Advancement of medical sciences have influenced significantly on the lives of people, it broadened the scope for well being, improved the quality and expectancy of life. A large number of health problems and diseases are under control through the improvement of medical technology. Emergence of medical technology for human organ transplantation is one of the crucial steps in the journey of sustaining health, and life. Even the technology is advanced in regard with the organ transplantation but the non availability of the organs always constrained the process.
Present paper analysis how the changing epidemiology and etiology have an impact on the organ shortage crisis and the various prospect to address these issues. Different types of organ donation and its sources are discussed in detail. This paper views the lack of availability of organs as an important health issue by correlating it with the needs and importance of availing organs through a voluntary donation perspective. The statistical data on existing demand and supply has been analyzed in this paper. Possible attempt were made to rationalize the strategies to meet the existing needs of human organs by exploring different sources of availability, especially in the voluntary donation perspective. The existing data shows that there are huge variations in demand and availability of organs and that are correlated with voluminous socio-cultural and legal aspects.
Key Words: Organ Failure, Organ Donation, Voluntary, Challenges, Prospects.
Health care is one of the fields that achieved significant development in the past century in regard with the advancement in the technology of care and cure. The innovation in medical care has reflected as the potential benefits in different dimensions of human life include physical, psychological and social well being. Many of the health problems, issues, diseases are under control through continues research and advanced practices. The improvement of pharmacology and vaccination methods yields positive results in preventing number of public health vulnerabilities. The first organ transplantation in the year 1952 was one of such milestones in the history of medical care, especially the critical care. It gave hope to a colossal section of population who are under the burden of organ failure. Organ failure is a public health issue, that’s having significant implications on the lives of people and the whole society. The failure of a human organ is disabling him/her in holistic aspects of life which include familial, economic and psychological and social dimensions. The possibilities of modern medical science can be better utilized for overcoming the issues created by organ failure, but the shortage of organ availability for transplantation is a constrain. The changing epidemiology of health problems shows that organ failure is one of the foremost health issues that create significant socio-demographic, psychological and economic impact. Every year lakhs of people were dying or severely disabled due to the failure of organs. Most of the organ failures are threaten to sustain life and organ failures like corneal blindness lead to extreme kind of socio- physical disability. Organ transplantation is the most suitable and last option for many diseases, but the shortage of donors is the challenges in this regard. Successful transplantations give patients with otherwise untreatable degenerative diseases a new lease on life, or enable them to lead a more fulfilling or productive existence. (Teck- Chuan Voo 2009). The transplantation is possible only when the availability of donor exists; in this context the endeavors on organ donation is a thorny for country like India where the awareness on the organ donation is quite low. According to Illangovan Veerappan (2012a) lack of organ donation awareness in India is the major barrier for deceased donation. The lack of awareness lead to the shortage of needed organs for transplantation. The primary ethical dilemmas surrounding organ transplantation arise from the shortage of available organs (Childress JF, 2001). The only tool and strategy to combat with the organ failure is ensuring the availability of organ for transplantation, it’s possible only through the voluntary donation. Then only the demand and supply can be adjusted.
Organ Failure: Issues and Challenges
Organ failure is a medical condition where the expected function of an organ unable to perform it. This may affect the functions of other body functions too and the person may have to face multiple difficulties in healthy body function which affects the overall quality of life of the individual. Organ failure is being considered as one of the foremost among the modern health issues, which is having correlation with different factors like the epidemiology and etiology of different diseases, especially life style health problems. An organ failure is having serious implications on the life of an individual which affects the different aspects of his/her life and those who dependents them also. In Indian context the increase in number of disease which affects the organ dysfunctions likes kidney failure, liver dysfunctions, cardiac dysfunctions, lungs dysfunctions and corneal blindness has raise the demands of organs for transplantation. In many cases, the best (and sometimes the only) answer is to replace the damaged organ with a healthy one (Tom Scheve, 2008). The variations in demand and supply is adversely affects the hope and life of people, who are waiting for organ transplantation with terminal illness. Unofficial statistics from India indicate that there are nearly 300 deaths every day due to failure of organ. That is more than one lakh deaths per year (Sudheendran, 2010). There are several issues which related should be highlighted in relation with the organ failure.
