Current Affairs Discussion
Term 1 Week 9, Term 2 Week 1 - Secondary 1
Ortus, iSpark (Term 1, Week 9, 6th Mar)
Aphelion, ProEd (Term 2, Week 1, 27th Mar)
ILLEGAL ORGAN TRANSPLANT
The Central Issue
In July 2008, Singaporean retail magnate Tang Wee Sung was revealed to have attempted to
buy a kidney for $300,000 from an Indonesian man. He was fined $17,000 and sentenced to
one day’s jail. The would-be donor, Sulaiman Damanik, was jailed for three weeks. Wang Chin
Sing, the man who arranged the meeting between the two, received the heftiest sentence of
fourteen months jail.
This case sparked off a furious public debate on the morality of legalizing the trade in organs.
Many people lambasted Tang, a prominent local businessman, for using his personal wealth to
break the law and secure an organ for himself. Others defended him, saying that this was
merely a last-ditch attempt to save his own life. Tang is diabetic and had been on dialysis for a
year. His diabetes is complicated by heart problems; doctors had given him less than five years
to live.
The Debate Motion
Singapore should legalize organ trade to meet the demand for organs needed for
transplants.
Consider the following statistics presented by the Minister of Health, Mr Khaw Boon Wan in
parliament in July 2008:
“Over the past three years, there were 228 kidney transplants involving Singaporeans, and 63%
of these were from deceased donors. During the same period, there were 33 liver transplants,
64% from deceased donors. There were 271 cornea transplants, all of course from cadavers.
Currently, the numbers of patients waiting for cadaveric organs are 563 for kidney, nine for liver
and 25 for cornea.”
Organ transplants are necessary to save lives. Practically all countries in the world suffer from
severe shortages in organs needed for transplant. Singapore is no exception. Legalizing the
trade in organs as a commodity may meet this demand. Is it moral or right to do so? Should
Singapore legalize the trade in organs?
Created by Laura Ng and Matthew Koh, February 2009.
Guiding Questions

Would legalizing organ trade effectively meet the demands for organs?

Since a black market already exists in illegal organ trade, would legalizing it be justifiable
as it makes regulation possible?

Will legalizing the organ trade result in the exploitation of poor people who, out of
desperation, sell their organs for money?

Is legalizing the organ trade justifiable solely on the pragmatic grounds that it means the
demand for organs, thus saving lives?

The current system allocates organs based on need, not on personal means. Will
commercializing the trade in organs favour the wealthy, who can afford the organs, and
disadvantage the poor?
Instructions for Panel Discussion
The five panelists will adopt the roles detail on the following page. They must act and argue
within the boundaries of the position assigned to them. Their arguments must be logical and
well-substantiated with examples.
The rest of the class will role-play the general public. They are free to adopt any reasonable
position on the issue. When speaking, they must likewise present a rational, well thought-out
argument.
The Debate Proceedings
The Chairman of the session will initiate by presenting an e-book to provide an introductory brief
on the issue for about 20 minutes.
The Chairman will then open the discussion to the various panelists for 3-4 minutes each, and
later the floor for the rest of the duration. Panelists can continue contributing and responding to
comments even during floor time
The Chairman has the option of concluding the debate with some personal remarks, offering a
brief summary.
As always, it is sincerely hoped that panellists will stay in character throughout the discussion,
much as it may be tempting to jump in with different points.
A simple flowchart is presented below to illustrate the flow of events.
Created by Laura Ng and Matthew Koh, February 2009.
The Panellists
Panellist
Minister of Health
Rich man in need
of organ
transplant, Mr
Tang Wee Sung
Point of View
Believes that legalizing trade in organs will not be helpful in reducing
the shortage in organs, but is willing to consider alternative solutions to
the current system. Wants to work towards increasing the number of
altruistic donations through public education and awareness.
Believes that organ trade should be legalized so that patients who
need an organ can get one easily and quickly. He feels that any
person should have the right to purchase an organ to stay alive. He
will resort to any means to save his own life.
Medical Doctor
Believes that the trade in organs, if legalized will lead to a huge
commercialization, and result in donors being exploited. He believes
that organs should be allocated based on need and that patients
should wait their turn for an organ. Hence, he opposes the legalizing
trade in organs.
Economist
Believes that the shortage of organs can be easily solved by legalizing
trade in organs. He sees the potential moral hazards in this solution as
negligible compared to the potential of saving so many more lives,
when people can get organs more easily.
Educated
layperson from
Singapore
Believes that legalizing the trade in organs will result in an ethical
“slippery slope” that might even lead to human cloning to increase
organ availability in the future. He feels that the existing system is
good because organs are allocated based on need, and not
dependent on how much one can pay for an organ. He opposes
legalizing organ trade.
