A person is legally dead when his brain dies. And that's the best time for the liver to be transplanted, says Professor Fan Sheung-tat of Queen Mary Hospital (QMH). For the success rate then is 90 per cent.

Yet it's one thing for doctors to know this and a totally different thing to convince a dying man's family to agree to that. For them, their loved ones are still alive as long as they are breathing and their heart is beating, even if it is with the support of a respirator.

Doctors know that all signs of life will disappear once the respirator is switched off and that the process will be painless. Still, many are reluctant to intervene at the right moment to persuade heart-breaking family members to agree to organ donation, said Fan, QMH's chief of hepatobiliary surgery and liver transplantation.

That is understandable, for nobody, including doctors, would like to be scolded and chased out of the ward by grieving relatives. But that the moment the brain is dead is the best time for a transplant is a truth Hongkongers must accept, Fan said.

People's attitude towards death and the dead - that the body should be intact - is the biggest hurdle in Hong Kong's fight to get more people to agree to donate organs. Fan has seen many cadaveric livers that could have been transplanted to save lives if dying people's relatives didn't object.

The Hong Kong Liver Foundation (HKLF) told China Daily that it would launch a campaign in the second half of the year to promote liver donations. The exercise will consist of a survey and public debates.

HKLF executive director Doris Ho said the "brain dead" question would certainly be a topic the campaign would focus on.

Hong Kong Medical Association statistics show that 20 cadaveric livers were donated in 2004, compared to 18 in 2003, 30 in 2002 and 23 in 2001. There were, however, more than 100 patients waiting for a transplant at any time, Fan said.

The city is thought to be among those where people are most unwilling to donate organs. In Spain, an average of 34 livers are donated per 1 million people a year. In the United States, the average is 25. In Hong Kong, the per-million average is two to three, Fan said.

They will try to educate senior citizens to accept the concept of organ donations in the campaign, explaining that it's common for parents to refuse even though their dying children had agreed to donate their organs after death.

"It has been very difficult to get the senior family members to sign the agreement at the sad moment," she said, fully aware of the difficulties ahead of campaign. There are also more doctors and public bodies such as Hospital Authority (HA) and the government could do more.

Doctors could have taken greater initiative on their part in alerting hospital coordinators about the imminent availability of an organ so that the coordinators could intervene at the right time. "Hong Kong doctors haven't done enough," Fan said.

HA, meanwhile, could refer to overseas practice to reimburse hospitals an amount for every organ donated under medics' persuasion. Fan said doctors at these hospitals had exhibited greater willingness to take the lead in persuading family members. The sum is not paid to the doctors.

HKLF's Ho said the city needed more public discussion on liver donations and that the public opinion survey on the selection criteria for donor liver recipients, published by Hong Kong Medical Journal (HKMJ), might set off the momentum.

As reported by the China Daily yesterday, HKMJ poll has shown a public preference for the young over the old, non-drinkers over drinkers, those more likely to survive, those who have waited the longest and primary over re-transplant candidates on the question of who should get priority in receiving donor livers.

Surveyor author Chan Ho-mun, an associate professor of City University of Hong Kong's Department of Public and Social Administration, said the findings highlighted the ethical conflicts between distributive justice, social utility and medical judgment.

Who first

Were the public preferences as shown in Chan's survey to weigh upon doctors' decision, patients such as Leung Chi-ming, a father of two who has been waiting for five years, would become a forerunner to get a donor liver. But this is not the case: the more acute ones get the greater priority.

Chan conceded that he personally disagreed with the public preferences, but said that the ethical issue merited more public debate at the end of which the public would become more conscious of the need for organ donation.

"If a potential donor knows where his organ will go to, he may be more ready to donate," Chan said.

Patients' rights campaigner Ho Hei-wah, however, cautioned that society should not get involved in such an ethical debate. "The findings are appalling. Should a public debate rage in society, it may lead us to the dreadful end where one's existence would be judged by somebody... according to his/her social deeds and with no respect to humanism," Ho said.

Professor Fan said the existing practice of prioritizing according to the Model for End-Stage Liver Disease (MELD) was the best and fairest the city could adhere to in the face of a scarcity of donor livers. MELD is a scoring system that predicts one's risk of dying within three months without a transplant.

The closure of Prince of Wales Hospital's (PWH) liver transplant centre by HA to centralize resources has made Fan's team the only medical unit in the city to conduct such an operation.

Fan suggests Hong Kong should have a legislation instead of a debate so that people who have agreed to donate their organs after death can have their wishes honoured irrespective of family members' opposition.

Chan said it could go even further, saying there were laws in some states of the US that permitted people to donate their family members' organs after death if those members had not specifically opposed such an idea in life.

"Their basis is that the relatives are supposed to know the wishes of their family members best. So, if they say 'yes' to donation, this 'yes' should be sufficient to reflect the will of the deceased members," Chan said.

Also, there are some arrangements to ease the financial burden of the family if a dead person's organ is donated to save a life, Chan added.

Fan said his unit normally didn't perform transplants on patients older than 60 but there could be occasions when they would consider operating on a 65-year-old. He insisted that that had nothing to do with age discrimination but rather patients older than 65 normally could not withstand the physical stress of an organ transplant.

Having said that, he conceded that the age limit was "arbitrary". The public's preference for non-drinkers over drinkers was already in practice in his unit. A patient must have stopped drinking for at least six months and be assessed by a clinical psychologist that he/she had done so and would hit the bottle again before he can be considered for an organ transplant. The reason: donor livers are extremely rare in Hong Kong.

The city would never be a perfect formula for allocating cadaveric livers until the people become more willing to donate organs, Fan said.

(HK Edition 03/18/2006 page2)