Transcript Cadaver Transplantation in India

Managing Trustee, MOHAN Foundation, Chennai
Head of Department - Urology & Renal Transplantation,
Sri Ramachandra Medical College & Research Institution,
Chennai, India
[email protected]
F O U N D A T I O N
Dr.Sunil Shroff
M O H A N
ORGAN DONATION &
TRANSPLANTATIONLegal & Social Issues
M O H A N
- Rabindranath Tagore
F O U N D A T I O N
Death is not extinguishing the light but
putting out the lamp because the dawn has come
M O H A N
F O U N D A T I O N
Organ Donation – Concepts
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F O U N D A T I O N
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After Natural Death
Living person – related to patient
Living person – unrelated to patient
After Brain Death
M O H A N
Types of Organ Donors
Blood
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Eyes
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Bone marrow
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Kidneys
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Portion of Liver
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Portion of Lung
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Portion of Pancreas
Iddham Shariram Paropkardum
(This body is for the use of others)
F O U N D A T I O N
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M O H A N
Organ Donation by a Living person
- Shankracharya
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The only thing you take with you when you're gone is what
you leave behind
- John Allston
F O U N D A T I O N
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Eyes
Skin and fascia
Heart Valves
Bones and Tendons
Cartilage
Veins and Arteries
Middle Ear Bones
M O H A N
Organ Donation after Natural Death
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Middle Ear Bones ( 2 )
Skin and fascia - Numerous
Bone - Numerous
Cartilage - Numerous
Tendons - Numerous
Veins - Numerous
Arteries - Numerous
Nerves - Numerous
Fingers and Toes ( 20 )
F O U N D A T I O N
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Eyes ( 2 )
Kidneys ( 2 )
Liver ( 1 )
Lung ( 2 )
Pancreas ( 1 )
Small Intestine ( 1 )
Voice Box or Larynx( 1 )
Hand ( 2 )
Penis ( 1 )
M O H A N
Organ Donation After Brain Death
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And he will wipe out every tear from their eyes and death will be
no more.
- Revelations 21:4
F O U N D A T I O N
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Blood - Living related or unrelated
Eyes After Natural Death
Kidney Donation - Mostly unrelated and
sometimes related
M O H A N
COMMMONEST TYPE OF ORGAN
DONATION IN INDIA
M O H A N
Eye Donation
1998-99
1997-98
1996-97
0
5,000
10,000
15,000
20,000
Corneas Retrieved in India 1996- 99
3 million corneally blind people in India. 60% are children below the age of 12.
Target retrieval of corneas by Eye bank of India is 150,000 corneas per year.
F O U N D A T I O N
1998-99
1997-98
1996-97
ETHICAL * MORAL
ISSUES
Philoshers
MEDICAL ISSUES - Physicians
M O H A N
ORGAN DONATION & TRANSPLANTATION
SURGICAL ISSUES - Surgeons
RELIGIOUS ISSUES –
Religious Heads of a
Society
IMMUNOLOGICAL ISSUES –
Immunologist
ORGAN REGENERATION Basic Scinetists
IMMMUNOSUPPRESSIVE DRUGS – Pharmacist & Pharmaceuticals
F O U N D A T I O N
SOCIAL ISSUES –
Social Scientists
- Upanishads
F O U N D A T I O N
Death is just a beginning of another life
M O H A N
ORGAN DONATION & RELIGION
Hinduism
Religious law does not prohibit Hindus from donating their
organs, This act is an individual decision.
For that which is born death is certain and for the dead, birth
certain.. Therefore grieve not over that which is inevitable.
- Bhagavad Gita
F O U N D A T I O N
Jainism
Jain religious leaders consider eye donation as a sublime form
of charity and stress a powerful link between ‘daan’ (charity)
and ‘moksha’ (salvation). Highest eye donation rate in India
among Jains of Gujarat.
M O H A N
Religion & Organ Donation
Catholicism
Catholics view organ donation as an act of charity, and selfsacrifice. Transplants are ethically and morally acceptable to the
Vatican. Pope John Paul II
"We accept and believe that our Lord Jesus Christ came to give life and came to give it in
abundance. Organ donations enables more abundant life, alleviates pain and suffering,
and is an expression of love in the times of tragedy.”
- Rev. James W. Rassbach
F O U N D A T I O N
Protestantism
Protestants encourage and endorse organ donation.
M O H A N
Religion & Organ Donation
Jehovah’s Witnesses
Jehovah’s Witnesses do not encourage organ donation but
Believe it is a matter best left to the individual’s conscience
God created man to be immortal and made him to be an image of his own
eternity
- Bible, The Wisdom of Solomon
F O U N D A T I O N
Islam
In 1983 the Muslim Religious Council initially rejected organ
donation by followers of Islam, but it has reversed its position,
provided donors consent in writing prior to their death. The
organs of Muslim donors must be transplanted immediately
and should not be stored in organ banks.
