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.

We welcome your comments at letters@scroll.in.
Sponsored Content BY 

What hospitals can do to drive entrepreneurship and enhance patient experience

Hospitals can perform better by partnering with entrepreneurs and encouraging a culture of intrapreneurship focused on customer centricity.

At the Emory University Hospital in Atlanta, visitors don’t have to worry about navigating their way across the complex hospital premises. All they need to do is download wayfinding tools from the installed digital signage onto their smartphone and get step by step directions. Other hospitals have digital signage in surgical waiting rooms that share surgery updates with the anxious families waiting outside, or offer general information to visitors in waiting rooms. Many others use digital registration tools to reduce check-in time or have Smart TVs in patient rooms that serve educational and anxiety alleviating content.

Most of these tech enabled solutions have emerged as hospitals look for better ways to enhance patient experience – one of the top criteria in evaluating hospital performance. Patient experience accounts for 25% of a hospital’s Value-Based Purchasing (VBP) score as per the US government’s Centres for Medicare and Mediaid Services (CMS) programme. As a Mckinsey report says, hospitals need to break down a patient’s journey into various aspects, clinical and non-clinical, and seek ways of improving every touch point in the journey. As hospitals also need to focus on delivering quality healthcare, they are increasingly collaborating with entrepreneurs who offer such patient centric solutions or encouraging innovative intrapreneurship within the organization.

At the Hospital Leadership Summit hosted by Abbott, some of the speakers from diverse industry backgrounds brought up the role of entrepreneurship in order to deliver on patient experience.

Getting the best from collaborations

Speakers such as Dr Naresh Trehan, Chairman and Managing Director - Medanta Hospitals, and Meena Ganesh, CEO and MD - Portea Medical, who spoke at the panel discussion on “Are we fit for the world of new consumers?”, highlighted the importance of collaborating with entrepreneurs to fill the gaps in the patient experience eco system. As Dr Trehan says, “As healthcare service providers we are too steeped in our own work. So even though we may realize there are gaps in customer experience delivery, we don’t want to get distracted from our core job, which is healthcare delivery. We would rather leave the job of filling those gaps to an outsider who can do it well.”

Meena Ganesh shares a similar view when she says that entrepreneurs offer an outsider’s fresh perspective on the existing gaps in healthcare. They are therefore better equipped to offer disruptive technology solutions that put the customer right at the center. Her own venture, Portea Medical, was born out of a need in the hitherto unaddressed area of patient experience – quality home care.

There are enough examples of hospitals that have gained significantly by partnering with or investing in such ventures. For example, the Children’s Medical Centre in Dallas actively invests in tech startups to offer better care to its patients. One such startup produces sensors smaller than a grain of sand, that can be embedded in pills to alert caregivers if a medication has been taken or not. Another app delivers care givers at customers’ door step for check-ups. Providence St Joseph’s Health, that has medical centres across the U.S., has invested in a range of startups that address different patient needs – from patient feedback and wearable monitoring devices to remote video interpretation and surgical blood loss monitoring. UNC Hospital in North Carolina uses a change management platform developed by a startup in order to improve patient experience at its Emergency and Dermatology departments. The platform essentially comes with a friendly and non-intrusive way to gather patient feedback.

When intrapreneurship can lead to patient centric innovation

Hospitals can also encourage a culture of intrapreneurship within the organization. According to Meena Ganesh, this would mean building a ‘listening organization’ because as she says, listening and being open to new ideas leads to innovation. Santosh Desai, MD& CEO - Future Brands Ltd, who was also part of the panel discussion, feels that most innovations are a result of looking at “large cultural shifts, outside the frame of narrow business”. So hospitals will need to encourage enterprising professionals in the organization to observe behavior trends as part of the ideation process. Also, as Dr Ram Narain, Executive Director, Kokilaben Dhirubhai Ambani Hospital, points out, they will need to tell the employees who have the potential to drive innovative initiatives, “Do not fail, but if you fail, we still back you.” Innovative companies such as Google actively follow this practice, allowing employees to pick projects they are passionate about and work on them to deliver fresh solutions.

Realizing the need to encourage new ideas among employees to enhance patient experience, many healthcare enterprises are instituting innovative strategies. Henry Ford System, for example, began a system of rewarding great employee ideas. One internal contest was around clinical applications for wearable technology. The incentive was particularly attractive – a cash prize of $ 10,000 to the winners. Not surprisingly, the employees came up with some very innovative ideas that included: a system to record mobility of acute care patients through wearable trackers, health reminder system for elderly patients and mobile game interface with activity trackers to encourage children towards exercising. The employees admitted later that the exercise was so interesting that they would have participated in it even without a cash prize incentive.

Another example is Penn Medicine in Philadelphia which launched an ‘innovation tournament’ across the organization as part of its efforts to improve patient care. Participants worked with professors from Wharton Business School to prepare for the ideas challenge. More than 1,750 ideas were submitted by 1,400 participants, out of which 10 were selected. The focus was on getting ideas around the front end and some of the submitted ideas included:

  • Check-out management: Exclusive waiting rooms with TV, Internet and other facilities for patients waiting to be discharged so as to reduce space congestion and make their waiting time more comfortable.
  • Space for emotional privacy: An exclusive and friendly space for individuals and families to mourn the loss of dear ones in private.
  • Online patient organizer: A web based app that helps first time patients prepare better for their appointment by providing check lists for documents, medicines, etc to be carried and giving information regarding the hospital navigation, the consulting doctor etc.
  • Help for non-English speakers: Iconography cards to help non-English speaking patients express themselves and seek help in case of emergencies or other situations.

As Arlen Meyers, MD, President and CEO of the Society of Physician Entrepreneurs, says in a report, although many good ideas come from the front line, physicians must also be encouraged to think innovatively about patient experience. An academic study also builds a strong case to encourage intrapreneurship among nurses. Given they comprise a large part of the front-line staff for healthcare delivery, nurses should also be given the freedom to create and design innovative systems for improving patient experience.

According to a Harvard Business Review article quoted in a university study, employees who have the potential to be intrapreneurs, show some marked characteristics. These include a sense of ownership, perseverance, emotional intelligence and the ability to look at the big picture along with the desire, and ideas, to improve it. But trust and support of the management is essential to bringing out and taking the ideas forward.

Creating an environment conducive to innovation is the first step to bringing about innovation-driven outcomes. These were just some of the insights on healthcare management gleaned from the Hospital Leadership Summit hosted by Abbott. In over 150 countries, Abbott, which is among the top 100 global innovator companies, is working with hospitals and healthcare professionals to improve the quality of health services.

To read more content on best practices for hospital leaders, visit Abbott’s Bringing Health to Life portal here.

This article was produced on behalf of Abbott by the Scroll.in marketing team and not by the Scroll.in editorial staff.