Watani talks to Dr Rashad Barsoum
For many years poor Egyptians have been exploited by the illegal organ trade. Wealthy patients from the Gulf would come here in search of a new kidney or a lobe from a liver, and organ trade brokers would lure poor and needy people into ‘donating’ an organ in return for money. This went on until the Ministry of Health issued a law in 2010 to legalise the organ transplant process and end the illegal trade.
Watani talked to Dr Rashad Barsoum, Emeritus Professor of Medicine and Nephrology at Qasr al-Aini Medical School and a member of the Supreme National Committee for Organ Transplantation.
Why did the government issue the Organ Transplant Law of 2010?
Before this law took effect, Egypt had become a thriving market for human organs. Wealthy patients from the Gulf would come to Egypt seeking to buy a human organ, while poor young men from Eritrea and Somalia would come offering to sell their organs. There is a street in Attaba in Downtown Cairo that is notorious as a hub for organ brokers. They perform medical tests for these young men and keep the information on record. When a wealthy patient contacts the brokers, they can easily find a matching donor, of course for a hefty commission. Doctors noticed this and feared that Egypt was becoming a market for organ trade, so the Doctors’ Syndicate and the Egyptian Society for Nephrology and Transplantation called on the government to put an end to this disgraceful practice. The Ministry of Health established an organ transplant committee to draft a law for organ donation and transplant.
What are the main features of this law?
One of the main articles prohibits the transplant of any organ from one person to another in return for financial reward, and allows it only in the form of ‘donation’. The law allows organ donation and reception exclusively among Egyptians, and sanctions organ donations among non-relatives. In cases where the organ to be transplanted is taken from a deceased person, there must be a written, officially certified authorisation signed by the donor prior to death, or approval from the deceased’s family. The law also determines how to prioritise cases on waiting lists for organ transplant, organises the steps of the transplant process, and stipulates the penalties for breaching the law.
Even though the organ transplant issue started by focusing on kidney and liver transplant, new specialisations were added such as transplants in the fields of cardiology, ophthalmology, orthopaedics and gastric medicine.
What procedures have currently been adopted for organ transplants?
On the practical front, a tripartite medical committee is formed in each establishment authorised to perform organ transplants. The members of these committees must not be among the owners or the shareholders of the establishment and must not be related in any way to a patient. This committee first determines if the patient needs the transplant; if it grants its approval, both the donor and recipient proceed to the Ministry of Health where they sign a declaration that the donor is not taking any financial compensation from the recipient. The procedure is repeated at the medical establishment where the transplant will be performed.
A new, official committee was formed and assigned not with a medical issue but with a societal one, that of raising awareness among Egyptians of the importance of organ donation. The controversy involves the media, and tackles religious and practical aspects. This role of the committee is mainly informative. A number of young members were included, to take advantage of their enthusiasm and innovativeness.
Are there still legal or religious doubts vis-à-vis organ transplants?
These are thorny issues and that’s why we are planning to add members from the judiciary and the clergy to the committee. Whenever we need to issue new regulations, we need to reinforce them with legal and religious opinion. It is no secret that Egyptian society is particularly influenced by religion, hence the significance of the opinion of both Muslim and Christian clergy.
The same applies to the media. Sadly, the media only highlights the shortcomings on all fronts and stops short of highlighting any positive move. If media people participate in the committee’s decision-making, they will probably be more enthusiastic about bringing them to the public eye.
As for the legal part, the legal counsellor of the Ministry of Health is a member of the committee which makes it easier to issue decisions and regulations.
What about citing a person’s willingness to donate organs on their ID cards?
One of our current goals is to note the person’s willingness to donate organs after death on national ID cards. Two policies about organ donation have been adopted worldwide: Opt-in and Opt-out. The Opt-out policy, often referred to as presumed consent, means that the State presumes that everyone consents to donate their organs after death and whoever does not wish to do so must notify the State, in which case the ID card is marked to indicate the refusal. So far Spain, which has adopted Opt-out, is the most successful country worldwide in organ donation, with the highest number of donors.
It is the Opt-in policy that we wish to apply in Egypt. Whoever wishes to donate organs after death must fill in an application, and the ID will be marked to indicate consent. In this case, this person’s organs may be donated without the family’s written consent. An independent authority will be established to build a donor database, facilitate the application process and ensure that the application is easily accessible in various medical establishments.
Will donors enjoy any special privileges?
I believe the most important privilege they receive is that society will see them as philanthropists who by donating their organs give other people a second chance to life. We are studying proposals to give them health care privileges and special health insurance, and if at any time they need an organ transplant themselves to put them on top of the waiting list.
How are the recipients for donated organs chosen?
