ORGAN DONATION

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ORGAN DONATION TRANSPLANTATION- Legal
Social Issues

• Dr.Sunil Shroff
• Managing Trustee, MOHAN Foundation, Chennai
• Head of Department - Urology Renal
  Transplantation,
• Sri Ramachandra Medical College Research
  Institution, Chennai, India
• info_at_mohanfoundation.org

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Death is not extinguishing the light but putting
out the lamp because the dawn has come -
Rabindranath Tagore
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Organ Donation Concepts
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Types of Organ Donors

• After Natural Death
• Living person related to patient
• Living person unrelated to patient
• After Brain Death

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Organ Donation by a Living person

• Blood
• Eyes
• Bone marrow
• Kidneys
• Portion of Liver
• Portion of Lung
• Portion of Pancreas

Iddham Shariram Paropkardum (This body is for
the use of others) - Shankracharya
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Organ Donation after Natural Death

• Eyes
• Skin and fascia
• Heart Valves
• Bones and Tendons
• Cartilage
• Veins and Arteries
• Middle Ear Bones

The only thing you take with you when you're gone
is what you leave behind  - John Allston
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Organ Donation After Brain Death

• Eyes ( 2 )
• Kidneys ( 2 )
• Liver ( 1 )
• Lung ( 2 )
• Pancreas ( 1 )
• Small Intestine ( 1 )
• Voice Box or Larynx( 1 )
• Hand ( 2 )
• Penis ( 1 )

• Middle Ear Bones ( 2 )
• Skin and fascia - Numerous
• Bone - Numerous
• Cartilage - Numerous
• Tendons - Numerous
• Veins - Numerous
• Arteries - Numerous
• Nerves - Numerous
• Fingers and Toes ( 20 )

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COMMMONEST TYPE OF ORGAN DONATION IN INDIA

• Blood - Living related or unrelated
• Eyes - After Natural Death
• Kidney Donation - Mostly unrelated and sometimes
  related

And he will wipe out every tear from their eyes
and death will be no more. - Revelations 214 
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Eye Donation
1998-99
1997-98
1996-97
Corneas Retrieved in India 1996- 99
3 million corneally blind people in India. 60
are children below the age of 12. Target
retrieval of corneas by Eye bank of India is
150,000 corneas per year.
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ORGAN DONATION TRANSPLANTATION
ETHICAL MORAL ISSUES Philoshers
MEDICAL ISSUES - Physicians
SURGICAL ISSUES - Surgeons
SOCIAL ISSUES Social Scientists
IMMUNOLOGICAL ISSUES Immunologist
RELIGIOUS ISSUES Religious Heads of a Society
ORGAN REGENERATION - Basic Scinetists
IMMMUNOSUPPRESSIVE DRUGS Pharmacist
Pharmaceuticals
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ORGAN DONATION RELIGION
Death is just a beginning of another life 
                        - Upanishads
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Religion Organ Donation
Hinduism Religious law does not prohibit Hindus
from donating their organs, This act is an
individual decision.
Jainism Jain religious leaders consider eye
donation as a sublime form of charity and stress 
a powerful link between daan (charity) and
moksha (salvation).  Highest eye donation rate
in India among Jains of Gujarat.
For that which is born death is certain and for
the dead, birth certain.. Therefore grieve not
over that which is inevitable. - Bhagavad
Gita
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Religion Organ Donation
Catholicism Catholics view organ donation as an
act of charity, and self-sacrifice. Transplants
are ethically and morally acceptable to the
Vatican. Pope John Paul II
Protestantism Protestants encourage and endorse
organ donation.