Changing Epidemiology and Etiology of Diseases
The last two decades of the 20th Century and the first decade of 21st century have distinguished in regard with the pattern of epidemiology and the etiology. The health profile of India at the close of the 20th century appears promising. Impressive improvements in the socioeconomic, nutrition and health status of people as well as the successful eradication, elimination and control of major killer diseases have contributed largely to the resultant epidemiological and demographic transition observable in the country (M.D. Gupte, 2001). Even though with the advancement, there is a marked change can be observed in the past two decades on the pattern of diseases, chronic illness and the mortality rate. Among these, life style diseases are the prominent in relation with the death rates and which leads to dysfunction. The changes in the living pattern widely contributed for the variations in the etiological pattern. Non-communicable Diseases (NCDs) account for nearly half of all deaths in India. Cardiovascular Diseases (CVD), Cancer, Diabetes, Chronic Obstructive Lung Disease (COPD), Mental Disorders and Injuries are main causes of death and disability due to NCDs. (People’s Health Report, 2011). Except the mental diseases all of the above diseases are directly or indirectly adversely effects the functions of organs and ultimately it will be life threaten. Although non-communicable diseases like cancers, diabetes, cardiovascular diseases, chronic obstructive pulmonary diseases, etc are on the rise due to change in life style (Peoples Health Report, 2011).
The numbers of people who are effecting with life style diseases and other illness which lead to organ failure is in increase subsequently it caused to raise the mortality rate and dysfunctions of human being. Another most crucial socially and biologically relevant dimension of organ failure is the severity of Burden of Diseases. The burden of diseases is high in organ failure, which limits the patients from basic biological functions and reflects on the personal and social life. Finally leads to disability and death.
Demand and Supply: The variations
There are reasonable differences are exists in demand and supply of the organ availability for transplantation. Globally, especially in the developing and under developed countries the shortage of organs for transplantation is a leading cause for death, where in developed country at some extent awareness on the issue, leads to the donation and availability. In developing societies the lack of appropriate medical facility, experts in the field, financial resources and availability of organs are the serious health issue. There is currently shortage of donor organs worldwide; the ageing populations and increasing incidents of diabetics will worsen the shortage (Ritahlia et al, 2009). Of the worlds 6 billion population, four-fifth is from developing countries. Unfortunately the transplant rates in the developing world is much to be desired at less than 10 per million population comparing to the 45-50 per million in the developed countries (Vathsala, Moosa, 2004). This organ shortage crisis has deprived thousands of patients of a new and better quality of life and has caused a substantial increase in the cost of alternative medical care such as dialysis. (Abouna, 2008b)
The major barrier to transplantation is money and availability of live related donor in India. Even in the better performing regions of the country the deceased or cadaver renal transplantation rate is only 0.08 per million per year, i.e., 2 % of the total transplantation. (Chugh KS, 2009). Of the 9.5 million deaths in India every year, at least one lakh are believed to be potential donors; however less than 100 actually become donors. The remaining nearly 99,900 are lost. The demand for organ transplantation has rapidly increased all over the world during the past decade due to the increased incidence of vital organ failure, the rising success and greater improvement in post transplant outcome. However, the unavailability of adequate organs for transplantation to meet the existing demand has resulted in major organ shortage crises. As a result there has been a major increase in the number of patients on transplant waiting lists as well as in the number of patients dying while on the waiting list. (Abouna, 2008a)
In developing countries socio cultural factors and lack of awareness adversely affects the availability of organs for transplantation. Without awareness it is going to be difficult to convince the relatives of the deceased patients to donate the organs for transplantation. Contrary to logical understanding, educational status, socio-economic status, language barrier, cultural and religious factors do not affect the decision for or against donation (Alkhawari FS, 2005).
Source: Times of India, DNA India.
Organ transplantation is a surgical method where the failed organs of human body is removed and replace with a healthier one. The advancement in medical technology significantly influences in the quality of the surgery and post surgery care. Today, most organ transplantations are safe procedures, no longer considered as experiments, but considered as treatment option for thousands of patients with medical indication, such as those suffering from renal failure, heart diseases, respiratory disease and cirrhosis of liver (Otak. K, 2004). Organ transplantation has been hailed as one of the greatest achievements in modern surgery (Linda, 2009). It’s one of the sensitive kinds of surgery in regard with the issues of medical, legal, social and psychological aspects. The modern medical ethics stresses on the needs of providing medico-legal education to the donor and recipient, which helps the patients to be aware about the risks, possibilities and pre and post transplant complications.
