Death in a doctor’s perspective happens in two ways : when the heart stops and subsequently the blood stops moving through arteries and veins or in a more complex case, the brain fails. In the second setting, autonomous organs like the heart, kidneys and liver continue to work if respiration is supported by a ventilator and other life-supporting measures. It is in this situation that a person is declared brain-dead due to irreversible coma with no comebacks possible and just the traces of life remaining before it gets extinguished later as the heart fails. Medical sciences were quick to see an opportunity here to help the living when a dying man’s organs could be harvested to help another direly in need of it. Cornea, kidneys, liver, pancreas, skin and even the hand can be used for helping another human as one leaves this world.
Kerala began its tryst with organ transplant from deceased donors in 2012. Frustrated with sourcing kidneys from unrelated donors (often with a financial exchange), Dr Ramdas Pisharody envisaged a programme based on Tamil Nadu, a pioneer in this altruistic endeavour. He found a backer in Health Secretary Rajeev Sadanandan, who gave the administrative impetus direly needed for such a programme. The media too chipped in and Kerala had a flying start in organ harvesting from brain-dead donors. As numbers grew, patients condemned to death and dialysis (the latter in kidney failure) saw a ray of hope and the waitlist for organs seemed to move, but then this happiness of hope was short-lived. The State Government clearly mandated that one kidney from every donor be given to a patient waiting for it at one of its medical colleges. However, liver transplant surgeries were expensive and available only in private hospitals though the government did attempt in providing the infrastructure.
Keralite’s innate suspicions about private hospitals making hay were raised and media too sensed that something was rotten. Critical stories began to appear and screaming headlines provoked panic among all stakeholders of the deceased organ donation programme. A few errors in the paper work of the certification added fuel to fire. The deceased organ- donor programme came to a standstill as doctors feared that the police might knock on their doors if they participated in the organ donation process from their brain-dead patients. The Government stepped in to make the certification process more credible and got their doctors in every such process, ensuring there is no foul play or room for suspicion. Videography of the certification process was made mandatory and even a test to rule out a drug-induced paralysis mimicking coma was introduced.
A writ petition filed in the High Court of Kerala led to some hard questions and it took some governmental effort to stall a judicial rebuke and a ban on all cadaver-origin transplants as the court upheld the Kerala Government’s efforts.
A lot of harm done, the programme was derailed. The government has promised to bring it back on course following the evolution of a credible brain-death certification process after consultations with all stakeholders. Doctors need to get over the fear of witch-hunt that has come to be associated with such transplants .The media should endeavour not to raise the fear-quotient among the public. The people must come forward to help the less-fortunate ones, who wait in hospitals for a much-needed organ in order to reclaim their healthy life. If there is any delight in death, that is only in helping the living.
Make death meaningful
Everyone expects their dear ones to live as long as themselves but then nature has a plan that can be different from ours. Being a doctor, I knew that my father would die anytime as he aged and faltered as diseases took their toll on his frame. We discussed the “end of life care” and he was categorical that he didn’t want to die in an intensive care unit. He also wanted his organs to benefit someone who needed them though the transplant programme from soon-to-die patients has not begun in our state formally. Months later an epidemic of chikungunya virus hit Kerala and my father went down with a fever caused by this virus. By the third day he was becoming fatigued and delirious suggesting that his brain too had begun to falter and he was in hospital. In between he came around and even criticized my mother for some silly reason which he always did at home and we almost believed that he has beaten the odds. The virus raged through his blood stream shutting his organs one by one. He slipped into coma and we were confronted with two questions –should we hook him to a ventilator and support his failed kidneys with dialysis?
As a doctor and son, I had to face the dilemma of taking a stand on whether the props for prolonging his life were to be employed, something that will confer a few more days of life which ultimately will be snuffed out soon. My mother chipped in with a clear answer: not to support a life that is dependent on machines if the ultimate result is not going to be different. We moved him to a larger room where everyone could see him. I was sure that if he is going to die, he will do it in the midst of people who love him. Soon the gasping respiration happened and we chanted all the prayers that we knew as this life’s last breaths ebbed. I told relatives to stop crying as I thought this was a spectacle that needs to be seen just as a newborn’s first cry. The breathing stopped later and my father was not there anymore in the physical sense.