"We accept and believe that our Lord Jesus Christ
came to give life and came to give it in
abundance. Organ donations enables more abundant
life, alleviates pain and suffering, and is an
expression of love in the times of tragedy.
- Rev. James W. Rassbach
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Religion Organ Donation
Islam In 1983 the Muslim Religious Council
initially rejected organ donation by followers of
Islam, but it has reversed its position, provided
donors consent in writing prior to their death.
The organs of Muslim donors must be transplanted
immediately and should not be stored in organ
banks.
Jehovahs Witnesses Jehovahs Witnesses do not
encourage organ donation but Believe it is a
matter best left to the individuals conscience
God created man to be immortal and made him to be
an image of his own eternity - Bible, The
Wisdom of Solomon
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Religion Organ Donation
Buddhism No written doctrine but founder of a
Buddhist Temple of Chicago said "We honor those
people who donate their bodies and organs to the
advancement of medical science and to saving
lives.
Judaism Judaism teaches that saving a human life
takes precedence over maintaining the sanctity of
the human body.
"If one is in the position to donate an organ to
save anothers life its obligatory to do so,
even if the donor never knows who the beneficiary
will be, - Rabbi Moses Tendler
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Organ Donation Ethical Issues
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Is Living Organ donation Ethical ?

• Hippocratic oath Do no Harm
• Voluntarism Decision to donate in a family may
  not be voluntary
• Usually more woman donate than men - mother or
  wife are the commonest donors

One in 1000 living donor is likely to die even in
best of surgical hands!!
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Commercial Aspects of Organ Donation

• Most of the social and Ethical problems in organ
  donation due to kidney donation
• A person has a pair of kidneys and can donate one
  and still be healthy
• Usually trafficking of organs from the poor to
  the rich

On e-bay the famous Internet Auction websites a
Kidney was being auctioned for almost One
million dollars!!!
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Commercial Aspects of Organ Donation

• Despite Govt. authorization committee to regulate
  organ donation activity many instances of paid
  donors are reported!!
• Regular kidney scandals have become part of
  accepted newspaper readings in India!!

Kidney in Indian society is looked upon as a
commodity hence the task of popularizing the
concept of organ donation can be difficult!!
20
Questionable Ethics

• Human Rights Violation- in China (1990) 1670
  kidneys transplanted mostly from executed
  criminals
• Commercial Trading of Organs in India
• (1990) 1580 kidneys transplanted mostly from
  unrelated donors
• Bizarre instances of kidneys being removed by
  surgeons from an innocent donor is reported from
  all over the world regularly

Internet may be facilitating the whole process of
organ trafficking
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Ethical isues Cost Factors

• Detractors
• Transplant Surgery and patient maintenance
  -expensive not suitable for India.
• Transplant surgery adds a few extra years to life
  but takes away most of the family savings of
  Middle income group family
• Only rich can benefit with a transplant.
• No hope for Poor in this field

Kidney Tx Rs.2 Lakhs for surgery Rs.1 lakh /
year afterwards Heart Transplant Rs. 5 Lakhs
for Surgery Rs.75,000 / year afterwards Liver
Tx. Rs.10 to 15 lakhs for surgery and Rs.50,000
to 75,000/ year afterwards
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Ethical issues - Is Transplant Surgery Necessary
at all in India?

• Detractors
• Transplants benefits a few in India and the same
  time and resources can be used by the doctors to
  instead save many other lives

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Ethical issues - Is Transplant Surgery Necessary
at all in India?

• Evangelist
• There are 150,000 Patients with Kidney failure
  needing transplants
• The only hope for living for an Acute liver
  failure patient is to undergo a transplant
• Heart transplant gives an almost immediate
  improved quality of life to the patient
• The long term success of the surgery are better
  than some of the cancers
• Transplant practice - Cutting edge of medicine
  practice- keeps us abreast with the latest in
  the field of research.

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Organ donation Legal Aspects in India
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Transplantation of Human Organs Act, 1994

• Aims
• Regulate removal, storage and transplantation of
  human organs for therapeutic purposes
• To prevent commercial dealings in organs

Tamil Nadu Assembly passed the Act in May 1995
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Main Provisions of THO Act

• Concept of Brain Stem death accepted
• Only Living related Donors are allowed to
  donate organs without legal problems
• For unrelated Donors - Permission from
  Authority required prior to surgery
• Requires - Regulation and Registration of
  hospitals undertaking transplantation
• Punishment for any commercial dealings in
  organs

1st Relative Father / Mother / Brother / Sister
/ Spouse / Son/ Daughter
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Brain Stem Death

• Definition - Stage at which all functions of the
  Brain Stem have permanently and irreversibly
  ceased
• Certification
• Panel of four doctors
• Two sets of tests to be carried out - minimum of
  six hours in between the tests
• Form No. 8 to be used for certification

Death is usually a gradual event. Nail and hair
can continue to Grow even after death !!
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Organ Donor

• Person may authorize removal of any human organ
  before his death.
• Person may express his wish to donate his organs
  in the event of his death, through a ( Form No. 5
  )
• Informed Consent of Family is crucial to
  cadaver organ donation.

