Asia-Pacific, Development & Aid, Headlines, Health

HEALTH-THAILAND: Legal Hassles, Taboos Hamper Organ Donation

Lynette Lee Corporal

BANGKOK, Sep 19 2007 (IPS) - "I feel great! I&#39ve never felt better," said Gisele Ceppi of Switzerland. At 61, she exudes vitality and is positively glowing with health. The toned muscles, lithe steps, bright eyes and smile belie the fact that she is a kidney recipient.

Ceppi after winning the 800 m dash at Bangkok&#39s Transplant Games Credit: Lynette Lee Corporal/IPS

Ceppi after winning the 800 m dash at Bangkok's Transplant Games Credit: Lynette Lee Corporal/IPS

Ceppi won the gold medal for the 800-metre dash at the 16th World Transplant Games held here from Aug 26 to Sep 1. With more than 200 participants from all over the world competing in different athletic events, the games once again served as a call to encourage organ donation.

But Thailand, this year&#39s hosts, has made slow progress in the donation and transplant of organs because of a lack of comprehensive legislation to govern an issue with medico-legal and ethical ramifications. "In the last four years, there have only been 250 kidney transplants done in Thailand. At the moment, there are about 3,000 registered patients waiting for donors," said Dr Phaibul Jitpraphai, the chair for this year&#39s games.

"Some have been waiting for more than 10 years now. Many of them pay, at the very least, 20,000 baht (625 dollars) a month for medicine and dialysis," added the former president of the Transplantee Society of Thailand.

Paisal Chartpitak, a 49-year-old Thai engineer, knows the agony of waiting only too well. But he was lucky in that, after waiting for three-and-a-half years for a brain-dead donor, his wife stepped in taking advantage of laws that allow a spouse to donate a kidney.

"Three-and-a-half years was a long wait for me. I had to go to the hospital for haemodialysis three times a week," he said. "My medicines cost about 30,000 baht (937 dollars) per month now. It used to be higher before the transplant."

In Thailand kidney transplants from living donors are governed by the 1995 Code of Ethics on organ transplantation, drawn up by the country&#39s General Medical Council, which restricts donations to blood relations of the recipient. Exceptions are made for spouses, as in Paisal&#39s case – but even here the rules are strict.

"In the case of a spouse donating a kidney, the couple should have been married not less than three years. They also need to submit all necessary legal documents, along with the consent form, to prove that they are legally married," explained Phaibul.

The alternative to live donations is cadaveric transplants through an &#39organ bank&#39, but this has not quite taken off in Thailand because of misperceptions, ignorance and fear among the public, said Phaibul.

He explained that many are still confused about the difference between live donation (organs from a living donor) and cadaveric donation, or organs harvested from those who die suddenly, usually from accidents, and are declared brain-dead.

Dr Visist Dhitavat, director of the Thai Red Cross&#39 Organ Donation Centre, explained that organ harvesting can be done only after a donor has been declared brain-dead, when all activity in the brain stem – the centre of consciousness and respiration – have ceased, but transplantable organs such as the kidneys, heart, liver and lungs are still alive.

"The issue of organ transplantation has always been thorny in that it&#39s not as simple as harvesting an organ from a dead body and transplanting it into a waiting recipient," he said.

According to Visist, doctors in Thailand are authorised to declare a person brain-dead. But health professionals, doctors and the patient&#39s family need to agree on the proper definition of what can be considered "brain-dead".

"At least three or four doctors need to declare that the donor is brain-dead. Soon after, we need to get the informed consent of surviving family members to harvest the organ. Then we evaluate the organ to make sure it&#39s in good shape and matches that of the recipient, after which we coordinate with the Red Cross Organ Donation Centre (ODC), prepare the operating theatre for the harvest, and proceed with the transplant," he said.

In the last 12 years or so, the ODC has issued 400,000 donor cards. This means that out of 60 million Thais, 400,000 have expressed their intention to donate healthy organs in case of sudden death.

"On average, we get about 1,800 brain-dead donors each year," said Visist. But matters become complicated because one-third of these donors have family members who ignore the wishes of the deceased, and another one-third have diseased organs. "That leaves us with a small number of brain-dead donors whose organs we can actually use," he said.

The primary reason for a family&#39s refusal to donate a dead relative&#39s organs is rooted in religious beliefs. Being a predominantly Buddhist nation, many Thais, especially the older ones, believe that they will be reborn with incomplete body parts or organs if they donate them in this lifetime, said Paisal.

"We need to educate people and tell them that donation is a kind act and fits in well with the basic teaching of &#39doing good&#39 or making merit. To donate or sacrifice your organ (or even life) for a good cause is considered a supreme act and will bring one joy and happiness in this life and the next," said Visist, echoing the words of the monk Phra Dhammapittaka, recipient of the UNESCO Prize for Peace Education in 1994.

However, Phaibul said the situation was a lot better than a few years before when Thais would go to China for &#39organ shopping&#39. News reports speak of a black market in kidneys not only in China but also India, Pakistan and the Philippines where, for a price, a living donor may sell a kidney to a desperate patient.

A study conducted in 2003 by the Health Economics and Financing Programme for Thailand&#39s Ministry of Health indicated the possibility of illegal transplants taking place in Thailand. "In-depth interviews intimated the possible existence of living non-related donation but the magnitude is not known," the study reported.

According to Visist, if any hospital accredited by the Thai Red Cross is found indulging in unethical practices, such as accepting living unrelated donors, it is immediately removed from membership from the ODC. Likewise, doctors caught in illegal practices are stripped of their license.

The study drew attention to the need for greater cooperation among different regulatory bodies involved in organ transplantation. At the moment, it reported, the rules and regulations are fragmented. "While the General Medical Council has legal authority, it does not permit a monitoring function. The legal authority for monitoring is allocated to the ODC, whose focus has mostly been on accrediting transplant hospitals," it said.

Regulations, besides the code of ethics, include the 1989 and 1996 Brain Death Criteria, the Criminal Code and Civil and Commercial Code, which provides for harsh punishment of those engaged in illegal organ donation.

Phaibul said better government subsidy is needed to help transplantees cope. Kidney transplants in public hospitals cost about 300,000 baht (9,300 dollars), while those in private hospitals cost at least 500,000 baht (15,600 dollars). "Having social security helps because it will shoulder half the cost of post-transplant treatment, but this only applies to kidney transplant cases and not heart, liver and lung,’’ he said.

Visist said the ODC, established in 1994, shoulders the cost for the brain-dead donor&#39s maintenance in the intensive care unit and the use of the operating theatre. "We usually spend 100,000 baht (3,100 dollars) on organ testing, preservation and harvesting," he said.

Data from ODC show that 218 organ and tissue transplants have been carried out from January to July 2007. Thanks to an aggressive media campaign, the Centre expects to have more by the end of the year. Organ donation proponents agree that a comprehensive national policy on organ donation and transplants is needed to facilitate coordination among the agencies concerned and the hospitals.

For a country that conducted its first successful kidney transplant 30 years ago, Visist said it&#39s about time Thais looked at organ donation in a new light. "We already have a system running. All that&#39s needed now is greater awareness and coordination among the parties concerned," said Phaibul.

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