It is not possible to discuss about organ donation after death without first having a clear concept of what is medically defined death. Traditional definition of death had been when the heart stops pumping and when all visible activity of vital organ system has stopped. Yet we know today that millions of people had undergone open heart surgery where in the heart was stopped during surgery for a variable period of time using a heart-lung machine to maintain the circulation and they wake up alive and better than before! What determines the life of person clearly does not totally depend on whether the heart is pumping or not as long as there is an alternative way to supply the essential circulation and with it the nutrients the person will not die. Whereas essential heart and lung functions can be taken over by machines, the capacity to mental function cannot be replaced artificially. Hence it is only when the brain had completely ceased to function and has no possibility to recover that real death occurs.

The real centre of control of human life lies in an area between the brain proper and the spinal cord. This small but vital area is known as the brain stem. Within it lays the control mechanism for our respiration, consciousness and circulation control. It is this area that contains the pre-requisite for all possible intellectual and physical activities. When the function of the brainstem ceases, no possible recovery of life can be expected and all bodily functions will cease within a short time without artificial support. Death ensures and is unavoidable. Our modern medical concept of death is really a "Brain Stem death".

Organ donation in Brain-Dead patient

Modern artificial support systems can maintain the function of the vital organs such as the heart, lungs, liver and kidneys for a period of time while the brain stem has ceased to function.. There are well tested and well proven criteria to determine brain death in a patient in the intensive care unit setting. In such situation, the brain is dead but the heart and lungs are kept alive by drugs and machines. Discontinuing artificial support invariably results in these organs to lose their viability within a short time. It is in this situation when organs can be maintained for a period of time without losing their functions or viability that the question of organ donation arises.

Hence it is wrong to think that by having a legislation to govern organ donation all persons will be forced to donate their organs upon their death. It is only this very small group of patients in the intensive care unit with brain death but viable organs maintained by artificial means that are suitable for organ donation.

In this very small subgroup of patients with brain death, further criteria have to be fulfilled before they can be considered for organ donation. In the case of kidney donation for example, the potential donor must be under the age of 65 years, free from infections, AIDS, with no cancers and has no previous history of diabetes, high blood pressure etc., which might potentially cause kidney disease. This is to ensure that only healthy organs free from potential infections or cancers can be transplanted, in practice, this group of patients are almost invariably young patients who suffered irreversible brain injury during road traffic accidents brain bleeding or death due to severe asthma.

When we look at these criteria objectively, the number of potential organ donors will be very small indeed. Despite the mandatory organ donation law in Singapore, in a small population with very low motor vehicle accident and brain death rate, the available organs are very few indeed in our country, with an unfortunate high annual rate of death caused by road traffic accidents, the pool of potentially suitable donors will be much larger. Having say that, it will be beyond the government’s wildest dreams if we can have even 100 donors a year! If we put a conservative figure of 80 new cases of kidney failure per million population a year and 50% of these patients can be transplanted, we will still need to transplant approximately 700 patients a year (i.e. 350 donors). In the 41 years since independence in our country, we have less than 20 cases of cadaveric donations of kidneys!

The story of patients with kidney failure is filled with sadness in this country. Because it is possible to maintain the life of these people with dialysis, the demand for such treatment is ever increasing. There is no light at the end of the tunnel except transplantation. New cases will increase everyday while old patients on dialysis can be maintained alive for years. Unless there is an active transplantation program to take these patients out of dialysis, there will be no end to the needs of machines and personnel. Further, the quality of life after a successful transplantation is far superior than the three times weekly dialysis patients. The long term cost of drugs and maintenance treatment after transplantation also drops to about a third of that required on dialysis.

For these reasons, the taxpayer cannot possibly go on expanding the dialysis facilities limitlessly. However, the current situation in our country is certainly not much to be proud of. In government hospitals, dialysis therapy is only provided for civil servants, those awaiting for transplants and those who had failed their living-related transplants. The great majority of the patients are forced to seek expensive private dialysis facilities. In most private institutions, the patient may have to pay up to RM2000 or more a month to keep going.

