BRAIN DEATH DONORS (ETHICAL POINTS)

2. G.POURMAND, M.D. Urology Research Center, Medical Sciences/University of Tehran Tehran, IRAN The 2nd International Congress of Medical Ethics in Iran (Apr. 2008) BRAIN DEATH DONORS (ETHICAL POINTS)

8. CANADIAN TRANSPLANT NUMBERS (1994-2003)

9. DONORS, ORGANS & WAITING PATIENTS Number of Patients 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Wait List at Year End Cadaveric Transplants Cadaveric Organ Donors

10. Organ shortage — the main limitation to saving lives of critically ill patients — is due to individuals and their families not considering organ donation out of fear, ignorance misunderstanding. THE ORGAN SHORTAGE

11. THE CRITICAL ORGAN SHORTAGE • 60 people daily transplant, • 13 die non-availability of organs. • 5,984 deceased organ donors; • 22,953 lifesaving organ transplants performed in 2000 (17,255 cadaveric donor transplants, 5,653 living donor transplants); • 77,179 on waiting list as of June 3, 2001; • 5,597 deaths while on Wait List at end of 2000.

12. Japan - 12,974 Taiwan - 7000 Saudi Arabia - 4248 Korea - 4000 Pakistan - 1650 Hong Kong - 1018 Singapore - 666 Bangladesh - 125 Waiting Time Taiwan – 1.9 yrs Korea – 2.2 yrs Hong Kong – 4.3 yrs Singapore – 5.8 yrs No Waiting list in Iran for Kidney Tx. KIDNEY TX WAITING LIST IN ASIA (2002)

13. KIDNEY TX WAITING LIST IN THE WORLD (2002)

14. Deceased donors Donor has been declared dead by two physicians independent of the transplant team Usually occurs only in cases of neurologically determined death (the brain stops working 1st but the donor is still on artificial support such as a ventilator to allow the other organs to maintain a blood supply and remain suitable for transplant) Live donors Patient chooses to donate one or part of an organ to someone on a transplant waiting list  Can only occur with organs when removal will NOT cause grave harm to the donor DONATION

15. Prevalence: 357 PMP • Incidence: 59 PMP • Currently, • 50% on HD • 47.5% transplanted • 2.5% on PD INCIDENCE OF ESRD IN IRAN

16. WORLD STATUS OF RENAL TRANSPLANTS Annual Number of kidney transplantations per million population (pmp) per year - USA - 52 Predominantly Deceased Donors Europe - 27 Predominantly Deceased Donors Asia - 3 Predominantly Living Donors

17. The number of deceased donors has increased steadily in recent years. Between 2003 and 2006, there has been a 24 percent increase in donation from deceased donors. Living donation rose sharply in the 1990s and has remained at a steady level the last few years.

18. DECEASED DONATION

19. DECEASED DONOR RATES The deceased donors per million population per year • USA - 20.7 • Europe - 15.9 • Asia - 1.1 • South America - 2.6

20. COMMON PROBLEMS & PLATFORMS IN CADAVER TRANSPLANT  Incidence of organ failure  Public and Professionals Attitude to Brain Death & Organ Donation  Legal Aspects  Trained Transplant Co-ordinators /Counsellors

21.  Media and Scandals  Reporting of Brain Death  Hospital Infrastructure  Religion & Organ Donation COMMON PROBLEMS & PLATFORMS IN CADAVER TRANSPLANT

22. PROBLEMS WITH CADAVER ORGAN DONATION PROGRAM IN ASIA Govt. Problem No Funding for program Hospital problem No efforts to identify & maintain “Brain Dead” donors Community Problem No Awareness of “Brain- Death” Concept For cadaveric donation, ‘ Society remains a crucial aspect in a transplant program’

23. MAKE LOCAL SHARING PROTOCOLS 6 Kidneys have been wasted in the last four years of the 112 Kidneys shared in the UNOS due to these problems • Poor Retrieval Technique – 2 • No Blood for Cross Match – 2 • Poor Packing of Organ - 2

24. PHYSICIANS ATTITUDE TO ORGAN DONATION A large proportion of Physicians are indifferent to organ donation process. Reason cited for this were • Lack of information regarding the donation process (28.7%), • Concerns about the sale of organs (22.1%), • Islamic religious beliefs (21.6%)

25. Media and Scandals Doctors May Face Murder Charge

26. PUBLIC ATTITUDE Important misconceptions and fears are – • Fear of death, • Belief that removal of organ violates sanctity of deceased • Concern about being cut up after death, • Desire to be buried whole, • Dislike of idea of kidneys inside another person, • Wrong concept of brain death, • Idea of donation being against religious conviction

27. RELIGION AND ORGAN DONATION Religion plays major role in promoting Organ Donation. Common thread that binds all religions of the world – • Saving of life overrides all objections • There is no religion that is against organ donation • What holds back is cultural reservations – • Ignorance of the process of organ donation, • Fear of mutilation, • Lack of emotional support at time of tragedy, • Fear that organs will be sold or used only by the rich • Mistrust of hospitals and health professionals • Myths

28. Dynamic Religious Jurisprudential

29. MUSLIMS & ORGAN DONATION Muslims: the most controversial group - • Quran does not forbid tissue donation • Quran states that if by not transplanting an organ or tissue, the person will die, then it is permissible to donate. It is allowed for an emergency to save life. • Different interpretations by different religious leaders, ‘ustazs’ and ‘ulamas’

30. MUSLIMS & ORGAN DONATION Fatwas declared in several countries • Saudi Arabia : 1985 - permit both living related and cadaveric donation of organs • Iran – 1989 (parliament legislation: 2000) • Pakistan, • Bangladesh, • Malaysia - 1995 • Indonesia

31. CHRISTIANITY – ORGAN DONATION STATEMENT BY POPE JOHN PAUL II – Full support of organ and tissue donation concluded with words of Jesus narrated by evangelist and physician LUKE: “give…, and it will be given to you; good measure, pressed down, shaken together, running over, will be put into your lap (Luke 6 : 38).” We shall receive our supreme reward from God according to the genuine and effective love we have shown to our neighbor.