M O H A N
Religion & Organ Donation
Buddhism
No written doctrine but founder of a Buddhist Temple of Chicago
said: "We honor those people who donate their bodies and organs
to the advancement of medical science and to saving lives.”
"If one is in the position to donate an organ to save another’s life it’s
obligatory to do so, even if the donor never knows who the beneficiary
will be,”
- Rabbi Moses Tendler
F O U N D A T I O N
Judaism
Judaism teaches that saving a human life takes precedence over
maintaining the sanctity of the human body.
M O H A N
Religion & Organ Donation
M O H A N
F O U N D A T I O N
Organ Donation
Ethical Issues
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F O U N D A T I O N
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Hippocratic oath – Do no Harm
Voluntarism – Decision to donate in a family
may not be voluntary
Usually more woman donate than men - mother
or wife are the commonest donors
M O H A N
Is Living Organ donation Ethical ?
One in 1000 living donor is likely to die even in best of surgical
hands!!
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On e-bay the famous Internet Auction websites a Kidney was being
auctioned for almost One million dollars!!!
F O U N D A T I O N
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Most of the social and Ethical problems in
organ donation due to kidney donation
A person has a pair of kidneys and can donate
one and still be healthy
Usually trafficking of organs from the poor to
the rich
M O H A N
Commercial Aspects of Organ Donation
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F O U N D A T I O N
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Despite Govt. authorization committee to
regulate organ donation activity many
instances of paid donors are reported!!
Regular kidney scandals have become part of
accepted newspaper readings in India!!
M O H A N
Commercial Aspects of Organ
Donation
Kidney in Indian society is looked upon as a commodity hence the
task of popularizing the concept of organ donation can be difficult!!
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F O U N D A T I O N
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Human Rights Violation- in China (1990) –
1670 kidneys transplanted mostly from
executed criminals
Commercial Trading of Organs – in India
(1990) – 1580 kidneys transplanted mostly from
unrelated donors
Bizarre instances of kidneys being removed by
surgeons from an innocent donor is reported
from all over the world regularly
M O H A N
Questionable Ethics
Internet may be facilitating the whole process of organ trafficking
Detractors –
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Transplant surgery adds a few
extra years to life but takes away
most of the family savings of
Middle income group family
Only rich can benefit with a
transplant.
No hope for Poor in this field
Kidney Tx – Rs.2 Lakhs for
surgery & Rs.1 lakh / year
afterwards
Heart Transplant – Rs. 5
Lakhs for Surgery &
Rs.75,000 / year afterwards
Liver Tx. – Rs.10 to 15 lakhs
for surgery and Rs.50,000 to
75,000/ year afterwards
F O U N D A T I O N
Transplant Surgery and patient
maintenance -expensive not
suitable for India.
M O H A N
Ethical isues & Cost Factors
- Is Transplant Surgery Necessary at all in
India?
Detractors –
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F O U N D A T I O N
Transplants benefits a few in India and the same time
and resources can be used by the doctors to instead
save many other lives
M O H A N
Ethical issues
- Is Transplant Surgery Necessary at all in
India?
M O H A N
Ethical issues
F O U N D A T I O N
Evangelist –
 There are 150,000 Patients with Kidney failure needing
transplants
 The only hope for living for an Acute liver failure patient is
to undergo a transplant
 Heart transplant gives an almost immediate improved
quality of life to the patient
 The long term success of the surgery are better than some
of the cancers
 Transplant practice - “Cutting edge of medicine practice”keeps us abreast with the latest in the field of research.
M O H A N
F O U N D A T I O N
Organ donation
Legal Aspects in India
Aims
Tamil Nadu Assembly passed the Act in May 1995
F O U N D A T I O N
Regulate removal, storage and
transplantation of human organs for
therapeutic purposes
 To prevent commercial dealings in organs
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M O H A N
Transplantation of Human Organs Act, 1994
Concept of “Brain Stem death” accepted
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Only “Living related Donors” are allowed to donate
organs without legal problems
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For unrelated Donors - Permission from “Authority”
required prior to surgery
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Requires - “Regulation and Registration of hospitals”
undertaking transplantation
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“Punishment for any commercial dealings in organs”
1st Relative – Father / Mother / Brother / Sister / Spouse / Son/ Daughter
F O U N D A T I O N
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M O H A N
Main Provisions of THO Act
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– Panel of four doctors
– Two sets of tests to be carried out - minimum of six
hours in between the tests
– Form No. 8 to be used for certification
Death is usually a gradual event. Nail and hair can continue to
Grow even after death !!
