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Al-Ahram Weekly 11 - 17 March 1999 Issue No. 420 
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Published in Cairo by AL-AHRAM established in 1875 |
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Al-Ahram Weekly 11 - 17 March 1999 Issue No. 420
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| Published in Cairo by AL-AHRAM established in 1875 |
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Egypt Region International Economy Opinion Culture Focus Special Features Travel Sports People Time Out Chronicles Cartoons Letters When does the soul depart?
By Gihan ShahineKhaled Ali, a 20-year-old student at the Faculty of Education, has been suffering from renal failure for two years. His doctors say he must receive a kidney transplant. "I just can't spend four hours in dialysis three times a week for the rest of my life. It's time-consuming and makes it impossible to live a normal life. I'm young and I need to work, get married and live my life normally," Ali says in despair.
In Egypt, there is no legislation regulating organ transplants, except for the 1962 law which legalises cornea transplants. The Doctor's Syndicate, however, regulates kidney donation under rigid conditions and on a strictly voluntary basis. The donor must be a first, second, or, in very serious cases, a third or fourth relative to the patient. The donor must also state in writing that he has consented to donate his kidney without accepting any money in return. Doctors must prove that the kidney transplant will cause neither the donor nor the patient any harm. The sale of human organs and the donation of kidneys to foreigners are forbidden under the law.
Organ transplants from deceased donors are medically viable only in cases of clinical death, as long as the heart continues to beat. But such transplants are not legal in Egypt. Medically, the cornea and the skin can be transplanted up to 24 hours after the donor's death. But the cornea can only be legally transplanted after the donor's death if he includes his decision to donate it in a written or spoken testament. The donor's heirs are prohibited from taking any money in return.
Ali hopes a new law will be drafted regulating organ transplants. "Patients like me are the ones who actually pay the price for the prohibition of such operations." Ali's parents and siblings have different blood types, which make a kidney transplant medically impossible. The only one of his brothers who has an identical blood type is 16, and Doctors' Syndicate regulations stipulate the donor should be between 21 and 50-years-old. A fourth relation would not risk donating a kidney, and Ali cannot afford to travel abroad for an operation. "I'm at a dead end," he says.
Ali is not the only one. According to unofficial estimates, 6,000 to 9,000 patients are waiting for kidney transplants. There is also a bottleneck for liver transplants, with around four million Hepatitis C patients on the waiting list. For those who can afford it, travelling abroad for a transplant is an option; but a kidney can cost from LE500,000 to LE750,000, while a liver transplant may reach LE1 million, unofficial sources maintain. Even then, patients may have to wait for months until they can find a suitable donor. There are 60,299 patients on the US National Transplant waiting list, and US law stipulates that out of every four US donors, one may donate to a foreign patient.
"Those who cannot afford an operation abroad, however, are destined to die a slow death," remarks Hamdi El-Sayed, head of the Doctors' Syndicate. "It is very unfair that we have had no legislation regulating organ transplants so far. We are miles behind the world. At least 80 countries have legalised organ transplant, including such conservative Islamic countries as Saudi Arabia."
Perhaps this is why two highly controversial bills have finally been brought back to the fore after being two years on the shelf in the People's Assembly. The two draft laws, one prepared by the Ministry of Health and the other by MP Mamdouh Fouda and Mansoura University professors, legalise organ transplant from a living donor on a strictly voluntary basis, and from a clinically dead donor. Tragically enough, Fouda, who was suffering no health complaints when he was working on the bill, now has to receive a liver transplant abroad.
A heated debate has marked the two bills since their inception, however. The definition of clinical death is the largest bone of contention among religious scholars and medical doctors. According to Shari'a, a person is dead when the soul leaves the body and all the vital organs stop functioning. According to many doctors and scientists, a brain-dead patient will never recover, even if the heart continues to beat. A number of doctors, however, disagree on whether clinical death is irreversible. And many worry that legislation allowing organ transplant may open the door to an illegal organ trade. This controversy caused the two bills to be dropped just as they were due for discussion before the People's Assembly two years ago. In a series of articles at the time, Al-Ahram Weekly documented the debate, and noted that Parliament Speaker Fathi Sorour had vowed to oppose them, condemning them for being "against the public order, religion and the Constitution". The Weekly also quoted Grand Mufti of the Republic Sheikh Nasr Farid Wassel as saying that "transplants from 'clinically dead' people are against Shari'a," that "a patient, breathing his last, has the same rights as a weight-lifting champion", and that "committing aggression against a clinically dead person is like committing aggression against a completely fit person."
Last week, the bills were presented to the Parliament's Health Committee for further study after Wassel amended some of their terms to conform with Shari'a. The committee, along with several religious scholars, is now in the process of studying the draft laws, and will prepare a final draft to be publicly discussed by parliament. Wassel's amendments stipulate that organ transplant is permissible in Islam from a living donor, who must be a first or second relative to the patient. In very urgent cases, donors may be third or fourth relatives. The donor, however, must be an adult, must volunteer freely, and is entitled to change his mind at any time before the operation. The donor must also state his consent in writing, and the doctor must present a written opinion that the operation will not seriously harm the donor. Wassel added that organ transplants from individuals who are proven to be "legally dead" are permissible in Islam if the operation is absolutely necessary and if the deceased left a will stating consent. The donor, in this case, must also be a relative of the patient.
In any case, Wassel insisted that the extraction of an organ should not cause physical deformities to a living donor or violate the sanctity of the dead. Tantawi concurred with Wassel that selling an organ is prohibited. He explained that "God has entrusted the human body to people, who thus have no right to harm or sell any of its organs. Selling a human organ would violate the sanctity of the body," Tantawi maintained. "A person, however, has the right to dispose of his body in a way that benefits him and/or society," he added. "Donation is thus legitimate when a doctor determines that its benefit to the patient overrides its harm to the donor." Tantawi, unlike Wassel, does not deem it necessary that the donor be a relative of the patient, as long as no financial transaction takes place and as long as doctors find the donor suitable. Wassel, on the other hand, explained that this particular condition "guarantees that such operations do not develop into a trade." For Tantawi, the donor, whether a relative or not, "will be rewarded by God, for donation is considered an act of self-denial."
