In Taiwan, the development of organ transplantation has been assured since 1984, when Dr. Chen Chao-long performed Asia's first successful liver transplant operation here. For patients awaiting transplants, however, the state of medicine is not in doubt so much as the availability of donor organs. Posthumous organ donation has never been popular with the Chinese because of the value that is given to the "complete corpse" at death.
Nonetheless, organ donation has become something of a hot topic in recent months, and was given a big boost at the end of last year when the family of shot policeman Chan Ping-li, pronounced brain dead by doctors, agreed for his organs to be donated. Also, last December in Kaoshiung, a convict under sentence of death volunteered the donation of his organs after execution. The operation was later carried out at the Chang Gung Hospital there. His case was followed in January by three more condemned men volunteering as organ donors. Altogether, the four left a bequest that gave over forty beneficiaries a new lease on life.
Surgeons first became interested in organ transplantation through advances in the surgical rejoining of blood vessels, and research dates from 1902 when the Austrian physicist Ullman transplanted a dog's kidney to its head while still enabling it to urinate.
In Taiwan, corneal transplants have been carried out since 1954, and the first kidney transplant was performed in 1968. "The world's first kidney transplant was in 1961, so we were not far behind", says Dr. Li Chi-hsueh, surgeon at National Taiwan University Hospital and president of the Trans-plantation Society of the ROC. According to Dr. Li, organ rejection is the biggest problem in transplantation, but the emergence in re cent years of the drug Cyclosporin, which combats rejection, has brought an increased success rate.
Modern medicine at present enables the heart, liver, lungs, kidneys, pancreas, bones, bone marrow and the cornea of the eye to be transplanted, with corneal transplants having the highest success rate according to Dr. Hu Fang-jung of the ophthalmology department at National Taiwan University Hospital, "because there are no blood vessels and rejection is uncommon." In contrast, the liver is the most difficult organ to transplant, says Dr. Chen Chao-long, surgeon-in- chief of the Chang Gung Memorial Hospital at Keelung, because of the many blood vessels that need to be rejoined, and large loss of blood incurred. One such operation in the United States required the record transfusion of a million cc.s of blood, so "extremely meticulous excision and suture is called for, and the operation often lasts up to twenty hours."
The most common type of transplant in Taiwan is the cornea operation, with around 250 cases annually. The operation is easier for patients because it is relatively simple to accomplish and has a high success rate of about 90%. Additionally there is ample supply of new corneas, with imports from Sri Lanka and the US supplementing domestic supply. Next most common is the kidney transplant, which over 700 people have had in Taiwan, almost 97% of whom were able to return to normal life after the operation.
Says Dr. Li Chi-hsueh: "One year of kidney dialysis costs approximately NT$600,000, while the operation to replace a kidney costs from NT$250-500,000, followed by annual medication expenses of only NT$150,000." So kidney replacement pays in terms of cost, not to mention the saving in time (dialysis requires ten hours every week) and in pain. Long term dialysis in particular leads to starch deposits accruing around the joints, causing acute pain that makes it impossible to even clean one's teeth.
Since we only need one kidney to live, the donor can be a living relative who has the same blood type and corresponds physically to the patient, as well of course as having two healthy kidneys. Thus there is a relatively good supply of kidneys compared to other organs. Even so, "there are around 600 people every year awaiting kidney replacement," says Dr. Li, "yet only 80 operations took place last year because not enough kid neys are available."
This situation, where the "supply" of transplant organs fails to meet "demand", is one that concerned individuals from all walks of life have been doing their best to improve in Taiwan, aided by legislative backing. The law used to hold the position that clinical death only occurs once the respiratory and circulatory systems have ceased to function--at which time the condition of physical organs begins to decline rapidly, limiting the possibilities for transplantation. In 1984 however, Dr. Chen Chao-long was the first in Taiwan to apply brain death as the basis for proceeding with removal of a donor's liver, redefining death in the process.
The success of that operation and the fact that it was a first in Asia, brought a succession of positive results. In October the same year, the National Council of the China Medical Association issued a resolution on "Death and Brain Death", and in 1987 the Legislative Yuan enacted "Regulations governing human organ transplantation" which established brain death as the basis for pronouncing actual death, though limiting this to the specific scope of human organ transplantation.
In simple terms, brain death means that the patient is in a deep coma and unable to breathe independently, or has sustained comainducing brain damage from which there is no recovery. Beyond this, strict medical tests have to be carried out before brain death can be confirmed. For example, under artificially aided respiration the patient must remain in deep coma for 12 hours without making any independent or involuntary movement. Further tests are needed to verify the patient's inability to breathe alone, and observe for signs of brain activity.
