Health Ministry should adopt a more professional approach before banning living donor liver transplantation (LDLT) by establishing a Living Donors Organ Transplantation Review Committee to study and make policy recommendations to government and Parliament

Media Conference Statement
by Lim Kit Siang

(Klang,  Sunday): The director-general to the Ministry of Health, Tan Sri Dr. Mohd Taha Arif sparked off a controversy when Thursday's papers reported his announcement of a ban on live donor organ transplants in government hospitals because of the negative implications for both the donors and society.

He said his ministry also discouraged private hospitals from doing the same, adding that it was against medical ethics although several such transplants had been carried out at private hospitals in Malaysia and other parts of the world.

He also warned that "If something goes wrong, disciplinary action can be taken against the surgeons" when asked about several liver transplants which had been performed in the country.

The immediate reaction was the Malay Mail report the next day (28.2.03), under the headline "Liver Surgeon Opts Out of KL Ops" which said:

"LEADING Asian liver transplant surgeon Datuk Dr K.C. Tan will cease all operations on liver patients in Malaysia, saying that he cannot work under a threat from the Health Ministry.

"The Malaysian-born hepatobiliary surgeon, based in Singapore, has decided to shelve his work in Malaysia after the Ministry threatened to take disciplinary action against any surgeon who performed organ transplant from a living donor if the operation goes wrong.

'"I cannot operate under such a threat, more so before such a surgery is being carried out,' he told The Malay Mail in a telephone interview yesterday.

"'Until and unless the threat is removed, I will not operate in Malaysia.'"

Dr. Tan, a consultant surgeon at the Subang Jaya Medical Centre (SJMC), had carried out 40 liver transplants in Malaysia since 1995. He has performed more than 450 liver transplants since 1987.

SJMC executive director Dr. Jacob Thomas announced on Friday that SJMC will temporarily cease all operations related to liver transplants and asked the Health Ministry to draw up clearer guidelines on such operations.

The manner the controversy over the ban on live donor organ transplants erupted was most unfortunate and unwarranted, raising anew the question of the lack of seriousness and professionalism of the Health Ministry in its approach to both medical and health issues and problems.

Firstly, Dr. Taha made the announcement in response to allegations that the Health Ministry had not released funds for a liver transplant for 18-month-old Muhammad Nabil Hakimin Muslimin, who died on Monday at the Universiti Malaya Medical Centre before undergoing the transplant. The child's parents claimed that the transplant could not be done because the Ministry did not release the funds.

Whatever the right and wrongs, merit or demerits of the allegations of Muhammad Nabil's parents, why should such an important public policy issue as the ban or otherwise on live donor organ transplants be made as an incidental response to these allegations?

Secondly, why the threat by Dr. Taha to take disciplinary action against the surgeons who performed live donor liver transplants at private hospitals in the country, and was he directing his warning specifically at Dr. Tan?

I fully support Dr. Taha's concern about "the risk of morbidity and mortality" faced by the donors and the need for a policy approach of "Even one donor death is too many" - except that Dr. Taha would be more convincing and credible if he had adopted a similar position of "Even one dengue death is too many" in the worst dengue epidemic raging on in the country for the past nine months, claiming at least 100 lives last year and as high as 20 lives in the first two months of this year.

Thirdly, in zeroing in on living donor liver transplantations (LDLT) in the private hospitals, is Dr. Taha drawing a line between live liver transplants from other live organ transplants, where the former is "No, No" while the latter are in "a no man's land"?

Dr. Taha is right that live organ transplants present grave medical and ethical issues and dilemmas, but to impose a sudden ban on live organ transplants is not only a misjudgment but a disservice to Malaysia, as it sends the wrong message to the world of a major retrograde development in Malaysian medicine in direct contradiction to the professed claim that Malaysia wants to be at the very forefront of global ICT, scientific and bio-medical developments and advances.

The first organ transplant in the world was carried out 50 years ago in 1953, and since then, major advances and breakthroughs have been made in the field, including those involving living donors.

Living donor transplantation, which began with kidneys, has been extended to livers, pancreas, intestines and lungs. It has been reported that in the United States, kidney transplants using organ from live donors exceeded those from cadaveric donors for the first time between 2000 and 2001. In 2001, 6,485 people donated a kidney for a transplant, compared with 6,081 cadaveric donor kidneys.

Liver donation is generally riskier than kidney donation. Although there is at present no official living donor liver registry, it is estimated that more than 2,500 living donor liver transplantation (LDLT) had been performed worldwide.

It has been reported that the largest LDLT programme in the world is at Kyoto University in Japan.

Although LDLT represents a number of positive medical and economic benefits, including shorter hospital stays and a faster recuperation time, it poses decidedly tough ethical and medical questions and dilemmas, such as:

  • Whether live organ transplantation will unwittingly violate the Hippocratic Oath to "first, do no harm", as it is said that "to do a live donation, a physician must harm someone".

  • The profit incentive that motivates some surgeons and medical centres to establish transplant units.

  • Lack of clarity as to what qualities constitute a competent donor and which healthcare professionals should make that determination.

  • Who in the transplant community can best serve as the donors' advocate - "Whose primary duty is the transplant team to - the donor or to the receipient?"

These issues and the need for safeguards, in particular on donor safety, uncoerced consent, and to ensure that there should be no financial arrangements between receipients and donors, need to be addressed.through candid discussions, disclosures and policies.

The Health Ministry should adopt a more professional approach before banning living donor liver transplantation (LDLT) or other forms of live organ transplants, whether in government or private hospitals, by establishing a Living Donors Organ Transplantation Review Committee to study and make policy recommendations to the government and Parliament.

This Review Committee should provide for a tripartite composition - the government, the medical professionals (the Association of Private Hospitals Malaysia and Malaysian Medical Association) and the Malaysian public, to represent directly the interests of the donors and receipients of such transplantations.


* Lim Kit Siang, DAP National Chairman