The basic guidelines for donation, therefore, seem to have been agreed upon, at least by religious officials. But will the controversy over clinical death be settled this time? "We have only discussed principals without details so far," said Sherif Omar, the head of the Parliament Health Committee. "But almost everybody seems to agree that there is an urgent need for legislation regulating transplants. The draft laws are being studied and we will try to reach a compromise conforming with both religion and scientific facts."
The Mufti and scholars at the Islamic Research Centre, however, remain sceptical. "It is the responsibility of the doctors to decide whether what they call clinical death conforms with the religious definition of the soul's complete departure from the body and all its organs," Wassel maintained. "If there is even a slight chance that the person could recover, he should be given that chance, otherwise the removal of an organ would be considered murder."
Dr Omar Mansi, professor of neurology at Cairo University, finds such controversies meaningless, arguing that scientists reached a consensus several years ago. "Brain cells are responsible for all the vital functions of the body, and their death means that the person will never ever come back to life," he explained. The controversy over clinical death stems from a confusion between brain-death and coma, according to Mansi. "In a coma, the brain cells may stop functioning for a time, but there is still a chance of recovery," he maintained. "In the case of brain-death, however, the cells are dead for ever and it is impossible for the person to recover even if the heart continues to beat. The heart is not the centre of life. The difference between a coma and brain-death can be easily defined according to internationally acknowledged criteria."
Both Mansi and El-Sayed are sure that, in most brain-dead patients, the physical functions are maintained by artificial animation. "It would be no crime, therefore, if the heart is taken for transplant to a patient whose heart is damaged beyond recovery," El-Sayed said.
On the other hand, Dr Safwat Hassan Lutfi, professor of anaesthesiology at Cairo University and the chairman of the Egyptian Society for Medical Ethics, insists that brain-death is a concept, not a fact, and that its criteria differ from one country to another. "Those patients who fulfil the criteria of brain stem death show different signs of life," explained Lutfi. A clinically dead person, he added, can still retain normal reflexes against stimuli -- for instance an increase in heart rate and a rise in blood pressure. This is why clinically dead patients must receive full anaesthesia before their organs are removed. Many reports also state that brain-dead women can carry a pregnancy through for more than 65 days and give birth to normal children, delivered by caesarian section, according to Lutfi. "All these facts prove that a clinically dead patient is not dead but is only dying. Therefore, harvesting his organs is a violation of both human rights and religion," he maintained. "I remember a professor of anaesthesia at Cambridge University once wondering indignantly whether it was not time to give brain-dead patients at least the same security we insist upon for animals."
Regardless of the controversy, many commentators go still further, and oppose any legislation regulating organ transplant, arguing that it will promote an already active organ trade. Last year, Al-Ahram Weekly documented a thriving illegal trade in kidneys. In June 1997, a Libyan kidney patient alleged the involvement of a downtown clinic in organ trade. According to the Weekly, the laboratory's manager and secretary promised to find him a donor for a fee of LE10,000. They also demanded LE3,000 for a forged Egyptian identity card and LE10,000 in payment to the donor. The surgeon who was to perform the transplant demanded LE120,000. A police investigation revealed that the laboratory was acting as an agent, purchasing kidneys from low-income Egyptians and selling them to wealthy foreign patients.
Last year, the Doctors' Syndicate slapped a lifetime ban on a surgeon for performing illegal kidney transplant operations. According to press reports, one of the surgeon's patients complained to the Syndicate after the operation, alleging that the surgeon had paid LE12,000 instead of the LE100,000 he had promised him before the operation.
"New legislation will only make it easier to take advantage of the poor who are ready to sell," said Lutfi. Profits from the global organ trade have been estimated at a staggering $19 billion. In Egypt alone, there are no less that 15 laboratories trading in kidneys, and at least 300 illegal organ transplants are conducted yearly, according to Lutfi. "Again, kidney transplants have serious side effects on the patient and the donor. The latter, of course, also becomes a potential renal failure patient," Lutfi concluded. El-Sayed, however, argues that legislation regulating transplants will put a stop to the illegal organ trade. "The new law will regulate transplants and put harsh penalties on the violators," El-Sayed maintained, "besides including strict safeguards against malpractice."
Omar added that transplants will be only allowed in government hospitals and under strict state supervision. A medical team of four renowned doctors in different fields will be established to determine clinical death according to set criteria. To guarantee the objectivity of the team's decisions, none of the members will be allowed to perform the transplants.
The new bill, however, has also been contested on legal grounds. Two years ago, Sorour denounced it as being unconstitutional. But Mohamed Hamed El-Gamal, former president of Maglis Al-Dawla (the State Council, an administrative court), argues that the new bill conforms with the constitutional principle upholding the human right to a free, healthy life. "I believe legislation is urgently needed because it is in the interest of humanity, and will save thousands of patients," El-Gamal maintained. "I respect the legal opinions of Islamic scholars who insist donation should be allowed on strict voluntary basis. But I still believe that necessity should overrule prohibition." El-Gamal suggests that donors receive compensation, as is the case for those who lose an organ while performing their military service or discharging an official duty. If the donor is deceased, the family should receive compensation as determined by the law. A specialised medical department should also be established to supervise the implementation of the law and punish violators strictly. "This way, I believe, we can combat illegal trade, prevent pointless deaths and stop the blackmail of organ traders," El-Gamal concluded.
