Letters
by FK-506

In reply to Carpe Diem’s cherry picked quotes to the letter, ‘Organ transplant: Are we on the right track?’, the writer’s attempts to endorse this country’s nascent transplant program by trying to downplay key issues in any transplant program — financial implications and controversies surrounding brain death is reprehensible.

Quote : “… … … ..it isn’t quite right to place patients on VADs which have a limited life of their own into patients, not knowing if they are ever going to get a heart. This cannot be ethically correct.”

“Is it more ethical to deny me this option, based on not knowing whether I will get a heart in time, if the expertise is available and I am more than willing?”

For how long and at whose cost? Is Carpe going to pay this out from his or her own pocket? Clearly this person doesn’t realize the economic costs of such programs on government expenditure, unless of course, Carpe thinks that it is the state’s moral duty to transplant everyone with end-stage heart failure, liver failure, renal failure, etc. Chua Soi Lek moaned only last year that the MOH couldn’t afford to pay the RM900 million pharmaceutical bill for patients being treated by the Ministry. But miraculously he today is quoted to have said that the Cabinet, which has never shown respect for tax-payers money, is willing to provide even up to a billion ringgit for a transplant program. Incredible. Where is the set of priorities? Why don’t the cabinet approve the billion ringgit so that patients get better care, better follow-ups, better education programs, home nursing and of course better medicines, so that less patients end up in heart failure, renal or liver failures.

The age old idiom “prevention is better then cure” must hold true for this country based on the economy that we have unless Carpe is advocating American style healthcare, in which case, I would like to suggest that the technology be kept going but all transplants be borne by private funds. And I do hope Carpe fathoms the economic consequences of transplant programs. I hope he/she realized what happened to Barnard’s pioneering transplant work at Groote-Schur in South Africa. Transplant programs were immediately shut down by incoming President Nelson Mandela in 1994 when he realized that precious and limited health resources that could be used for Soweto’s populace suffering from cholera, typhoid, malaria and an AIDs incidence of almost 14% in some provinces, were being channeled to a glamorous transplant program. Are we in Malaysia any different if the startling statistics provided by our own MOH are anything to go by? In Sabah alone, even decades after independence, we have still not eradicated malaria and TB.

Quote: “Merican howled that what SJMC and Tan did were improper as ignorant patients may “not have been briefed about complications”. Tan, who pioneered liver transplant techniques at King’s College, London, of course left, preferring to base himself in “less ethical” Singapore, leaving Merican to focus on traditional medicine back here in Malaysia.”

That Merican howled is a fact. It is also a fact that K.C. Tan announced in the media that he was not willing to work in the ethical environment imposed on him. But the end result of this entire episode was clear. Malaysia’s liver transplant program in the private sector, supported quite earnestly by the media even then, was dead in the water. No RM30 million, 100 million or 1 billion ringgit boost to this program, although it was led by a Malaysian surgeon and the incidence of patients requiring liver transplants were equally a concern. Even private donations collected to help patients in this program were ultimately taken over by the Ministry. Why the double standards? Was it because K.C.Tan was a private surgeon working at a private hospital? Or was it due to something else? Yes the insinuation is direct. I am sure readers can make their own conclusions.

Quote: “Many fail to realise that the most painful thing about losing a family member to a traffic accident is the suddenness.”

In dealing with the emotions of doctors in trying to convince patients to donate their organs, I have to assume Carpe is unaware of Singapore’s HOTA where despite the objections of the family, the state still has the right to the patient’s organs and doctors are duty bound to remove them either by gentle persuasion or by force as in the case of Sim Tee Hua in February of this year. Chua Soi Lek, well known now for his medico-legal bungling, during the euphoria of the recent heart transplant, actually announced that the laws of this nation would be changed so that families of patients who had pledged their organs previously will not be able to object.

Can we implement this in culturally and religiously sensitive Malaysia? A doctor’s feelings will become irrelevant if this Act comes through just as in the HOTA. He/she will just have to carry out his duty irrespective of the suddenness of the death so that organs harvested remain fresh and viable. Culture, religion, family objections including doctor’s feelings will have to take a back seat.

Quote: “And if you define human death as brain death and give doctors the power to demand or request organs, a family member might have his heart or lung ripped out even before they have a chance to mourn.”

