BY SAM L. MARCELO, Senior Reporter | Business World, Manila

One death, many lives

I HAVE to die a specific death to be an  organ donor. Even if I, fine specimen of a human being that I am, wish to “hereby donate any organ upon my death” (as the tick box on the back of my driver’s license puts it), the Grim Reaper must wield his scythe in such a way that he renders me brain dead. No other death will do. If this happens, my body gets to hang around on this earth a little longer although my ego, my soul -- or whatever it is that makes me “me” -- is gone.

Instead of going to the morgue, my brain-dead self will be hooked to a ventilator and a multitude of ma-chines and intravenous lines, and treated as if it were a case in the Intensive Care Unit. Calls will be placed to institutions; foremost among them the National Kidney and Transplant Institute (NKTI), which has seven transplant coordinators -- all of them nurses -- who are available 24/7.

Kidneys fly commercial
Once the NKTI receives the call, a four-man retrieval team composed of two transplant coordinators (one family coordinator and one clinical coordinator), one nephrology fellow, and one transplant fellow, travels to my location to determine my suita-bility as a donor.

The family coordinator talks to my legal next-of-kin to get consent. Even if I ticked the donor box on my license, the NKTI still has to verify that it’s okay to procure or retrieve (those are the proper terms, “harvest” is avoided) my organs.

The consent system of organ donation varies from country to country.

Spain, for example, uses an “opt-out” model, where everyone is presumed to be a donor unless he states his refusal in writing.

Once consent is secured, I will be subjected to several laboratory tests, which can take up to four hours. The team will test for HIV, hepatitis B and C, and any other conditions that might be passed on to the recipient. People with tattoos (like me) can still donate, as long as the ink didn’t come with any blood-related diseases. An ultrasound of my kidneys will also be ordered, especially if the cause of death was a vehicular accident.

All these results are relayed to the consultant, who gives his go signal depending on his evaluation. If cleared, two things can happen depending on my location: If I’m in Laguna or Metro Manila, my body will be transported by an ambulance to the NKTI facility in Quezon City, where my kidneys can be transplanted right after retrieval.

“Everything is done in such a manner that the human body is treated with respect,” said Dr. Antonio R. Paraiso, program manager of NKTI’s Renal Disease Control Program and founder of the Human Organ Preservation Effort (HOPE), which, in turn, follows the implementing guidelines set by the Department of Health’s (DoH) Philippine Organ Donation Program. “There should be no external evidence of things having been removed. It’s very similar to an autopsy except that in an autopsy, the organs are removed after death. When you donate, the organs, which are still ‘alive,’ are removed from a brain-dead person.”

If, on the other hand, my body is in a hospital located outside of Laguna, the team has to do the retrieval there and bring the organs to NKTI. The retrieved kidneys are placed in a canister filled with Custodiol, a preservation solution; packed in an ice chest (most probably of the Coleman brand); and flown commercial along with the retrieval team since, unlike those hospitals in TV medical dramas, NKTI doesn’t have any helicopters on standby.

According to its web site, HOPE recovers mainly kidneys (viable up to 48 hours after retrieval and the most commonly transplanted organ), pan-creas and liver (liver transplants are costly and only one or two are per-formed annually). HOPE also provides a network for tissues such as corneas (more on them later), heart valves, skin, and bones (in 2000, a long bone was successfully transplanted).

When a proper program is put in place, other vital organs like the lungs and heart, which can be kept fresh for about six hours after removal, can be included.

Asked why heart transplants aren’t performed here (an inquiry to the Philippine Heart Center yielded the vernacular equivalent of “We don’t have that here. It’s not done.”), Dr. Paraiso answered that no one is championing the procedure.

“We need someone to come back from the United States and take the lead. If the interest is there, the equipment will come. It’s not a question of technology,” he said. “You need someone who believes in it and will do it here.”

Another reason why a program hasn’t been put in place for vital organs is that patients don’t live long enough to be placed on a recipient list, assuming there was one.

“Many diseases of the vital organs kill you quickly. That’s the dismal reality,” said Dr. Paraiso.
Filipinos don’t donate

Once retrieval is done, my body, decorated by a stitched-up Y-incision running from both shoulders down to the pubic bone, can go to the morgue after hanging around up to 12 hours longer than if I weren’t a donor.

By this time, the placement coor-dinator at NKTI has called up potential recipients on its transplant waiting list. It is estimated that in the Philippines, 120 to 200 people per million develop kidney failure per year. Not all, however, are diagnosed or reported. In 2009, there were 8,700 patients on dialysis, a number lower than the projected incidence rate.

Recipients, who are classified according to blood and tissue type, are either “active” or “inactive” and ranked according to a donor allocation scoring system.

