Saturday, February 10, 2007

Brain death case at SGH (HOTA)

Dear Friends,

Human Organ Transplant Act (HOTA) has been in place since 1987 and ammendments made to it in 2004 .

Link to MOH Hota page ( read it - don't be lazy)

To put it simply, HOTA initially consisted only of cadaveric (dead person) donation of kidneys from accidental death ---> cadaveric donation ( kidneys) from any death (not just accidental)---> cadaveric donations of kidneys+liver+heart+cornea --->living donor ( relative only) --->living donor ( non-relative) but only if no emotional coercion and financial inducement ( ie not organ for sale scenario) . Muslims are exempted.

It is an opt-out system : If you don't bother to opt out, it is Presumed that you have agreed.

Very easy to opt out, just download a form or get it from the usual places and sign it.

HOTA is law

Whether we agree to it or now, it is now the law of the land.

There is much controversy about HOTA, including:

1.Overall issue about organ transplantation (religious objection etc)
2.Opt-in system: Is it fair? ( taking advantage of apathy)

The Case in question

The tragic Mr Sim case shows how little Singaporeans take control of their lives.

Most of us care 2 hoots about anything ( ok, we can blame society for a stressful and dogeatdog lifestyle). We have been conditioned ( or undergone socialisation) to leave nearly everything to the government. We have almost abdicated the right to decide on all aspects of our lives.

The family of Mr Sim Tee Hua is understandably grieving and certainly don't need additional stress from anyone, esply police and medical personel.

but Police and Medical Personnel are just doing their job

But the policemen and medical staff are in a lose-lose position. They have to carry out their jobs and yet risk being labelled as "unfeeling and inflexible". Of course, all concerned can be more tactful, communicate more effectively etc. But no amount of tact will completely alleviate the grief that the Sim family is going through now.

If there were more delays, the organs would be of no use to anyone. We are already short of these organs.

Diagnosis of Brain Death (FAQ Min of Health)

There are clear guidelines for the diagnosis of "Brain Death" and the people on the panel responsible for this dreaded diagnosis of Death are not connected to the organ transplantation team and hence have no vested interest in the whole procedure (to avoid conflict of interest.)

As much as we sympathise with the grieving family, let us have a thought for these public servants. Don't make it harder for them to carry out their duties ( unless you want to be in their shoes)

What can we do if you don't agree with HOTA ( or any law)

Instead of attacking the messengers ( these public servants), those who are against HOTA (or any law) should try to get it changed/rescinded. I know most say it is futile to try to change any law in Singapore but we never know till we've tried.

Anyway, the majority of Singaporeans have elected this government and what it stands for. So we get what we deserve ( but that's a subject of another post)

I am not against HOTA. It is better than commercialised organ trading ( some say HOTA may a be disguise for organ trading in the non-related donor scenario).

Dr.Huang Shoou Chyuan

Two samples of letters to the forum about this case ( 10th Feb 07 ST forum)

Letter One:
'Brain-dead man's kin in scuffle over op to remove organs' (ST, Feb 8)

THE report, 'Brain-dead man's kin in scuffle over op to remove organs' (ST, Feb 8), shows clearly that there is much to be done to educate the public on the Human Organ Transplant Act (Hota), as amended in July 2004.
The public must be made aware that kidneys, livers, hearts and corneas suitable for transplant can be removed from all Singaporeans and permanent residents upon their death as defined by the Act - unless they have opted out.
Hospitals and polyclinics should be in the forefront, explaining to patients Hota whenever the opportunity to do so arises.
The various community institutions can also help in educating the public at the grassroots level.
This will prevent the tussle the relatives of Mr Sim Tee Hua had with the hospital staff because they would have known that Hota will kick in in such circumstances and would also be aware of the window of time needed for transplants.
Alternatively, hospitals can, whenever they anticipate the possibility of enforcing Hota, pre-empt any outburst by making the patient's relatives aware that the organs will be removed upon confirmation of brain death.
This must be done with the utmost sensitivity.
Harry Chia Kim Seng

