Dr. George Jacob, 
Senior Specialist, Surgical gastroenterology, Lakeshore hospital,Kochi.

There is no act nobler than donating organs by individuals with normal organs   to person/persons in whom various organs such as the liver, kidneys, intestine, pancreas, heart and cornea have undergone permanent damage, both structurally and functionally, what is called End Stage Organ Failure. Having said this, there is no area in the medical field which is more bereft of awareness and acceptance by the public and fraught with suspicion, ignorance and misunderstanding. What is organ transplantation? Transplantation of an organ from one person to another is known as the organ transplant. The person who gives the organ
                  Is called the Donor while the one who receives it is called the
                  Recipient. Organ transplant is done to replace the recipient’s
                  damaged organ with the working organ of the donor so that the
                  Recipient could function normally. Organ Transplantation is a boon to medical industry as it has:

                  helped in saving the lives of those who would have died
                  otherwise. There is a great need for human organs for
                  transplantation. In fact, the need far exceeds the supply of
                  transplantable organs. There are several reasons for the shortage of organs. Perhaps
                  The most common reason is that people are hesitant to donate
                  organs due to reasons which may be financial, religious and more often sentimental and importantly, ignorance of the concept of organ transplantation, and suspicion of involvement of huge amounts of money in the procedure, brought about by ‘organ trade’ whereby organs are sold for large amounts of money for the purpose of transplantatation, with involvement of ‘middle men’ as does exist even in this country  . There are other reasons as well: for example,
                  physicians may neglect to inquire of family members whether
                  they would consent to donating organs when their loved one
                  dies, or is declared ‘brain dead’ most often fearing emotional outburst from them . In other cases, the deceased's wishes to donate his or
                  her organs may not be known by those in the position to act on
                  those wishes. This disparity has led to the
                  formulation of various legislations, attempting to regulate
                  the scarce resources (transplantable human organs) and to help
                  establish an equitable system to allocate the organs where
                  they can do the most good. Legally, organ donation can take place from
                  Living, genetically-related individuals (live-related), or from living, unrelated   individuals (live-unrelated) in special circumstances where no unauthorized
                  payment is made to the donor; or from cadavers(cadaveric) or animals       (Xenotransplantation).

                  History of transplantation Live donation
                  of a single kidney was the first done in 1954, but live
                  donation of parts of other organs is a relatively recent
                  innovation since 1980s:first successful heart lung transplant(1981),first artificial heart transplant(1982) first successful living- related liver transplant (1989) Baboon heart transplanted into Baby Faye(1986) first ‘split-liver’ transplant(1996) .a single donor can donate his organs to more than one needy individuals, for example, each of his kidneys to two different persons, each half of his liver to two people, his pancreas, heart, lung, cornea, small intestine, to those others who need them.  To date the major source of organs and tissues in the West has    been from cadaveric (brain dead) donors. Living tissue deteriorates rapidlywhen it loses its blood supply, and organs need to be cooled
                  and transported for implantation into the recipient within a
                  limited number of hours. Short transfer time, entailing
                  removal of organs from ‘beating heart’ donors, was made
                  possible by the acceptance of ‘brain stem death’ as death. In this context, it is important to throw light on the concept of brain death. It is defined as the irreversible loss of function of the brain including the brain stem, the part of the brain that controls respiration and heartbeat. Brain death can occur as the result of severe head injury following an accident or cerebrovascular accidents (commonly called stroke). Three cardinal features of brain death include: 1.coma or unresponsiveness to deep pain, 2.absence of brain stem reflexes such as coughing, swallowing and gag reflex, such as lack of response to the pupils of the eyes to light, no deviation of the eyes to irrigation in each ear with cold water, corneal reflex, pharyngeal reflex, etc, 3. Loss of spontaneous breathing, which means the person cannot breathe without the help of a ventilator and that no life is possible without the ventilator. If the diagnosis of brain death is still in doubt, other investigations are performed to confirm brain death, such as, Electro Encephalogram (EEG), which shows absence of any electrical activity in the brain, and aortic arch angiography, which shows loss of blood supply to the brain.
Who decides or certifies that a person is brain dead? Certification of brain death requires 2 series of 8 tests by four independent doctors, which includes a neurologist and a neurosurgeon, one of whom has no attachment to the hospital whatsoever and chosen from a panel of doctors recruited by the government. Moreover, there is a law existing in India as well, ‘transplantation of human organs act’ (1994), which, 1.accepts brain death as also a definition of death 2.bans commercial dealings in organs 3. Defines first degree relative (father, mother, brother, sister, son, daughter and wife) who could donate organs without permission of the government, apart from this act, there are state authorization committees that scrutinize all applications for unrelated transplants. Hospitals conducting transplants are registered with committees that monitor their functioning. The states Medical Councils have suo moto powers to investigate malpractice in transplantations.  
How does ‘cardiac’ death differ from ‘brain’ death? Most people understand that death occurs when a person’s heart and breathing stop. This is called ‘cardiac’ death and is how most people die. Death also occurs when the brain and brainstem stops functioning completely. This is called ‘brain’ death and usually occurs when blood supply to the brain cells gets cut off for a long period of time. When this happens, the brain cells die permanently; the usual causes of brain death are severe head injury following an accident, bleeding into the brain, such as in stroke. In a person dying a cardiac death, the heart does not beat and, is unable to move or breathe and becomes pale as blood does not flow through the skin. When a person is brain dead, the heart can function normally, meaning that other vital organs like the liver, kidneys, pancreas and the intestines continue to receive blood and remains healthy, meaning further that a brain dead person has vital organs capable of functioning normally and can be considered for transplantation, provided the blood supply to these organs can be maintained. 

