J ChungMarch 19, 2013

Ethical issues in 

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• Describe the current situation of organ donation in Hong Kong.

• Discuss the general misconception in organ donation.

• Discuss the ethical issues in organ donation.

At the end of this session, students will be able to:

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A graft is similar to a transplant. It does not removeor replace an entire organ, rather only a portion.

What is organ transplant?

An organ transplant is a surgical operation where afailing or damaged organ in the human body isremoved and replaced a new one.

What is the difference between a graft and a transplant?

Organ transplant 

• Typically refers to transplant of the solid organ• Two sources for donor organs:

– Cadaveric organ donation: a person indicates thathe/she would like to be an organ donor whenhe/she died

– Living organ donation: donor organs is a livingperson. Living donors are often related to thepatient

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Year Organ / Tissue

1961 Cornea

1969 Kidney

1991Liver

Bone

1992Heart

Skin

1995Lung

Combined Heart & Lung

Hong Kong Organ Transplantation

Milestones 

http://www.organdonation.gov.hk/eng/statistics.html

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Organ/ Tissue Donated(cases)

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Waiting(as at 31.12.2012)

Kidney1808Cadaveric 49 74 42 44 50 53 58 65 87 74 59 84

Living 14 9 7 6 8 13 8 12 8 7 8 15Liver

121Cadaveric 23 30 19 20 24 23 26 26 43 42 30 45Living 37 45 36 56 38 48 41 42 41 53 44 33

Heart 10 12 5 7 8 7 5 6 10 13 9 17 17Lung 1 4 0 0 2 1 1 1 2 2 1 3 15Cornea(piece) 239 295 198 230 214 244 198 211 203 250 238 259 500

Skin 37 22 5 30 13 8 13 19 17 23 21 6 uncertain

Bone 6 5 0 4 3 3 1 1 0 6 0 3 uncertainhttp://www.organdonation.gov.hk/eng/statistics.html

Number of organ/tissue donations & patient waiting for transplantation under HospitalAuthority (2001‐2012)

Centralised Organ Donation Register (CODR) 

• Set up by the Department of Health(DH) in 2008

• More convenient for prospectivedonors to voluntarily register theirwish to donate organs after death

• The Register will enable medicalpersonnel responsible for organdonation to know upon the patients'death about their wish to donateorgans

• The bereaved family to acknowledgethe deceased's wish to rekindle livesof other people

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http://www.organdonation.gov.hk/eng/knowmore.html

http://www.organdonation.gov.hk/eng/lightuplives.html

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Ethical issues

How to fairly divide resources?

Distributive justice theory states that there is not one“right” way to distribute organs, but rather many ways aperson could justify giving an organ to one particularindividual over someone else.

Organ shortage… not everyone who needs an organ transplant gets one!      

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• Equal access: Organs allocated according to Equal access criteriabased on objective factors aims to limit biases and unfairdistribution– Criteria: __________________________________

• Free of biases based on race, sex, social status

• Equal access supporters who believe organ distribution processfree of medical worthiness and social worthiness.

Age (youngest to oldest); Length of time waiting 

Distributive justice criteria

Ethical issues

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Maximum benefit: To maximize the number of successfultransplants.

Criteria include:

Medical need (i.e. the sickest people are given the firstopportunity for a Transplantable organ)

Probable success of a transplant (i.e. giving organs to the personwho will be most likely to live the longest)

Distributive justice criteria

Ethical issues

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The central registry prioritizes allocation of cadaveric livers topatients in accordance with objective clinical parameters

Ensure fairness and consistency in distribution facilitate efficient management enable doctors to make judgment based on consensus and to ensure

the benefits of patients

Scoring system (the criteria for cadaveric organ allocation)e.g. Liver transplant

Each patient will be assigned the status probability of pre‐transplantdeath derived from a mortality risk score corresponding to thedegree of medical urgency

http://www21.ha.org.hk/files/PDF/more%20disease%20zone/Liver_Transplant‐eng__revised%209%20Dec%2009.pdf

Ethical issuesHow do we decide who will receive the transplants?