Letter Two

SGH could have handled removal of organs better

READING the article, 'Brain-dead man's kin in scuffle over op to remove organs' (ST, Feb 8), the Singapore General Hospital came across as rather unfeeling in its handling of the situation.
The man's mother and five relatives kneeled and begged the doctors not to remove his kidneys and corneas, to no avail. His family was not convinced that he was really dead as his body was still warm.
Yes, the hospital was carrying out the procedure under the
Human Organ Transplant Act (Hota) but, surely, the matter could have been handled better.
On one hand there is this family reeling from shock over the death of a loved one and, on the other hand, there is the law, in the form of surgeons and nurses bent on removing all his useable parts.
Where is the compassion and humanity that are so clearly lacking?
Many people are still unaware that their organs can be taken away from them unless they opt out.
To avoid such heartrending confrontations. I suggest that the Ministry of Health educates Singaporeans and permanent residents that unless they opt out, under Hota their organs will be removed once they are considered brain dead.
The ministry should also make opt-out forms more readily available - and also available online - so that people do not have to go hunting for this vital form in clinics and hospitals.
Dr Lim Boon Hee


TPH said...

It is never easy to remove organs from anyone (unless of course money is involved!!)
While we empathise with the grieving family of the deceased, we should also remember the suffering families of people in need or organs to live
Who has the right? Difficult to answer? Not really. The answer lies with the government. It is not enough to just tell people over the media about HOTA and the opt-out scheme. The govt should remind the people repeatedly about it and advise on how one should go about opting out. (They (the Govt) are afraid that if opting out is too easy everyone will be opting out and there will be no organs available? Maybe) There are many instances that not enough publicity is given by the relevant authorities about various public schemes. How many of us know that citizens above 65 years can apply for Primary Care Partnership Scheme whereby they can consult affiliated GPs for common acute ailments and pay only $4/=! Very few know of its existence. From the media we learn that Medisave can be used for chronic illnesses like hypertension, diabetes, high cholesterol and stroke up to a maximum of $300/= per year. But do we know that to make use of this scheme, there are admin fees involved and that there are data to be submitted by the attending doctors to MOH which includes blood and urine tests! The actual mathematics of it is never clearly explained. This is typical of any schemes coming from the authorities. The lack of explanation resulting in 'misunderstandings'. Hopefully with this latest incident, the people in charge should rethink their publicity strategies and make sure that the people are truly and fully informed of all schemes available and the mechanics of the schemes!

travailingdoc said...

Hi. Dr. Huang.

As doctors we see the good intentions that the legislators have when HOTA was passed. We need organs for the many who are waiting desperately for these organs. Organ transplantation , being constrained by time restraints, must be carried out swiftly to ensure the best outcome.
As such, this gives little time for communication and consent from the next of kins .
So the law was passed that you are presumed to have consented to have
opted in to have your organs removed, on your demise, if you have not actively opted out.

The crux of it all , and we should hear from the legal experts; is such a law just and reasonable?
Can it be assumed that silence is consent?
Is this consent an informed one?
Is this consent given in full knowlege, with a clear mind and without undue influence and pressure?
Is the consent valid if the donor is a minor?

Being in a miltifaceted society with profound cultural and religious nuances the HOTA invariably will bring about much consternation.

In the USA, when ever we renew our driving licences, we are always asked if we will be donors. This consent can be withdrawn at will

The different approaches illustrate the respect and consideration given to both the living and the dead in the two countries.

Without being cited for contempt of court or parliament, such laws are an indication why citizens must be on the lookout for themselves.

A tida apa attitude cannot remain a luxury anymore in a modern and metropolitan city.
Citizens must reclaim their voices and be heard.
They must be educated and speak out , or be taken for granted.


nofearSingapore said...

tph: thanks for visiting and comments.
Yes, the govt needs to keep reminding the people about HOTA. At the time it was enacted (1987), there was understandably lots of publicity, but how will the people now know that by remaining silent, they are automatically consented to donating their organs.
How will the MOH tell the people?
Perhaps, the moment they turn 20 ( or whatever the age of consent is), ICA/MOH should automatically send them info about HOTA with opt-out forms attached?
Yes there are so many schemes for us to use but we don't know about them ( perhaps we don't use them cos of paperwork). Shame isn't it?

Travailingdoc: I am just as concerned that the Opt-out is actually a "cop-out" of our society. Whenever we cannot get enough support for anything, we use the good-old "opt-out" knowing that the infamous S'porean apathy will allow them to get the organs or whatever law they want to pass!
I wonder if anyone would want to test this in our courts but they would be labelled anti-social.
I am sure in a developed society like the USA, the opt-out clause is not used as liberally.


recruit ong said...