Created by Laura Ng and Matthew Koh, February 2009.
Proceedings
Forum Chairman
Introduction
1-2 minutes
Minister for
Health
Rich Patient,
Tang Wee
Sung
Medical
Doctor
Order of speech after Minister for
Health will be decided by Chairman
Economist
Educated
Singaporean
Layperson
Forum Chairman
summarizes
salient points
The chair opens
the discussion to
the floor
The chair monitors the discussion from the audience, representing the general
public.
Chairman and observers sum up
Created by Laura Ng and Matthew Koh, February 2009.
Readings
Read the following articles to get you started in your research. However, these are very brief. Do
read widely to have an in-depth understanding of the issues at hand.
Tangs boss charged; he was allegedly going to pay $300k
http://www.asiaone.com/Health/News/Story/A1Story20080711-76041.html
Two Indonesian men in illegal organ trading case jailed and fined
http://www.channelnewsasia.com/stories/singaporelocalnews/view/358062/1/.html
Kidney Sale Case: Tang jailed for a day
http://www.straitstimes.com/Breaking%2BNews/Singapore/Story/STIStory_275038.html
Organ trading debate continues with renewed call for more living donors
http://www.channelnewsasia.com/stories/singaporelocalnews/view/373780/1/.html
Middleman in kidney-for-sale deal gets 14 months' jail; out on bail
http://www.channelnewsasia.com/stories/singaporelocalnews/view/373928/1/.html
Illegal Organ Trading – Extract of Parliamentary Debates
http://www.pap.org.sg/articleview.php?id=3521&mode=&cid=23
Should the Purchase and Sale of Organs for Transplant Surgery be Permitted?
http://www.becker-posner-blog.com/archives/2006/01/should_the_purc.html
Important Web Resources
Singapore Ministry of Health – Human Organ Transplant Act
http://www.moh.gov.sg/mohcorp/legislations.aspx?id=1672
Singapore Ministry of Health – Human Organ Transplant Programme
http://www.moh.gov.sg/mohcorp/programmes.aspx?id=208
Created by Laura Ng and Matthew Koh, February 2009.
Tangs boss charged; he was allegedly going to pay $300k
BY: Elena Chong & Salma Khalik
RETAIL magnate Tang Wee Sung was going to pay $300,000 for a kidney, a court heard yesterday.
That was the sum that would have gone into the hands of his alleged broker, Wang Chin Sing, 43, who is accused
of getting him an Indonesian man willing to sell the organ.
The transaction, which is illegal under the Human Organ Transplant Act (Hota), was derailed when the authorities
stepped in and arrested the organ seller in Lucky Plaza last month, before the transplant took place.
Tang, 56, the executive chairman of retail chain C.K. Tang, appeared in court yesterday afternoon accompanied by
family, friends and a private nurse.
Dressed in a light blue shirt and tie, he looked well despite a medical emergency that had landed him in Gleneagles
Hospital earlier, preventing him from turning up in the morning to hear the charges against him.
The bachelor became the first person in Singapore to be charged with trying to buy a kidney, an offence that carries
a fine of up to $10,000, a year in jail, or both.
A diabetic for some years, he had to go on dialysis a year ago.
His health woes were further complicated by high blood pressure and heart problems, putting him at a higher risk of
death than most diabetics. Without a transplant, his chances of surviving five years were slim.
Kidney patients have got around the Hota by travelling overseas to buy an organ for transplant and having the
operation abroad.
Some 300 people have done so, going to India and China and paying between $100,000 and $200,000. Tang had
previously said that he might get a kidney in Beijing, where he has relatives, or the United States.
It is not clear what the $300,000 fee Tang allegedly promised Wang was supposed to cover, nor how much of a cut
Wang would keep. A transplant operation here costs about $87,000.
Another man was also named in the court documents as being a party to the arrangements: Mr Whang Sung Lin,
43, who is believed to be married to Tang's niece and is in the bedlinen trade. Mr Whang declined comment when
contacted.
The man who was to give Tang his kidney, Mr Sulaiman Damanik, 26, was freed on Saturday after three weeks in
jail. He was supposed to be paid about $23,700.
Wang had also allegedly acted as the middleman for another donor and recipient, who paid him $8,000 for his
service.
Created by Laura Ng and Matthew Koh, February 2009.
An Indonesian man, Toni, 27, had given up a kidney to an Indonesian woman, Ms Juliana Soh. He was paid
$29,390. The transplant took place at Mount Elizabeth Hospital on March 17. Toni is now serving out his sentence.
Wang, whose wife runs a music school, was charged yesterday morning for his role in both transactions.
