VIEW: Missing kidneys from Kot Momin

Editorial By Syed Mansoor Hussain

Since a ban on the sale of organs is probably unenforceable, an interesting possibility is to place it under the control of the federal government by creating a national registry of potential donors and recipients. The donors can then be properly educated about the risks. Finally, if money is to be made in these operations, the bulk of it should go to the organ donors

On August 12, 2004, there appeared in Daily Times a picture showing a group of villagers who had sold their kidneys for transplantation, and yet were unable to pay off their debts. The placards they carried suggested that four hundred labourers from their village alone had sold their kidneys. In almost any country of the world that deems itself civilised, this would have been a huge scandal.

Transplantation of organs saves thousands of lives all over the world every year. Most commonly transplanted organs today are the kidneys. Heart, liver and lung transplantation, though common in the West, are not being attempted in Pakistan. The only thing that limits transplantation is the fact that every organ implanted comes from another human being. And, other than the ones from identical twins almost all other organs once transplanted undergo some element of rejection, requiring regular testing and continuous medications to prevent failure. Therefore, even after successful transplants, the patients need medical supervision and drug treatments for the rest of their lives.

Kidney transplantation is now well established and relative to other transplants is performed more frequently. The kidney is unique in that everybody has two of them and somebody who donates one can still live a normal life. Still most people are unwilling to give up a kidney except for some close relative. The most reliable source of organs for transplantation, therefore, is people who have just died. These are referred to as cadaver donors. Unfortunately once a person dies, the organs rapidly become incapable of being used as transplants. For this reason the brain death concept has been refined so that irrespective of the physical condition of the body, as long the brain has no detectable function, the person is deemed dead and the organs can be removed for transplantation.

Over the last few decades most medically advanced countries have developed laws to govern transplantation of organs. These laws control definitions of brain death, harvesting of organs and determination of who should receive these organs. The reason for such controls is that the number of patients in need of transplantation far exceeds the numbers of organs available from healthy donors as well as from cadavers. Many layers of regulation and national transplant registries also help to ensure that organs for transplantation are given to those in most urgent need. Besides these specific regulations, there are general regulations that control the quality of care and the certification of hospitals and physicians who can perform these procedures.

In the US and most western countries sale of organs for transplantation is strictly prohibited. However, in many Third World countries that have no such laws or where these laws are not enforced, a thriving black market of organs exists. Most black markets depend upon unsavoury characters at the periphery of society who are thought of as criminals. However, when it comes to black-marketing of human organs, these modern day flesh peddlers are often respected! They include prominent physicians and owners of profitable private hospitals. Considering our law enforcement capability, it is extremely unlikely that a ban on sale of organs can be enforced in Pakistan soon. All such a ban will do is drive the prices higher and make the service available exclusively to the rich and the very well connected.

The reasonable alternative would seem to be to try and increase the number of cadaver organs available for transplantation. Unfortunately, cadaver donors too are unlikely to become widely available in Pakistan in the foreseeable future. Most of these donors are victims of violence, usually vehicular accidents. At this time, Pakistan does not have any system of trauma care that can salvage a reasonable number of organs from such people. Only if we try to save all of them, can we expect that some who do not survive will become possible donors. Even if we had rules about brain death and were able to overcome social, legal and cultural impediments to harvesting of organs, we would still need an effective system of tissue matching, preservation and rapid transport of such organs.

Clearly, there is need to regulate transplantation. Since a ban on the sale of organs is probably unenforceable, an interesting possibility might be to make it legal and bring it under the control of the federal government. This can be done by creating a national registry of potential donors and recipients, especially for kidneys but also for other organs including bone marrow. The donors can then be properly educated about the risks of organ removal surgery and long-term consequences of the operation. Once informed about these things, they can then make a decision about whether they want to go ahead with it. Once they have freely agreed to become donors, they can get appropriate healthcare to assure fitness for organ donation, be tested for tissue compatibility against registered recipients, and then be "rewarded" through a standardised system of payments for their organs when they are harvested. This could include payment of all debts, free education of children or a paid annuity for the rest of their lives. Part of this should be subsidised by the government and the rest by the recipient of the organ. Registration fees from transplant centres, recipients, donors and yes, a sales tax on the sale of these organs can be used to defray the cost to the government. Also, all transplant surgeons and transplant centres should be registered and required by law to provide the government with the number of procedures performed; breakdowns between foreign and domestic patients and of course their results.

Transplantation of organs from one person, living or dead to another besides being a challenge in terms of technology and logistics is also a complex ethical and religious problem. Perhaps a national debate that includes religious opinions along with those of medical specialists and administrators needs to happen. Western standards on transplantation should not be transplanted into this environment where they are sure to fail. Finally, if money is to be made in these operations, the bulk of it should go to the organ donors.

The writer, a cardiac surgeon, has practised and taught medicine in the US.

Copyright © 2004 The Daily Times, a new voice for a new Pakistan.

This article posted September 21, 1004.