The Human Organ Transplant (Amendment) Bill Second Reading Speech

23 Mar 2009

By Khaw Boon Wan

1. Mr Speaker, Sir, I beg to move, “That the Bill be now read a second time.”

2. This is the third time I am coming to the House to seek Members’ support to amend the Human Organ Transplant Act (HOTA).  I am grateful to Members for your strong support for the previous amendments.  As a result, we have been able to save the lives of more patients with organ failure who would otherwise die prematurely or live in misery.  Prior to the first round of amendments in 2004, there were, on average, 13 cadaveric kidney transplants in Singapore under HOTA each year, about one a month.  Now, we are doing an average of 41 such transplants a year, more than three times as many.  This is almost one every week.  The two rounds of amendments have helped save many more lives.

3. I am now ready to seek Members’ support for the third round of HOTA amendments.  There remains a shortage of organs.  Last year, 26 patients died waiting for an organ; currently, more than 560 patients remain waiting.  We must continue to try to raise both our cadaveric and living donor transplant rates.

Proposed Amendments

4. We intend to do this by making the following changes to the Act.

5. First, we propose to remove the upper age limit for cadaveric organ donation under HOTA.  This will increase the number of cadaveric donors.

6. Second, we propose to allow paired matching for the exchange of organs between living donor-recipient pairs. This will facilitate living donor transplants.

7. Third, we propose to remove the prohibition of payment to reimburse or defray the costs or expenses of living organ donors.  This will better protect their welfare and ensure that they do not suffer from additional losses because of their altruistic acts.

8. Finally, we propose to raise the penalties on middlemen and syndicates that engage in organ trading.  This will help to deter organ trading.

9. Let me now go into the details of the amendments.

(a) Remove Upper Age Limit

10. Currently, organs from deceased persons who were over 60 years of age at the time of death are not removed for transplant under HOTA even though their organs may be medically suitable for transplant.  The limit of 60 years was set many years ago as a indicator of a person’s health in relation to his suitability as a donor.  In practice, however, whether an organ can be used for transplant depends on the organ’s condition, not the age of the donor.  Clause 2 of the Bill will remove the age limit of 60 years for cadaveric organ donation under HOTA.  As it is with all transplants today, before any organ is removed, a transplant doctor will assess the organ’s condition to ensure that it is suitable for transplantation.

11. We estimate that the removal of the age limit could increase the number of cadaveric organ donors by 10 to 12 each year, about 1 a month.  This would potentially save and benefit 70 more patients a year.

12. If the Bill is passed, we will carry out intensive public education to inform persons over 60 of how they will be affected.  They will be given time to decide whether or not to opt-out of HOTA.  The Bill clarifies in clause 6 that those who have already opted out of HOTA before this amendment will continue to be excluded even when they turn 60, unless they have withdrawn their objections.  In parallel, we will also remove the upper age limit of 60 years for patients to be placed on the transplant waiting list.  This will allow more elderly patients to benefit from organ transplant, which is a fair arrangement.

(b) Allow Paired Matching

13. Second, clause 3 of the Bill will allow “paired matching”.  This is a way of matching living donors with compatible recipients across two or more medically incompatible donor-recipient pairs.  The recipients essentially exchange donors so that each recipient can receive a medically suitable organ.  Currently, HOTA does not explicitly allow this.

14. We have had patients with relatives who were willing to donate their organs, but who were found to be medically incompatible.  These patients thus had to be placed on the cadaveric organ waiting list for a suitable organ.  With “paired matching”, arrangements could be made for the relative of a patient to donate his organ to another medically compatible patient in return for that patient’s relative to donate an organ to the first patient.  This way, more patients can be matched with a suitable living organ donor.

15. Such “pair-matched donations” already take place overseas, such as in the US and UK.  The Johns Hopkins Hospital was particularly successful, having transplanted over 50 patients involving more than 20 exchanges since its paired kidney exchange programme start in 2001.  It also performed the world’s first known 3-way swap (3 pairs), bringing 6 willing donors and recipients together for simultaneous operations in 2003.  Recently, two lives were saved in Hong Kong’s first paired exchange liver transplant where the wife of a patient and the sister-in-law of another patient cross-donated part of their livers.  With our small population, the number of donor-recipient pairs that can be successfully matched may not be large, but such exchanges should be allowed where possible.  To facilitate matching, we will set up a living donor registry.