His lawyer, Mr Shashi Nathan, described Wang as a "medical concierge" who would bring Indonesian clients to
Singapore and arrange for medical treatment with various hospitals here. He would match his clients' requirements
with specialist doctors available here.
The lawyer said that the incidents involving the kidney transplants were separate from his usual activity of referring
clients to local doctors.
Tang posted bail of $15,000, while Wang is out on $30,000 bail. Their next court date is on July 21.
About this case
SINGAPORE'S first illegal organ transplant cases were exposed on May 29 when the Health Ministry learnt that
blood samples from various foreign nationals had been sent here to cross-match against the blood sample of a
Singaporean.
Two Indonesian men were arrested and later pleaded guilty in court last month. Mr Sulaiman Damanik, 26, was
jailed for two weeks and fined $1,000. He spent an extra week in jail for failing to pay the fine.
He was prepared to sell his kidney to retail magnate Tang Wee Sung for about $23,700. He has served his
sentence.
Toni, 27, was jailed for 31/2 months and fined $2,000. He sold his kidney to Indonesian Juliana Soh for $29,390 in
March.
The accusations:
Wang Chin Sing, 43, faces 10 charges
The alleged broker was supposedly to receive about $300,000 to get Tang a kidney donor.
He found Mr Sulaiman. Wang allegedly coached Mr Sulaiman and Tang to lie before a Commissioner of Oaths that
they were related and that no money was changing hands in the organ donation.
He was also accused of coaching them to lie to a Transplant Ethics Committee which had to be satisfied that all
was above board before the transplant could go ahead. Wang also allegedly did the same in the case of Toni who
sold his kidney to Ms Soh.
Tang Wee Sung, 56, faces three charges
He allegedly planned to pay Wang $300,000 for a kidney.
He was also accused of lying in a statutory declaration and to a transplant ethics committee that Mr Sulaiman was
his distant relative and that he had not paid for the kidney.
The maximum punishments:

For supplying an organ illegally: a fine of not more than $10,000 or a jail term of up to 12 months, or both.

For making or abetting the making of a false statutory declaration: a jail term of up to three years and a
fine.

For lying or abetting a lie to the transplant ethics committee: a fine of up to $2,000 or a jail term of up to 12
months, or both.
This article was first published in The Straits Times on July 11, 2008.
Created by Laura Ng and Matthew Koh, February 2009.
Two Indonesian men in illegal organ trading case jailed and fined
By May Wong and Valarie Tan, Channel NewsAsia | Posted: 03 July 2008 1953 hrs
SINGAPORE : The two Indonesian men convicted of human
organ trading have been sentenced in a Singapore subordinate
court on Thursday.
26-year-old Sulaiman Damanik and 27-year-old Toni had
pleaded guilty in court to agreeing to sell their kidneys to two
patients in Singapore.
Sulaiman was sentenced to two weeks' jail and a S$1,000 fine. If
he cannot pay the fine, he will be jailed for another one week.
Toni was sentenced to a jail term of three months and two
weeks, and a fine of S$2,000. If he cannot pay the fine, he will
face another two weeks in prison.
Court sketch of the two
Indonesians in the organ trading
case
Toni had already sold his kidney to an Indonesian woman,
Juliana Soh, for over S$29,000, while Sulaiman had intended to
sell his kidney for S$23,700 to CK Tang's executive chairman Tang Wee Sung.
All their sentences will be backdated to the day of their remand on June 21.
Kemal Haripurwanto, Minister Counsellor and Head of Protocol & Consular Affairs at the Indonesian Embassy,
said: "It is a just and proportional sentence. The sentence is light and hopefully, they will go back home together to
their families and get on with their lives.
"This is a strong signal that one should consider deeply (before) getting involved in organ transplants."
The lawyer for the two accused is glad the court took into consideration that they were exploited to sell their organs.
"The court has been very fair, taking into account the mitigating factors. The (two Indonesian men) come from very
poor families. One important factor which the court took into consideration is that they did not actively go round
offering their organs for transplant or for sale," said Mohd Muzammil Mohd, lawyer for the two accused.
District Judge Bala Reddy said the sentence imposed should resonate a clear signal that Singapore does not and
will not condone the commercial trade in human organs. He said offenders will face severe penalties if convicted.
The district judge also added that longer custodial sentences should be reserved for the ring leaders and major
players in the organ trade syndicate.
This is the first such illegal organ trading case to be prosecuted in Singapore.
Meanwhile, Chairman of the Government Parliamentary Committee for Health, Halimah Yacob said Singapore
should tighten its screening processes in organ transplants.
She said would-be organ donors and recipients should be screened by the Ministry of Health (MOH).