It is for this reason that we hope by providing more patients with a hope of transplantation and return to normal productive life, those dialysis facilities can be used for those who are not eligible and the total number of dialysis patients kept down to a reasonable figure. In order to do this, a plan for cadaveric donors from brain death patients is unavoidable based on our current state of knowledge and art .

The process of organ donation:

There were doubts expressed as to whether the doctors and hospitals could be less than enthusiastic in saving life in order to obtain organs for transplant. By the very nature of definition of brain death, this is not possible without all efforts made to keep an injured person alive by supporting the person with all the best and advanced machines known today, otherwise the patient will die from his organ failure before the brain death and his organs are of no use for the purpose of transplantation. The sequence of events is clear-cut, if we keep every organ alive and the brain dies, the situation is irreversible. However, should one of these organs lose function and the brain die as a consequence of it, the organ is of no use anyway. There can be no doubt as to the utmost effort being made to save a victim’s life before the possibility of a brain-death in the intensive care unit selling could even arise.

In normal situation, upon suspected brain death of a patient in the intensive care unit with the patient on life support system, the transplant team, nephrologist or the surgeon cannot be involved in the decision of diagnosing brain death. This decision is always done by the other consultants of different discipline separately on at least two different occasions several hours apart. The diagnosis has to be made only after a set of rigidly defined pre-conditions has been satisfied and another set of strict clinical tests has been performed by these 2 consultants separately before a diagnosis of brainstem death can be made. The transplantation team’s involvement can begin only after the diagnosis has been clearly established and recorded and the consent of the pathologist or public coroner obtained.

At this juncture, the bereaved relative are always approached. While we sympathised with their loss, nevertheless, a suggestion of the possibility of the noble act or organ donation will then be proposed. The relatives’ opinion and choices are always respected and the implications carefully discussed. If the deceased has indicated the wish for organ donation during life, then there is no question about his/her wishes. If not, the relatives will be approached to consider organ donation for the first time, and in the light that their loved one stands no chance of recovery. This is of course carried out tactfully by a trained professional person, either a medical professional or a trained transplant co-ordinator.

The harvesting of the organs donated is a major operation by itself. It is always conducted in the same way as a normal operation in the theatre, with proper sterile gowns and equipment and upon completion of the operation the wound is also closed in the standard manner as would any other operation. Except the surgical scar there is no disfigurement.

The relatives will also be informed of successful transplantation. However, no names or identification of the recipient will be made known to them. This is to avoid the possibility of trading or other forms of financial rewards. We in the medical profession respect the noble act of organ donation and would not blemish the deceased by allowing it to be converted into some form of organ trading.

Conclusion:

The state of care of patients with kidney failure in our country is far from satisfactory, if not deplorable. This did not stem from a lack of expertise or medical manpower, but from a lack of social awareness and public neglect, it is high time that we Malaysians look at this group of unfortunate patients and act. We must together attempt to lessen the problem, if not solve it. We Malaysians are one of the most benevolent society in the world, there is no lack of everyday newspaper appeals for funds and no lack of donors, why should we donate our money to encourage the evil organ trading in India and China, where horror stories abound the greedy middlemen and mercenary doctors there get rich selling organs? Why should we not channel our money, resources and love within our own country to make our own cadaveric transplantation program a success?

The act of organ donation after brain death is the most noble act of the deceased, for although the body is dead. The love for others survived - and like a phoenix after the fire, it has allowed someone else to reborn and a gift of a leash of new life is an act next to God.

For those who may be interested to find out more, contact

National Kidney Foundation:
28-2 Jalan Hang Lekiu
Kuala Lumpur
Tel: 03-2012437

Malaysian Transplant Society
C/O Institute of Urology
Hospital Besar
Kuala Lumpur

Haemodialysis and Transplant Unit
Ward 13C
University Hospital
Kuala Lumpur