The 6th National Bioethics Conference (6th NBC) was held from 13th - 15th January 2017 at YASHADA, Baner Road, Pune. The theme of the 6th NBC was Healing and dying with Dignity: Ethical Issues in Palliative Care, End of Life Care and Euthanasia. One of the sub-themes was ‘Organ donation and body donation in the context of end-of-life care decision making.’
MOHAN Foundation was one of the collaborating bodies and organised a symposium on ‘Organ Donation & Transplantation in India - Ethical Challenges and Solutions’ at the 6th NBC from 2 pm - 3.30 pm on Saturday 14th January 2017. The facilitators were Dr. Sunil Shroff, Managing Trustee and Dr. Sumana Navin, Course Director. The audience comprised doctors, transplant coordinators and social workers.
Background of the symposium
Organ donation and transplantation in India is fraught with ethical challenges and dilemmas. Living donation was synonymous with organ commerce till the law makers stepped in to regulate it. In spite of this, scandals repeatedly surface and the recent incidents in private hospitals in Delhi and Mumbai have thrown up more questions than answers. Given that the requirement for organs is not going to go down anytime soon, living donation is something that one has to live with. This means that the ethical concerns surrounding living donation need to be addressed. Deceased organ donation and transplantation needs to be examined just as carefully, if not more, since altruism is the cornerstone here. The ethics with regard to the needs of the families of deceased donors, transparency in organ allocation, directed donation, uniform declaration of death, validity of the pledge form, information about recipients need to be clarified.
The symposium began with an overview of Transplantation ethics by Dr. Dominique Martin, Deakin University, Australia. She set the tone by outlining some ethical challenges –
She said that Transplantation ethics was a dynamic field and that the internet was now a key influencer in terms of donor recruitment, travel for transplantation and trust in organ donation and transplantation
The next session was on Living donation: can we get it right? The three topics covered here were –
1. Overview of current living donation scandals in hospitals & Falsifying relationship documents - should doctors be held responsible? – Dr. Sunil Shroff
Dr. Shroff started with a case study - the kidney scandal in Hiranandani Hospital, Mumbai and the perspectives of the various players. He spoke about how one could identify document discrepancies, many a time, by creating a master chart with details of different proofs of identification. He added that it was important for the doctors to spend time with the potential donor and recipient. In addition, the hospital authorisation committee needed to remain extremely vigilant.
2. Effect of living donation scandals on Donation after Brainstem Death – Dr. Atul Mulay, Ruby Hall Clinic, Pune
Dr. Mulay said that sensational headlines regarding organ trade in the media had an adverse impact on the deceased donation and transplantation programme. There was a fear of removal of organs without consent and that doctors would sell the donated organs. He said that this fear could be countered by increasing public awareness, transparency about the deceased donation process and participation of public hospitals.
3. Role of a hospital based ethics committee - Mrs. Arati Gokhale, ZTCC – Pune
Mrs. Gokhale spoke about who were the members of a hospital based ethics (authorisation) committee and their role as per the legal framework in India. She also detailed the procedure in vetting a living donor and potential recipient.
The last session was on Deceased donation: dilemmas and decisions. The four topics in this session were -
1. “Dead enough to donate organs, but not dead enough to discontinue ventilation” – Should Brain stem Death declaration be made mandatory? – Dr. Sushma Patil, Ruby Hall Clinic, Pune
Dr. Patil pointed out that brain stem death certification needed to be done to avoid unnecessary prolongation of treatment. In India, since brain stem death certification is mentioned in the context of organ transplantation it has led to untenable situations. Transparency and rigorous adherence to protocols could help circumvent such situations to a certain extent, but in the long run greater clarity from the lawmakers is required.
2. Directed deceased donation - are there any ethical challenges? - Surg Cmde (Dr) C S Naidu, AFMC, Pune
Dr. Naidu said that living donation is usually directed (to a specific recipient), while deceased donation is governed by a societal and legal framework and therefore is largely non-directed. Some of the questions raised were - Does this mean that autonomy can be exercised only when one is alive? Who decided that the ‘gift of life’ is a public resource? An organ – private property or societal resource – the debate continues, but there is no role for dogmatism.
3. Ethical issues in organ allocation in deceased organ donation - Dr. J. Amalorpavanathan, Chennai
Dr. Amalorpavanathan dwelt on the dilemmas of allocating a scarce resource like organs - should the sickest person get it or should the person in whom graft survival is longest, should all be treated equally, how does one maximise total benefit, should simplicity be the hallmark of allocation, what role does affordability have?
4. The two faces of social media in organ donation - Ms. Pallavi Kumar, MOHAN Foundation
Ms. Kumar spoke about the enormous reach of social media today and the fact that it was a double-edged sword. It has an extremely dark side to it in terms of the ease with which commercial dealings in organs can take place across the globe. On the other hand, there are powerful positive campaigns and real-life stories that create awareness about organ donation and the impact of lifesaving transplants.
The eminent chairpersons for the symposium were Dr. Samiran Nundy, Emeritus Consultant, Gastroenterology & Liver Transplant, Sir Ganga Ram Hospital, New Delhi and Dr. Aamir Jafarey, Centre of Biomedical Ethics and Culture, SIUT, Karachi. One of the points that Dr. Nundy made was that living donor deaths should be reported, and not swept under the carpet. Dr. Jafarey was emphatic in saying that we needed to move from “what is” to “what it ought to be.”
Dr. Sunil Shroff, Managing Trustee, MOHAN Foundation was one of the keynote speakers for a plenary session on Bodies in law, humanities and medical sciences: who declares me dead and why? He spoke on ‘Brain death and the need for Uniform declaration of death in India.’ He made a strong appeal to delink the declaration of brain death from organ donation. He also stressed the need for guidelines regarding removal of mechanical ventilation once brain death is certified.
In addition three papers from MOHAN Foundation were selected for presentation at the 6th NBC. The presentations were –