There is an independent body to regulate this issue. Patients in need of an organ must register with the Ministry of Health. They are then placed on the waiting list, which is sorted on a first-come first-served basis. The patient’s data is added to the legal authority’s database. When an organ becomes available, the legal authority is immediately notified and the database is searched for a potential recipient. Tests are conducted to determine a match. Once a positive match is found, the doctor in charge of the case is contacted and the organ immediately transferred to the hospital where it is kept chilled until the patient and the doctor arrive and the transplant surgery can be performed. It is important to note that all these steps must be performed swiftly and precisely to ensure the success of the transplant.
If kept chilled in preservation solution, donated organs can remain viable for transplant for a duration ranging from a few to several hours, although it is best if they are transplanted as quickly as possible. Typical storage times are 30 hours or less for a kidney, less than 12 hours for a pancreas or liver, and less than six hours for a heart or lungs. These times vary because of the relative speed at which deterioration begins in the organ tissues.
What medical centres in Egypt are allowed to perform transplants?
So far, we have set the rules for pronouncing a person dead and determining the hospitals allowed to perform organ transplants. Those chosen were the medical schools of teaching hospitals. All the necessary medical equipment needed to perform these operations have been purchased and all the ministerial decrees signed. We are in the process of determining which intensive care units will be allowed to extract organs from dead donors.
All medical centres in Egypt can perform organ removal from living donors. There are 32 centres for kidney transplants, 15 for liver transplants, and two for bone marrow transplants; in addition, most hospitals perform corneal transplants.
We are planning to establish centres for heart and lung transplants, but this can only be possible when organ transplants from the recently deceased is approved.
How about organ transplants from people who are recently deceased?
The implementation mechanism is very important, since organ removal from a dead person can have serious consequences. It is virtually impossible to transplant an organ from someone who dies in an accident. The committee setting the rules for transplants has set specific criteria for removing organs from people who have died. Prior to death the deceased must have been admitted to intensive care and received proper treatment—this to ensure that he or she is not left to die in order for someone else to receive organs. The medical file of the deceased must be studied carefully to ensure freedom from any virus or disease.
Specific neurological criteria are adopted worldwide to determine if a person is brain dead. This is to prevent anyone from taking advantage of a person’s organ donation approval. These criteria have been approved by the Ministry of Health. A three-member committee of neurologists and anaesthesiologists examines the donor and determines whether he has received proper medical care, and then writes down the cause of death. After each doctor has signed the report, it is presented to the Ministry of Health. These doctors are considered legally accountable for their report.
How can you persuade the deceased’s family to donate his or her organs?
We studied other countries’ experiences and found there were courses on how to address the family of the recently deceased. Some of our medical staff were accordingly enrolled in these courses. The scenario for talking to the family usually starts with noting the individuals’ emotions and addressing the one most composed and receptive. But it is the deceased’s pre-consent that matters most. It sometimes helps to be able to persuade the family that a part of the deceased will live on through someone else. The leading countries in this approach are Italy and Spain.
What is now needed to put the new decisions into action?
The problem is not administrative; it is about achieving a breakthrough in the social taboos held by the community, many of whose members believe that taking an organ from a dead person is tantamount to desecrating the body. We recently polled members of the medical profession, doctors and nurses, on the issue. The results were shocking. A large portion rejected organ transplant on the grounds that organs belong to Allah, not to the donor; therefore, one has no right to donate them in the first place. I always answer such allegations with the argument that if a person’s organs don’t belong to him or her, then it is only logical that we take them from him and give them to another person who needs them. In both cases the organ would belong to God and we only transfer them from one person to another to bestow the gift of life.
How can public awareness be raised?
The media is very well positioned to raise societal awareness and attitudes, and promote a culture of organ donation. We are preparing a huge awareness campaign to inform Egyptians of the importance of organ transplants.
What about the illegal organ trade?
I believe the State is responsible for the spread of the illegal organ trade. As long as the law is not firmly put into action and remains, as it still does today, mere ink on paper I don’t blame anyone who badly needs a transplant so opts for the illegal solution. My close contact with patients makes me feel their suffering. Renal failure patients have to suffer the six-hour-long, three-times-a-week dialysis, but if they could get a kidney transplant they could proceed with life normally. On the other hand, a person with very scarce means and many mouths to feed might believe the only way out would be to sell an organ. But the State does not allow for such ‘cooperation’ between the two sides, and therefore they have no other way but to circumvent the State and the law. But if the State provides for human organs in a legal, well-regulated manner while at the same time offering good health insurance for the donor, the illegal organ trade will disappear. I believe we ought to proceed fast in this direction to protect both organ donors and recipients from this ruthless trade.
Rashad Sami Barsoum
Facts on organ transplant
19 August 2015