F O U N D A T I O N
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Definition - Stage at which all functions of the
Brain Stem have permanently and irreversibly
ceased
Certification
M O H A N
Brain Stem Death
“Presumed Consent” – In some countries the law demands organ donation
from its citizens, unless they express otherwise in writing
F O U N D A T I O N
Person may authorize removal of any
human organ before his death.
 Person may express his wish to donate his
organs in the event of his death, through
a ( Form No. 5 )
 “Informed Consent” of Family is crucial
to cadaver organ donation.
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M O H A N
Organ Donor
Since the Act was passed there has been two criminal prosecution against doctors
F O U N D A T I O N
Commercial dealings in organs
 Imprisonment : 2 to 7 years
 Fines : Rs.10,000/- to Rs.20,000/Penalties for Doctors
 First Offence : Name struck off State Medical
Register for 2 years
 Subsequent Offence : Name struck off
permanently
M O H A N
Offences and Penalties
Donors
• Scrapping of Sub Clause (3) , Clause 9 of
Chapter II
Majority of kidney transplants in the country use this
clause resulting in “ legal commercialisation of kidneys”
F O U N D A T I O N
– If any donor authorizes the removal of any of his
human organs before his death under sub-section
(1) of section 3 for transplantation into the body of
such recipient, not being a near relative as is
specified by the donor, by reason of affection or
attachment towards the recipient or for any other
special reasons, such human organ shall not be
removed and transplanted without the prior
approval of the Authorization Committee.
M O H A N
Pitfalls - THO ACT
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F O U N D A T I O N
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Restrict the number of Live unrelated kidney
transplants
Push the “Brain death organ donation”
Programme forward
Make amendments in the THO Act
Make punishments for offences more stringent
and effective
M O H A N
Is There a solution to these Legal & Ethical
Problems
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In Babies under one year brain death concept not applicable
F O U N D A T I O N
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First recognised in 1959 in Paris in
Intensive care units (coma de passe )
Formally accepted as a form of death in
1968 by the ad hoc committee at
Harvard
Accepted by Govt. of India in 1994 as a
form of death
M O H A N
Brain Death Concepts
F O U N D A T I O N
No wastage of organs if organ donation
from brain dead donors undertaken
 Almost 95% of organ donors in western
world originate from Brain Dead Donors
 Largest pool of organ Donors in the world
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M O H A N
Brain dead Pool of Donors
F O U N D A T I O N
In India Road traffic Accidents the commonest cause of brain death
M O H A N
Common Causes of Brain Death
In any of the metropolitan city in India
Even Doctors often fail to diagnose or recognise this condition!!
F O U N D A T I O N
There are at least on an average between 10 to 20
patients admitted in different ICUs who are
brain Dead
M O H A N
Brain dead Pool of Donors in India
• Number of transplants done throughout
the world - 5,50000
• Number of Transplants worldwide
1997 - 37,072
Annual transplant figures are not rising. Though Waiting lists though are
perpetually going up.
F O U N D A T I O N
• Number of patients on transplant
waiting list - 1,50000
M O H A N
Transplant Statistics
(1985 to 1992)
25000
M O H A N
Transplant Activity of Western World
20000
10000
5000
0
F O U N D A T I O N
Kidneys - Cadaver
kidneys - Living
Liver
Heart
15000
1985 1986
1987 1988 1989 1990 1991 1992
(1998 – 1999)
3500
3000
M O H A N
TOTAL TRANSPLANT ACTIVITY IN INDIA
2500
1500
1000
500
0
1998
1999
Golden IT triangle of India Hyderabad, Chennai, Bangalore are also
famous as “Kidney Bazaars” in the western world
F O U N D A T I O N
Kidney - Living
Kidneys - cadaver
Liver
Heart
2000
M O H A N
DON’T TAKE YOUR ORGANS TO HEAVEN FOR
F O U N D A T I O N
HEAVEN KNOWS THEY ARE NEEDED HERE !!