Madam Halimah said: "That could be another consideration, instead of going to the hospital ethics committee. If
screening is done at the MOH level, then maybe one could sense that there's a lot more arm's length dealing, in
terms of determining the relationship.
"I really do hope to see a more thorough system of screening of would-be donors and recipients, particularly in
terms of their relationship. Two (illegal) cases were (uncovered), and people will wonder if there were other cases
that had gone through undetected."
While some hope the recent case would act as a deterrent, others call for doctors to take greater responsibility with
transplant patients, instead of leaving it all to the ethics committee.
Created by Laura Ng and Matthew Koh, February 2009.
"We should ensure that we tell any patient who comes in with a prospective donor... that we would take action if
they are paid donors... That's the only way we can send the message to people," said Dr Pary Sivaraman at the
Singapore Clinic for Kidney Diseases.
One lawyer commented that, if necessary, the Human Organ Transplant Act (HOTA) can be used against organ
buyers - in this case, Juliana Soh and Tang Wee Sung.
"Section 14 of HOTA does not make a distinction between buyer and seller, hence I would have thought the buyer
is equally responsible," said lawyer S Palaniappan, Straits Law Practice.
When contacted, the MOH was not able to say whether the buyers in the illegal organ trading case will be
prosecuted. However, it did say that investigations are still ongoing, and it will wait for the outcome before taking
further action. - CNA /ls
Created by Laura Ng and Matthew Koh, February 2009.
Ailing retail magnate Tang Wee Sung (left) walking out of Queenstown Remand Prison with his lawyer
Cavinder Bull. Tang's sentence for his attempt to illegally purchase a kidney included a day's jail, but he
was released after a few hours. -- ST PHOTO: AZ
KIDNEY SALE CASE
Tang jailed for a day
By Khushwant Singh and Sujin Thomas Sep 4, 2008
AT 5.45PM yesterday, ailing retail magnate Tang Wee Sung, 56, walked out of Queenstown Remand Prison.
He had been sentenced in the afternoon to a day's jail, but was set free at the end of the business day, after two
hours.
'I'm fine,' were the only words he uttered. He waved at family members as he got into a waiting car.
It brought to an end his run-in with the law in the first case here involving the illegal sale of a human organ - a
kidney in this instance.
Earlier in the day, he paid $17,000 in fines for lying under oath and for organ trading.
In handing down the sentence, District Judge Ng Peng Hong said he was mindful that Tang's potential kidney donor
Sulaiman Damanik had been jailed two weeks for the same offence of making a false statutory declaration, but that,
'given the very exceptional circumstances of Tang's extreme ill health', a long jail term was unnecessary.
Judge Ng acknowledged that Tang had broken the law, but added that more guilt should be placed with the dealers
or middleman who sought to profit from the desperation of the poor organ seller and that of the terminally-ill buyer.
Tang, who pleaded guilty last week, stood expressionless in the dock for about half an hour before he was allowed
to sit down.
When the hearing started at 2.30pm, the public gallery was packed with about 50 family members, friends and
colleagues. Police turned away latecomers.
Tang's lawyer, Senior Counsel Cavinder Bull, had asked the court to be lenient to his client last week, citing Tang's
long list of ailments and his daily regimen of 50 pills and injections.
Mr Bull suggested that the court impose a fine for his client's offence of organ trading, which, under the Human
Organ Transplant Act, stipulates a fine of up to $10,000 or a jail term of up to a year or both.
Created by Laura Ng and Matthew Koh, February 2009.
He also asked the court to consider a conditional discharge for Tang's making of a false statutory declaration. This
offence comes with a mandatory jail term of up to three years. Offenders may also be fined up to $10,000.
Mr Bull's arguments last week centred on how inexpedient it would be to jail Tang, and that, at most, the penalty
should not be more than a day's jail.
The prosecution had argued that Tang was as guilty as Sulaiman in the eyes of the law and was the driving force in
the illicit transaction.
The case has sparked a national debate on whether laws here need to be changed to allow some form of organ
trading.
On the defence's arguments that organ trading could soon be decriminalised by Parliament, Judge Ng said the
matter was too speculative for him to consider.
He noted, however, that Tang had acted out of desperation, believing he was likely to die without a kidney
transplant.
Mr Bull told reporters outside the courtroom that he was satisfied with the sentence and ruled out an appeal.
He said: 'He is obviously going to be relieved that it is not longer than what he got, but I would not underestimate
the impact of the sentence on him.'
Family members were, however, upset that Tang was jailed even a day. His older sister Janet Liok told The Straits
Times: 'We are very sad. He's very sick and we are very worried now.'
Several members of the Singapore Retailers Association were also present.
Mr Keith Chua, 55, who has been close to Tang since their days at Anglo-Chinese School, felt that the judge had
been merciful.
