Life After Death - Precious Human Organs

Vinod Agarwal,
Convenor , North Zone, Dadhichi Deh Dan Samiti

Modern Techniques and advancements in Medical Science and transplant surgery have done wonders for human life. The essential aspect is that death is being pushed away and a human being can extend the life of up to 50 other living beings. It happens in case a patient is declared brain dead, doctors can harvest 35 different organs and tissues to help other patients to enable a blind person to see this world and other ailing persons because of so many chronic diseases to lead a normal life again.

Recently, a family volunteered to donate organs of their brain-dead son in Delhi. The doctors at AIIMS worked almost for 12 hours to retrieve 32 different organs. The family desired to see their son in as many people as possible and decided to donate his organs which benefitted more than 33 patients. It is intended to discuss various significant aspect of organ donation with this back ground.

Basic Concept

For organ donation, a person pledges during her/his lifetime, that after death, organ/s from the body can be retrieved from the body and may be used for transplantation to help terminally ill patients get a new lease of life. According to the law, however, the prerogative on the decision eventually rests with the next of kin of the deceased.

Organs Retrieved from patients who are declared brain dead are called ‘Cadaver Organ Donation’. Organs which can be retrieved are – heart, heart valves, eyes, liver, lungs, kidneys, pancreas, Intestines, larynx, Middle ear bone, skin, bones, etc. Brain death usually occurs before cardiac arrest and the person can be kept on artificial support.

Declaring a Patient ‘Brain Dead’

Brain death is the irreversible and permanent cessation of all brain functions. In situations of brain death, a person cannot sustain his own life, but vital body functions may be maintained in an 'intensive care unit' for a short period of time. Such persons are kept on artificial support to maintain oxygenation of organs so that the organs are in a healthy condition until they are retrieved.

The average time recorded from certification of brain death to organ harvesting was 33 to 46 hours. This is a Medico-Legal process to declare a patient brain dead. A panel of four doctors in any hospital needs to declare brain stem death twice in a time frame of six hours. The panel consists of: the medical administrator in charge of the hospital, an authorized specialist, a neurologist/ neuro-surgeon and the medical officer treating the patient. The authority required to give consent for organ donation lies with the person lawfully in possession of the dead body. There is no charge or payment made on account of organ donation. Healthy organs should be transplanted as soon as possible from the donor to the recipient i.e terminally ill patient.

Legal Aspects on organ donations

Organ donations are legal by Indian law. The Indian government enacted the Transplantation of Human Organs Act (THOA), 1994, which allows organ donation, and legalized the concept of 'brain death'. All these activities involving Organ donation, Organ harvesting and Organ transplantation in our country are monitored by an organization National Organ and Tissue Transplant Organization (NOTTO) working under Central Government.

National Organ and Tissue Transplant Organization

National Organ and Tissue Transplant Organization (NOTTO) is a national level organisation set up under Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India located at 4th and 5th Floor of Institute of Pathology (ICMR) Building in Safdarjung Hospital New Delhi. It has two divisions: 1. National Human Organ and Tissue Removal and Storage Network 2. National Biomaterial Centre

1. National Human Organ and Tissue Removal and Storage Network

This has been mandated as per the Transplantation of Human Organs (Amendment) Act 2011. The network was established initially for Delhi and gradually expanded to other States and Regions of the country. Thus, this division of the NOTTO is the nodal networking agency for Delhi and shall network for Procurement Allocation and Distribution of Organs and Tissues in Delhi. National Network division of NOTTO would function as apex centre for all India activities of coordination and networking for procurement and distribution of Organs and Tissues and registry of Organs and Tissues Donation and Transplantation in the country.

2. National Biomaterial Centre (National Tissue Bank)

The Transplantation of Human Organs (Amendment) Act 2011 has included the component of tissue donation and registration of tissue Banks. It becomes imperative under the changed circumstances to establish National level Tissue Bank to fulfill the demands of tissue transplantation including activities for procurement, storage and fulfil distribution of biomaterials.

The main thrust & objective of establishing the centre is to fill up the gap between ‘Demand’ and ‘Supply’ as well as ‘Quality Assurance’ in the availability of various tissues.

