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Year : 2017  |  Volume : 11  |  Issue : 2  |  Page : 26-30

Factors that determine deceased organ transplantation in India


1 Centre for Public Health, School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, Maharashtra, India
2 Centre for Hospital Management, School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, Maharashtra, India

Date of Web Publication12-Sep-2017

Correspondence Address:
G S Adithyan
School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai - 400 088, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_13_17

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  Abstract 

Extension of life through organ transplantation is indeed a glorious tribute to the progress of science and the progressive mentality of the society at large. It is a sign of our changing times. Even though India has all the potential in becoming the leading nation in the transplantation process, the country lags behind due to multiple determinants. The present paper looks into those determinants that restrict deceased organ transplantation in India, through empirical evidences and literature review. The evidences suggest that the practice of deceased organ transplantation in India is still on the back foot due to various factors such as the lack of awareness among general public as well as medical professionals, sociocultural and religious factors, organizational issues, and legal and ethical aspects.

Keywords: Deceased, determinants, donors, India, organ donation, transplantation


How to cite this article:
Adithyan G S, Mariappan M. Factors that determine deceased organ transplantation in India. Indian J Transplant 2017;11:26-30

How to cite this URL:
Adithyan G S, Mariappan M. Factors that determine deceased organ transplantation in India. Indian J Transplant [serial online] 2017 [cited 2017 Nov 24];11:26-30. Available from: http://www.ijtonline.in/text.asp?2017/11/2/26/214377


  Introduction Top


The concept of sharing the essence of life is nothing but divine. An organ donor has the envious distinction of giving life to a needy (at times to a dying) fellow human being. The donor who willingly consents to give his/her vital organ for donation after death can live again through the recipient's life; on the other hand, the recipient also cherishes rest of his/her life. This concept of sharing the life through organ transplantation is revolutionizing the basic factors of our existence. It gives a new meaning to life and defines the purposefulness of life in a far better way. It is a fact that the importance of organ donation is not fully understood by the community due to multitude of factors which determine and restrict organ donation in India.


  Determining Factors for Deceased Organ Donation Top


The factors that restrict deceased organ transplantation are manifold. The key findings of the articles reviewed are represented in [Table 1].
Table 1: Key findings from articles reviewed related to determinants of deceased organ transplantation

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Sociocultural factors

The Western societies are largely governed by materialistic concepts and scientific assessment of life, death, and life after death. This is an attitude that makes organ donation easily imbibed and practiced. In the West, death (also brain death) is seen as a biological process and in nonwest as a social process.[1] The attitude toward organ donation is mostly based on humanitarian and altruistic concepts in the West. However, in Asian countries such as India, Japan, and China, life, death, and life after death are embroiled in concepts of ethics, religion, and tenets of spirituality. It is very cumbersome to initiate a social as well as personal dialog on a subject like organ donation in these countries. In Japan, there is no tradition of altruism and it is socially unacceptable to take things from others (receiving organs).[2] To some extent, the similar understanding had been practiced in India also. Hence, sociocultural factors play a decisive role in organ donation in India and other Asian countries. Religious concern may also impede the decision toward organ donation.[3]

Knowledge, beliefs, and personal values

Horton and Horton's model of factors related to organ donation directs that the strongest predictors of organ donation willingness are knowledge and attitudes, with personal values (including altruism) playing a much weaker (though statistically significant) role.[4] Public awareness regarding organ donation in India is extremely low and also there exists a negative attitude among the general public regarding the issue.[5],[6] It may be due to the many myths and misconceptions clouding organ donation. During the recent launch of Nationwide Registry for Organ and Tissue Donation in 2015, the Health Minister of India said that even now, there exists many myths and misconceptions regarding organ donation in India.[7] The concept of “brain death” and its legal implications are still not familiar to many in India. There is a lack of awareness about it even among the health professionals.[8],[9] Medical professional's knowledge, attitudes, and practices are also quintessential in promoting an atmosphere that positively impacts organ donation rate.[10]

