Tuesday, May 6, 2008

Kidney Transplant

Wanted to document my thoughts on something I read recently in The Hindu and that which set me to think on a few related things.

A chennai doctor has opined that sensitizing the public on cadaver transplantation for organs like kidney would greatly address the large imbalance
in the demand and supply(Ah..well, thats the kind of language they speak) of kidney for the patients requiring transplantation. This is not just his personal opinion
but a view shared by many. He also adds that such an initiative has paid off in the case of eye donations. I think there is a distinct difference between the two scenarios which relates to the issue of "brain" dead and the "real dead" dead, and this difference is what makes this suggestion extremely scary to me.

Some basic information on this (whole write-up is described in the Indian context).

Treatment options for the end-stage kidney disease are life-long dialysis and kidney transplantation. Dialysis is not a permanent solution and may become medically unviable to continue after some time. Kidney transplantation is recommended for end-stage renal failure as the patient can get back to near normal life style after the surgery and post- operative care. Kidney transplantation can be acquired from a live or a cadaver donor. In India majority of the kidney transplantation is
a live donor transplantation, where a near relative donates
one of their kidneys to their dear ones. Organ transplantations from a cadaver constitutes a very small percentage.

Cadaver transplantation is a process where healthy live organs from patients who are declared "brain dead " are retrieved and transplanted in patients with end-stage disease. The eye donations (which I personally do strongly advocate and has materialized convincing my own family in the case of two of my grand parents) are distinctly different in the sense, they are taken from a “dead dead” person within a short period of time after the actual clinical death of the person. But most other organ donations like kidney for organ transplantation is done in the setting of brain death.

Let me just summarize some of my understanding on this issue of brain death focusing on this specific context of organ transplantation. Traditionally, death has been defined as the cessation of all body functions, including respiration and heartbeat. It became possible to revive some people after a period without respiration, heart beat, or other visible signs of life by maintaining cardiovascular and pulmonary functions of the body through modern medical technology. But these technologies indiscriminatingly sustain such bodily functions on people who are considered by the medical community as having irreversibly lost all brain functions and also of those who are critically ill patients. With modern medical technology blurring an important distinction between those who are dead(read "brain" dead ), those
who are dying and those recovering from a life saving surgery or severe trauma- defining death with better criteria became an important issue. One of the reasons for the update of definition of death is this issue of obtaining viable organs from neomorts for transplantation.

This definition of brain death and the consequences of it are a highly contentious issue. Independent of the transplant interest to this definition this usually raises heated debates on various counts such as its consequences to the question of continuing life support to the brain dead. Over the world when issues of Euthanasia, mercy killing questions props up it is argued and debated with strong emotions by the rationalists, religious bodies and the larger public.


Though sort of digression to the topic in discussion, I have an intense unease towards the arguments and rationale put forth against continual of life support to the patients who are perceived by the medical community as “brain dead”.
I personally had to deal with this situation twice in my own life to argue to continue with life support when it was perceived by the medical community as a futile exercise. In modern medical decision making, personal choice is upheld as the highest good(I have some disagreement even on this, but that is something that will be hard to contest through reasoned arguments). On instances when that was not feasible (patient is not in a state to make a decision and does not have a will expressed before), immediate family is put into an unenviable position of having to decide on behalf of the patient. The arguments in favor of pressuring the family ranges from limited medical resources being put into effective use to have to evaluate the “quality of life” of the dying individual. I completely fail to understand what is this quality of life that these people talking of?. Does not ones life have a meaning if he/she cannot experience the sensory pleasures and the life needs to be rendered futile. Does not ones life serve a purpose for the simple fact that the satisfaction it brings to their immediate family that the person is still surviving (this becomes all the more relevant in instances when the life in question is too young to die)? In a normal instance everyone does value quality of life as prime is accepted, but in the end of life process, quality of life is often surrendered early on. And the argument on putting resources to effective use is not so much about bed shortages in the hospital or a case by case evaluation of the hour and money spent on some one who has a better chance of survival than the other.


Getting back to the defining death(brain dead) for the purpose of organ transplantation, I think it is a legitimate fear that a dying person would be less aggressively cared for if that person is perceived by the doctor to be a potential source of organs. I don’t think that these concerns are unfounded and can be ignored as something that does not warrant any serious thought. Given the crass commercialization and the consequent compromise on the ethical/moral standards of the medical professionals this is a serious issue. The people who have carried out surgeries on unwilling/un-informed donors or those who have been bought for money are not some quacks or crooks, but actual doctors trained at some of the best colleges in India and abroad and are recognized by the Indian Medical Association(IMA)

In the current climate of general public distrust of medical professionals, if public confidence in such transplantation programs is to be established, a high level of scrutiny by the government and a body of well meaning medical professionals must first be established before they form legislation and sensitization of public towards such transplantations. Otherwise it would be like putting the cart before the horse. The very thought of our loved ones and other lives at ICU, would be evaluated with cost benefit analysis of its survival against odds vs hastening death for organ harvesting is too scary to say the least

1 comment:

Rohit said...

Magesh,

You say,

''Does not ones life serve a purpose for the simple fact that the satisfaction it brings to their immediate family that the person is still surviving (this becomes all the more relevant in instances when the life in question is too young to die)''

Well, you are ignoring the desires of the person concerned. Should someone be forced to live in a vegetative state merely because it provides satisfaction to the family?

The issue of resources is an important one too: dollars are not limited and if medical care is publicly funded, I think there is a point where the society has the right to say that artificially continuing someone's life would be a waste of resources.

I am more sympathetic to your other argument: I think there is some dangers that if left entirely in the hands of doctors without institutional oversight, it might lead to situations where people's life might be endangered by a physician to harvest his organs. The issue of trust is an important one and I think the best way to tackle that problem is at the institutional lelve.