Present Status

There is a vast shortage of donated organs in India as a result of which thousands of patients on the waiting list succumb to disorders as they do not receive an organ in time. As per an estimate

  • 500,000 people die because of non-availability of organs
  • 200,000 people die of liver disease
  • 50,000 people die from heart disease
  • 150,000 people await a kidney transplant but only 5,000 get one
  • 1,000,000 lakh people suffer from corneal blindness and await transplant

Nationally, with a population of 1.2 billion people, the statistic stands at 0.08 persons as organ donors per million population (PMP). This is an incredibly small and insignificant number compared to the statistics around the world. In a study published in the Indian Journal of Anesthesia, the AIIMS Trauma Centre, which admits over 6,500 patients every year, analysed the number of cadaver donations between September 2007 and August 2012. According to this study, in this trauma centre, of the 205 patients declared brain dead at the trauma centre in the past five years, only 10 were potential donors.

According to an estimate more than 90,000 Indians die in road accidents every year and 40% of those people are ‘brain dead’. The experts of this arena opines that 50% of national requirement for all organs could be catered by using organs retrieved from road accident casualties.

Deceased Organ Donation : Year wise (All India basis)

Sl. No. Name of the Organ Year 2012 Year 2013 Year 2014 Year 2015
1 Kidney 352 548 720 1007
2 Liver 147 257 354 510
3 Heart 19 25 54 110
4 Lungs 9 22 16 37
5 Pancreas 1 - 5 4
6 Intestines - - 1 2
7 Hand - - - 4
8 Larynx - - - 1
9 Total Organs 530 852 1150 1675
10 Number of Donors 190 388 411 570
11 ODR(PMP) 0.16 0.26 0.340.5

As reflected in the data given in the above table, In the year 2012, a total of 530 organs were retrieved from 196 multi-organ donors resulting in a organs were national organ donation rate (ODR) of 0.16 per million population(PMP). In 2013, 852 retrieved from 388 multi-organ donors in 2013 resulting in a national ODR of 0.26 PPM. In 2014, 1150 organs were retrieved from 411 multi-organ donors, resulting ODR 0.34 MPM. And in the year 2015, 1675 organs were retrieved from 570 multi-organ donors, resulting in a national ODR of 0.50 PPM.

Looking at the available data for various states(State’s data has not been given for the paucity of space), it is observed that there is more awareness for organ donation in Tamilnadu, Kerala and Andhra Pradesh while the larger states in Northern India like Uttar Pradesh, Madhya Pradesh and Bihar legs much behind in this race. In the year 2015, 519 organs were retrieved from 155 donors in Tamilnadu, 222 organs from 60 donors in Maharashtra, while only 8 organs from 4 donors in UP and 9 organs from 3 donors were retrieved from MP. The data from Union territory Chandigarh is quite encouraging- 97 organs from 33 donors were retrieved resulting ODR 37.0 MPM(it was 5.7 in 2014), the highest in the country.

In the last two years, ODR has doubled from 196 donors in 2012 or 0.16 PMP to 411 in 2014 or 0.34 PMP. The figures may not look impressive enough, but the reflection is given from the figures are of only 10 states and union territories (UTs) of India and the donations resulted in 1150 solid organs like kidney, liver, heart, lung, pancreas and intestine being retrieved, it does become significant. Rather than looking at the national average, it may be better to look at the state wise figures and many states have crossed 1 or 2 donations per million population. It also means that deceased donation transplantation is now responsible for almost 40% of the liver transplants done in the country and over 15% of kidney transplants.

The states that have led the way forward include Tamil Nadu, Kerala, Andhra Pradesh, Maharashtra, Karnataka, Gujarat, Puducherry, Delhi-NCR and Chandigarh. Tamil Nadu leads the table in 2014 with an organ donation rate of 1.9PMP closely followed by Kerala at 1.7 PMP.

The Latest in France

France introduces opt-out policy on organ donation: France has reversed its policy on organ donations so that all people could become donors on their death unless they join an official register to opt out. The new law presumes consent for organs to be removed, even if it goes against the wishes of the family. The legislation was changed in France which means consent for organs to be removed is presumed unless person joins official ‘refusal register’ (Until 1 January, when the legislation took effect, unless the person who had died had previously expressed a clear wish for or against donation, doctors were required to consult relatives who, in almost a third of cases, refused.)

