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Living after death

Organ transplantation is an issue that must be dealt with sensitively. Orienting society to accepting the `value of life after death' will go a long way in strengthening transplantation as medical treatment. USHA RAMAN writes.

LIFE CONSTANTLY throws up interesting and challenging questions, often forcing us to make choices that are not only difficult but also constrained by a variety of factors. And though we do not think about it as much, death too throws up its own set of questions. The way we deal with death, as individuals, as family members, and as social beings, can make all the difference to life.

This may seem an odd topic to be raising when we are more used to discussing material issues, but a recent development in our city begs the question. How prepared are we to see life (and contribute to life) even in death?

About two months ago, Global Hospitals in Hyderabad opened the country's first facility for

multi-organ transplantation. The technological and medical environment for the facility is ripe; it is equipped with all the required technology and is staffed by competent physicians and surgeons. While accurate statistics are hard to come by, it is known that thousands of Indians could gain from transplantation. It is estimated that there are around 80,000 cases of renal failure, added to which are probably thousands of cases of liver, heart, or lung failure where transplants could make a difference. Measures such as dialysis for kidney failure and palliative medication for other organ problems are only temporary. So obviously, there is a large potential patient base that such a hospital could serve. However, the social environment is far from ready for such a facility to provide the services it could and should. Organ transplantation is not just about surgery, or even just about medical science and technology. It touches a host of other issues - legal, social, emotional, religious - that have to be addressed with sensitivity and thoroughness.

Transplantation depends on the availability of human organs - which in turn depends on voluntary donation of organs by relatives of persons who have met with sudden brain death. "We have the technology and the expertise needed for transplants, but the main problem is shortage of organ and tissue donors," notes Dr. K. Ravindranath, chief of Global Hospitals. While kidneys can be transplanted from a living donor, all the other organs must be recovered only from cadavers -- and herein lies the rub. Much of the problem lies with the social understanding of the term "cadaver", our attitudes to death and our beliefs about what happens after it, and the "urban legends" that have grown around the theme of organ transplantation, fed mainly by the illegal trade in kidneys that India has become infamous for. "The first step for us is to create a social and legal climate where ethical transplantation is facilitated," says Lalitha Raghuram, Chief Transplant Coordinator at Global. People must be prepared to consider the idea of doing something meaningful which makes the loss of a near and dear one easier to bear. Many Western countries have what is called the Required Request Law, which makes it mandatory for the hospital to ask the relatives of a person who has suffered brain death whether they are willing to consider donation. "The thought may not even have occurred to many people, so the first step is to bring it within the public consciousness," says Lalitha.

For a transplantation programme to succeed, therefore, it must be preceded by a huge amount of attitudinal change. As Dr. P.B.N. Gopal of Global Hospitals explains, "We need massive support from the public for transplantation based on voluntary organ donation." The main drawbacks, as he sees it, fall into three domains: our attitudes to death, the negative publicity resulting from the illegal trade in organs, and the high cost of the procedure and its follow-up. While the last factor - cost -- is difficult to control at this point, with transplantation still being in its infancy in India, the first two can be addressed with some effort. The organs or tissues that can be transplanted are the cornea (the outer layer of the eye), kidney, liver, heart, lung, pancreas, skin, bone marrow and blood. Donations from a single person can save the lives of at least seven people in need, not counting those helped by skin and bone marrow transplants. Of these, blood, bone marrow and kidneys can be donated by people during their lifetime, because the first two are regenerated, and people can live complete lives even with one kidney. Kidney donations can come either from living relatives or from unrelated donors but the process requires sanction by medico-legal authorities. In either case, it is illegal to pay for the organ -- the donation must be made voluntarily and freely. The recipient's family may bear only the medical expenses of the donor and any loss of pay due to absence from work. Despite the presence of a law to this effect (Transplantation of Human Organs Act, 1995), there continues to be a black market in kidneys. "The only solution in such a scenario is to step up cadaveric organ donation," says Dr. Ravindran. But despite the passage of the Central law in 1994, followed up by State laws (the AP Act was passed in 1995), in these eight years only 500 organs have been harvested through cadaveric donations. Of course, this does not include eye (or corneal) donations, where public information campaigns have generated a higher level of acceptance with many

people coming forward to pledge to donate their eyes after death. As Lalitha Raghuram says, "Eye donation in India has already reached maturity, while with organ donation we are still in our infancy." One of the fundamental problems with cadaveric organ donation lies in our understanding of death. A "cadaver" refers to a human body that has been declared brain dead-that is, the brain has stopped functioning and the heart continues to beat only on an artificial support system (a ventilator). "Many people confuse brain death with a state of coma," says Lalitha Raghuram. A person who is in a coma is actually in a state of deep unconsciousness; the heart beats on its own and breathing therefore is natural. The person may emerge from a comatose state and regain most normal organ functions. Brain death, on the other hand, is irreversible -- the person is clinically and legally deceased. "People find it very hard to accept this as death, because the body is still warm, and the heart is still beating," says Lalitha Raghuram. It is estimated that nearly 60,000 brain deaths occur every year in this country - representing a potential pool of thousands of organs. "We have to understand that death can occur when either the heart

or the brain stops working," says Dr. Gopal. This is important to organ donation because organs can be harvested only from cadavers that are being maintained on ventilators -- the organs are still being pumped with blood, and are in a state where they can continue to function in another body. Lalitha Raghuram says, "The family must decide to donate when their dear one still appears to be breathing and the body is still warm."Organs cannot be harvested in home deaths because even the slightest time lag between the stop of circulation and the removal of the organ can make it unusable.

While corneal donations also involve making a decision soon after death, families tend to find this an easier decision because there is no disfigurement and the procedure is very quick, says Dr. Usha Gopinathan, who is in charge of the Ramayamma International Eye Bank at L.V. Prasad Eye Institute. The cornea can be harvested by mobile teams who visit the person's home. With other organs that must be removed from cadavers, however, the issue is more complex. Once the authorised medical team has declared brain death, explains Lalitha, the person is maintained on a life support system and there is a six-hour window for the family to decide upon organ donation. "This is when counsellors approach the family and talk about the possibility of donation." Says Dr. Gopinathan, "Grief counselling -- as this process is called - in hospitals has helped increase eye donation considerably." Most families, even in their moment of grief, have appreciated that their decision could help to save or enhance the quality of another person's life. "There has to be a lot of awareness before motivation can happen," says Dr. Gopinathan. The movement to educate people about organ donation must take a long and arduous route. Several religions are ambiguous about it, although in some cases religious leaders have explicitly supported organ donation as a noble act. People worry about possible disfigurement after the organs are removed, although, as Lalitha Raghuram explains, the incisions are like those in a normal thoracic surgery. Another area of concern is the delay in bringing the body of the loved one home from hospital, as the organ retrieval process takes a minimum of six to eight hours after consent has been obtained. "However, we have found that once people have decided to donate the organs, they also have the strength to deal with these logistics," says Lalitha. "It helps tremendously if the person has indicated a wish to donate their organs and has discussed it with their family," she adds. "Then the family is more likely to want to honour their last wishes."

To begin the public sensitisation process and to simultaneously lobby for better laws to facilitate ethical transplantation, Global has tied up with the MOHAN Foundation (Multi-Organ Harvesting Aid Network) based in Chennai. Through this Foundation, which will now have a chapter in Hyderabad, transplantation surgeons, counsellors, paramedical and medico-legal experts hope to motivate people to talk about and think about organ donation, and a climate where transplantation becomes an acceptable mode of medical treatment.

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