This article is a response to Dr. Sumanth C. Raman's piece ‘Organ donation: is tokenism costing lives?' in The Hindu (Open Page, May 27, 2012).
In February 2012, a group of corporate, government and non-governmental organisations came together to sensitise their employees and members to organ donation. Many people pledged to donate their organs after death and undertook to carry a donor card. Among them was a young man from a leading IT company. This seemingly token act would prove fateful very soon and place him in a situation where he would have to follow it through with real deeds.
A week after the event, the young man's brother fell ill with dengue. He was shifted to a private hospital in Chennai, but his condition deteriorated very rapidly. The doctors informed the young man that his brother was brain-dead. He was stunned. But even in that moment of shock and grief he knew what needed to be done. He donated his brother's organs to help others live. Many such examples come to our memory where the trigger to donate has been sensitisation to the cause either through a talk, a media story or though carrying an organ donor card.
Public relations (PR) are a proven social tool that yields long-term benefits. The donor card that expresses one's wish to donate organs does not have any legal validity, but gives a person a sense of ownership. It initiates a dialogue within the family. In India, we follow “informed consent.” This means consent from the next of kin is essential before any organ harvesting is possible in the event of brain death or after natural death. By carrying a donor card the family discusses organ donation and the decision to donate becomes less difficult to make.
In the last six years, MOHAN Foundation's counsellors who have done grief counselling in intensive care units (ICUs) have noticed a paradigm shift in the attitudes of people to organ donation. In close to 220 donations that took place, it was noted that in almost 20% the family came forward spontaneously wanting to donate the organs of their loved ones. In many instances, the family member had either carried a card or discussed the issue with the family before death.
Ongoing public education helps the message to spread in society, creating a responsive community. Involving celebrities in social causes is something that is being done the world over and underestimating the power they wield to draw attention to causes is not correct. Angelina Jolie, Brad Pitt and Aamir Khan — if their ‘star power' results in social good, there is no harm in harnessing that power. Eye donation campaigns featuring Rajinikanth and Aishwarya Rai have had an immeasurable impact in popularising the concept.
In addition, good infrastructure and strengthening hospitals to handle deceased (cadaver) organ donation and retrieval are a necessity and are being done. However, good infrastructure alone in the face of an unresponsive society will not yield the results.
Creating awareness in senior citizens' homes can help improve home donations of corneas, but not solid organs like kidneys, liver and heart. Physiologically, the organs will not be fit for donation given the age of the donors. Also, brain death is not something that is likely happen in these places.
Youth are an instrument of change. Many young people become ambassadors for organ donation by bringing about a change in the way their families and friends perceive organ donation. It is also a fact that many of the deceased organ donors are young people in their 20s and 30s who have become brain-dead due to road traffic accidents. Every hour, 40 people under 25 die in road accidents around the globe (http://www.dw.de/dw/article/0,,5519345,00.html). In India, the total number of deaths due to road accidents has crossed 1,35,000 according to the 2010 statistics of the National Crime Records Bureau.
The Transplantation of Human Organs (Amendment) Act, 2011 makes it mandatory for doctors in intensive care units to make a request for organ donation in the event of brain death. This will be part of the ICU protocol. In addition, it is now mandatory for a grief counsellor/transplant coordinator to be appointed in hospitals undertaking transplants.
Trained transplant coordinators are already in place in major transplant centres. In the Rajiv Gandhi Government General Hospital, Chennai, MOHAN Foundation's grief counsellors/transplant coordinators have successfully counselled the families of 69 brain-dead patients out of a total of 104 whom they approached. This “yes” for organ donation translates into a conversion rate of 66% in a two-year period (February 2010 – March 2012).
In the final reckoning, after medical clearance, 282 organ and tissues were retrieved and transplanted from 56 deceased organ and tissue donors from this hospital alone. Tamil Nadu, in fact, through a very successful public-private partnership has the highest deceased organ donation rate in India. At 1.3 per million population, it is 15 times the national average. The Tamil Nadu government's Cadaver Transplant Programme facilitated the retrieval of 1,412 organs and tissues from 248 donors from October 2008 to March 2012.
The Iranian model of government-supervised, paid organ donation is often quoted as the solution to help patients with organ failure. Paid donation, regulated or commercial, leads to coercion and exploitation of the poor and benefits only the rich. This has been seen in the Iranian model too. In two reports published from Iran by Zargooshi and Malakoutian, of the 100 donors and 478 unrelated kidney donors respectively, 75% of the paid donors were dissatisfied two years or more after donation. Malakoutian showed that the majority of the donors were men and 60% were living below the poverty line by Iranian standards. The majority donated organs for the financial incentive and 56% used the payment to repay debts. Many suffered from ill-health and saw a decline in their daily income as they were not able to return to manual labour. This is why this model, started in 2000, has not been replicated elsewhere.
A question of basic human ethics remains — can organs be bought and sold? By putting a price tag on everything, do we not run the risk of dehumanising society? Commerce in organs will end up benefiting one section of society at the cost of another and lead to inequitable distribution of organs. Organ failure does not just affect the wealthy, but the poor as well. The rich will buy their way out and the poor will be left languishing for want of an organ, if the door is shut on altruistic organ donation.
Spain, which has the highest donation rate in the world, has the system of “presumed consent,” coupled with a strong hospital deceased organ donation protocol. “Presumed consent” means every citizen by default is considered an organ donor unless he or she has expressly specified in writing that he or she does not wish to donate organs after death. On the face of it, ‘Project Daan' could be seen as just another “PR gimmick” and another example of “tokenism.” Project Daan – “Donate organs, Save lives” is a unique public initiative where HCL Technologies linked up with the Apollo Group of Hospitals, the Indian Medical Association (IMA), and the Chennai Police to sensitise their staff and members to organ donation. MOHAN Foundation and the Cadaver Transplant Programme (the Government of Tamil Nadu) were the knowledge partners. The event culminated on February 29, 2012 with a record 12,900 organ donation pledges.
Symbols and tokens are an important part of human society and serve to inspire society. And despite what cynics may say, we sometimes surprise ourselves by sudden acts of humanity powered by such small tokens — like an Organ Donor Card.
(Dr. Sunil Shroff is Professor and Head, Department of Urology & Renal Transplantation, Department of Urology, Sri Ramachandra Medical College & Research Institute, Porur, Chennai. Dr. Sumana Navin is Course Director, MOHAN Foundation (Multi Organ Harvesting Aid Network), Chennai. Email: firstname.lastname@example.org)