Parliament Speech 21 Jan Closing Speech for the HOTA (Amendment) Bill

21 Feb 2008

By Khaw Boon Wan

Venue: Parliament

Mr Speaker, Sir, let me thank Minister Yaacob Ibrahim and the Members for their strong support of this Bill. The Muslim MPs, in particular, have gone all out to help rally support for this Bill.  They have not merely stated their stand clearly in this House, they have conducted many dialogue sessions in the mosques and the community centres, to help us reach out to the Muslim community, to explain what HOTA is all about and how they can save lives by supporting HOTA and that HOTA is not in conflict with their religion.  My Ministry and the many patients with kidney failure are grateful for your support and your tireless efforts.

Continuing public education

And the efforts to reach out to explain and reassure will continue.  As noted by all Members, it is important that we keep up the efforts to improve the public’s understanding of organ donation, brain death and presumed consent. My Ministry will work closely with MUIS and Muslim leaders on this.  As Dr Ahmad Magad put it, we need to strengthen the belief of those who say “yes”, address the concerns of those who say “may be” and convince those who say “no”.

Indeed, we will henceforth no longer need to make the distinction between Muslims and non-Muslims for HOTA.  Information regarding organ donation and HOTA will continue to appear regularly all local newspapers; organ donation booklets and opt-out forms will continue to be couriered to every Singapore citizen and PR when they turn 21 years old. We will continue to partner the Society of Transplantation, the NKF, the Malay Kidney Action Association, and other entities, to reach out to Singaporeans on organ donation and HOTA.

We will also intensify efforts to reach out to community centres, grassroots organisations, schools, colleges and tertiary institutions.   Concepts like brain death, presumed consent and the religious implications require regular explanation and a sustained educational effort.  It is time-consuming and it is costly, but it is necessary.  The more effective we are in this, in easing the fears and concerns of donors and their families, the more lives we can save.   

Dr Ahmad Magad suggested that we rope in organ recipients, professionals, grassroots leaders and other persons who strongly believe in HOTA as “HOTA ambassadors”, to help us explain HOTA and ensure buy-in.  Next month, we will refresh our HOTA website, to also be a repository of human stories from people whose lives have been changed after receiving the “gift of life.”  They will be our on-line “HOTA ambassadors”.

One-Off Exercise

Meanwhile we are preparing 300,000 packages to be individually delivered to all the Muslim Citizens and Permanent Residents aged 21 to 60.  The packages will be comprehensive and easily readable.  Each package will contain four things: (1) a letter informing them that they will soon be included under HOTA, (2) an information booklet on HOTA describing in detail the implications of being included under HOTA, (3) a booklet by MUIS explaining why Muslims can now be included under HOTA and Islam’s position on organ donation and (4) an opt-out form for those who decide to do so.   

We have done a similar exercise before when we first introduced HOTA in 1987, and again in 2004 when we amended it to include other organs [1].  Nevertheless, it will be a massive exercise and we will take 3 months, from Feb to June to complete it.  The actual inclusion of Muslims under HOTA will commence on 1 Aug 08.  

Age of Consent

Dr Fatimah proposed that we lower the age of HOTA inclusion from 21 to 18 years of age. I have also received suggestions from the public to raise the maximum age of 60, as the organs of those dying above 60 are often also suitable for transplantation.  These proposals will require further study.  Let’s concentrate on extending HOTA to the Muslims first as that itself is a major milestone and I want to ensure that it is implemented well, achieving results of saving lives, without causing undue worries and concern to the community.

Meanwhile, those who are between 18 and 21 years of age and who wish to make an organ pledge can do so under the Medical (Therapy, Education and Research) Act (MTERA).

Emotional support for families

Mdm Halimah and Dr Fatimah reminded our hospitals to be extra-sensitive when approaching organ donation cases and their families.  Our hospital staff should be well trained and have relevant communication skills, so as to minimise conflicts with the distressed family members.  We should also streamline the process flow, to make it a little easier for the grieving families. I fully agree.  We have had 20 years of such experience but each incident is a case study for us to learn and to refine our process.  Following the SGH incident last year which Mdm Halimah quoted, we have now made social worker support for the donor family mandatory in every organ donation case. All such family members will receive grief counselling and emotional support. We have enhanced the training of the senior doctors who are responsible for giving final authorisation in organ donation cases, to further equip them with crisis management skills. Measures have been put in place to ensure that all doctors who take on this task are well trained and retrained. We have also sought the assistance of the various religious groups to provide volunteers whom we can call upon to help address any religious concerns that may arise during the organ retrieval process.

