasonable and ethically more defensible to presume consent in the absence of dissent. Perhaps this should have been done before HOTA was fully implemented. It would have gone a long way toward ensuring that those currently affected by HOTA are indeed willing donors in the absence of explicit dissent.

Incentives and Disincentives

In implementing HOTA, Singapore also adopted a controversial set of incentives and disincentives. Article 12 of HOTA stipulates that in the event of need, those who have accepted HOTA will have priority of access to kidneys over dissenters. Dissenters can achieve the same priority of access only two years after they withdraw their objections. Furthermore, the government has pledged to subsidize 50 percent of all medical expenses incurred at government hospitals for the immediate family members of organ donors, effective for five years following donation. These benefits were described as "a token of appreciation to those who donated their kidneys." [3]

While these measurs aim to deter dissent and reward assent, they raise ethical questions about whether th priority principal is coercive and discriminatory--and whether the medical benefits are indirect forms of payment for donated organs.

Human freedom is indeed compromised, and the priority principle coercive, if the fear of reduced chance of access to kidneys in the event of need influences anyone to give assent to HOTA. But while this principle might coerce some individuals to accept HOTA, it is also reasonable to suppose that there ar others who will gladly give their organs for truly humanitarian and altruistic motives. For such people, the priority principle is irrelevant. Since it is impossible to ascertain that the priority principle is the coercive factor in every case of assent, it is as such insufficient to render HOTA ethically unacceptable.

The priority principle's more serious challenge to HOTA's ethical acceptability lies in its discrimination against objector transplant candidates, especially Muslims, unless they have made prior voluntary pledges. Does this principle per se violate the principle of equitable access, an issue the U.S. Federal Task force on Organ Transplanation considered central? [4] Is public trust betrayed when people magnanimously contribute to the community's scarce life-saving resources for humanitarian ideals, only to have the resources distributed in this particular manner?

No one is ever denied a transplant because of race, gender, religious beliefs, or inability to pay. Nor are dissenters denied access to transplants; they are only disadvantaged. Only two dissenters were given transplants, one in 1988, and one in 1989.

Since the priority principle is openly declared, public trust in and expectation of a fair system of access to organs are not violated. Individuals unhappy with the principle are always free to dissent from HOTA. I believe, however, that the priority principle is superfluous. If the record of Muslim kidney recipients averages no more than two per year even with HOTA in force, it is doubtful that there would be any significant change wer priorities not established on the basis of dissent from HOTA. On the contrary, retaining the priority principle might eventually exclude Muslims altogether: no Muslim was a recipient of the forty-five transplants performed in 1990. The principle not only has the potential of making Muslims feel like second-class citizens, but also of eroding their goodwill toward, and support for, the transplant program. Revoking the principle is arguably the wiser alternative. As the donors are almost exclusively Chinese, revocation will not only foster the spirit of compassion for the sick that ought to surmount all racial or religious barriers, but also promote communal goodwill and social cohesion in the multitracial fabric of Singapore society.

If the priority principle is intended to deter dissent from HOTA, it will most likely have no effect on those who have already decided to opt out. To date only 5,728 individuals, excluding Muslims, have registered their objection. They might have considered their chances of becoming a kidney transplant candidate too small to serve as an incentive to donate. They might also have considered that their chances of access to transplants are still good, given that those on the priority list will not be able to use all available organs because of histocompatibility and other tissue-matching problems.

Similarly, the five-year, 50 percent state subsidy of hospital bills for the donor's immediate family is a superfluous policy. It is doubtful that such incentives per se will encourage people not to opt out. Dissenters may have considered the chances of their families enjoying these benefits too remote to entice them to accept HOTA. Furthermore, it is hard not to view the scheme as indirect payment for donated organs, even if it is not meant to be. The ethical ambiguity of the scheme weakens the ethical defensibility of Singapore's organ transplant program.

It is a paradox that while HOTA has a humanitarian goal, both the priority principle and incentives tend to undermine it. Not only do these policies underestimate the genuinely altrusitic spirit of many people, but they also tend to foster the spirit of self-interest in some donors. If Singpaore wants to foster a gentler and more caring society, a goal declared by the country's leaders in many recent statements, then these policies should be rescinded. It would be better to expend effort on educating and encouraging people to become willing organ donors out of selfless compassion for the sick.