Stakeholders' participation in organ donation

Even though organ donation is promoted by multiple stakeholders, and many have donor cards, all these have not yet produced a high rate of cadaveric donation in India. Thus, there is a great mismatch between the potential donors and the actual number of cadaveric donations. Even among those individuals who gave assent or likely to give assent, the question arises about their inner convictions and vulnerability toward influences from family members in doing what they really want after death. Thus, one reason for the donor shortage in this country is due to the fact that the family of a potential donor will not adhere or comply with the decision of a potential donor after death. The reasons for the family to refuse include lack of awareness regarding brain death, superstitions, delay in funeral, disagreement among other family members, fear of social criticisms, dissatisfaction with hospital staffs, and being unaware about the deceased's wish.[11]

Even though there exists a multitude of factors determining organ donation, imparting knowledge and awareness and changing the attitude of the general public are very vital for any organ donation program to succeed.[5],[6] This entails involvement of the nongovernmental organizations (NGOs), civil society, religious leaders, and other stakeholders in creating awareness. However, there are changes seen in sections of Indian society, mainly among the youth who are now willing to donate their organs after death.

Role of effective communication

Becoming a deceased organ donor is mostly decided by one's next of kin. Lange studied that family members agree to organ donation in over 90% of the cases where family members have some indication of the wishes of the person who has died.[12] Hence, a good communication with family about the intention to donate is a determining factor which changes a potential donor to a real donor after death. A potential donor with ample knowledge and positive attitude toward organ donation is likely to effectively communicate and convince the family members.[13] Hence, the best way to ensure this certainty is to persuade those who are willing to donate organs to discuss the issue with family members. Unfortunately, there appears to be an assumption that simply signing an organ donor card will stimulate family discussion although it is apparent to those working in the area of organ procurement that this is not the case.[14] There is also a larger section among youth who move along with the tide and accede to this demand and sign donor cards on account of peer pressure and media enthusiasm. These sections are having low knowledge on organ donation and are highly unlikely to stick to their consent and decision. This information is also vital to the creation of future organ donation awareness campaigns.

Organizational support for organ donation

In the initial years of organ donation in India, it was thought that sociocultural, religious, and lack of knowledge on the issue are the only reasons that barred families from giving consent for organ donation, but it was soon apparent that there were many other factors other than these impeding organ donations.[15] The lack of adequate number of transplant centers with inadequate infrastructure and staffs as well as lack of adequate number of trained transplant coordinators is acting as hindrance to the deceased donation program of India.[5],[6] A study has also reported that about 20% of nephrologists from India have migrated abroad.[16] The high cost of immunosuppressive agents, poor maintenance of dialysis programs, absence of research, lack of national health insurance programs that cover patients undergoing transplantation, lack of coordination between various medical units, etc., are posing challenges to India's deceased donation program.[6] In many hospitals in India, there are no clear protocols to certify brain deaths. Many hospitals do not have the adequate institutional mechanisms to approach and take consent from families of brain dead patients.[15]

Legal and ethical issues

There are many ethical issues and loopholes within “The Transplantation of Human Organs Act” (THOA) which acts as another determining factor in organ donation. There are issues regarding consent, incentives to donors and families and equitable distribution of donated organs.[15] The subclause (3) clause 9 of chapter II in the law which says about unrelated live donation has high likelihood to get misused and is an important reason why kidney trade still exists in India.[17],[18] The THOA failed to prevent the commercialization of organ donation as it was before the implementation of the act and was also not able to increase the number of deceased donors to take care of organ shortage existing in the country.[19],[20] Even though there are many issues and concerns with the act, it was the first step in the right direction. A strong legislation will not be sufficient enough to improve the organ donation scenario in India. There may be other factors that determine organ donation. Even though the government has come up with a national registry to streamline and centralize the process, it is still not fully active and operationalized. Here, it is the prevalent mode of inertia in the administrative and government setups in India acting as the bottleneck.

Negative propaganda by print and digital media on organ donation

Cadaveric organ donation is built upon predominantly by altruism and public trust. If anything shakes that trust, everyone loses the hope in the whole process of organ donation. The print and social media are a prerequisite in today's world to promote organ donation but there are many which also propagate negative propaganda particularly on the financial gains of the hospitals/institutions without any evidence. This phenomenon has been on the rise recently, and it may act as a deterrent to organ donation.

