Optingin vs opting out - Malaysian Thoracic Society

Malaysian Thoracic Society Annual Congress (MTS 2016), 29 July 2016, Penang

Lung Transplant – Opting In vs. Opting OutHirman Ismail MD (UKM) MPH (Nottingham) Head of Transplantation Unit, Medical Development Division & Honorary Secretary to the Malaysian Society of Transplantation


Objective Main objective of this presentation is discuss on suitability of opting out system as an option in authorisation for removal of human organ and tissue in Malaysia.


Content Introduction Transplant legal framework in Malaysia Opting in vs. opting outConclusion


INTRODUCTIONDefinition | Why this is happening? | Why we need to fight?


Demand of organs in MalaysiaORGAN NUMBERKidney 20,777Liver 5Heart 5Lungs 2Heart & lungs 6TOTAL 20,795

Source: National Transplant Resource Centre, National Renal Registry 2016

200020012002200320042005200620072008200920102011201220132014201501020304050607080

16

2430

25

1613

25 25 26

39 38

4744 44

56

71

30 31

42

2932

42

29

45

3235

27

44 46

56

29 31

No. of Organ & Tissue Donor (Deceased vs. Living) in Malaysia, 2000 - 2015

Deceased LivingMalaysian Thoracic Society Annual Congress (MTS 2016), 29 July 2016, Penang


Kidney Liver Heart Lungs Heart & lungs

0200400600800

1,0001,2001,400 1,292

69

511

64 26 6 4

No. of Organ Transplantation performed in Malaysia, 1975 – April 2016

Living DeceasedMalaysian Thoracic Society Annual Congress (MTS 2016), 29 July 2016, Penang




2005 2006 2007 2008 2009 2010 2011 2012 2013 2014020406080

100120140160180200

No. of Kidney Transplant Recipients in Malaysia, performed locally (public &

private institutions) vs. overseas, 2005 - 2014

Total Overseas LocalMalaysian Thoracic Society Annual Congress (MTS 2016), 29 July 2016, Penang

Source: 22nd Report of the Malaysian Dialysis and Transplantation Registry 2014


2005 2006 2007 2008 2009 2010 2011 2012 2013 2014020406080

100120140

No. of Kidney Transplant Recipients in Malaysia, performed locally (live donor & cadaveric) vs. overseas, 2005 - 2014

Overseas (commercial) Local (live donors)Local (cadaveric)

Malaysian Thoracic Society Annual Congress (MTS 2016), 29 July 2016, PenangSource: 22nd Report of the Malaysian Dialysis and Transplantation Registry 2014

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 201505,000

10,00015,00020,00025,00030,00035,00040,00045,00050,000

7,49210,081 8,885

12,24215,996 15,861

30,529

21,040 22,522

37,093

45,580

No. of Malaysians Pledged as Organ Donors, 2005 - 2015

Total Chinese Indian MalayMalaysian Thoracic Society Annual Congress (MTS 2016), 29 July 2016, Penang



Transplant legal frameworkHuman Tissues Act 1974 [Act 130] | Anti-Trafficking in Person Act 2007 [Act 670] | Private Healthcare Facility and Services Act 1997 [Act 586] |Medical Act 1971 [Act 50\




Opting in vs. opting outDefinition | International perspectives | Malaysia’s perspectives


Definition Also known as “presumed consent” is “(t)he system by which consent to donate is presumed unless a person has expressly indicated otherwise during his/her lifetime

Source: Jennifer Dolling. (2009)


Variant of opting out system

“Soft” vs. “hard” opting out system In “soft” system – family is still consulted and has final say even though by law it is not required In “hard” system – family is not consulted or not even informed. Even if there is doubt, removal will still take place

“Selective” opting out systemIn 1987, Uniform Anatomical Gift Act (“UAGA”) in the US allowed removal of cornea, pituitary gland if the body under the custody of coroner Source: Jennifer Dolling. (2009)


Opting out – increases donation rate?

Shepherd, L et al (2014) reported “Deceased donor rates (per-million population) were higher in opt-out (M = 14.24) than opt-in consent countries (M = 9.98; χ = -4.27, 95% confidence interval (CI) = -8.08, -0.45, P = .029)”. Kidney and liver transplantation rates (living and deceased) are higher in opting out countriesNo. of living donors is higher in opting in countries


Source: Shepherd, L et al. (2014)

PhillipinesMalaysiaThailand

Saudi ArabiaTurkey

AustraliaCanada

UKFranceAustria

USSpain

0.2300.500

2.9002.900

6.28018.300

15.70020.200

25.50022.900

25.48839.700

Deceased organ donation rates (per mil-lion population) by country, 2013

Malaysian Thoracic Society Annual Congress (MTS 2016), 29 July 2016, PenangSource: Global Observatory on Donation and Transplantation WHO 2013

Opting out – ethical consideration

Autonomy – encroachment into personal autonomy, ability to exercise opting out (esp. by vulnerable groups)Beneficence vs. non maleficence – psychological effect to family members after the donation if they don’t agree to itJustice – ability to exercise exercise opting out (esp. by vulnerable groups)


Opting out – in Malaysia?Awareness and acceptance towards organ donation is still lowNegative impression and perception need to be carefully studied Cultural consideration Religious consideration




Source: Medical Practice Division. (2013) Online Public Engagement on Proposed New Law on Organ Transplantation. [Unpublished Report]. Ministry of Health Malaysia

Agree

Disagree

Not sure

28.90%

64.70%

6.38%

In your opinion, should Malaysia practice opt-ing out system in authorisation for removal of

human organs and tissues?

N = 1,581


Conclusion


Conclusion The option on opting out system has been widely discussed in Malaysia Opting out system is not the only way to improve organ donation ratesEven though, transplantation rate is better in countries with opting out system, cultural, ethical and religious considerations shall be further studied before it can be implemented in Malaysia


References Jennifer Dolling. (2009) Opting In To An Opt-Out System: Presumed Consent As A Valid Policy Choice For Ontario’s Cadaveric Organ Shortage [Unpublished thesis]. Graduate Department of the Faculty of Law University of Toronto. Available from : https://tspace.library.utoronto.ca/bitstream/1807/18276/1/Dolling_Jennifer_M_200911_LLM_thesis.pdf [Accessed 16 June 2016]Medical Practice Division. (2013) Online Public Engagement on Proposed New Law on Organ Transplantation. [Unpublished Report]. Ministry of Health Malaysia Shepherd et al. 2014. An international comparison of deceased and living organ donation/transplant rates in opt-in and opt-out systems: a panel study. BMC Medicine.12:131. Available from : http://www.biomedcentral.com/1741-7015/12/131 [Accessed 17 June 2016]Medical Development Division, 2007. National Organ Tissue and Cell Transplantation Policy. Putrajaya: Ministry of Health Malaysia. Medical Development Division, 2011. Unrelated Living Organ Donation: Policy and Procedures. Putrajaya: Ministry of Health Malaysia. Ministry of Health Malaysia, 2012. Policy on Unrelated Living Organ Donation. [Circular Letter by the Director General of Health], 4 January 2012, available at: http://www.moh.gov.my/attachments/1763 [accessed 6 February 2012]World Health Organization, 2010. WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation. New York: WHO.



Thank you [email protected] | Twitter @DrHirman #MedTweetMy | www.about.me/hirmanismail

Health & Medicine

Optingin vs opting out - Malaysian Thoracic Society