The businessman, who showed up in court with five other former schoolmates, said: 'The judge explained the basis
for his decision quite clearly. He is still going to have to deal with his medical condition once this is over.'
Later yesterday evening, Mr Bull told The Straits Times that Tang had gone home after being released from prison.
'He was tired from the day's activities. We discussed some legal matters and then I left him with his nurse,' said Mr
Bull.
Tang, who stepped down as the executive chairman of the C.K. Tang retail empire after his conviction last week,
has one to two years to live without a kidney transplant.
About the case
TANG Wee Sung is the third person to be jailed in the first illegal organ transplant case here.
In June, an Indonesian by the name of Toni, 27, was jailed 31/2 months and fined $2,000, while his compatriot
Sulaiman Damanik, 26, served a three-week prison term.
Both men had lied in statutory declarations and before a transplant ethics committee that they were distant relatives
of the organ recipients.
Created by Laura Ng and Matthew Koh, February 2009.
Toni sold his kidney for 186 million rupiah (S$29,000) to an Indonesian woman; Mr Sulaiman was arrested here
before he could sell his kidney to Tang for $23,700.
Wang Chin Seng, 44, who helped arrange the illegal deals, will be sentenced tomorrow.
He admitted to 10 charges which included organ trading and coaching Tang and the Indonesians to lie in their
statutory declarations; he also coached them to lie to the ethics committee that they were related to their respective
recipients and that no payment was involved.
Wang was offered $300,000 to arrange the deal between Tang and Mr Sulaiman.
Another man, Whang Sung Lin, Tang's 44-year-old nephew-in-law, has been charged with abetment by introducing
Wang to Tang in return for a fee.
His trial is being arranged.
Created by Laura Ng and Matthew Koh, February 2009.
Organ trading debate continues with renewed call for more living donors
By Imelda Saad, Channel NewsAsia | Posted: 04 September 2008 2109 hrs
SINGAPORE: The middleman involved in Singapore's first
illegal kidney transplant case will be sentenced on September
5.
Even before the case is wrapped up, there are renewed calls
for authorities here to do more to increase the number of living
donors.
While it may be a closed chapter for Mr Tang Wee Sung, who
was jailed and fined on Wednesday in Singapore's first kidneyfor-sale case, it is still an open book when it comes to the
debate on organ trading in Singapore.
The Ministry of Health (MOH) has said that it will not rule out
legalising organ trading.
Surgeons carry out a kidney
transplant
In the case of renal failure, some 600 people are on a waiting list with an average waiting time of nine years before
they get a transplant.
It seems that the way forward is to encourage more living donors, but there are costs involved.
Ameerali Abdeali, president, Singapore Muslim Kidney Action Association, said: "You really need an altruistic
person to say I want to donate my kidney to save a life. For this person, there is a cost to them. Even to do a test
for compatibility, there is already a cost."
Ideas that authorities here may look at include having philanthropic, charitable or religious bodies funding the
compensation for donors. But compensation does not have to involve money changing hands between donor and
recipient.
Mr Ameerali said: "I think that Singapore’s society is not ready for organ trading and certainly not developing
Singapore as an organ trading hub. That.. (is) not acceptable. But there can be certain scenarios where it can be
comfortable.
"Take for example, one person is affluent and suffering from kidney failure and there's another man who can give
him that kidney, but his mother is critically ill in hospital and needs expensive surgery.
"So on this basis on quid pro quo, where no money actually exchange hands, this person pays for the medical bills
and surgery bills for his donor's mother. Personally, I'm comfortable with that and I don't think that amounts to organ
trading."
Mr Ameerali added that with trading, there is usually a profit component. He said: "Where there are actual organ
sales and the money is used by the donor (for reasons such as) starting a business, that kind of scenario is really
clear-cut trading."
Responding to Channel NewsAsia, MOH said moving forward, its focus is to prevent end-stage kidney failure.
It added that the key is in prevention, maximising organ yield from cadaveric kidney transplants, promoting livingrelated transplants and public education on the Human Organ Transplant Act.
Health Minister Khaw Boon Wan is expected to visit a village in the Philippines on the sidelines of a World Health
Organisation meeting later this month. He plans to meet donors to find out what drove them to sell their organs and
perhaps look at the compensation they received to understand their situation. - CNA/vm
Created by Laura Ng and Matthew Koh, February 2009.
Middleman in kidney-for-sale deal gets 14 months' jail; out on bail
By May Wong, Channel NewsAsia | Posted: 05 September 2008 1629 hrs
SINGAPORE: The man who brokered the kidney-for-sale deal,
Wang Chin Sing, was on Friday sentenced to 14 months' jail.