Tph: While we empathise with the grieving family of the deceased, we should also remember the suffering families of people in need or organs to live

We must not forget that organ donation is just a donation. No one owes any duty to the families of those in need of organs. Take ordinary charity donations, if i choose to spend my money in a wasteful manner, buy a bigger car instead of a small car and so on, and not donate $ to the needies, the needies do not have a say in my affairs.

Organ Harvesting said...

Hi Dr H,

Thank you so much for educating us masses on the HOTA.

After reading abt how traumatic it was for the deceased family, I decided to opt-out so that my next-of-kin can decide to opt-in if they were ready to do some good with my body-parts. My bad, on my earlier apathy on this matter... actually I misunderstood that if the next-of-kin strongly objected, HOTA will not be done.

In my opinion, MOH is doing a lot of harm to a potentially helpful principle (one which I agree with) by its lack of public education and its opportunistic approach (to use public apathy to their benefit). Its current stand is causing unnecessary trauma to all involved (donor's family, receipient's family, police, hospital staff).

Another doubt is over the lack of transparency with regards to priority for receipients. Will the elites or those well-connected be favored and jump the queue?

Sorry, but the lack of info/transparency is creating unnecessary fears/doubts in peasants like me.

Organ Harvesting said...

One more question, perhaps more of a topic for discussion:

If human euthanasia is legalized (think there was some talk on not too long ago), then will organs from the euthanasia dead be harvested too under the HOTA?

nofearSingapore said...

Yes HOTA is donation even if it relies on opting-out mechanism. In a way, hundreds of thousands of S'poreans don't know that they are donors!!

organharvesting:Once you opt out, your family cannot opt-in for you on your passing away ( I think).
Yes more should be done to publicise the HOTA and how it affects all of us.
I am sure there is a proper way where patients who need organs are placed in a queue. But if you want to bet with me that ,all things being equal, an ordinary humble heartlander will get the organ with the same priority as an VVIP super-dooper supremo minister, I will not bet even $2 with you. But usually it should be quite fair.

Euthanasia ( mercy killing) - this is different from Advanced Medical Directive (AMD), causes death and according to HOTA, any death will lead to HOTA being triggered off.

AMD is when a person signs a document to tell the doctors/govt that he does not want too much medical treatment to be done when he has terminal disease ( eg advanced cancer). The doctors do not do anything active to cause his death.

Euthanasia is active procedure to cause death .


Recruit Ong said...

Thks doc. I got a question. Imagine this scenario:

Say a person lets call him A, he did not opt out. Say A's sister is suffering from kidney failure and is on the waiting list. Then one day A got into an accident and died. So his organs are up for harvesting. Now will his sister get first priority on A's organs? Or does she have to wait in line according to this "waiting list"? If the answer is she has to wait in line. Then i find it unfair. Shouldn't a family member get priority? I will also want to know how this waiting list is managed. Some transparency at least...

Any comments?

Organ Harvesting said...

Hi Dr H,

Thanks for your explanations, esp the clarification on AMD-vs-euthanasia which is reassuring.

I think that an opt-in scheme may be less traumatic for all involved (donor family, recipient family, police, hospital staff). Hospital can explain to donor family that it was the dead person's "active wish" (not default wish due to apathy) to do something good from his/her death.

Be in opt-in or opt-out, I wonder if it is feasible for the deceased's next-of-kin to be consulted with regards to the possibility of harvesting organs to save a matching recipient (btw, I got the impression that it is not easy to find a match). Afterall, it is possibly a very traumatic period for them.

Dr H: according to HOTA, any death will lead to HOTA being triggered off.

Sorry to bother you again. If any death will trigger HOTA, does it mean that those Singaporeans/PRs on death sentence will also have their organs harvested? Just curious, cos of some rumours about some of China's sources of donors.

As for priority of receipients, I vaguely remember many years ago on some MSM someone explained why a young person was unlikely to get donor because a breadwinner of family (who have dependents) will get priority. But I dun remember the source now :-(

When it comes to an "ordinary humble heartlander" vs "VVIP super-dooper", I think Albert Schweitzer's philosophy on ethics ring a bell.