Presumed Consent In some countries the law
demands organ donation from its citizens, unless
they express otherwise in writing
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Offences and Penalties

• Commercial dealings in organs
• Imprisonment 2 to 7 years
• Fines Rs.10,000/- to Rs.20,000/-
• Penalties for Doctors
• First Offence Name struck off State Medical
  Register for 2 years
• Subsequent Offence Name struck off permanently

Since the Act was passed there has been two
criminal prosecution against doctors
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Pitfalls - THO ACT

• Donors
• Scrapping of Sub Clause (3) , Clause 9 of Chapter
  II
• If any donor authorizes the removal of any of his
  human organs before his death under sub-section
  (1) of section 3 for transplantation into the
  body of such recipient, not being a near relative
  as is specified by the donor, by reason of
  affection or attachment towards the recipient or
  for any other special reasons, such human organ
  shall not be removed and transplanted without the
  prior approval of the Authorization Committee.

Majority of kidney transplants in the country use
this clause resulting in legal
commercialisation of kidneys
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Is There a solution to these Legal Ethical
Problems

• Restrict the number of Live unrelated kidney
  transplants
• Push the Brain death organ donation Programme
  forward
• Make amendments in the THO Act
• Make punishments for offences more stringent and
  effective

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Brain Death Concepts

• First recognised in 1959 in Paris in Intensive
  care units (coma de passe )
• Formally accepted as a form of death in 1968 by
  the ad hoc committee at Harvard
• Accepted by Govt. of India in 1994 as a form of
  death

In Babies under one year brain death concept not
applicable
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Brain dead Pool of Donors

• No wastage of organs if organ donation from
  brain dead donors undertaken
• Almost 95 of organ donors in western world
  originate from Brain Dead Donors
• Largest pool of organ Donors in the world

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Common Causes of Brain Death
In India Road traffic Accidents the commonest
cause of brain death
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Brain dead Pool of Donors in India

• In any of the metropolitan city in India
• There are at least on an average between 10 to
  20 patients admitted in different ICUs who are
  brain Dead

Even Doctors often fail to diagnose or recognise
this condition!!
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Transplant Statistics

• Number of transplants done throughout the world -
  5,50000
• Number of patients on transplant waiting list -
  1,50000
• Number of Transplants worldwide 1997 - 37,072

Annual transplant figures are not rising.
Though Waiting lists though are perpetually
going up.
37
Transplant Activity of Western World (1985 to
1992)
1989
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TOTAL TRANSPLANT ACTIVITY IN INDIA (1998 1999)
Golden IT triangle of India Hyderabad, Chennai,
Bangalore are also famous as Kidney Bazaars in
the western world
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DONT TAKE YOUR ORGANS TO HEAVEN FOR HEAVEN
KNOWS THEY ARE NEEDED HERE !!
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Organ Donation - Social Issues
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Unusual Social Situations Dilemmnas

• In certain brain death situations despite the
  consent of the family organ donation was not
  possible -
• Two wives where first legal wife raised an
  objection to organ donation
• Asking for money by family for organs
• Death by hanging in recently married girl
• Brain death in a destitute where no relatives
  were available for consent

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Problems with Cadaver Organ Donation Programme
in India

• Govt. Problem
• No Funding for programme
• Hospital problem
• No efforts to identify maintain Brain Dead
  donors
• Community Problem
• No Awareness of Brain-Death Concept

Spain has the highest number of brain death
patients going on to organ donation 32 per
million population
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Streamlining of THO ACT

• Make it compulsory for doctors or medical social
  workers to ask for Organ Donation in a Brain Dead
  Situation
• Identify doctors or senior nurses to work as
  Transplant Coordinators in each ICU
• In Medico-legal cases it should be possible to
  perform Post-Mortem at same time as organ
  retrieval in presence of a Forensic Expert