The main sources of organ availability can be classified as cadaveric donation and live donation. The first one, Cadaveric donation means the organs taken from the recently died individual, it’s include both natural and brain death. Second source of organ donation is live donor, in this type of transplant the organ is taken from the living human being and transplanted to the person in need. A colossal percentage of live donors are relatives of the recipient. In Indian context the live donation is much more time double than cadaveric organ donation, where this one is considered as most sustainable and medically suggestible kind of organ transplantation. Cadaveric transplantation reduces the risk factors, which exists in live donation.
Cadaveric Donation & Brain Death
As discussed cadaveric donation is the most sustainable and balanced mode of organ transplantation, which helps to avoid unnecessary surgical and clinical intervention on the donor. In western world and other developed countries cadaveric donation is much wider than the remaining part of the world. The national average of India in Cadaveric donation is many times lower than developed countries, even though the country is having much more possibility to avail of human organs through deceased donor. According to Vathsla (2008b), the differences in cadaveric donation and live donor in Asian countries are due to the racial and cultural attitudes towards death and sanctity of the human body, thereby affecting consent for cadaveric donation. Therefore it’s not surprising that living donor organs contributes 85- 100% of developing countries as opposed to 1-25% in developed countries (Moosa, 2004b).
There are two sources for cadaveric organ donation.
Brain Death is the irreversible and permanent cessation of all brain/ nervous system functions. Brain is the centre which controls the vital body activities includes the basic and necessary functions like breathing, sensation, obeying commands etc. Most of the brain deaths are due to the head injuries. Brain death is a complex issue encompassing overlapping areas of medicine, philosophy, ethics, and the law (Laureys S, 2005).Conformation on brain death is medically and legally a sensitive issue, the procedures are different from countries to country and region to region. In India, organ transplantation is regulated by the Transplantation of Human Organs Act, 1994. The act defines “brainstem” death to mean “the stage at which all functions of the brainstem have permanently and irreversibly ceased.”
This Act calls for a panel of four physicians to make the diagnosis of brainstem death, composed of the following team.
(i) Physician treating the patient
(ii) Physician in charge of the hospital treating the patient
(iii) A specialist physician from an unspecified specialty
(iv) A neurologist or a neurosurgeon.
In the context of organ transplantation, brain death is one of the potential sources of organ. Therefore one cadaveric donor can possibly save many terminally ill patients by donating both solid and non solid organs, as indicated in the Table. No. 01. Cadaver transplantation involves declaring brain death, seeking permission from the relatives, retrieval of the organs, storage of organs, transport to the recipient’s hospital and ultimately transplantation. The first two stages are the more difficult ones (Illangovan Veerappan, 2012b). There are number of organs, that can transplant only from the brain dead individuals, heart, and lungs are the typical examples. Deceased donor transplantation has the potential to significantly reduce the mismatch between need and availability of the organs for transplantation and minimize the burden on living donors for organ donation (Illangovan Veerappan, 2012c).
Table: 01. Shows the possible organ donation in different situations
Death other than Brain Death
In natural death or any death other than brain death also there are prosperities for organ donation. Eyes, blood vessels and bones are the examples of this. The potential benefit of organs donation after natural death have limitation to combat with terminal and chronic illness.
A considerable percent of organ donation in India depends up on the living donor; most probably the potential donors are the relatives of the patient. A live donor who wishes to donate organs can do it in two ways.
1. Donate one half of the paired organ set: Kidney is the best suitable organ that can donate among the paired set of human organs. Even with among the pair, both recipient and donor can live healthily.
2. Donate a portion of an organ: This type of organ donation shall possible only for those organs that will able to function still without the donated portion. Liver and lob of lung are the typical examples of this model of donation.