Human death IS brain death? Really! By whose standards? Perhaps Carpe has forgotten that human death was always defined as cessation of the beating heart before Barnard did his transplant. The issue of brain death only arose when Barnard did his transplant. The following year an adhoc committee at Harvard Medical School rejected the notion that death was when the heart stopped. Rather they claimed a person was dead when higher neurological functions ceased. They came out with a list of criteria and quickly established brain death laws which were challenged half-heartedly in US courts. (Report of Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death: A definition of irreversible coma. JAMA 1968; 205:337). These criteria subsequently became law in the United States. As all things done in a hurry no one knew the implications it would have in the future. An ever-trusting American public believed the medical fraternity who were largely responsible for coming up with these criteria.

If Carpe thinks Malaysians, with their cultural and religious attachments, would be as gullible as the American public to believe that “human death is brain death”, then surely Carpe has not worked in a Pusat Kesihatan Kecil or on the outbacks of Kelantan, Trengganu or Kedah. It is certainly not going to be the same here and brain death regulations may have to mirror those in Japan rather than Singapore. The 1968 committee that endorsed brain-death syndrome in the United States consisted largely of physicians. But when Japan established its own brain-death committee in 1989, it included human rights activists, social scientists, a Buddhist lawyer, a Catholic novelist, a newspaper editor, an environmentalist, and a labor leader. Whereas the American committee reached consensus quickly, the Japanese committee debated for three years.

On June 16, 1997, brain death became a legal definition of death in Japan, but not the legal definition of death. Under the amended law, only people who sign up in advance to be donors can be pronounced legally dead upon meeting brain-death criteria. For citizens uncomfortable with brain death, the age-old stopped-heart criterion remains the standard.

Carpe’s repeated pronouncement that human death is brain death is not only grossly misplaced but reveals a disturbing impudence in the absolute definition of brain death when this science is still being debated although the rushed Harvard’s consensus and its modified versions are currently accepted as necessary for possible euthanasia and transplant programs.

Quote : “Add this to the current perception of widespread political corruption with a judiciary hopelessly entangled in a quagmire from which no one knows if they are ever going to extricate themselves, you will end up with a family or relative not wanting to believe anything the authorities tell you including the fact that their beloved is brain dead.”

Clearly Carpe doesn’t appear quite current in the often reported medical blunders in the media these last few years. Perhaps in Carpe’s eyes, all of them including failing ambulances, undiagnosed dengue deaths, lost arms, etc are anectodal. They may be. But there is a trend, a trend dangerously associated with the quality of medical schools and students in and out of the country. As theses anectodes appear common place, missing or confirming a person brain dead and thereby removing his vital organs consequentially killing him or her is not a remote possibility.

Quote: “And is brain death criteria in Malaysia strictly adhered to? Are our anesthetists, neurologists, neurosurgeons or critical care physicians well trained in ascertaining brain death? Will our brain death certifiers be singularly medically unbiased or will they lean towards to a lower criteria as the demand for the organ rises just as in Argentina, Brazil, Chile, China and India or if the VAD’s 3,000 hours ticks closer.”

Yes to all the above? This is a travesty. The anesthetists in our unit who claim that although they were taught about brain death, admit that they have had little exposure or experience in actually confirming someone brain dead. They seem unfamiliar with the criteria and at times quarrel which criteria should be followed and which one should be given any particular importance. Perhaps they do this to avoid having to make a decision or maybe they are just ethically shy. But ratcheting brain death criteria downwards is a problem in the United States where organs are in high demand.

China has been repeatedly been in the news and was the focus of a BBC documentary this year where prisoners’ organs were booked prior to them being executed. In India, kidnapping for the removal of kidneys is not uncommon. The CEO of a large corporate hospital in India in fact even campaigned that the sale of organs be legalized to reduce the black market trade of organs in India.

Can Carpe really be oblivious to organ trafficking which is an established massive problem globally? A kidney fetches US$2700 in Turkey. An Indian or Iraqi kidney is a mere US$1000. Wealthy clients later pay for a rare organ up to US$150,000. Organs are even auctioned on e-Bay and can fetch between US100,000 to US 1million depending on the organ and demand. Organ harvesting operations flourish in Turkey, central Europe, mainly in the Czech Republic, the Caucasus, mainly in Georgia. They operate in Turkey, Moldavia, Russia, Ukraine, Belarusia, Romania, Bosnia, Kosovo, Macedonia and Albania. They remove kidneys, lungs, pieces of liver, even corneas, bones, tendons, heart valves, skin and other sellable human bits. The organs are kept in cold storage and air lifted to illegal distribution centers in the United States, Germany, Scandinavia, the United Kingdom, Israel, South Africa, and other rich, industrialized locales. It gives “brain drain” a new, spine chilling, meaning.