The usual scenario when such a patient is admitted to an ICU is that the patient is immediately put on life-saving procedures such as artificial ventilation, administration of drugs that help maintain the patient’s blood pressure, and therefore blood supply to the various vital organs, and also to save life, antibiotics, IV fluids,etc. as days proceed, the clinical course of the patient can worsen or may not show response to treatment making the treating doctor suspect that the patient is brain-dead, which he confirms by the tests mentioned above, performed by the panel of doctors appointed to do them if brain death is confirmed, it means the patient is technically dead, and is surviving just because, he/she is on life support, which if continued indefinitely, the patient goes in for a ‘vegetative’ existence, which is a futile and an expensive exercise, one which entails unnecessary suffering for the patient and unnecessary expense on the family for a seemingly lost cause. And if discontinued, will surely die. It is at this point, that the doctor considers the possibility of harvesting organs from the brain dead patient to be transplanted into deserving patients with end-stage organ failure. And chooses to discuss with the dear and near ones of the patient regarding this option. This option may either be considered or rejected by those concerned, a choice which involves the factors mentioned above. It is also a time when money transaction between the families of the recipient and the donor can take place, with the involvement of ‘middle-men’ sullying the nobility of organ transplantation, bringing into the picture the laws and stringent guidelines put in place to safeguard the legality and healthy intention of transplantation, for example, the Human Organ Transplantation Act of 1994,conducting the whole procedure under the auspices, supervision, authorization and watchful eyes of bodies such as the Society for Organ Retrieval and Transplantation (SORT), that exists at Kochi to prevent malpractice and transaction of money. The first liver transplant in Kerala was performed in one of the major private hospitals of Kochi on June 27th under the direct supervision and direction of SORT, recently, ten premier hospitals of Kochi decided to share organs harvested from brain-dead patients, on the occasion of the World Kidney Day again under the auspices of SORT. Even at this point, the physician of the dying patient only considers what is best for the patient and his family, giving no priority to transplant surgeons and their patients. When the transplant patient is ready for the donor organ, the transplant center surgically removes and replaces the failed organ/organs through the following general procedure: 1. Make an incision on the recipient 2. Cut the arteries and veins that run to the organ 3. Remove the organ through the incision (explantation) 4. Take the new organ and insert it into the body through the incision 5. Connect the organ to the artery and vein 6. Close the incision once this is over the incision on the cadaver is also closed, by which time the brain dead person would be dead from the cardiac point of view, and the body is returned to the relatives, treating it with utmost respect and dignity or to the legal authorities such as the police or the coroner for medico-legal proceedings if the cause of brain death was a road traffic accident or injury, in which case the transplantation will take place only with the permission of the coroner.    

Indian Scenario: In India, as in rest of the world, there is a gross disparity between need for transplantable organs by patients suffering from end- stage organ failure and availability of organs; unofficial statistics reveal that there are 1000 deaths everyday due to failure of an organ. Of the 8 million deaths in India every year, at least 20,000 are believed to be potential organ donors. However, less than 150 actually become donors! The remaining 19,850 donors are lost. At an average of 5 organs per donor that could have been transplanted, 1 million organs are needlessly burnt or buried. The disparity can be overcome only if cadaveric organ donations increase.
This can be brought about by 1. Education-the government has a huge role to play in this aspect, the government of Tamil Nadu has an Organ Donor programme which it propagates with the help of certain hospitals; people should realize that organ donation is a social responsibility, and the idea of ‘the gift of life’ must be ingrained into public thinking and psyche through advertisements, especially by the government, media, both visual and print, by prominent personalities of society 2. Mandated choice, wherein citizens would have to indicate their wishes regarding organ transplantation, perhaps on income tax return forms or driving licenses, as in the US, when a person dies, or is declared brain dead, the hospital must comply with their written wishes regardless of what their family may want, enforcing the individual autonomy of the organ donor a simple signature consenting to donate organs can make a world of difference and gift life to patients and their families.3. Presumed consent, as is the policy in many European nations. Where their citizens’ organs are taken after they die or are declared brain dead, unless a person specifically requests not to donate while still living, advocates of presumed consent maintain that it is every person’s civic duty to donate organs once they no longer need them (i.e., after they die or are brain dead) 4. Incentives, as is frequently practiced in the US, various incentives are offered to the family of the cadaver donor, such as assistance with funeral costs, donation to a charity in the deceased person’s name, plaques or memorial
In the US, the Uniform Anatomical Gift Act (1987) requires every hospital to ask each patient on or before admission to the hospital as to weather the patient has pledged to donate his organs or tissues; it is believed that as the result of this, in that country, the awareness of organ donation and number of donors increased substantially.

 Major Hospitals in Kerala offer transplantation of the liver, kidney, heart, hair, cornea, bone marrow, at much cheaper rates compared to the West, as the result of which the state is fast becoming a much sought out place for transplant surgery. But our state, in spite of it’s high literacy rate has yet to be completely aware of the concept of organ donation and transplant surgery, the biggest onus for this being on the shoulders of the government; every citizen of this land must become aware that every person in need of an organ should be in a position to receive one, and to achieve this, must be willing to donate, as organ donation is not about death, but rather about life, that organ donation is a social and a moral obligation.

Tamil nadu the torch-bearer in organ donation: Two years ago, Dr Pushpanjali Ashokan in Tamil Nadu donated all organs of her son Hithendran, declared brain dead following a road accident. This incident served as a turning point and the state now ranks number one in multiple organ donation. "Even though you are losing a loved one after brain death yet you can feel comforted that his organs are going to stay in somebody's body. In fact this way he's going to live again." said Dr Ashokan.
Last year, Tamil Nadu alone registered 59 cadaver transplants. This is 10 times the national average.


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