I could only donate his eyes as the infection that consumed him rendered most of his organs unsuitable for transplantation into another human being. I thought that I failed to carry out his wishes as I saw patients in neighbouring rooms awaiting a kidney-donor and were on dialysis. It was only the next day that his absence was felt as I went to the crematorium to find ashes instead of a human form that you are so used to. Ashes or just sand ,this is what you become after you die but then as you leave this world, donate your organs as it will confer meaning to someone who yearns for their life after one of their organs has failed them a little too early
Doctors ‘aid’ organ trade
The virtual halt to deceased donor organ transplantation owes to noncooperation by doctors, which indirectly aids the banned organ trade in the State. Apprehensions and misapprehensions about commercially-minded doctors declaring patients brain-dead to harvest their organs have contributed to a fear psychosis among the public. This is partly owing to media misreporting. Doctors fear misguided relatives of brain-dead patients, from whom organs have been harvested, might sue them, leaving them branded for life. This has led to a situation of non-reporting of brain-dead cases by doctors across the State and the resultant halt to cadaver organ transplant.
Kerala Deceased Donor transplant data, compiled by the Kerala State Network for Organ Sharing (KNOS), show only 20 kidney transplants have taken place this year as against 113 in 2015, 132 in 2014 and 104 in 2013. This fatal trend is wholly attributed to noncooperation by the medical fraternity and has contributed to the agonizing long queue of patients waiting for organ transplant. There are very stringent provisions for certifying brain death and doctors in attendance are duty-bound to report to KNOS brain-death cases so that steps for organ harvest can be initiated.
Instead, doctors, especially in the private sector, either deliberately or not, collude in the transplantation of organs, obtained for a price. Insiders say the organ racketeer pockets Rs 10 L for a kidney while the hapless donor ends up getting a mere Rs 4 L. Buying an organ for transplant is banned by law and hence risky. Another dimension to the racket is it helps only those who can buy an organ. Chances of the poor, who are unable to get close relatives to donate, benefitting by cadaver donation are bleak in the context of non-reporting of brain deaths. Patients, who curse their fate for being deprived of timely donation, are even driven to justify organ trade out of sheer desperation. Clinicians warn against this situation because it will snuff out deceased organ transplant in Kerala, which reports at least 200 road accident deaths every month. At least 20 of these cases are brain-dead and people perish without being able to light up lives of fellowmen.
State scotches doubts in HC
Apart from challenges of bad publicity that Kerala’s Deceased Donor Organ Transplant programme faced, another tough battle awaited it at the High Court in the form of a public interest litigation. The petitioner alleged that there were malpractices in declaring someone brain-dead with the ill intention to harvest organs .The State responded by saying that videography of the procedure was being done which the courts observed, answered the petitioner’s apprehensions.
The Division Bench heard the process of brain-death certification that includes a battery of neurological tests and the Apnoea Test in detail. In the latter case, the ventilator is disconnected from a presumed- to -be -brain -dead patient for a while to raise the carbon dioxide level in blood, which is a potent trigger of a gasp or respiratory effort emanating from the brain. If this is absent, it indicates that the brain has stopped its basic function of breathing, much needed to sustain life.
The petitioner also criticized the use of doctors with basic training being drafted for brain-death certification. The state responded by saying the Transplant of Human Organs Act 2014 stipulates that among the four doctors needed for such certifications, only one-a neurologist or neurosurgeon or an intensivist- needs to perform the test while the others in attendance observe that proper procedure has been done. The government has been training doctors in its health services for certifying brain death. The Court also observed that there is insufficient evidence to determine if any other tests like angiogram of the brain and Doppler studies (which were found wanting in categorically confirming cessation of brain’s functions) are useful. The court asked if a test like Electro Encephalograph- y (EEG), which shows the electrical activity happening in the brain when alive can be considered as a confirmatory tests. However, Kerala Government had received negative feedback from a committee of experts it constituted to determine the utility EEG in brain-death declaration.
The petitioner also tried to bring the cases of alleged medical malpractice in the transplantation process. However, the Justices observed that they did plan to do medical policing and such cases must be raised in other fora meant for sorting out medical malpractice-related disputes. The court thanked Dr Easwer H. V., who served as expert and briefed the court on the matters pertaining to brain-death, and closed the writ petition. The Deceased Donor Organ Transplant Programme started breathing again as a ban was averted.
(The author is Professor of Neurosurgery at Sree Chitra Tirunal Institute for Medical Sciences and Technology)