Organ trafficking is an international trade. It involves Indian, Thai, Philippine, Brazilian, Turkish and Israeli doctors who scour the Balkan and other destitute regions for tissues. There have been reports that Moldavia and Romania stopped the practice of baby adoption by desperate foreign couples for fear that babies were being sliced open for their organs. That the abuse of brain death criteria here is not in question, but more importantly how do we monitor and halt this errant practice? Yes, you need to be a legal eagle if you are going to spot a problem in establishing brain death.

As for the local scene, only two reports have been reported so widely as to raise eyebrows. The first is the double lung transplant on an Indian patient whose donor was from a private hospital across town. The NST reported that despite valiant attempts the recipient died on the table. But the lungs came from a hospital where the operating surgeon had a friendly anesthetist with whom he had worked previously with at that hospital. Whether brain death was confirmed by the friendly anesthetist or by a team independent of the operating team was questionable.

However, the recent double transplant was just filled with too many coincidences for comfort. A patient on a VAD, without a heart for a year. Then a media blitz. A heart is found in Ipoh where presumably brain death was certified independently. Then the transplanted heart sustains “hyperacute rejection”. A second heart “comes by” after another patient is certified brain dead, with the same blood type, size etc and also hopefully certified brain dead by anesthetists/neurologists/neurosurgeons independent of the harvesting team with the usual 6 hour repeat tests or the isoelectric EEG 24 hours apart all within the space of a day. It may have been a miracle, but it does sound too close for comfort. Readers, I am certain can draw their own conclusions.

Splitting hairs, storm in a tea cup? No. Brain death is a serious matter as it involves taking away a person’s life if vital organs are harvested. And no doctor in his right mind will do it unless he is very certain that this patient has absolutely no chance of waking-up. The views of Dr. Yusho Muranaka, parliamentarian Takashi Yamamoto, Dr David Wainwright Evans, Dr David Hill, Michael Potts, the Hastings Centre Report (1993) and cardiologist Yoshio Watanabe, all of whom have expressed dissenting views regarding brain death cannot just be wished away. There are anesthetists even in Britain who don’t carry a donor card because they know what actually transpires when determining brain death. Even Islamic views on brain death are mixed. The strongest proponents, understandably, for the establishment of brain death criteria have almost always been the transplant industry. Brain death is a scientific definition but it doesn’t mean this definition is accepted globally let alone Malaysia.

Quote: “In Japan, the name Juro Wada is almost synonymous with how society can turn distrustful of organ donation. … … .”

Another incidence of cherry-picking using anecdotal evidence? There isn’t any need to. There are enough Juro Wadas from Brazil, right across to China, India and East European countries. Malaysia probably does not have one because we don’t have an active transplant program. The danger is always there when there is little or no surveillance.
Quote: “Even within the medical fraternity no one knows the short, medium and long term results of mortality and morbidity rates of all organs transplanted in Malaysia.”

Excellent. The renal guys have done good. Now if only we can have some data for the corneas, bones, livers, lungs, hearts, etc. I am sure the public will glow with confidence.

Quote: “These transplants may be less glamorous but a long and gratifying track record in these areas may warm Malaysians eventually to actually accepting brain death.”

Do we have an active transplant program for organs that don’t involve brain death? Corneas, kidneys, living related livers, bones, etc. We don’t. Why don’t you show the public that you can do these operations well with little complications and establish properly your organ procurement programs for these organs before you rush into taking out hearts or lungs that causes another person to die. The public cannot be rushed into accepting brain death, especially a society as diverse as Malaysia. But an active transplant program in areas that does not involve brain death will certainly encourage and educate the public about the pros of transplants. One brain death diagnosed wrongly, will see a backlash so bad that the public may not want transplant programs at all.

Quote: “Hopefully someday we will have a primary healthcare system that will prevent the emergence of most diseases but until then we should avoid descending into the questionable achievement of killing people to save the dying.”

Either the writer is hopelessly immature or downright ignorant for taking this phrase out of context. A first class, well funded primary health care system will reduce the emergence of most of these diseases which require transplantation. And yes, if you take the heart or lung out of a person, you do kill him unless you want to paraphrase it differently. And you do put the donor organ into generally a sick or dying patient or at least we hope that’s the way it’s done in Malaysia. Transplant technology entails killing people to save the dying. Hard facts are sometimes difficult to swallow. Carpe Diem is welcome to rephrase this any other way he/she chooses if it helps him/her sleep better at night.