To quote wikipedia,

"Ethics, according to Schweitzer, consists in the compulsion to show toward the will-to-live of each and every being the same reverence as one does to one's own".

Anonymous said...

Why can't the Govt or hospitals enlighten the public as they do with the mandatory death sentence for drug trafficking.
All commuters into Singapore are given dire warnings about the conseguences of breaking this law.
Hospitals can tactfully put a reminder in admission forms and ensure that it is easily understood by the patients about the HOTA, as they are signing to be admitted.
I do not think this will be such a big burden to do and if patients do not agree, thay can sign to opt out there and then, at the admission room. There can also be posters and reminders at admission referring to the HOTA.Of course, this will not work for those already brought in brain dead, but nevertheless, relatives of these patients will be made aware of these laws and may be more emotionally prepared when the time comes for the harvesting of the organs.

Dr Oz bloke said...

Anon's suggestion is intriguing.

Imagine you go to a govt hospital ready to be admitted and there are signs, announcements and pamphlets everywhere saying "Do note that if you should become brain dead, it is mandatory that your organs will be harvested under the HOTA."

Is that what anon is suggesting we do?

nofearSingapore said...

Hi all,
the FAQ website at MOH explains several of your queries clearly. I advise all to read it.
recruitong: HOTA does not allow you to choose your recipient. So the best option would be a. either donate as living donor or b. ( I am not sure about this) opt out of HOTA BUT will your organ away with the help of lawyer, so that on death, your organ will be harvested for the sister only.

organharvesting: Yes organ from any death from any person is included including prisoners executed. That's why in China, there is GREAT controversy as rumours that prisoners are chosen for execution according to whether their organs have matching recipients. That is one of reason I am against organ-trading ( for money) as it leads to abuse by local politicians/officials and organ theft ( take out kidney when you only went to remove appendix etc).

anon/drozbloke: ha ha
I know Gleneagles/Mt Elizabeth will definitely not do this.
Imagine scenario at admission desk, someone greets you then says,
"Welcome Mr.ABC, thank you for choonsing Gleneagles Hospital. Although you are coming for Tonsillectomy, please note that in case you die, we will removed your kidneys/liver/heart & cornea unless you have opted out.
Hope you have a nice stay.
Please visit us again ( ... if you survive)

The patients are already afraid of the surgery etc, any reminder of death is not really palatable.


Organ Harvesting said...

'Please visit us again ( ... if you survive)'

HA HA HA! Funny lah! Thanks for breaking the seriousness, phew!

Yes, I also worry about potential abuse if organ trading is legalized. Esp in $-faced Singapore where people are often valued by their economic contribution :-( Without an established culture of accountability and transparency, it is a slippery road down.

Anonymous said...

I am not sure what is funny about informing patients about the HOTA at admission.
It is a lesser evil than when you take out their organs when they are brain dead after a tonsillectomy which by the way do happen, and having a fight with the family thereafter.
It can be a tactful reminder. If not then live with the law and don't gripe about it.

Dr Oz bloke said...

Hi Dr Huang,

actually your comment about the reminder of death etc.

Brings up another issue that I have always felt rather peeved about.

Granted we do now want to "scare" our patients who are going for surgery. But when is too much too much and too little too little?

I have always thought that the "consent" forms we get our patients to sign way too sketchy and flimsy as legal documents.

When I sign a contract for a flat or a car, insurance policy etc....there are so many fine print words! Do we read all the words? Majority don't. The sales staff might highlight a few important points and then ask you if you want to read all of it before signing. And then the person signs it. After signing, even if the fella did not read it, the terms are legally binding. hey some of the things can be very technical involving interest accrued according to market rates blah blah blah that I won't understand despite me reading it but it still stands.

But consent form for surgery?

Why not have consent forms for surgery include every single possibility and complication? Give it to the patient, and in the same way highlight some points, give it to them and let them read and offer to answer should they have any questions about the points. If they sign it....(as like any other contract) then whatever is written there is legally binding. No more legal suits!

Why don't we do that? Why do the other companies have the privelege of having contracts that way, but surgeons don't?

It is after all a legal issue. Even a medico-legal issue is still a legal issue. So I say we conform to what is practised in our society.