32. RELIGIONS AGAINST ORGAN DONATION • Greek Orthodox, Shinto and Gypsies are three religions that do not encourage body donation • Jehovah’s witness is another Christian sect that is against such acts

34. Don't take your organs to Heaven because Heaven knows we need them here!

35. HISTORY OF DEATH • During ancient times, most people agreed that death occurred when a person's heartbeat and breathing stopped. • For the Greeks, the heart was the center of life • For the ancient Hebrews and Christians, the breath was the center of life

36. HISTORY • In the 12th century, Maimonides pointed toward the head, and the loss thereof, as the reason for lack of central guidance of the soul. • During the Enlightenment, the necessity of heartbeat, breath, and consciousness for the definition of life was questioned, leading to questioning regarding the definition of death.

37. LEGAL DEFINITION OF DEATH • The cessation of life; the ceasing to exist; defined by physicians as a total stoppage of circulation of the blood, and a cessation of the animal and vital functions consequent thereon, such as respiration, pulsation, etc. • Black’s Law Dictionary (4th edition)

38. UNIFORM DETERMINATION OF DEATH • An individual who has sustained either • Irreversible cessation of circulatory and respiratory functions • Irreversible cessation of all functions of the entire brain, including the brain stem is dead. A determination of death must be made in accordance with accepted medical standards. • Uniform Determination of Death Act (1980)

39. BRAIN DEATH • In 1959, patients were described as being in "coma depasse" or beyond coma. • In 1967, the first successful heart transplantation took place, with the organ coming from a brain-dead, beating-heart donor. • Farrell MM and Levin DL. Critical Care Medicine. 21(12):1951-65, 1993 Dec.

40. ... و مَنَ اَحياها فَكَاَ نما اَحيَا الناسَ جميعاً ... And he who saves a man’s life shall be considered as one who has saved the life of mankind as a whole سوره المائده آيه 32

41. Imam Khomeini’s (the supreme leader of Iran) positive response to the letter of the Iranian ex-minister of Health on the permissibility of organ donation from brain death patients.

42. Iran facts: • The oldest organ transplant (Cornea) was performed in 1314 (1935). • The first kidney transplantation was performed in Shiraz in 1346 (1967). • The total number of transplants in 2005 was 19501 kidneys, 203 livers, 104 hearts, 13 lungs, 28362 corneas, 1468 bone marrows, 1382 heart valves and 1283 bone transplants. • One, five and ten years survival rate is reported to be 92.8%, 83.7% and 73.3%, respectively. • Iran is the only country who doesn’t have any waiting list for kidney transplant & the patients can receive the necessary organ in less than 2 months.

43. ENCOURAGING PEOPLE TO DISCUSS ORGAN DONATION When the wishes of the deceased are not known, only 50% of people will agree to organ retrieval from their relatives Encouraging people to speak about organ donation and transplantation and to make their wishes known to their relatives could change the picture resulting in 93-94% of people allowing donation

44. PROJECT POSITIVE ASPECTS Many donor relatives have stated that donating their loved one's organs does not make the pain of their death disappear Bereaved families can experience comfort that their loved one's gift gave another person a second chance at life

45. PRESENCE OF FAMILY MEMBER DURING BRAIN DEATH TESTING • Most families faced with brain stem death of a relative find the concept difficult to understand and have trouble in accepting that their relative is actually dead • Family members were given choice to be or not to be present during brain stem death testing • It is suggested that presence of family members during brain stem death testing not only helps families to accept this concept of death but also promotes the grieving process

46. ACTION REOUIRED – MUSLIM COUNTRIES • Most people are ill- informed about their religions attitude towards organ donation. • More public education needed to change cultural beliefs and practices although Islam does not forbid Organ or tissue donation • Constantly addressing masses through media by religious head may help to improve sentiments

47. CONSENT FOR DONATION • Pre-mortem – via Donor Cards, Driving License • Consent of his family following death • Some form of a combination of the two are necessary • ‘Supererogatory permission’ - Underlying premise of such a consent would be that “organs of dead people are public goods”, and donation must be considered “similar to other compulsory civil obligations” within society • The permission is a moral rather than a legal requirement

48. MANDATED CHOICE • This requires people to state their ’willingness to donate or not’ when filing some state of institutional return such as a driving license or income tax form. • The information would be kept on a central register, accessible at time of death

49. PROMOTE ORGAN DONATION AMONG BLOOD DONORS • Study shows that blood donors have better knowledge of organ donation and are more willing to donate their organs and sign an Donor card than general public. • A substantial proportion of blood donors have not signed a Donor Card. • It would be useful to design promotion programs to facilitate blood donors' participation in organ donation.

50. CONCLUSION Organ Shortage is a Crisis, however the Crisis has a Cure • We need to Network and start thinking of sharing resources, expertise and organs • Set up Collaborative projects • Use Television Media for Promotion • Get Religious heads to Participate regularly • Have Transparency in program • Set up regional Transplant coordinators Forums