Medical ethics

Transplant surgery for Sasikala’s husband highlights skewed organ donation practices across India

Loopholes in organ transplant rules incentivise private hospitals receiving organs from smaller government and non-transplant facilities.

Last week, M Natarajan, husband of All India Anna Dravida Munnetra Kazhagam leader VK Sasikala, underwent an organ transplant procedure that has raised several ethical questions.

Natarajan received a kidney and liver from a 19-year-old daily wage labourer, N Karthik, who had been airlifted from a government medical college in Thanjavur where he had been hospitalised with severe head injuries to the privately-run Gleneagles Global Health City hospital in Chennai. Karthik’s transfer to the Chennai hospital was supposedly for a second opinion on his medical condition. He was declared brain dead a day after the transfer.

The Tamil Nadu Bharatiya Janata Party has alleged several violations in Karthik’s transfer and in the donation of his organ and has sought an inquiry.

“Shifting such a critical patient is wrong, when a facility [of supporting a critical accident patient] is available” in a medical college hospital, said Dr Jagdish Prasad, the country’s Director General of Health Services. “The organs could have been retrieved in the hospital and given to a deserving candidate.”

Prasad said that the state government should investigate the matter and take appropriate action.

Organ donation programmes in each state are run under the Transplantation of Human Organs Act, 1994 that aims to ensure equitable distribution of organs to those who need them. Several state governments have laid down guidelines in accordance with the Act for how a brain dead patient’s organs are to be distributed.

In most states like Tamil Nadu, Maharashtra and Kerala, the hospital that retrieves the organs gets the first right to transplant a certain number of organs. Organs that are not used by the hospital go into a common pool and may then be distributed to patients who are on a waiting list of organs. Priority is based on how long patients have been on the list and on how urgently they may need organs.

After Karthik’s liver and kidney used for Natarajan’s transplant surgery, the rest of his organs including his lungs and heart went to other patients a Gleneagles Global Health City hospital. Only the remaining kidney was added to the general pool for waitlisted patients.

Shifting donors between hospitals

For decades in India, hospitals equipped and certified to conduct transplant surgeries have been permitted to harvest donor organs. Many smaller health facilities do not have the facilities to conduct transplants but can maintain brain dead people on life support systems and harvest organs following brain death declaration. However, until a few years ago, the law did not permit these smaller facilities to harvest organs.

However, in 2008, Tamil Nadu was the first state to pass orders allow hospitals to harvest organs even if they are not certified to conduct organ transplants. These centres were called Non Transplant Organ Retrieval Centres. Maharashtra and Kerala implemented this system in 2012 and Karnataka followed suit in 2013. Organs harvested by these non-transplant centres go into the general state organ pool and can speed up the rate of transplants for those on the waiting list. Yet, very few organs are harvested in such non-transplant centres. More than 95% of organ retrievals still happen in transplant centres. “That is because there is no incentive for the smaller centre to harvest organs,” said a senior state government official. “It is a costly exercise.”

Harvesting organs from brain dead donor requires a day’s charges of the intensive care unit where the donor is kept on a ventilator to keep the organs viable. Therefore, only transplant centres that charge for expensive transplant procedures have the incentive to harvest organs. Tamil Nadu has tried to address this problem in transplants arranged between private donor and recipient hospitals by reimbursing private donor hospitals the costs of maintaining a donor up to Rs 75,000 from the time that the donor’s family consents to donating his or her organs.

But there are others factors at play.

Guidelines in some states and the norms in practice in others continue to incentivise transfer of a patient to a transplant facility rather than organ harvesting from a cadaver in a non-transplant centre.

These guidelines and norms allows certified transplant centres the right to first allocate cadaver organs, which incentivises the transfer of a potential organ donor from a smaller institution or public hospital to a large private hospital whose patients benefit from the organs.

Dr Vivekanand Jha, nephrologist and executive director of the George Institute of Global Health, said that sometimes critically ill patients are transferred to private hospitals. When the patients die, the hospital gets priority to use their organs. Sometimes patients who are already brain dead are transferred from non-transplant to transplant centres but the declaration of brain death is made only after the move.

“The entire process of transferring a patient to a private organ transplant centre looks above board,” said Jha. “But, in this way, the parties concerned manage to circumvent the rules which try to establish equitable distribution of organs.”

What skews the system further is the lack of transplant capacity at government hospitals that serve poorer patients as opposed to private hospitals that have richer clients.

The Nashik case

The Maharashtra government’s health department is currently investigating violations in a transplant case in Nashik. Last fortnight, a critically ill patient was declared brain dead at a small non-transplant Nashik hospital and was transferred to a private organ transplant centre. A member of the Zonal Transplant Coordination Authority that oversees organ donation and transplantation found that the the non-transplant hospital offered the donor’s family a monetary incentive to allow the patient to be transferred while the transplant centre would pay it for receiving the cadaver. As per law, organs cannot be donated for any kind of remuneration.

“During investigation, we found out that the patient’s relatives were told that their fees [at the non-transplant hospital] would be waived if they agreed to donate the organ,” said Dr Satish Pawar, director of health services for Maharashtra. “The smaller hospital was asking for their fees from the private hospital.”

Pawar said that the authorities are yet to complete the investigation.

“A body should not be moved for organ donation,” said Dr Sunil Shroff from the non-profit organisation Mohan Foundation, which works towards increasing organ donations in the country. “We need to strengthen the non transplant organ retrieval centres.”

Maharashtra’s health department has decided to overhaul the system related to Non Transplant Organ Retrieval Centres. Maharashtra has about 600 health facilities that have intensive care units, but only 200 are registered as transplant retrieval centres.

“We are planning to give temporary approvals to centres [that have necessary facilities but not yet certified as Non Transplant Organ Retrieval Centres] where a brain dead patient’s relatives agree to donate organs, most of which can go in into the general pool,” said Pawar.

The department is looking at a “hub and spoke model” where a registered organ transplant centre can receive organs from at least five or six retrieval centres that are within 100 km. “In India, where the demand is high and the supply is low, there will be malpractice,” said Pawar. “Once we regulate the system [to increase supply of donor organs], we think even malpractice will come down. Even the costs for transplant perhaps.”

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