Financial issues

Last but not the least, an important hurdle is the financial incompetency of many poor recipients. Nowadays, it is a common feature in newspapers and roadside hoardings to see request for help to the poor patients who are awaiting transplantation. In India, especially for the poor, most of the transplantations are achieved through social contributions and not necessarily government funds.

Apart from this, there are multiple factors that affect live organ donation in India, but the relative influence is different for cadaveric versus live donation. All the actions to improve the organ donation scenario should hence be directed toward factors that are most vital in elucidating the present variation in willingness for donation.[21]


  Necessity of Organ Donation in India Top


Globally and nationally, there is an urgent need to promote organ donation since there is an acute mismatch between the organs donated and people in queue for transplantation. Every day, a number of people are dying while waiting for an organ transplant. It has been now estimated that in India, only 2.5% of patients with end-stage renal disease finally end up getting a transplant.[22] While 2.1 lakhs Indians have need of kidney transplantation every year, the actual cases which happens are ranging from 3000 to 4000.[23] While 12 lakhs Indians require a corneal transplant every year, about 45,000–50,000 eyes are only collected every year by efforts from all eye banks operating in the country.[24] It is also to be noted that compared to renal dialysis, transplant leads to a longer and quality life.[25] Transplantation is also more cost-effective than renal dialysis.[26]


  Cadaveric Donation: The Way Ahead Top


An unswerving cadaveric or deceased organ donation program is seen by many experts as the only viable and sustainable solution to the problem of organ shortage in India. Cadaveric donation refers to transplantation of organs from a brain dead person to a recipient. Brain death refers to the irreversible loss of all functions of the brain, including the brainstem. It is different from coma or vegetative state where the brain is still functioning. Unlike to living donation, the deceased organ donation program has the potential to transplant heart, kidneys, liver, lungs, pancreas, small intestine, larynx as well as tissues such as heart valves, corneas, and bone marrow.

The prospective for cadaveric donation is high in India due to the vast numbers of road traffic accidents occurring annually. The road traffic accident accounts for around 1.4 lakhs deaths in India annually. Among this, 65% sustain severe head injuries according to a study conducted by AIIMS, Delhi. Hence, it can be assumed that around 90,000 cases will befall in the “brain dead” category.[23] If we are able to tap this, by promoting cadaveric donation, India can be the global leader in deceased organ donation. Hence, all the future efforts in promoting organ donation in India should primarily focus on cadaveric donation programs.


  Conclusion Top


It is regrettable that governmental initiatives have not taken wings till date to its full extent. There is inequity existing in the organ donation scenario of the country. NGOs working on this issue in India have also not yet caught up with this issue in a satisfactory manner except for few organizations. The government should address this issue with utmost importance to bring equity.

The stigmas and misconceptions surrounding this issue can be removed only through awareness programs. Since the issue has a clear religious overtones, there should be a concerted effort to rope in organizations that have a say in such matters to address the issue. A simple fact is that almost all organs in a cadaver can be transplanted in a living body within prescribed conditions of time limit. Hence, there is also a need to further rationalize the process through innovative methods and techniques. Research in this regard is another frontier into which the country has not ventured into so far, vigorously. Hence, government should allocate funds for new medical researches in organ transplantation.

The concept of organ donation should reach the public, and the role of various stakeholders is pivotal in this process. The government, NGOs, medical fraternity, media, and youth organizations should join hands for this endeavor. The loopholes in the law should be rectified and administrative bottlenecks should be reduced from the government side.

The infrastructure in government and private hospitals to conduct transplantation should be strengthened. Various awareness programs such as continuing medical education programs among medical and paramedical personnel, transplant counselors, and coordinators should be done. The “standard operating procedures” established to identify and certify brain death, maintain and transport organs, and tackling medicolegal cases should be uniform and standardized in both government and private hospitals. Since lack of uniformity may pave way for malpractices.

To propagate organ transplantation in a big way, we have to enlist support from various stakeholders on priority basis. Doctors have their role in facilitating this. However, the medical students have the added responsibility to carry out the meaningful propagation of this noble mission. There should be a systematic evaluation of the doctors' knowledge and commitment to this concept. We should inculcate these ideas of life-giving and life-extending measures in the medical curriculum as well as in school curriculum to promote organ donation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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