To Give or Not To Give--On Organ Transplants

Lin Ching-hua is 32 this year. A lecturer at the National Taiwan Institute of Technology, she is also the longest surviving kidney transplant patient in the country.

Twenty years ago, Lin Ching-hua was still just a middle-school student, but after contracting uremia she had to spend long periods on a kidney dialysis machine. Fortunately she received kidneys donated from a brain-dead patient and was able to return to the healthy, active life of a young child. Not only did she go on to university, but she even went overseas to study. On her return, she took up a teaching position and entered into the brilliant springtime of her life.

Having accepted this new life from the kindness of another person, Lin Ching-hua always says she hopes everyone will do the same thing if the opportunity arises, donating their organs to allow life to continue in another person's body.

After 20 years, however, the kidneys Lin Ching-hua received gradually stopped functioning and had to be taken out. Doctors removed them in February of this year and she temporarily had to again rely on dialysis. Fortunately, in April of this year she got another transplant opportunity. This longest surviving organ transplant recipient in Taiwan will perhaps have another chance to become an unrestricted "normal human being."

Signing this organ donor card means an extension of life.

Too many hopes--too few sacrifices:

There are nearly 10,000 patients on dialysis in the country, and large hospitals have a transplant waiting list of more than 2,500. Yet with people still not prepared to donate organs, there are on average only 3.5 donors for every million of the population, and every year there are only about l00 brain-dead people whose organs will be donated. This proportion is far lower than that in many European countries, where organ donation is already more acceptable. In Austria, for example, there are 58 donors for every million people. In Holland there are 28. Even in the United States, where organ donation has met forces of resistance, the proportion is 20 per million.

Doctor Lai Ming-kun of the Chang Gung Memorial Hospital's urological clinic points out that the kidney transplant operation in Taiwan was long ago recognized as a standard treatment for failing kidneys. The rate of survival in the first year after kidney transplant is 96 percent, and around 86 percent survive into the third year. In comparison to other transplant operations, this is considered a very low risk.

Doctor Lai's inclination is to encourage patients to have transplants. "It should be considered that if the transplant is a failure, patients can go back on dialysis again. It cannot create any immediate danger."

At the end of last year, a group of people who have been given a new life through kidney transplants took to the street to extol the virtues of organ donation.

Blue chips and new issues:

No matter whether it is dialysis or transplant, both have their advantages and disadvantages. Shen Fu-hsiung, head of the Adventist Hospital's blood filter center compares both to playing the stock market. He says that dialysis is like buying blue chip shares which will not go up or down dramatically. You can keep your health in a certain stable condition, not very good and not very bad. Kidney transplant is like buying into a new issue, with the risks being somewhat higher. If you do not do very well then you stand to lose a lot. "Of course the risks of transplant are higher. But if the operation is a success, then you can return to full health." The decision of which option to take is still up to the party concerned.

Although kidney transplants can return a sick person to health, for the rest of your life you have to take anti-rejection drugs and regularly attend a clinic for treatment. In the long run, it is easy for some people to get tired of this. "According to research statistics, about four percent of the people who have had kidney transplants decide to stop taking their anti-rejection medication after one or two years and die from the complications that arise," says Lai Ming-kun. These regrettable cases are usually young people who lack patience and do not look after their health properly.

They've all been lingering on the edge of life and death, but have all found new, healthy lives thanks to someone having given their precious organs.

The Singapore experience of finding a supply:

In order to make the supply of kidneys as open as possible--and perhaps because the situation is causing so much concern--Lee Chih-hsueh, director of the ROC Medical Transplant Council, has publicly stated that he hopes the ROC will copy Singapore's example and propagate a law of elimination. The law in Singapore says that new drivers who do not register with the government their desire not to donate their organs, may have their organs used by a hospital for transplant if they are rendered brain dead by an accident.

"If an elimination law were enacted it would help provide a supply of kidneys, because some 4,000 people are killed on the roads every year in Taiwan, " is the opinion of Ralph H.C. Su, director of the ROC Organ Donation Educational Center.

The intention of establishing a law might be a very good one, but it is really not an easy thing to do. "Many older people believe that when they are dead and go to another world they will still need their body. How can you destroy their completeness?" Ralph Su once tried to advise a bereaved father to donate his brain-dead son's organs. The answer he got was, "I never want to see you again!"

In fact, those who are intent on establishing an elimination law also know that the time is still not really ripe to implement it in Taiwan. So looking to learn from elsewhere is no more than a way of hoping to draw the attention of the nation to the problem.

According to Singapore's kidney donation laws, when citizens reach the age of 21 the department of health sends them a donor's consent form. If they do not disagree, then the form expresses that in the event of brain death the state can compulsorily take a person's organs to supply those in need of transplants.

Ralph Su points out that there are two points where the Singapore experience has been successful. First, apart from giving guidance to people, the Singapore government has placed great emphasis on training the medical personnel who have to decide whether someone is brain dead. It is hoped that if medical personnel can comprehend and make rigorous diagnostic decisions, people will have confidence in their professional judgements, so that there will be no unnecessary disputes.

The second point is the determination of the government in carrying out the law. Singapore's establishment of the elimination law is certainly not just a matter of empty legal articles. It has concrete measures for implementation. For example, if bereaved relatives are not willing to allow medical personnel to extract the organs of a brain-dead person, the law says that the police can assist the doctors to forcibly do the operation.