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should someone who has received one organ transplant be given asecond transplant?

should people who have not had a transplant be given priorityover those who have already had one?

should people who have young children to be given a priority overa single person? Over an elderly person?

should people whose lifestyle choices (smoking, drinking, druguse, obesity, etc.) damaged their organ be given a chance at anorgan transplant?

What do you think… 

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捐肝英雄」被遺忘 今年不足20宗•星島日報 – 2012年4月25日 星期三

(綜合報道)(星島日報報道)前年海關督察許細文捐肝救同袍一事感動全城，惟「捐肝英雄」效應卻早已銷聲匿迹。本港今年首四個月只有六宗遺體肝臟移植，料今年總數少於二十宗，屬十年以來新低，至今亦只有十八人獲捐肝重生，院方形容數字更較○九年「跌得驚人」。為增加屍肝移植數字，醫管局由一○年至今已成功進行二宗分肝移植，將一個屍肝給兩名病人進行移植。

09年有96宗移植根據醫管局數字，今年截至三月底只有六名遺體捐出肝臟，九人活體捐出肝臟，共有十八人受惠。瑪麗醫院外科部顧問醫生竺兆豪表示，最高峰期○九年有九十六名患者進行肝臟移植手術，去年降至七十四名，至今年截至四月卻只得十八人，他形容「數字跌得驚人」。他稱現時仍有一百一十五人正等待肝臟移植，但有二十七人卻於等候期間死亡，於等候首四個月因病重不治的，佔當中逾百分之八。

Why is the organ donation rate in Hong Kong so low compared with other developed countries? 

• Hong Kong people usually want to preserve a'complete body' after death.

• The family members or relatives do not like tocause any 'mutilation' to the deceased after death.

• The family members or relatives were reluctant togive consent for organ donation because they donot know the wish of the deceased.

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I am too young/too old  to have to think about organ donation.

Once I have signed the organ donation card, I will not be 

taken care of if I have an accident. 

The transplant of an organ from one body to anothermay not be acceptable according to my religious belief.

Sources: Organ donation, Department of Heath  http://www.organdonation.gov.hk/eng/faq.html

General misconceptions on organ donation 

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I have a history of medical illness and my organs ortissues may not be suitable for donation.

I am worried that the removal of an organ willaffect the appearance of the body and look in thefuneral.

I am worried that all my organs will be taken awayeven if I only wish to donate one of them.

General misconceptions on organ donation 

Sources: Organ donation, Department of Heath  http://www.organdonation.gov.hk/eng/faq.html

• No age limit in general

• Brain Death donors ( with organ function temporarily

maintained by respiratory machines and drugs support) can

donate both organs and tissue

• When cardiac death occurs, the deceased can mostly donate

tissue only, such as corneas, skin and bones

• Has adequate organ function

• No severe / systemic infection

• No HIV infection

• No cancer (except primary brain tumors)

General criteria for deceased donation

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How to determine death?

• Lay persons typically regard the permanent cessationof heart and lung function as determining death; thelaw and the medical profession regard thepermanent cessation of brain function (brain death)as determining death.

• Once brain death has been diagnosed, and consentfor organ retrieval received, every effort is made tostabilize patients before they are taken to theatre fororgan removal. 18

Is the signed organ donation card or organ donation form legally valid in Hong Kong? 

Yes, both the card and the organ donation form are

legally valid.

However, even with a legally valid document,

doctors in Hong Kong will not remove any organ if

the close relatives object. In any event, the

authorization from the close relatives will be

obtained before the organs are removed.

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Reasons for supporting organ donation

• Add extra meaning to life

• A moral act / Act of charity

• Giving people hope, and keep other living

• A “gift of life”

• Set good example

• Feel proud of oneself

• Life is valuablehttp://streetanatomy.com/author/luis/page/7/

Reasons against organ donation

• A lack of knowledge of the wishes of the deceased.

• The belief that removal of organ violates sanctity of deceased / body is sacred.