With the inclusion of Muslims under HOTA, MUIS has agreed to provide religious support to advise Muslim families on the position of Islam on organ donation and HOTA should the need arise.  Hospitals will also rope in doctors and nurses who can better communicate in Bahasa Melayu in this effort.  Volunteer “HOTA ambassadors” are welcome to join in such hospital activities, whenever the need arises.

During the dialogues with the Muslim community, many expressed the concern that any organ transplantation should not unduly delay the release of the body to the family.  We took this feedback to heart.  We have tightened operational procedures and the coordination between hospitals, the Police and the pathologists.  We will cut out any unnecessary delay.  There was a request that hospital mortuaries should provide for “washing and shrouding facilities” for the use of the family members.  Our hospitals will proceed to set up such facilities in the mortuaries.

Living Organ Transplantation

Dr Ahmad Magad spoke about living donor organ transplants and how this could augment cadaveric transplants. Since this House legislated on living organ transplantation in 2004, the number of living organ transplants has risen.  There were 111 living organ transplantations last year.

My ministry encourages living organ donation.  This is a viable option for many patients but cultural hindrances remain.  We will step up patient and professional education efforts.  We are supporting a pilot programme to counsel newly diagnosed kidney failure patients on the benefits of living kidney donation, so that living donor transplant is considered ahead of dialysis.  We do provide some subsidies to live organ recipients to help defray the cost of organ transplantation and long-term immunosuppressive medication.  

Organ Trading

But we should not unwittingly end up promoting trading of organs. The problem of organ shortage is worldwide.  Not surprisingly, an international organ trade has emerged as observed by Mdm Halimah.  We should not be a party to it. The beefed up investigative and enforcement powers in the Bill will further help keep Singapore stay clear of organ trading.

Investigation and Enforcement Powers

Dr Ahmad Magad would like to know the difference between MOH officers conducting investigations under HOTA, and the Police conducting such investigations. He has asked what will be done to ensure that MOH enforcement officers are properly trained.

We will ensure that our enforcement officers will receive the necessary training and instruction, internally and from the Police, so that they can carry out their work professionally. Some of these officers are likely to be ex-Police officers with relevant experience.  They will be closely supervised by a chain of command and be required to carry identification cards, which they must produce on demand when exercising their powers.  In substance, the change will not differ much from today.  The key difference is that we will build up investigation and enforcement internally within MOH, so that we do not have to rely on the Police which have so many other responsibilities.  Hopefully, this will speed up investigation and enforcement.

Professor Thio asked whether detention beyond 48 hours is contemplated under clause 15I of the Bill. This is consistent with Article 9(4) of the Constitution[2].

Health Promotion

Mr Speaker, Sir, even as we amend HOTA to help save lives, the best approach is still prevention. Those who are pre-disposed to develop kidney failure should actively change their lifestyle and diet. They should start exercising regularly, if they have not already done so. They should work with their family GPs, take medication diligently and test their blood sugar and cholesterol regularly.

Each year, in Singapore, there are close to 700 patients who have amputations involving the lower limb as a result of uncontrolled diabetes. This is equivalent to 2 amputations per day which is largely avoidable. Many more suffer from other complications such as heart disease, stroke and blindness. All these conditions cause unnecessary suffering and loss of productivity. Let’s be proactive to reduce such miseries.

Conclusion

As Mdm Halimah put it, this Bill makes an important and significant change.  Muslims will soon be included under HOTA.  The change comes too late for some who died while waiting.  But better late than never.

I thank Members for joining me in this fight to save some more lives, without even having to lift a finger, as Mayor Zainudin put it.  Sir, I beg to move.     

1-- In the 1987 and 2004 exercise, information on HOTA was included in the monthly PUB bill that is delivered to all households in Singapore.

2-- Art 9(4) states — Where a person is arrested and not released, he shall, without unreasonable delay, and in any case within 48 hours (excluding the time of any necessary journey), be produced before a Magistrate and shall not be further detained in custody without the Magistrate’s authority