He is out on a S$60,000 bail, pending an appeal. He is the
fourth person to be sentenced in this case.
Wang, 44, had introduced Indonesian kidney donor Sulaiman
Damanik to local retail magnate Tang Wee Sung. Wang also
coached them to lie to the Commissioner of Oaths about the
illegal kidney donation.
Wang had also introduced another Indonesian donor, Toni, to
Wang Chin Sing (L)
an Indonesian woman, Juliana Soh, for a successful illegal
kidney transplant here. These were among the five of 10 charges Wang pleaded guilty to. The remaining five
charges were taken into consideration during the sentencing.
Tang was on Wednesday jailed for a day and fined S$17,000. Sulaiman was jailed for three weeks, while Toni
served three-and-a-half months and was fined S$2,000 in July.
Reading out his judgement in court on Friday, District Judge Ng Peng Hong said Wang was clearly not a mere
medical concierge, but a middleman who actively brokered the illegal deals. The judge added that the case smacks
of being a syndicated operation.
Judge Ng said Wang was clearly the prime mover in the illicit organ trading.
"He negotiated the price for the purchase and supply of the kidney. He sourced for the kidney. He orchestrated the
entire course of action that needed to be taken... for the transplant operation to be carried through," said Judge Ng.
He added that condoning Wang's conduct could lead Singapore into becoming a hub for illegal organ trading.
Lawyer Shashi Nathan, in Wang's defence, had suggested a total of 12 weeks in jail, saying his client did not intend
to exploit the poor and his actions were motivated by sympathy and compassion, and not greed.
But the prosecution called for a deterrent sentence, saying he had no qualms exploiting both the donor and
recipient. They said Wang was one of the directing minds behind the scams, if not the directing mind.
Mr Nathan expressed disappointment in the sentence. "Disappointed in the sense that given the sentences that
were meted out earlier to other people who were involved, I thought 14 months was a bit high," he said.
About five family members, including Wang's wife, were in court for his sentencing. Wang was expressionless when
the sentence was passed.
Mr Nathan said: "He's obviously disappointed and I think he's a bit numb. He came in today, prepared to go to jail,
of course, and he's hoping that he could start his sentence today."
But after the sentence was passed, Wang decided to file an appeal, which is expected to be heard in the High
Court in about two months.
A fifth and last person involved in this case, Whang Sung Lin, has been charged with introducing Wang to Tang.
His trial is being arranged.
- CNA/ir
Created by Laura Ng and Matthew Koh, February 2009.
ILLEGAL ORGAN TRADING
EXTRACT OF PARLIAMENTARY DEBATES
OFFICIAL REPORT
ELEVENTH PARLIAMENT
SITTING ON 21ST JULY 2008
ORAL ANSWERS TO QUESTIONS
ILLEGAL ORGAN TRADING
1. Mdm Halimah Yacob (Jurong GRC) asked the Minister for Health in light of the recent convictions of two men for illegal
organ trading (a) whether the existing safeguards are effective and sufficient to prevent illegal organ trading; (b) whether the
hospitals' ethics committees are well equipped to carry out their task; and (c) what is the status of his Ministry's investigations
into this matter.
2. Dr Lam Pin Min (Ang Mo Kio GRC) asked the Minister for Health in light of the recent revelation of illegal organ trading
in Singapore (a) what additional measures will be put in place to ensure that similar illegal transactions do not occur; and (b)
whether the Ministry will consider legalising the ethical sale of organs in the near future.
The Minister for Health (Mr Khaw Boon Wan): Mr Speaker, Sir, may I have your permission to take Question Nos 1 and 2
together?
Mr Speaker: Yes.
Mr Khaw Boon Wan: Sir, both questions pertain to alleged illegal organ trading transactions in Singapore. As the case is
before the courts and further investigations are still on-going, I should not comment on them. After the case has been fully
wrapped up, my Ministry will review existing measures and fix any inadequacy.
Let me instead discuss this subject generally to outline the extent of the problem, our current approach and our strategy going
forward.
End stage renal disease (ESRD) or kidney failure is a dreadful disease. Every year, about 1,000 new cases are diagnosed here.
38% of the patients will not survive the first year given the severity of their illness. For the remaining 600 patients, the
treatment options are limited: either a kidney transplant or life-long kidney dialysis.
Kidney transplant is the preferred option as patients’ life expectancy is longer and their quality of life is better as the
transplanted patients do not have to be hooked on to a dialysis machine for a significant portion of their life. But kidney
transplant is a major operation with its attendant risk. Old age and other co-morbidity of the patient can significantly increase
the surgical risk to the patient and reduce the chance of a successful transplant. That is why only about a third of the 600 new
patients, ie, 200, are suitable for kidney transplant and can potentially benefit from the transplant option. The other 400 new
patients will have to depend on kidney dialysis.