• Fears of bodily mutilation, e.g. concern about body being cut up after death, want to preserve a 'complete body' after death, body disfigured.

• Dislike of idea of organs inside another person.

• Wrong concept of brain death.

• Against religious conviction, e.g.beliefs that the body must not be mutilated.

• Fear of medical neglect, e.g. less likely to receive medical care, pronounce death even alive.

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伊利沙伯醫院再次發生將癌症患者的器官移植給病人事件，該院五十一歲女病人本月廿日中風不治，捐出心、肝、腎及眼角膜，醫護人員切除器官時已發現死者有胸腺瘤，評估為良性，豈料兩日後的化驗結果證實為早期胸腺上皮瘤，即惡性腫瘤，但心、肝及兩腎已移植到四名病人身上。換心的五十一歲心衰竭男病人因多重器官衰竭，昨凌晨去世；其餘三名病人仍留醫，情況穩定，但體內埋下癌症「計時炸彈」。伊院擺烏龍，死者遺愛人間的良好意願，卻可能令移植器官病人「遺恨」。

五十一歲女病人死後捐出多個器官，本欲遺愛人間，豈料化驗證實女病人生前患癌。

2012年02月24日(五)

http://orientaldaily.on.cc/cnt/news/20120224/00176_030.html

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Should Selling Human Organs Be Legal?

Is it ethical to let organs be sold on the open market?

Should we pay for organs?

Since there is  a shortage of organs…

Live donor transplant 

• Human Organ Transplant Ordinance

– Prevent organ trading – Protect self determination   

A related  donation  (have a close status relationship) his allowed to proceed subjected  to certain preconditions;An related donation is prohibited unless the Human Organ  Transplant Board approves.  

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• The government prohibits commercial dealings in human organs

intended for transplanting, to restrict the transplanting of human

organs between persons who are not genetically related.

• The living donor should be genetically related or is, at the time of

the transplant, the spouse of the donor and their marriage has

subsisted for not less than 3 years.

Hong Kong Human Organ Transplant Ordinance

(Chapter 465)

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Section: 4 Prohibition of commercial dealings in human organs

Section: 5A Organ transplants between spouses or genetically related persons

Living organ donation 

AdvantagesThe donation can be pre‐arranged. The patient  can take the anti‐rejection drug in advanceBetter matches between donors and recipients (genetically related to the patients)  Psychological benefit for both donors and recipients 

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Disadvantages Physical: Pain, discomfort,infection, bleeding, potentialfuture health complications

Psychological: Family pressure, guilt or resentment

Pressure: family membersmay feel pressure to donatewhen they have a sick familymember

No donor advocate (Vastag, 2003) 

Organ donation in Hong Kong 

• In Hong Kong, as in most other communities, family consentis a necessity for organ donation, irrespective of anindividual’s intention as indicated by a donor card.

• Cadaveric organs and tissues are treated as public assets,but the individual or family may prohibit organ removal,thereby preserving autonomy.

• Organ donation by living donors presents a unique ethicaldilemma, in that physicians must risk the life of a healthyperson to save or improve the life of a patient.

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References: 

Human Organ Transplant Ordinance, administrative guidelines (2011)

http://www.dh.gov.hk/english/links/files/HOTO_Administrative_Guidelines_English.pdf

Hong Kong Medical Associationwww.hkma.org/chinese/care/care.htm

Hong Kong Human Organ Transplant Ordinance (Chapter 465)

http://www.legislation.gov.hk/index.htm

Organ donation website [愛心獻再生網站]http://www.organdonation.gov.hk/eng/lightuplives.html

Kim, J.R., Fisher, M.J., & Elliott, D. (2006). Attitudes of intensive care nurses towards brain deathand organ transplantation: Instrument development and testing.  Journal of Advanced Nursing, 53(5), 571‐582.

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Vastag B. (2003) Living‐donor transplants reexamined: experts cite growing concerns aboutsafety of donors. JAMA. Vol .290(2), pp.181‐2,