In the interest of saving lives and under continual prompting from the legal profession, appropriate changes were made last October in the rules covering implementation of the death penalty, to allow the execution of those offenders wishing to donate their organs to be carried out by a gunshot to the head. The convict donor is then brain dead, and his organs are removed by operation. The method was put into practice last December 15, marking a first in world medical history.
But the case raised some doubts. In a letter, Amnesty International condemned the use of shooting in the head to execute potential organ donors. The chairman of Department of Surgery at National Taiwan University Hospital, Dr. Chu Shu-hsun, responds to the charge saying that there is no more suffering involved for the offender in receiving a bullet in the head rather than in the heart. "He is already under anesthetic before the execution, and is unlikely to feel a thing. There can be no pain. If anything, this is a more humane method."
Brain death is first determined at the site of execution by an official inspector and a coroner, to satisfy stringent legal requirements, and then once more by a physician at the hospital before transplantation goes ahead. Good intentions and the inevitability of the criminal's death do not mean that standards can be overlooked, and the medical profession calls for strict attention to procedure through-out, as in the technique of shooting, the determination of death, and coordination with the hospital where transplantation is to be performed. Nevertheless, the numbers of those able to benefit from the organs of executed criminals is necessarily limited, and the organs themselves must function normally and come from a healthy source.
Says Dr. Li Chih-hsueh: "Car accident victims who are brain dead are our main source of organs." Around 4,000 people die annually in this way, of whom over 1,000 can be classified brain dead. If they could all be organ donors then there would be more than enough to help the 600 or so patients in need of a kidney transplant every year. But any such calculation would not be taking into account the traditional attitudes of the Chinese, which considerably reduce the quantity of available organs.
Traditional thinking values the notion of the complete corpse, and holds dear the Confucian concept that "one should not let injury befall any part of one's body, that was given by one's parents." Some fear that they may not be able to see their way into the next world if they donate their corneas, or have a normal "life" there without the full complement of organs.
Yet there are death-row convicts who see the matter in a clearer light than many. One such offender, executed by a bullet in the head this January, wrote in a final note to Yeh Kao-fang, the man overseeing arrangements for donation of his organs and director of the Social Welfare Office at the Chang Gung Hospital in Linkou, saying: "My grateful thanks for being given the chance to donate my organs. I hope that the doctors will transplant them to those who need them, and that the cuts in my body can be sewn up." If a corpse at least appears intact, then perhaps it counts as "complete" whether or not the insides are intact. Similarly, as one ophthalmologist points out, those who fear that the posthumous donation of both corneas will leave them blind in the next world, might consider donating one only. Buddhists may also recall the disciple Sariputra who gained enlightenment in consequence of giving his eyes to a blind person. It is a tale which helps the traditional Buddhist country of Sri Lanka to have a high rate of cornea donation.
"Another reason people often feel unhappy about organ donation is that after witnessing the suffering of a loved one close to death, they believe that allowing the corpse to be cut open would only be an added cruelty", says Liu Chia-chi, volunteer helper at Chang Gung Hospital in Linkou, with long experience in locating future donors. As she has found, intending donors are often put off by strong pressure from their relatives.
The Chang Gung, which had over seventy organ donors last year, is the hospital with the best and most active record in organ donation. Since direct pursuit of potential donors could easily bring sharp criticism, the hospital prefers a more subtle tack for its Social Welfare Office, under the recently appointed Yeh Kao-fang. Firstly, hospital staff are given badges to wear that read: "Organ donation, a parting gift to the world." "When patients or visitors ask about it, that's when we start to explain," says Yeh, who is also a clergyman. The better they volunteer concern for patients and their families, the better the results.
Hospital helpers can be found comforting families of those in the neurosurgery intensivecare ward, who are the patients most likely to succumb to brain death. "Relatives are desperate to know the patient's condition but are not allowed into the ward itself," says Liu Chia-chi, so the volunteers help with reports on the patient and provide comfort and guidance. They can also explain the legal situation regarding car accidents and the means of application for assisted medication charges. Should the patient become brain dead, the confidence that has been thus built up makes it easier to broach the possibility of organ donation, and the relatives are more likely to consider the proposal rationally, rather than responding with a flat refusal. As a woman who had allowed the donation of her brain dead husband's organs said, she did not want her last memories of him to be only ones of sorrow and grief, and felt that he was living on in being of benefit to others.
Yeh Kao-fang adds that this "parting gift to the world" is an act of charity that in some way makes up for the pain of bereavement, and is something for future generations in one's family to be proud of. However, what the donor is deprived of, is not guaranteed a grateful reception by the organ recipient, as many people feel very uncomfortable about the whole idea of transplantation.