Donated kidneys come from two sources: deceased donors and live donors. Like the rest of the world, we have worked to
increase the kidney transplant rate. While we are not yet getting 200 kidney transplants a year, we have raised our transplant
rate quite significantly. We are now about 50% sufficient, which is not bad as compared to many other countries. This is a
result of our adopting the Human Organ Transplant Act (HOTA) based on presumed consent in 1987, 21 years ago, and our
more recent efforts to promote living donor organ transplants. HOTA now contributes about 50 kidneys a year and livingrelated kidneys another 30, for a total of 80 kidneys a year. Another 20 Singaporeans go overseas for kidney transplant
annually.
We can expect our kidney transplant rate to continue to grow. First, from next month, HOTA will be extended to cover
Muslims. Second, the living-related kidney transplant rate has been rising and with greater awareness and understanding,
should go up further.
There is scope to raise both cadaveric and living donor transplant rates, and this is what we will do. Currently, HOTA sets an
age limit of 60 years on cadaveric donors. This is an arbitrary limit and has unnecessarily put many organs to waste. Many
Created by Laura Ng and Matthew Koh, February 2009.
countries, including Spain, do not set such an age limit. The suitability of the organ depends on its condition, rather than the
age of the donor. The condition of the kidney can be determined by the transplant doctor and that should be the criterion for
determining if an organ is suitable. We shall remove the HOTA age limit to help save many more lives. We will need to
amend HOTA and when I bring the Bill to this House, I hope to get the full support of Members for this initiative.
For living-related kidney donation, there are often family members who wish to donate to their loved ones but their tissues do
not match well. Some hospitals in the US and Europe have shown that with proactive coordination, “pair-matched donations”
can be done. This means matching a donor whose tissue is incompatible with the intended patient with another pair or even
pairs in a similar situation. This has not yet been done in Singapore. My Ministry is working on this idea so that we can meet
the altruistic wishes of such living-related donors. We will set up a live-donor registry to facilitate this. This may require the
legal backing of HOTA and, if so, we shall amend HOTA accordingly.
With these two additional initiatives, we can aim to raise our sufficiency level from 50% to 70% in the medium term.
Dr Lam Pin Min asked whether we will consider legalising the ethical sale of organs in the near future. This is controversial
and the current public debate shows that Singaporeans hold strong views both for and against. Moral and ethical issues aside,
there are major practical concerns over legalising the sale of kidneys. Would it result in more or fewer kidney
transplants?
Would it shrink the current cadaveric and living altruistic donor pool of organs? Some studies have shown that with a system
for paying organs in place, the altruistic donations may simply dry up. In Iran, where trading of organs is legalised, the
transplant rate remains low and the claim, that it has eliminated its kidney waiting list, has not been substantiated by
independent studies. According to the WHO, the only two countries almost self-sufficient in kidneys are Spain and Norway.
Both of these countries have successful altruistic organ donation systems built up through years of sustained public education.
In Singapore, we have not yet maximised the yield through altruistic organ donations. Let us emulate them and push altruistic
organ donations to their maximum potential.
With or without legalising kidney trading, HOTA and live-related kidney donations must be the predominant sources of kidney
transplantation. But if altruistic kidney donations cannot fully meet demand, we should continue to search for good
complementary solutions. We should not reject any idea just because it is radical or controversial. By forcing ourselves to
think about unconventional approaches, we may be able to find an acceptable way to allow a meaningful compensation for
some living-unrelated kidney donors, without breaching ethical principles or hurting the sensitivities of others.
Occasionally, I receive requests from some charities and religious bodies which wish to provide some compensation, in kind
and in cash, for the organ donors and their families, to acknowledge their altruistic act. But they worry that this may be
construed as organ-trading and they may be breaching the HOTA rules. My view is that we should encourage third parties,
especially those from the charity and religious sector, to help promote altruistic organ donations, and that we should consider
how they can be allowed to provide some financial compensation to the donors and their families after the transplants have
taken place. My Ministry will study whether such an idea is feasible and, if so, whether HOTA needs to be amended to
facilitate its implementation.
Meanwhile, the reality is that we have not fully met the demand for kidneys and there are desperate patients out there wishing
to live and desperately poor people willing to exchange a kidney for a hopefully improved life. While countries and ethicists
proclaim that organ trading is illegal and immoral, a black market of illegal transplants flourishes in many countries, and not
just in Asia, with poor clinical results for many patients and exploitation of many in poverty. This is the stark reality and the
human dilemma confronted by many in such desperate situations. We must therefore take a practical approach. Criminalising
organ trading does not eliminate it. But it merely breeds a black market with the middleman creaming off the bulk of the
compensation which the grateful patient is willing to offer the donor.