Active recipients are those who are ready to receive transplants within 24 to 48 hours. They have been cleared, and deemed emotionally and financially ready to go through with the procedure upon favorable tissue cross-matching results. The closer the age between donor and recipient, the better. So far, NKTI has procured organs from donors ranging from seven years old to 59. Sex is not a concern; there are no “boy” or “girl” kidneys.

According to proceedings of the 2007 symposium “Towards a National Consensus of Living Non-related Donor in Kidney Transplantation” only about 10% of kidney donations in the Philippines are from cadavers.

The reverse is true in developed countries like the United States where 90% are retrieved from the deceased.

Dr. Paraiso cited a study in Hawaii that found that Asians are very hesitant to donate upon death. “Ac-cording to this study, knowledge of organ donation and willingness to donate across the different races -- White, Black, Hispanic, or Asian -- are equal,” he said. “But when you look at the records, at how many actually donate assuming people go into brain death at about the same rate, results show that Asians donate the least.”

And among Asians, Filipinos are the most hesitant of all.

“If you look at certain cultural factors, Asians in general and Filipinos in particular, do not donate. Although I hope I’m wrong,” said Dr. Paraiso, who emphasized that he was talking about deceased or cadaveric donors. “There’s a tremendous difficulty in Asia, in terms of getting deceased donors.”

According to Dr. Paraiso, Taiwan, an island with a population of about 23 million manages to retrieve organs from 15 to 20 deceased donors a year. In the Philippines, a country with a population of about 92 million (four times that of Taiwan), the record for number of deceased donors is 34. This number was tallied in 2009 and of the organs retrieved from these 34 do-nors, 63 kidneys and two livers were transplanted. Spain, with its opt-out system, averages 34 deceased donors per million population.

“We’re very far away,” said Dr. Paraiso. “As to why that is, we can only speculate.”
Manna from heaven

The Catholic religion should not be a hurdle. In Evangelium Vitae, an encyclical released in 1995 on the value and inviolability of human life, Pope John Paul II wrote: “[T]he Gospel of life is to be celebrated above all in daily living, which should be filled with self-giving love for others... Over and above such outstanding mo-ments, there is an everyday heroism, made up of gestures of sharing, big or small, which build up an authentic culture of life. A particularly praise-worthy example of such gestures is the donation of organs, performed in an ethically acceptable manner, with a view to offering a chance of health and even of life itself to the sick who sometimes have no other hope.”

Despite this endorsement from the Catholic Church, the Philippines lags behind when it comes to de-ceased donations. When it comes to living donations, where the NKTI has had a lot more success, there is a heated debate regarding what “an ethically acceptable manner” -- as Pope John Paul II put it -- means, exactly.

Last year, 511 patients received kidney transplants, which can cost from P800,000 to P1 million for pay patients. As mentioned earlier, 63 kidneys came from deceased donors. The remainder came from either living related donors or living non-related donors.

Most of the ethical issues surround the latter. Just this year, the DoH issued an administrative order creating an organ donation sharing network to make sure that no one is exploited.

There are stories of kidneys being “exchanged” for, say, P200,000.

There are also “brokered” donations, which Dr. Paraiso believes is different from trafficking. “You can voluntarily seek out a recruiter without being coerced or forced. In an instance like that, you were brokered but, from my point of view, I doubt that you were trafficked,” he explained.

“I don’t know where the crime begins. The point behind our aversion towards such a situation is that there are things beyond the commerce of man. No one should make a business out of other people’s kidneys.

How-ever, what happens if it’s my own kidney? I don’t think I can indulge in commerce since I have only one to give up.”

According to the World Health Organization’s web site, the Guiding Principles on human organ transplantation, adopted by the World Health Assembly in 1991, prohibits “giving and receiving money, as well as any other commercial dealing.”

“The dominant world view is that donation should be altruistic,” said Dr. Paraiso. “If you need a kidney, it should fall like manna from heaven. Every-thing else is evil.”

The HOPE founder personally believes in a gray area he calls a “mutual-benefit situation” that falls somewhere in between altruism and commercialism. “I don’t like brokering but I am in favor of win-win situations where both patient and donor are better off after the operation. The altruistic model is not in consonance with everything else in life. It is so unrealistic,” he said. “People who can see shades in between black and white are more pragmatic and truer to life.” 

See through my eyes

The Eye Bank Foundation of the Philippines, which is celebrating its 15th anniversary, doesn’t face many of the ethical issues presented by organ donation, whether deceased or live, because corneas -- a fingernail-sized tissue -- can be retrieved in the morgue up to 12 hours after cardio-vascular (not brain) death.