A Policy Error?

Given the significant improvement in the reliability of its renal transplant program, is Singapore making a social policy error in adopting its organ procurement strategy and extending its transplant program to include other procedures? Will its transplant program expend so many resorces that it distorts Singapore's health care or social priorities? Such questions have not yet emerged as issues of importance for the nation's social agenda. Singapore has expended sufficient resources for its health care and other social needs to give its people the second highest standard of living in Asia after Japan. Its resources are sufficient to provide everyone with an adequate level of health care, with particular emphasis on primary care and preventive medicine. For its transplant program, there is willingness to commit the resources necessary to make it reliable, and to ensure access to anyone who needs a transplant.

But even with such commitment to a reliable transplant program, Singapore is cautious and prudent with its presumed consent policy. HOTA is currently applicable only to the removal of kidneys. Extending the policy to cover the removal of other organs must be approved parliament. With the heart and liver transplant programs still in their experimental stages, extension of HOTA to include these organs will depend on Singapore's willingness to commit sufficient resources to fund all these transplants. There are no immediat plans for HOTa to include the removal of heart or liver which are now voluntarily donated.

No matter how many resources Singapore is prepared to commit to its transplant program, its small population will ensure a proportionately small program. But even a small transplant program could expend a disproportionately large amount of available health resources. As Singapore will have the highest percentage of the elderly in Asia by 2025, and will need to allocate a larger proportion of health resources for their care, it will have to consider the question of the size of its transplant program within that context. Perhaps Singapore ought to have a "trip wire" provision in place for its transplant program. In the event it causes a distortion of national health or social priorities, or if it is judged wise to ration resources for the program, it could revert to less effcient organ procurement strategies, such as rescinding HOTA.

Learning from Singapore's

Procurement Strategy

Since its organ procurement strategy has made substantial improvements in the reliability of its transplant program, coud Singapore's approach offer any lesson for countries that suffer from persistent organ shortages and unreliable organ supply? Perhaps.

Singapore's transplant and organ procurement programs are tailored for its own unique needs. Its willingness to commit any resources necessary to meet the transplant needs of all was made prior to the adoption of its procurement strategy. Other countries wishing to learn from Singapore's experience ought to consider to what extent they are willing to commit the resources for their transplant needs before considering any organ procurement strategy. They could consider adopting more efficient methods of organ procurement, such as a modified Singapore model, commensurate with the resources committed to the program.

Singapore's presumed consent policy reflects its sensitivity to the multiracial, multireligious, and multicultural composition of its small population, confined in a small area. Even given such a restricted space and an educated population with easy access to the media, it is difficult to overcome some of the ethical problems associated with presumed consent. But Singapore has made very laudable efforts to make its presumed consent policy ethically defensible by promoting public awareness before it was passed into law, and by implementing the law carefully, with the exception of the superfluous policies of incentives and disincentives.

A country serious about the ethical defensibility of its presumed consent policy could perhaps follow the procedures involved in the Singapore model, including media publicity, highly visible public and parliamentary debates, public education, and hearings. It must take into consideration the diverse religious beliefs of the populace and exempt those whose beliefs could not accept such policies.

In implementing the policy, the soft approach of asking familial consent is still ethically superior to presuming consent. As the Singapore experience has shown, it is possible for people to be ignorant of the policy in spite of the best efforts to make it known. But asking the family would not be necessary if, before full implementation of the policy, each affected citizen or permanent resident is notified about the policy and offered an objection card in case the person desires to dissent from the policy.


[1] Figures supplied by Peter Soh, Singapore's chief organ transplant coordinator.

[2] Figures supplied by Peter Soh.

[3] The Straits Times, 29 December 1986.

[4] See U.S. Department of Health and Human Services, Organ Transplantation: Issues and Recommendations, Report of the Task Force on Organ Transplantation, April 1986, pp. 85-86.

Bernard Teo is associate professor of moral theology, Yarra Theological Union, Medlbourne, Australia.
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Author:Teo, Bernard
Publication:The Hastings Center Report
Date:Nov 1, 1991
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