With a successful kidney transplant, Cheng Ming-lang has escaped the worst, and now has a beautiful family and job that he enjoys. (photo by Diago Chiu)

Taking care of law, reason and emotion:

"This is not something that can be achieved in one step," stresses Su. In Singapore there was more than a decade of guidance on organ donation. It was only when there was a widespread awareness about organ donation among the citizens that the government established the elimination law. When it comes to promoting organ donation in Taiwan, although it has been something going on for the last few years, it is still unlikely that we could instantly bring in the Singapore model.

Then again, in accordance with human rights considerations, can public rights decide the fate of the individual after death? There remains much doubt. Doctor Shen Fu-hsiung, one of the freshman legislators, says that standing in the position of a kidney doctor he supports legislation to increase the supply of kidneys. Nevertheless, human rights considerations make him oppose this kind of law, because it is wrong to pare away inalienable human rights with legal techniques.

In fact, when Singapore established its elimination law some four or five years ago, different faiths and customs had to be taken into consideration. For example, out of respect for the Islamic rule that does not permit destruction of the completeness of the corpse, Moslems were excluded from the law. The result was that three years after the law was implemented, a steady stream of Moslems was joining the list of donors.

Ralph Su thinks that, for the present, the use of guidance and signed donor cards will be of help in seeing through the coming legislation.

Of course, the problem is not that simple. If people are to accept organ donation, then it should be coordinated with other procedures. For example, according to the regulations governing human organ transplants, when the party concerned consents to the transplant, only the definition "brain dead" can be used. Yet most deaths are still defined in traditional terms of cessation of breathing or heartbeat. If brain death can become the commonly accepted definition of death, unfortunate relatives might find death easier to face and not try pointless emergency measures to save a life. Medical resources will also then be saved, and perhaps more people will be willing to donate their organs.

Gratitude and joy:

It is very difficult for healthy people to really understand the joy of life. Perhaps the following examples will move us in a new way.

"I am really so grateful to the unknown person who gave me my kidneys," says Cheng Ming-lang, a cab driver who has been given a new life by the love somebody left behind.

He began receiving dialysis in 1984 when he contracted uremia. At that time he was a supervisor in a small company. Because his employer had overlooked his labor insurance, Cheng had to undergo dialysis for 18 months with absolutely no coverage. "It washed away the house," he says. So, to support the massive costs, he sold his original house and spent more than NT$2 million in 18 months.

Although Cheng Ming-lang recovered his insurance after 18 months and did not need to sell again, dialysis and therapy three times every week, six or seven hours at a time, meant that he could not work like a normal person. The family budget relied completely on his wife's selling vegetables. "Watching my wife go out at 3 :30 every morning to sell vegetables, and being completely unable to help, was a very hard experience to cope with," he recalls.

A turning point after five years:

After five years of suffering, a turning point was reached. "At first I just had this lingering idea about registering for a transplant. I never thought I would really get the chance," Cheng Ming-lang says, recalling the moment when he had just received notification for his transplant from the hospital. He was, "hopeful and afraid I might be harmed."

The dream finally came true. Not only did Cheng Ming-lang get the opportunity for a transplant, but the operation was a success. Now, apart from driving his cab ten hours a day, he uses his spare time to be a volunteer accompanying dialysis patients in the hospital. "I think that my own responsibility is even heavier," he says. Because the hospital keeps it a secret, he still does not know who the kind donor was who gave him a new lease on life. This only makes him even more grateful.

Lai Ming-kun says: "Every time the pallid donated kidney is implanted in the receiver's body, when the blood vessels are connected and the clamps released; in that instant when the blood flows into the kidney and the originally pallid organ immediately fills with the new blood to become fresh, red and swollen, every pulsation is full of the force of life." From this operation he claims to have come to understand the greatness and the ceaseless vitality of life.

Modern medicine and the miracle of winning back life naturally gets people's respect and admiration. Yet the biggest obstacle stopping most people from becoming organ donors is still religion.

Different views from religion:

Most people believe that when somebody stops breathing, it takes at least eight hours for the soul to completely leave the body. According to records in the classics, this process is something like a tortoise leaving its shell. If at this time the organs are taken and the body disturbed, it will be hard to escape the wrath of the deceased. Furthermore, according to Buddhist theory the soul must pass through the path of hell, from which it is hard to return. This has made a number of Buddhist masters adopt conservative views on organ donation.

The Venerable Hui Lu says, "Unless you have a strong Buddhist training, if you want to be an organ donor, you had better think about it very carefully." However, the highly respected Venerable Cheng Yen thinks that organ donation is the action of a Bodhisattva, is extremely virtuous and should be encouraged.

Then there is the case of Sri Lanka. Although it is a country which follows an esoteric branch of Buddhism, the people believe in the spirit of the story of the Buddha feeding his body to a starving lion. All the way from the premier down to the common people, people have signed cornea donor cards. The figures show that one in fifteen of the population-- a total of more than a million people--have given their consent.

Whether or not organ donation can be harmful to life after death is something that living people cannot control. But as human beings we have our full human nature and our rights. It is up to us to decide whether or not to relieve suffering and distress. If we do take the road of the Bodhisattva when we make our decision, will we also have the courage to shoulder the results?