Singapore kidney update

To follow up on my post yesterday about Organ donation and compensation in Singapore: new legislation, Sally Satel points me to The Human Organ Transplant (Amendment) Bill-Closing Speech by the Health Minister, Khaw Boon Wan.

It contains a number of points, not least of which is that the new legislation will legalize Kidney Exchange in Singapore. (It's interesting to note that they are thinking of legislating simultaneous exchange.) More interestingly, the speech elaborates on the manner in which the legislation is meant to continue to prohibit "organ trading," while allowing the reimbursement of donor expenses by the recipients.

All of this will make it interesting to see how procedures in Singapore evolve. Will willing donors become abundant, and will they thrive in the long term? Will the availability of compensation crowd out the familial donors who drive kidney exchange? Will it be possible to restrict payments to expenses and lost wages? As Jeff Ely noted yesterday in his post Organs for Money, "Whether or not the new laws truly legitimize organ sales, markets have a way of organizing themselves around and in-between the cracks of legislation."

Some excerpts from the speech (emphasis added):

"(II) Allow Paired Matching4. All supported the proposal to allow paired matching. Dr Fatimah called for the establishment of a “systematic, proactive and well-organised living donor registry” to support paired matching. I agree. The National Organ Transplant Unit of the Ministry of Health will take charge of this.
5. The same unit will also take charge of setting up a Donor Care Register to monitor the health of the donors. Mdm Halimah and some other Members are curious about the long term health of the living donors. If the donors are well selected, there is good medical evidence overseas to suggest that there are few adverse medical impacts. But there is little local research on this. The proposed register will help us track long-term clinical outcomes and allow us to better understand the long-term impact of organ donation, if any.
6. Prof Thio asked how “pair matched” organ transplants will be regulated. She noted that in other jurisdictions, the transplant surgeries are carried out simultaneously to avoid situations where one of the donors decides to back out. Dr Lim Wee Kiak stressed the need to carry out such procedures simultaneously. Indeed, this will be the requirement for paired matching, that the surgeries will all have to be done simultaneously. Our Bill includes provisions for subsidiary legislation to be made to regulate organ transplant arrangements, including mandating that paired transplants be simultaneously performed, if this is necessary. We can achieve such an outcome administratively since the operations are carried out in our hospitals, but we will study if there is a need for an explicit regulation."
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"(III) Allow Payment for Living Donors
7. Let me now address the more controversial issue of payment for living donors.
Safeguards against Organ Trading
8. While all Members supported the good intention to reduce the financial losses incurred by donors through reasonable payment, Members were concerned that it might lead to organ trading, and Singapore becoming a regional organ trading hub. For example, Miss Sylvia Lim was concerned that the reimbursement value could become a backdoor to organ trading. During the public consultation stage, the World Health Organization and many Singaporeans expressed a similar concern.
9. Let me reiterate that this Bill does not legalise organ trading. During the public consultation, decriminalising organ trading and the Iranian model were often cited. But this Bill is not to legalise organ trading. Hence, Mdm Halimah’s concern about the Bill affecting Singapore’s relationship with its ASEAN neighbours does not arise. Our Bill in fact contains an amendment to raise the penalty on syndicates involved in organ trading. The Bill is to catch up with what many OECD countries have already done for many years. In drafting our amendments, we took reference from similar legislations in several of these countries. We are correcting our current extreme position of criminalizing all kinds of payment to the donor. For example, currently donors are charged by the hospitals for all their transplant-related medical and surgical expenses. The recipients are prevented by HOTA from reimbursing the donors for these expenses. The proposed amendments will bring us in line with jurisdictions such as the US and UK to allow some payments to be made to the donor.
10. Let me also clarify that we are not making it compulsory to reimburse living donors. We are merely allowing organ recipients, if they wish, to make some payment to cover the financial losses incurred by their donors. In fact, I will not be surprised if many living donors continue the current practice of not requiring any reimbursements from the recipients. This would address the concern of some members that low income recipients may not be able to afford such payment. But in the event that some donors may need such reimbursements and the recipients agree to do so, the law should not prevent it from happening.
11. I must also explain that reimbursement only applies to living donors. It does not apply to cadaveric donation where allocation of organs will continue to be based on tissue matching, time on the waiting list and other clinical factors as objectively determined by an expert committee. Hence the concern of Mdm Halimah and Mr de Souza about rich patients jumping the queue for the cadaveric organs does not arise. Indeed, as carefully pointed out by Mr Sam Tan, the Bill does not discriminate against the poor. Among living donors today, there is a mix of high and low income donors.
12. But as Members put it, the real challenge in donor reimbursement lies in the practical difficulties of making a distinction between what is reasonable payment and what is inducement. I agree with Members that the key lies with putting in place appropriate safeguards. ..."
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"21. Some of the Members asked who would pay the donors. The organ recipients would make the payment. Some Members suggested that a third party should administer the payment. Some payments will indeed be via a third party. For example, reimbursement for hospital expenses incurred by the donor can be done via the hospital. But there will also be payments which are made directly between the donors and the recipients, without going through a third party. Mdm Halimah suggested that part of the payment can be made via the donor’s Medisave Account. I think it is a good idea, provided the CPF rule allows such a voluntary contribution. Mr Ang Mong Seng suggested having a trust to hold half of the money received by the donor to ensure that it is not frittered away. But such arrangements are best left to the donor and recipient to decide."