Challenges and Prospects of Organ Donation:
The Way Ahead
Shortage of organ availability is basically a medical issue but the complication of this will be affecting the holistic aspects of human life. The answer to the question arising from issues of organ shortage can deal by sensitizing it with a social concern in the public domain. India doesn’t have any governmental system for coordinating and registering the organ needs as like many other developed or western countries. The National Organ Transplant Programme (NOTP) initiated by the Government of India is still in babyhood and yet to develop. The NGO sector in India is significantly contributing for the promotion of organ donation by realizing awareness is the largest constrain for the shortage of organ availability. The medical advances achieved through decades can be utilized in the field of organ transplantation only through ensuring/availing the organs. In Indian scenario there is a great prospect for different sources of organs, the first and foremost are from the cadaveric organ donation, especially from brain death. Statistics shows that 90% of the brain death is due to the accidents, especially road accidents. According to WHO Global Status Report on Road Safety (2013), India is the country over 130,000 deaths annually; the country has overtaken China and now has the worst road traffic accident rate worldwide. Among the road accidents 70% of the cases are brain death. In the year 2013 India has witnessed for a death of 1, 33,938 people in road traffic accidents. The organs of the persons who died in accidents can be the prospective source for the cadaveric donation. Deceased donor transplantation has a great potential in bridging the ever widening gap between availability and demand of organs for transplantation (Illangovan Veerappan, 2012d). There are a plenty of reasons exists in the prevailing situation that prevents the prospects of organ transplantation.
India accounts large number of deaths and disability due to organ failure while comparing to the Western and developed countries, where 70 % of people voluntarily come forward or pledge for organ donation while India its only 0.1 %. This situation prevailing same for years mainly because of the lack of awareness people have on the issue. A colossal of our population has misconceptions and myths related to organ donation and it is related to socio-religious aspects. People even hesitate to donate their organs even after death. This has significant correlation with the religious aspects and usually they are not ready to come out from the believe system in they are. Unlike other western countries (where govt. is the custodian of dead body) in India after death also family still exist as the custodian of dead body and their decision on donating organ depends the whole scene. As Jyoti Nagda (Rito Paul 2011) a transplantation social worker said that “Immediate family members are often dissuaded by relatives. Some people believe that if an organ is taken out of the body then the deceased will be reborn without the same organs. Such misconceptions are common among people”.
Awareness generation and sensitization can bring positive result in the field of organ transplantation. Voluntary organ donation is only the answer in Indian context as a number of medico-legal, cultural and religious issues are prevalent. A pragmatic action to promote voluntary donation is need of the time. Many countries took active intervention to promote voluntary organ donation among its citizens, China is typical example for the same, as they have started nationwide programme in the year 2013.
Table No: 02. Number of accidental deaths during 2000-2013.
The above table shows the hazardousness of traffic accidents in Indian society. The persons who died in such situation can be the potential donors and a large extend can it solve the problems of organ shortage. Even though with these prospects of organ availability, only less than 3% of these cases, especially relatives are not ready to donate organs. The only answer to this dilemma is voluntary organ donation. In Indian context, enhanced awareness on the needs and importance of the issue of organ shortage definitely yields positive outcome. And it improve voluntary donation, which is the most suitable and sustainable strategy and tool for combat with the organ shortage. Voluntarism is considering as the best and tool and strategy for organ availability. This can be enhanced by sensitizing and making awareness on the issue. The personal pledge and decision on organ decision can helps to make light and hope on the lives of many people.
Social interventions for sensitizing the issue of organ donation can make a positive result. An intensive and grassroots level awareness only can make the things possible. The issue of organ availability will be manageable only when people are ready to donate organs voluntarily after death. The typical example of such improvement through awareness in medical field is blood donation. Before two-three decades availability of blood in the same group was a risky task but the meanwhile it has been improved a lot with millions of potential blood donors. The voluntary organ donation can also cease the commercialization of organ transplant. According to Delmonico (2009) the ease of communication technology in 21st century made organ trafficking and transplantation tourism/commercialism in to a global issue, accounting 10% of the organ transplant performed yearly in the world. The potential benefits of voluntary organ transplant after death can prevent these kinds of evils practice and shed hopes on the lives of many people.
Abdul Azeez E.P.
Assistant Professor, Department of Social Work, School of Social Sciences, Central University of Rajasthan Ajmer, Rajasthan, 305817.
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