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Legalization of organ trade?

Country: 
Singapore
Partner Institute: 
Department of Epidemiology and Public Health, National University of Singapore
Survey no: 
(12) 2008
Author(s): 
Lim Meng Kin
Health Policy Issues: 
Others, Remuneration / Payment
Others: 
Regulation
Reform formerly reported in: 
Amendments to the Human Organ Transplant Act
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? yes no no no no no no

Abstract

The Singapore government is considering amendments to its Human Organ Transplant Act (HOTA) to allow for appropriate compensation of living donors who donate their organs to unrelated patients. This would be in addition to two other measures being considered, i.e. lifting the present 60-year age limit when getting organs from a person who has died, and setting up a registry that will find a match among donors who are unrelated to the patient. The details will only be known in 2009.

Purpose of health policy or idea

In Singapore, where about 1,000 people lose the use of their kidneys a year, live and cadaveric donations are insufficient for existing and projected needs. Given the reality of organ shortage in Singapore and a de facto black market for organs in the region, the aim  of legalizing compensation to donors would be to augment the supply of kidneys for transplant.

Groups affected

Organ donors and recipients, Hospitals performing organ transplants

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Characteristics of this policy

Degree of Innovation traditional innovative innovative
Degree of Controversy consensual highly controversial highly controversial
Structural or Systemic Impact marginal neutral fundamental
Public Visibility very low very high very high
Transferability strongly system-dependent rather system-neutral system-neutral

Political and economic background

Organ trading is presently illegal in Singapore, where only living-related and cadaveric organ transplants are permitted. Under the Human Organ Transplant Act (HOTA), it is a criminal offence to enter into a contract or agreement on the sale or supply of any organ or blood. However, a national debate on whether regulated organ trading should be legalized has been sparked by a highly publicized organ trading case in which five men were charged in a Singapore court for a kidney sale which had come to light before the transplant could take place in a private hospital. The would-be donor and recipient had falsely declared their relationship before the hospital's ethics committee. The donor is from neighboring Indonesia, while the unrelated recipient (and purchaser) is a well-known Singaporean retail magnate on kidney dialysis.       

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? yes no no no no no no

Origins of health policy idea

The investigative journalism that accompanied the case revealed that illegal organ trade involving exploitation of donors by unscrupulous "middlemen" is not an uncommon occurrence in the Southeast Asia region.

While the government stood firm as far as enforcing the law was concerned, the Minister of Health appeared to soften his stance from one of initial outright condemnation of such transactions that are motivated by money as 'definitely wrong, morally and legally", to one of  "I think we should not write off or reject the idea of selling organs .. I think we need to study it carefully". He was actually of the view that the door should be kept ajar for some limited but regulated transactions to take place. In his estimate, it is possible that Singapore might have an acceptable model of organ trading in the next one to three years.

Aware that such a move would fly in the face of international norms (Iran being the only known country where organ trade is presently legal), the Minister of Health urged Singaporeans to "not reject any idea just because it is radical or controversial". In fact, he went on to  share some preliminary ideas about how such a system might work: For example, the government could set up a professional and independent kidney bank to perform kidney matching for patients and donors, the key principles being: "firstly, to restrict trading to kidneys; secondly, to eliminate a direct transaction between the donor and the patient by letting an independent professionally-run third party manage the donor pool and match the transplants; and thirdly, requiring stringent screening and full disclosure and communication on risks to the donors and their families."

Noting that patients were dying and the poor were being exploited while the debate raged on, he said the greatest value of legalizing kidney trading was to stop the exploitation of the poor and ignorant, who did not know the full value of their kidneys. He disclosed that he was also toying with the idea of the government letting patients with higher income pay more while subsidizing patients with lower income, thus allowing patients with lower income to also have a chance of having a kidney.