No financial costs involved in the above
recommendations
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Organ Donation Awareness Programmes

• Mandated Choice on Driving License about organ
  donation
• Education at School and College Level
• Free Air time on Doordarshan and Private Channels
  for films on Organ Donation
• Tax Exemption for documentaries on Organ Donation
• Indirect incentives to donor families
• Honoring cadaver donor families

In states of Maharastra Gujarat slogans about
Eye donation displayed on National Highways
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MOHAN Foundation - Objectives( Multi Organ
Harvesting Aid Network )

• Formed in 1997
• Spread Message of Organ Donation
• Works as a support group for Patients, Public
  Physicians
• Foundation subgroups
• Organ Sharing Group INOS
• Counselling unit Manashanthi
• Patient Support Group
• Publishes Indian Transplant Newsletter

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Organ Donor Cards by MOHAN Foundation
Carry the card in the wallet Serves also as an
emergency card
The Foundation has distributed almost 100,000
cards in India. Cards are available in English,
Tamil. Hindi and Marathi
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Organ Donor Cards by MOHAN Foundation
Give Life a SECOND Chance
Carry a Donor Card
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MEMORIAL SERVICE 31ST OCT 1999 Loyola College,
Chennai

• HONOUR OF CADAVER ORGAN DONORS ORGANISED BY
  MOHAN FOUNDATION

Saplings Planted in Memory of cadaver Organ
Donors by their family members in the Campus of
Loyola College on 30th Oct 1999 - organised by
MOHAN Foundation
Painting Completion on Organ Donation theme
organized for schools by MOHAN Foundation in
March 2002
Movie in English, Hindi and Tamil for Television
Channels Made by MOHAN Foundation
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INOS - Initiative for organ sharing Group

• Formed in Nov1999 by MOHAN Foundation
• Essence of INOS Not to Waste Any Organ
• Hospital in group includes Apollo, CMC
  Vellore, Sri Ramachandra Hospital and Sundaram
  Medical Foundation
• About 30 different organs shared between
  hospitals

UNOS in USA is the largest organization such
organization and is partly funded by the
government
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Counselling Unit- Manashanthi

• Formed in April 2001
• As a support group for emotional failure
• Located at Annanagar
• Counselling available between 10AM and 1PM
• Organises counselling lectures and workshops

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LIFE ......PASS IT ON !!
At a certain moment a doctor will determine that
my brain has ceased to function and that, for
all intents and purposes, my life has stopped
 When that happens don't call this my
DEATHBED, call it my "BED OF LIFE" and let my
body be used by others to lead fuller lives 
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LIFE ......PASS IT ON !!
Give my blood to the teenager who has been pulled
from the wreckage of his car, so that he might
live to see his grandchildren play
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LIFE ......PASS IT ON !!
Give my eyes to a man who has never seen.
Sunrise
A babys face
or Love in the eyes of a woman
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LIFE ......PASS IT ON !!
Give my kidneys to one who depends on a machine
to exist from week to week Give my heart to a
person whose own heart has caused nothing but
endless days of pain
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LIFE ......PASS IT ON !!
Explore every corner of my brain, take my cells
and let them grow so that someday.
a speechless boy will shout at the crack of a bat
and a deaf girl will hear the sound of rain
against her window
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LIFE ......PASS IT ON !!
Take my bones, every muscle, every fibre and
every nerve from my body.
..to find a way to make a crippled child walk
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LIFE ......PASS IT ON !!
Burn what is left of me and scatter the ashes to
the winds to help the flowers grow
If you must bury something, let it be my faults,
my weaknesses and all my prejudice against my
fellowmen
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LIFE ......PASS IT ON !!
Give my sins to the devil and give my soul to
God, If you do what I have asked, I WILL
LIVE FOREVER  ( The above is a Legacy of Robert
N.West written in 1976 )
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THANK YOU A MOHAN FOUNDATION PRESENTATION
In my end is my beginning                    
- T.S.Eliot, Four Quartets
For further information about organ donation
contact us at Multi Organ Harvesting Aid
Network www.mohanfoundation.org A -113
Annanagar, 3rd Avenue, Chennai 600102,
India Tel [phone] info_at_mohanfoundation.org