Medical ethics

A change in definition of organ donors may once again open doors for illegal commercial donations

The health ministry is proposing a definition change that will not widen the pool of donors but again gives hospitals power to decide more transplant cases.

The Indian government is considering an amendment to the Transplant of Human Organs and Tissues Act, 1994 to bring step-parents, step-children, other relatives through marriage and cousins under the category of “near relative” of a patient. This, the government says, will help bridge the mismatch between supply and demand for organs. However, the proposed amendment may not widen the pool of donors. Moreover, such an amendment allows hospitals to decide whether a donor is eligible in a greater number of cases. Leaving hospitals to check that that organ donations are not taking place under duress or in exchange for money has led to several instances of transplant rackets in the past.

Currently, the Transplant of Human Organs and Tissues Act, 1994 says that a “near relative” is a spouse, son, daughter, father, mother, brother, sister, grandfather, grandmother, granddaughter or grandson. Any person in this “near relative” category can donate an organ after a committee instituted by the hospital where the transplant operation is going to take place permits it. The committee is supposed to establish the relation between recipient and donor and ensure that the donation is purely altruistic.

Under the current Act,a person who is not a “near relative” of the patient and is “unrelated” can also donate an organ. Such donations have to be first approved by a hospital committee, then by a committee appointed by the state government to ensure that the donation is non-commercial and that there is no coercion of the donor.

In a circular dated August 21, the Ministry of Health and Family Welfare has suggested bridging the gap between supply and demand for human organs by bringing other relatives of a patient into the “near relative” category. These relatives will include:

  • Step father, step mother
  • Step brother, step sister, step son, step daughter and their spouses
  • Spouses of sons and daughters of recipient
  • Brothers and sisters of recipient’s spouse and their spouses
  • Brothers and sisters of recipient’s parents and their spouses
  • First cousins (having common grandparents) of the recipient and their spouses.

Such a step would ensure that all these potential donors, who would earlier have to be verified by two committees, will only have to be cleared by the hospital committee.

“It [the proposed amendment] is not going to increase the donor pool,” said Dr Sanjay Nagral, publisher and editorial board member of the Indian Journal of Medical Ethics, who has written extensively on the medical ethics surrounding organ donation in India. “These relatives could have donated as unrelated donors. This (proposed amendment) doesn’t add new potential donors.”

Instead, contrary to the government’s claim that the expanded definition of “near relative” may also help curb trading of organs, it once again puts organ donor verification solely in the hands of hospitals that benefit from payments for transplant surgeries and so have incentives to quickly clear procedures.

Failure of hospital scrutiny

In August 2016, five doctors of Dr LH Hiranandani Hospital were arrested in relation with a kidney racket. The Mumbai police said that a poor woman was lured into selling her kidney to a businessman and forged documents were submitted to establish their relationship as husband and wife. Here, the hospital committee had given the permission on the basis of the documents and interviews they conducted with the donor, recipient and their family members.

Doctors of Dr L H Hiranandani Hospital being taken away from a Mumbai Court on Aug 13, 2016. They were produced before the court in connection with a kidney racket. (Photo: IANS)
Doctors of Dr L H Hiranandani Hospital being taken away from a Mumbai Court on Aug 13, 2016. They were produced before the court in connection with a kidney racket. (Photo: IANS)

In June 2016, Delhi police busted a kidney racket at Apollo Hospital. The police found that touts scouted donors for kidney failure patients and forged documents to present before the hospital committee.

These cases have exposed the poor scrutiny followed by many hospital committees. “Impersonation can happen,” pointed out Dr Shrirang Bicchu, nephrologist from Bombay Hospital who is also the trustee of a non-profit working for kidney transplants.

Dr G Swarnalata, who is in charge of Telangana’s organ donation programme, said that if the definition of “near relative” is expanded, most cases that now fall in the “unrelated” category and were earlier sent to the state authorisation committees will end up receiving permission easily from the hospital based committees.

“Proving relationship is extremely difficult in such cases,” she said. “The state authorisation committee plays an important role of re-checking all the paperwork apart from conducting interviews with the potential recipient and donors and their family to make sure that there is no exchange of money or any pressure or coercion.”

Nagral aso agreed that if more cases are sent to be cleared only by hospital committees, there is a greater chance of abuse of the system.

The director of the National Organ and Tissue Transplant Organisation under the ministry of health and family welfare, Dr Vimal Bhandari, reiterated that the aim of the amendment is to increase the donor pool. “Once the amendment is made, the ministry may consider issuing guidelines on the procedures to be followed to establish and prove the relationships following the amendment.”

Living donors vs cadaver donors

Expanding the definition of “near relative” also promotes living donor transplants and shifts focus away from the need for more cadaveric donations.

“A patient is always given the option of both living donor organ and cadaveric organ transplant but most will choose the former because of the huge waiting list for cadaveric organs,” said Bicchu. In Mumbai alone at any given time, more than 3500 patients are waiting for a cadaveric kidney donation.

Moreover, a living transplant can be planned in advance depending on the need of the patient and availability of the donor while a cadaveric transplant needs to be performed within hours of the donor’s death. All transplant centres perform cadaveric transplants. But cadaver organs are allotment system according to a list of patients on a transplant list and the patient has to wait his or her turn. India does not have enough people who pledge to donate their organs after their death. If transplant centres were to depend on cadaver organs, they will not be able to perform enough surgeries.

Streamlining the process

Instead of tinkering with the definition of “near relative”, experts said that the government should focus on streamlining the procedure for granting permission for “unrelated” organ donors At present, state authorisation committees meet only once in a fortnight.

“If these committees meet more often and conduct the interview and reviews the documents faster, the permissions will come through quickly,” said Dr Sunil Shroff, managing trustee of Mohan Foundation, a non-profit organisation working on organ donation. “The most important thing that needs to be checked is that there is no organ commerce.”

Take the case of 48-year-old Anil More, who underwent a life-saving liver transplant at a Mumbai hospital after his niece donated a segment of her liver to him last month. “We applied for permission with all the documents in June and got permission after one and a half month,” Shobha More, the recipient’s wife. As none of More’s near relatives had his blood group, the family opted for an “unrelated” donation when his niece volunteered to donate her organ.

Shobha recalled how, while waiting for authorisation from the state committee, her husband’s condition deteriorated. “The wait for permission was scary as 90% of his liver was already damaged and transplant was the only chance of survival,” she said.

Luckily for Anil More, the permissions came in time and the transplant surgery was done three days after authorisation. Any further delay could have cost him his life, said Shobha More.

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