Initiators of idea/main actors

  • Government
  • Providers
  • Patients, Consumers

Approach of idea

The approach of the idea is described as:
amended: Organ trading is presently illegal in Singapore, where only living-related and cadaveric organ transplants are permitted under the Human Organ Transplant Act (HOTA)

Actors and positions

Description of actors and their positions
Government
Ministry of Healthvery supportivesupportive strongly opposed
Providers
Hospitals performing organ transplantsvery supportivevery supportive strongly opposed
Singapore Medical Associationvery supportivestrongly opposed strongly opposed
Patients, Consumers
Kidney patientsvery supportivevery supportive strongly opposed
Publicvery supportiveneutral strongly opposed

Influences in policy making and legislation

Most kidney patients lauded the move, saying that it gives hope to them.  The Singapore Medical Association (SMA) held an emergency meeting and came out steadfastly against legalizing the organ trade. According to its spokesman,"organ sellers face an array of short- and long-term medical risks. The sellers, almost always desperately poor, could also be abused and exploited… We see tremendous resources needed to enforce organ trade regulations in a transparent and equitable way. These make it inappropriate for SMA to support any move towards legalizing the trade."

Varying views were expressed by the public through the media. Those for legalizing organ trading pointed to the waiting list of about 600 people who would die without a transplant. The  average waiting time is currently nine years for a kidney. They felt that ethical concerns should not hinder any policy review that might help to save lives and reduce the shortages that promote a black market for organs. Ideas for preventing possible abuse include fixing the price, limiting the donors and recipients to Singaporeans, and starting a kidney bank.

Those against organ trading argued mainly on ethical and moral grounds. They especially decried the possible exploitation of poor organ sellers. One letter writer asked pointedly, "what if a poor person needed a transplant?" Another letter writer, a kidney dialysis patient herself, implored the Ministry of Health to come up with "innovative" ideas and suggested that perhaps the principle of compensation was more acceptable than payment.

It was perhaps this last idea that spurred the Ministry of Health to shift the language of the debate from legalizing "organ trading" to fair "compensation" of donors. It made the point that the aim of the proposed policy review was not to encourage organ trade but rather to better regulate organ transplantation in order to "ensure that organ donors' needs are taken care of."

The President of the Singapore Muslim Kidney Action Association has, in response, suggested that any such compensation need not involve money changing hands between donor and recipient; instead, philanthropic, charitable or religious bodies could be asked to fund the compensation for donors in acknowledgement of the altruistic act of the donation.  The Muslim Kidney Action Association (MKAC) said that they do not disapprove if kidney recipients wish to give money to the donors to express their gratitude. The MKAC is against organ trading, but felt that if the government were to allow compensation of donors, this should be done quietly so that it does not promote a buying culture.

A Buddhist group does not agree with the suggestion to compensate the donor, saying that this complicates the issue of organ donation, and will cast doubt over the donor's reasons for giving the organ. Expression of gratitude does not have to take the form of money, and can be in ways such as giving back to society. Another Buddhist group felt that compensation is fine, but this should not be administered by religious or charity groups, but should be done by the government.

Actors and influence

Description of actors and their influence

Government
Ministry of Healthvery strongvery strong none
Providers
Hospitals performing organ transplantsvery strongstrong none
Singapore Medical Associationvery strongweak none
Patients, Consumers
Kidney patientsvery strongweak none
Publicvery strongneutral none
Kidney patientsHospitals performing organ transplantsMinistry of HealthPublicSingapore Medical Association

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Expected outcome

Impact of this policy

Quality of Health Care Services marginal neutral fundamental
Level of Equity system less equitable two system more equitable
Cost Efficiency very low high very high

Currently, only about half the demand for kidneys for transplantation is being met. If passed, the proposed moves to amend the HOTA will increase the supply of kidneys and save lives.  The challenge is how to compensate donors in a way that is ethically acceptable.

A positive spin-off of this debate has been the redoubling of ongoing efforts to maximise organ yield from cadaveric kidney transplants, promote living-related transplants, and increase public education on the Human Organ Transplant Act.

References

Sources of Information

  • Valarie Tan. Human organ business: Legal trading no go: SMA. But Health Minister hasn't rejected idea. TODAY newspaper. Monday July 14, 2008 page 4.
  • Chitra Rajaram. If docs & patients GAIN, why not the donor? Today newspaper. Friday July 4, 2008, page 6.

Reform formerly reported in

Amendments to the Human Organ Transplant Act
Process Stages: Legislation

Author/s and/or contributors to this survey

Lim Meng Kin

Suggested citation for this online article

Lim Meng Kin. "Legalization of organ trade?". Health Policy Monitor, October 2008. Available at http://www.hpm.org/survey/sg/a12/1