Those who do not want all or any of their organs to be used must now put their name on a refusal register. Alternatively, those vehemently opposed to their organs being used can leave a signed document with their next-of-kin or transmit their wish orally to relatives who must make a written declaration of non-consent to doctors at the time of death.

Further, The European Union has highlighted the lack of organs for transplant and the increasing number of patients on waiting lists worldwide. Its figures claim that in 2014, 86,000 people were waiting for organ donations in EU states,

Measures for moving Forward

Undoubtedly, The donor scene in India is still very ‘dismal’ despite amendments to a law which the government passed in 2008 and other steps being taken by our govt and other agencies. While in western countries around 70-80 percent of people pledge their organs, in India only about 0.01 percent do so, ‘There has been the improvement in the organ donation situation, but much more is required to be done to meet the growing requirement. Things are changing but the pace is slow.

Harvesting organs from a dead body may appear logical from a scientific point of view. But human beings aren't creatures of logic alone. In this regard, the hesitancy surrounding organ donation is understandable. True, extracting healthy organs from a dead body might help save lives. But this is a decision that can only be made by the individual alone.

For even in death, the human body is a representation of the person — someone's child, father or mother, husband or wife. Mutilating the dead body for its organs could be perceived as disrespect. Then ask yourself: how would you like it if someone close to you couldn't be saved, because replacement organs couldn't be found when needed? There are several factors that make organ donation a sensitive subject.

People are not ready to part with organs of their loved ones even after death. Many don’t come forward to pledge organ donation because of religious or superstitious reasons. People have weird thinking like whichever organ you donate, in the next life you will be born without that. The expert opines ‘We need to rope in religious leaders, celebrities and national heros, politicians to make people aware of the need for organ donation.

The act of organ donation has the ability to comfort grieving families. It is always difficult to lose a loved one. Many grieving families of organ donors draw comfort from the fact that their loss may help to save or improve the lives of others. Studies carried out to understand how a family's wounds heal have shown that the support from family members helps a person to overcome grief.

It is also opined by the experts that the organ donation scene could change in the country if the government offers incentives. ‘Donors should also be appreciated on events like Independence Day and Republic Day,’ he said, adding that concessions in railway reservations/ educational institutions and medical benefits to the donors can make others come forward to pledge their organs. The other measures which may also add to give the required results are enumerated below:

  1. Our government may also the bring the legislature similar to France or alike.
  2. The central and state govt should be proactive to create awareness among masses through the district administration and other agencies at war footing like family planning programmes, Malaria eradication schemes etc.
  3. The message should be spread through schools, colleges, vocational and professional colleges. The assistance of HRD Ministry may be sought for this.
  4. The families of Cadaver Organ Donors should be recognized at District, state and National level. It may work as a catalyst in the society. In Hospitals also, the honour Rolls should be displayed at prominent places.
  5. Various NGOs and government agencies are working to increase awareness among the common man. One way to do this is by having driving licenses to double up as donor cards, a practice that’s followed in various Western countries. The Central Government is currently working on a new draft of the Human Organ Rules 2012 in which the health ministry has suggested that all people applying for driving licenses be asked whether they’re willing to donate their organs upon death or not. This belief is echoed by Dr Ashwin Mallya, a surgeon from Sir Ganga Ram Hospital, New Delhi who feels that since most cadaver donors are deaths from road accidents having their assent on their driving licenses would go a long way in fulfilling organ demands.
  6. Support of the media in promoting the cause of awareness and information of organ donation may be part of news bulletin.
  7. Increase in number of hospitals/centres doing transplantation. There are only 120 centres all over India which are deemed capable of organ transplant. One way to counter this would be to follow the Maha govt’s recent move to increase organ donation. The move to make compulsory for all non-transplant hospitals be equipped with an ICU and operation theatre’ to retrieve organs for harvesting and made it mandatory for them to officially identify brain dead patients. This would allow hospitals which don’t have organ transplant facilities to at least harvest organs from brain dead patients for use by the facilities. Increase in number of trained transplant coordinators in the programme and be posted in all the hospitals.
  8. Role of NGOs like DDDS in creating awareness among the public and in hospitals.

References: The information contained in the above article has been retrieved from various web-sites.