(c) Allow Payment for Living Donors

16. Currently, HOTA prohibits all forms of payment to organ donors, including the reimbursement for the costs and expenses that they incur.  For example, any reimbursement of lost income or medical expenses incurred by the donor is illegal.  This position is outdated and is unfair to the donors.  It is not in line with accepted ethical practice in other countries.  Many countries have already updated their legislations to provide for such reimbursements.  For instance, US law permits reasonable payments associated with the medical costs, and other expenses of travel, housing, and lost wages incurred by the donor due to the donation.  In the UK, payments to defray or reimburse any expenses or loss of earnings incurred by a living organ donor so far as reasonably and directly attributable to his donation are allowed.

17. Clauses 3 and 5 of the Bill will amend the Act to permit the comprehensive reimbursement of costs and expenses - such as for short- or long-term medical care or insurance protection - and loss of earnings, which may be reasonably incurred by living organ donors as a result of their donation.

18. This amendment does not condone organ trading or legalise it.  It seeks merely to allow some patients who wish to defray or reimburse the costs or expenses which their donors may incur, to ensure that these donors do not suffer financially as a result of their altruistic acts.  This is based on the ethical principles of equity and fairness, which demand that we protect not just the welfare of the recipients, but also that of the donors.  Our proposed amendment does not mandate, but merely allows, some reasonable payments to be made to the donors, insofar as they do not constitute an inducement to the donor.

(d) Increase Penalty for Syndicated Organ Trading

19. Finally, clause 3 of the Bill increases the penalty for syndicated organ trading.  The current penalty in HOTA for organ trading does not distinguish between the buyer, the seller and the middleman.

20. In syndicated organ trading, both the buyer and seller are exploited by the middleman, who often creams off a significant portion of the transacted amount.  We all sympathise with the plight of patients suffering from organ failure, as well as those who may be driven by desperation to sell their organs in order to make ends meet.  Within the existing framework that criminalises organ trading, we propose a specific, aggravated offence for middlemen and syndicates who engage in organ trading, with an increased maximum penalty of a fine not exceeding $100,000 or imprisonment not exceeding 10 years, or both.  This is a ten-fold increase from the current maximum penalty and will serve as a greater deterrence for these middlemen and syndicates and protect the vulnerable from being exploited.

Public Consultation

21. These proposed amendments were extensively discussed over several months last year, among the public, and the medical and professional organisations.  A formal public consultation based on the text of a draft Bill was further organized during the last two months of the year.  We received strong support for all the proposed amendments.  There were two concerns with regard to payment for living organ donors.

(a) Use of the Term “Compensation”

22. First, there was concern over the use of the term “compensation”.  Some Singaporeans felt that it might be misconstrued as the legalisation of organ trading.

23. We have thus removed the term “compensation” and instead used the words “defraying” and “reimbursing” to refer to the payment to cover the costs or expenses that a donor incurs as a result of his donation.  Hospital transplant ethics committees will continue to screen living donor transplants to weed out organ trading.  In addition, clause 5 of the Bill allows us to make subsidiary legislation, if necessary, to regulate and administer reimbursement and the payment process, as an added safeguard against organ trading.

(b) Applicability of the Law on Payment to Foreign Donors

24. Second, some suggested that foreign donors should not be paid, as what is a reasonable quantum in Singapore may end up inducing the poor in the region to sell their organs.  We appreciate the underlying concerns and we certainly do not wish Singapore to become a regional organ trading hub.  But we cannot address these concerns by enacting a law that unfairly discriminates against organ donors based on their nationality.  The principle underlying this amendment is one of fairness to donors.  We achieve this by allowing donors to be comprehensively reimbursed for costs, expenses and lost earnings that they incur.  It would be patently unfair if a donor in Singapore who is a citizen can be reimbursed, but a donor in Singapore who happens to be of a different nationality cannot.  Instead, we will continue to rely on the hospital transplant ethics committees, and our law, to prevent organ trading.

Lifting the Whip

25. Mr Speaker, Sir, as with past amendments to HOTA, I have asked that the Whip be lifted to allow Members to debate and vote on the Bill based on their religious and ethical beliefs.

26. If the House supports this Bill, my Ministry will continue with its efforts to increase the awareness among Singaporeans of these amendments and their implications.

Conclusion

27. Sir, today, many Singaporeans continue to suffer as a result of the shortage of organs for transplant.  We must try all reasonable means to maximise our yield of cadaveric donors and to promote altruistic living donor organ transplants.  Our proposed amendments will not eliminate the shortage of organs, but they will help to save more lives and reduce suffering.  I hope this House will join me in this mission.

28. Sir, I beg to move.