M O H A N
F O U N D A T I O N
Organ Donation Social Issues
In certain brain death situations despite the
consent of the family organ donation was
not possible 
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Two wives where first legal wife raised an
objection to organ donation
Asking for money by family for organs
Death by hanging in recently married girl
Brain death in a destitute where no relatives
were available for consent
F O U N D A T I O N
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M O H A N
Unusual Social Situations & Dilemmnas
Govt. Problem
M O H A N
Problems with Cadaver Organ Donation
Programme in India
No Funding for programme
No efforts to identify & maintain “Brain Dead” donors
Community Problem
No Awareness of “Brain-Death” Concept
Spain has the highest number of brain death patients going
on to organ donation – 32 per million population
F O U N D A T I O N
Hospital problem
Make it compulsory for doctors or medical social
workers to ask for Organ Donation in a Brain
Dead Situation
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Identify doctors or senior nurses to work as
Transplant Coordinators in each ICU
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In Medico-legal cases it should be possible to
perform Post-Mortem at same time as organ
retrieval in presence of a Forensic Expert
No financial costs involved in the above recommendations
F O U N D A T I O N
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M O H A N
Streamlining of THO ACT
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In states of Maharastra & Gujarat slogans about “Eye donation” displayed
on National Highways
F O U N D A T I O N
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Mandated Choice on Driving License about
organ donation
Education at School and College Level
Free Air time on Doordarshan and Private
Channels for films on Organ Donation
Tax Exemption for documentaries on Organ
Donation
Indirect incentives to donor families
Honoring cadaver donor families
M O H A N
Organ Donation Awareness Programmes
( Multi Organ Harvesting Aid Network )
Formed in 1997
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Spread Message of Organ Donation
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Works as a support group for Patients, Public &
Physicians
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Foundation subgroups –
Organ Sharing Group – INOS
Counselling unit – Manashanthi
Patient Support Group
Publishes “Indian Transplant Newsletter”
F O U N D A T I O N
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M O H A N
MOHAN Foundation - Objectives
The Foundation has distributed almost 100,000 cards in India.
Cards are available in English, Tamil. Hindi and Marathi
F O U N D A T I O N
Carry the card in the wallet
Serves also as an emergency card
M O H A N
Organ Donor Cards by MOHAN Foundation
Give Life a SECOND Chance…
F O U N D A T I O N
Carry a Donor Card
M O H A N
Organ Donor Cards by MOHAN Foundation
HONOUR OF CADAVER ORGAN DONORS
ORGANISED BY MOHAN FOUNDATION
Painting Completion on Organ Donation theme organized
for schools by MOHAN Foundation in March 2002
Movie in English, Hindi and Tamil for Television Channels
Made by MOHAN Foundation
F O U N D A T I O N
Saplings Planted in Memory of cadaver Organ Donors by
their family members in the Campus of Loyola College on
30th Oct 1999 - organised by MOHAN Foundation
M O H A N
MEMORIAL SERVICE
31ST OCT 1999 Loyola College, Chennai
Group
UNOS in USA is the largest organization such organization
and is partly funded by the government
F O U N D A T I O N
Formed in Nov’1999 by MOHAN Foundation
 Essence of INOS – “Not to Waste Any Organ”
 Hospital in group includes – Apollo, CMC
Vellore, Sri Ramachandra Hospital and Sundaram
Medical Foundation
 About 30 different organs shared between
hospitals
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M O H A N
INOS - Initiative for organ sharing
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F O U N D A T I O N
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Formed in April 2001
As a support group for emotional failure
Located at Annanagar
Counselling available between 10AM and 1PM
Organises counselling lectures and workshops
M O H A N
Counselling Unit- Manashanthi
"BED OF LIFE" and let my body be used by others to lead fuller lives
F O U N D A T I O N
… When that happens don't call this my “DEATHBED”, call it my
M O H A N
At a certain moment a doctor will determine that my brain has ceased to
function and that, for all intents and purposes, my life has stopped…
M O H A N
F O U N D A T I O N
Give my blood to the teenager who has been pulled
from the wreckage of his car, so that he might live to
see his grandchildren play
A baby’s face
or Love in the eyes
of a woman
F O U N D A T I O N
Sunrise
M O H A N
Give my eyes to a man who has never seen….
F O U N D A T I O N
Give my heart to a person whose own heart has caused
nothing but endless days of pain
M O H A N
Give my kidneys to one who depends on a machine to
exist from week to week
F O U N D A T I O N
a speechless boy will shout at the crack of a bat and a
deaf girl will hear the sound of rain against her
window
M O H A N
Explore every corner of my brain, take my cells and let
them grow so that someday….
F O U N D A T I O N
……..to find a way to make a crippled child walk
M O H A N
Take my bones, every muscle, every fibre and every
nerve from my body….
F O U N D A T I O N
If you must bury something, let it be my faults, my
weaknesses and all my prejudice against my fellowmen
M O H A N
Burn what is left of me and scatter the ashes to the
winds to help the flowers grow
I WILL LIVE FOREVER
( The above is a Legacy of Robert N.West written in 1976 )
F O U N D A T I O N
If you do what I have asked, ………
M O H A N
Give my sins to the devil and give my soul to God,
A MOHAN FOUNDATION PRESENTATION
In my end is my beginning
For further information about organ donation contact us at:
Multi Organ Harvesting Aid Network
www.mohanfoundation.org
A -113 Annanagar,
3rd Avenue, Chennai – 600102, India
Tel: 044 – 26207000
[email protected]
F O U N D A T I O N
- T.S.Eliot, Four Quartets
M O H A N
“THANK YOU”