Taiwan's first heart transplant took place in July 1987, but only nine such operations in total had been performed by the end of last year. "A major obstacle here is that people think of the heart as representing one's very personality and thoughts," comments Dr. Chu Shu-hsun. So long as a patient can totter a few steps out of bed he is not interested in a heart transplant, and by the time he realizes the seriousness of his own condition it may be too late to find a suitable donor. "One male patient received a heart from a female donor, and was worried he would turn into a woman," recalls Dr. Chu with a smile. In fact the patient's weak heart had arrested his physical development, and after receiving the strong and healthy transplant heart he grew bigger and his whiskers sprouted with new vigor. "The transplant actually made him more masculine!"
Dr. Chu was one of those who first encouraged condemned criminals to donate their organs. He once had to ask two patients awaiting heart transplants if they were willing to accept the heart of an executed man. For one, life was more important than anything else, and it did not matter whose heart it used to be as long as he could live on in good health. The other refused outright, saying that the idea of getting a wicked heart scared him, and he would rather do without the operation at all.
After Chen Hui-hua was arrested, the man notorious for shooting policeman Chan Ping-li cast regret over his lifetime of villainy, saying "even if I wanted to donate my organs, who would take them?" In cases involving the organs of an executed criminal therefore, hospitals take the reactions of organ recipients into account and generally avoid informing them of the donor's exact identity.
The relationship between giving and receiving in the case of organ transplantation, is one that reflects the degree of care and consideration for others that permeates society as a whole. Socially minded individuals and organizations have begun translating good sentiments into specific deeds, such as the Transplantation Society of the ROC with its plan to combine twelve hospitals from across the island to form the ROC Organ Donation Center, which will promote and oversee the fair allocation and use of transplant organs. Prominent figures like the tycoon Wang Yung- ching, and actors Sun Yueh and Yen Ma-li have signed organ donor cards, and made a big appeal to the public for support.
Although organ transplantation can be a lifeline for a dying person, it is accompanied by a large quantity of medication to restrain the reaction of the body's immune system and fight organ rejection, which considerably lowers the patient's resistance to infection and other illness. At the same time the functioning of the kidneys is badly impaired while the likelihood of contracting cancer rises dramatically. But as many doctors view it, transplantation "may not be perfect, but it's well worth a try." As Dr. Li Yuan-chi of National Taiwan University Hospital says: "For the critically ill, the chance of a few more years of life must be wonderful."
The great foe of transplantation medicine is still rejection, not only physical rejection of a new organ but also mental rejection of the whole concept. In Taiwan especially, these two problems need equally to be overcome.
[Picture Caption]
Heart, liver, pancreas, lungs, bones, bone marrow and cornea of the eye are all suitable for transplantation.
"A parting gift to the world," can help relatives of a deceased person to find some light in their grief.
The donation of slain policeman Chan Ping-li's organs gave a much-needed boost to organ transplantation in Taiwan. (photo by Yu Wei-fen)
Corneal transplants have a success rate of over 90%. No blood vessels are involved, and cases of rejection are rare. (photo by Hsiao Ming-fa)
Organ donation has begun to catch on recently. There were more donors la st year than in the three previous years combined.
Organ trans-plantation first became a possibility thanks to early advances in the surgical rejoining of blood vessels. The picture shows doctors using needle and forceps to suture kidney blood vessels. (photo by Hsiao Ming-fa)
The success of a transplant operation depends on full trust and cooperat ion between doctor, patient and donor (or relatives). (photo courtesy of National Taiwan University Hospital)
Before the donor liver can be implanted, blood residue must be removed by cleaning in saline solution. (photo by Hsiao Ming-fa)
"A parting gift to the world," can help relatives of a deceased person to find some light in their grief.
The donation of slain policeman Chan Ping-li's organs gave a much-needed boost to organ transplantation in Taiwan. （photo by Yu Wei-fen）
Corneal transplants have a success rate of over 90%. No blood vessels are involved, and cases of rejection are rare. （photo by Hsiao Ming-fa）
Organ donation has begun to catch on recently. There were more donors la st year than in the three previous years combined.
Organ trans-plantation first became a possibility thanks to early advances in the surgical rejoining of blood vessels. The picture shows doctors using needle and forceps to suture kidney blood vessels. （photo by Hsiao Ming-fa）
The success of a transplant operation depends on full trust and cooperat ion between doctor, patient and donor （or relatives）. （photo courtesy of National Taiwan University Hospital）
Before the donor liver can be implanted, blood residue must be removed by cleaning in saline solution. （photo by Hsiao Ming-fa）
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