And on that note I would say yes why not let the patients know about HOTA when they go to Gleneagles and Mt E? Why not?

HOTA is the law. Nothing to do with the hospital. It is just the law. We tell tourists and travellers about the death penalty for trafficking drugs into Singapore don't we? Are we afraid that there would be a drop in visitors?

If we don't tell the patients about HOTA, can they sue us for failure to inform? (I am no lawyer)

Guess I find the medical profession can be rather strange and apply double standards. Why should we be different? For fear of what? Loss of business? But then what is at stake? Who takes the risks?

We as doctors take the risks. Is that a wise thing to do?

Organ Harvesting said...

Anon at 2:52 AM: I am not sure what is funny about informing patients about the HOTA at admission.

Humour is an individual preference, aka "one mans meat is another man's poison". E.g. not everyone find spoofs of movies funny. I can imagine Jim Carrey deadpaning the one-liner by Dr H, hilarious! :-D

Of course, you can still insist it's too serious a matter to joke abt ;-) I'll leave you to sulk by yourself.

Dr Oz bloke said...

I was listening to the radio this morning (93.8FM)

issue was abt HOTA.

Actually HOTA opt out scheme has been around for a long time. There have been many who have donated their organs without fuss. This whole issue has been brought up simply because of this one case where the family created a big ruckus.

WHich begs the it really that serious a problem?

Why don't we just keep things simple. The HOTA is an opt out system for the simple reason that if it was an opt in system it wouldn't work in Singapore where people are largely apathetic to everything besides making money. So have it opt out as it is now.

However just add a clause that should there be violent objections from the relatives (either that they do not want the organs to be harvested or that some muslims might want the organs to be harvested for someone's good) then it can be done. Why not? Is it really such a problem that we have to force and go against the wishes of the relatives? What's the worry? That the majority relatives would opt out? In that case then to begin with the majority would have opted out right?

It's really not that hard an issue to me if we think of it in that manner. Respect the dead and respect the family's wishes.

nofearSingapore said...

Hi drozbloke:
about informed consent & consent forms: In USA, the consent forms may literally be 1/2 cm thick and filled with legal jargon ( cos drafted by lawyers)
I read somewhere, that in some places, the explanation of surgery/complications get video-taped to prove that the patient had been informed about nature of op and hence cannot turn around and say that they don't know.
In Sg, we definitely do not need such a situation. However, although we try to explain salient and known complications, it is impossible to include all, as there are some minor ones that the surgeon may not be aware of.
It will be impossible to practise medicine without trust.
That's why many in USA have given up in view of litiginous environment.

HOTA: from govt/law point of view, if a law cannot be enforced ( ie some can ask to be exempt due to personal reasons), then it becomes problematic. It the leaves to the public servant on the ground to make arbitrary judgements---> lead to complaints of lack of fairness etc.---> then in HOTA, many relatives will then claim for exemption etc.

So while being enacted ( before becoming law), we have to think thru all these aspects.

Hence, parliament should NEVER be a rubber-stamp. All will suffer later!


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The Human Battery said...

Many of you guys here seem to support the way SGH has acted. I would like to think that this is because you guys have been misled by our 146th-ranked newspaper. If you had access to this insider's info, you would have had 2nd thought and be disgusted.

Dah Cow said...

I firmly believe that the HOTA system is wrong. Each individual is entitled to an inherent human dignity and should he pass on without express instructions as to the disposal of his body then the wishes of his immediate kin via intestate should be respected. At no point should the STATE have the power to violently remove organs against the express wishes of the immediate family unless the individual wished it.

And since the HOTA is opt out instead of the more logically opt in, unlike how the brilliant mental cripple Minister Khaw said using the logic that the deceased would be aware of it and since he did not opt out he consented.

Having a system in place that expressly gives your organs to the state unless you state otherwise is inherently undemocratic. How can you be sure that everyone who did not opt out WANTED to donate his organs?

By any sane clear thinking logic, it should be a opt in system, open to family members according to intestate. Then there will be no arguments unlike the scene at SGH which stank of the PRC forced abortions.

Anonymous said...

No fear. Not sure if you have read this?


medifast diet plan said...

Hi im agreed if the person have brain death the organs can created life to another person is hard to accept but the person with brain death will not need them no more thank you .