The Eye Bank has partnerships with the Philippine National Police, since medico-legal officers have the authority to allow the Eye Bank to retrieve corneas from unaccom-panied, unidentified bodies waiting to be autopsied.

According to Dr. Ma. Dominga B. Padilla, Eye Bank president and chief executive officer, voluntary donations -- whether hospital- or funeral-home based -- are on the rise. Loyola Memorial Chapels and Crematorium has been quite progressive, including a question on corneal donation in its paperwork. While going about the business of death -- choosing a casket and such -- the bereaved are also asked if they would consider eye or corneal donation so that “someone blind may see.”

“It’s easier for us to persuade families because we don’t have the dilemma of dealing with brain death, where relatives can still see the heart beating. We don’t have to deal with the accompanying ethical and theo-logical questions of that situation,” Dr. Padilla said. “We come in after every-thing has ceased and the family has already accepted the death.”

She added that the Eye Bank does most of its retrievals in the morgue �“ the morgue, which is where I left my hypothetical cadaver. Allow me to go back to it in order to relate what happens during a corneal retrieval.

The NKTI, as mentioned before, coordinates with other institutions when a donor referral is made a partner hospital. It calls the Eye Bank, which has five donor development coordinators (whose task is to counsel the family) and 10 technicians on call 24/7.

Depending on my wishes, the retrieval team can procure any or all of my eyeballs’ two layers of connec-tive tissue: the cornea and the sclera (the white of the eye). The former is used to restore vision; the latter, for reconstruction.

If I donate my corneas, techni-cians will replace them with eye caps (similar to contact lenses) so that my eyelids don’t sag or don’t lose their form. If I donate both my eyeballs, they’re replaced by prosthesis.

It doesn’t matter that I’m astig-matic or that I wear glasses, either.

The Eye Bank will accept my donation gladly.

“Virtually anyone can be a donor,” said Dr. Padilla. Absolute contraindi-cations are the same as for other organs save for cancer.

“The cornea is a privileged tissue, it’s avascular meaning there are no blood vessels in it and the only types of cancer that are contraindicated are acute leuke-mia and cancer of the eye, of course.”

Once procured, the corneas and sclera are preserved separately. The first is stored in a two-inch bottle full of Optisol and can keep for about 14 days, although they’re used almost immediately. The sclera can last for about a year while submerged in pure alcohol.

Donations are tested for safety and quality (scratches, tears, and other structural damages). Those deemed unsuitable for surgery are used for education and research. The Eye Bank gets around 1,400 corneas a year, a fourth of which can’t be used. At any given time, there are around 40 people in the foundation’s transplant waiting list.

Usually, they are either young men who suffer from corneal trauma or seniors who experience complications after cataract removal
During the week of the interview, Dr. Padilla had just performed two transplant surgeries, which cost around P20,000 for pay patients. The Eye Bank is able to keep its rates low by sharing its surplus corneas internationally, although Dr. Padilla stressed that priority is always given to Filipinos.

If they have to be transported, the eye tissue is packed in ice in Styro-foam boxes that resemble ice cream tubs. Through the Eye Bank’s partner-ships with Philippine Airlines, Cebu Pacific Air, Emirates, and Lufthansa, they fly either free or at a discount to their destination. Cornea and sclera can also be sent to local recipient hospitals via LBC at no cost.

The Eye Bank is also in the process of acquiring new technology that allows sterile corneas to last a year on a shelf at room temperature �“ a boon to doctors in far-flung areas. Bringing around corneas could soon be as easy as bringing around contact lenses; you could carry them in your bag.
Look for me under
your boot-soles and other people

As a hypothetical donor, I would be disappointed -- pissed, even -- if my organ donation was for naught. I would appreciate it if my gift to humankind were maximized and enjoyed to the fullest. I would love it, for example, if recipients channeled Thoreau and went on to live deep and suck out all the marrow of life (Waldenesque existence in the woods optional).

It isn’t that romantic, however. A close match is never a perfect match and the lucky transplant recipient who has learned to “tolerate” my kidney faces a lifetime of anti-rejec-tion medications, which cost P10,000 to P30,000 a month. The most expensive drugs represent a success rate of 90% to 95%; older, cheaper drugs represent a success rate of 50% to 60%.

Cornea transplant recipients don’t have to spend as much.

Mainte-nance comes in the form of antibiotic eye drops that will cost them P800 to P1,000 a month. If there are no prob-lems, the drops can be discontinued after 18 months or so.

Organ donation, explained Dr. Padilla, offers the bereaved a chance to have their loved ones live on �“ in part, at least.

And for the donor? As I see it, a chance to bequeath myself to huma-nity and not just to the dirt under Whitman’s boot-soles.