Prof Arthur Lim, a senior doctor and a past President of the Singapore Medical Association, argued eloquently in a letter to the
Straits Times just last week that organ-trading "laws should be removed or amended to take into account the desperate
circumstances of dying kidney patients." While they have breached the technical aspects of the law, Prof Arthur Lim argued
that "It is wrong to consider them criminals ..... In the same way, kidney donors should be supported and not regarded as
criminals." He appealed to Singaporeans to think over this important issue carefully, knowing that it is complex. He hoped
that Singapore "will not go down in history as a nation with no support and empathy for those who are dying from kidney
failure."
As the practical problem of organ shortage grows, attitude towards compensating kidney donors is gradually changing, and not
just in Singapore. Prof Gary Becker, Professor of Economics and Sociology and Senior Fellow at the Hoover Institution,
published an article recently, entitled: "Should the purchase and sale of organs for transplant surgery be permitted?" Prof
Becker won the 1992 Nobel Prize in Economics and he studied the applications of economics to social policies. I would
suggest to our media to publish this article of his so that more Singaporeans can be informed of this school of thought. The
academic ethicists and medical doctors may be against the sale of organs, but the economists have analysed the problem from a
Created by Laura Ng and Matthew Koh, February 2009.
practical perspective, which deserves to be considered. In the article, Prof Becker carefully weighed the pros and cons and
came to this conclusion: "My conclusion is that markets in organs are the best available way to enable persons with defective
organs to get transplants much more quickly than under the present system. I do not find compelling the arguments against
allowing the sale of organs, especially when weighed against the number of lives that would be saved by the increased supply
stimulated by financial incentives."
On the part of my Ministry, even as we take action against those involved in illicit organ trading and unscrupulously exploiting
the desperate and the vulnerable, we will take a sympathetic approach to the plight of the exploited donors and the basic
instinct of kidney failure patients to try to live.
Mdm Halimah Yacob (Jurong GRC): Sir, I have three supplementary questions for the Minister. I would like to welcome the
two initiatives that the Minister has mentioned that will help to increase the number of donors available for transplants.
1) The Minister has not answered this question but I think it is still a pertinent one, especially since we still have the current
legal framework in place - will the Ministry consider setting up an independent Ethics Committee to assess donations of
kidneys by non-related donors and recipients? One of the difficulties is that of getting the hospital ethics committee to be able
to effectively assess whether there is a genuine relationship, especially when we have non-related donors and recipients.
2) I think the premise of wanting to legalise organ-trading is that it would eliminate the black market, but as the Iranian
situation shows us, even with a legal market, under-the-table arrangements and payments cannot be eliminated. It still
prevails. How confident are we, even as we consider this as part of the debate and on-going discussion, that this area will be
addressed?
3) Sir, may I ask the Minister whether we are focusing on the right issues? As we know, there is a huge number of
Singaporeans suffering from diabetes and hypertension which are contributing factors to renal failure. Instead of just focusing
on organ transplants, should we not be focusing more on prevention at the primary care level to prevent people from
contracting these chronic diseases? And if indeed they have contracted them, should we not be spending more efforts in
preventing their conditions from worsening, in other words, address the pipeline issue that contributes to the growing numbers
of renal failure cases?
Mr Khaw Boon Wan: Sir, I thank the Member for her support in advance of the proposed HOTA Amendments which I will
bring to this House. I agree totally with the Member on prevention as the best approach, going forward. But no matter how
hard we try on this front - and we will push it to the limit - patients will still fall sick and there will be kidney-failure patients.
Our end-stage renal failure rate is high, as compared to other populations. So there is scope for us to bring it down further. But
no matter how hard we try on this front, there will still be patients with kidney failure and we have to seriously think about how
to manage those kidney-failure patients.
On the existence of a black market in Iran, that is a model that we will study because, currently, this is the only country that
legalises it. They themselves admit that their solution is not perfect. That is why this topic needs a fairly deep study. It is not
something that I will bring to this House immediately, certainly not this year, but the more we discuss the practical difficulties
of pushing this front, the more we may be able to find better solutions out of it. The stark reality remains that a black market
exists in this part of the world and, as I have said, not only this part of the world but in Europe as well. I was having a
conversation with a transplant surgeon from the UK who knows this business very well, so I asked, "Where do desperate
British patients with kidney failure go to?" He said, "There are many countries in Europe where such things are happening."
Ethical concerns, I can understand. To me, the biggest concern about the ethics of this activity is the exploitation that is going
on. But if we apply our minds, if we do not shut off our minds to options like this, I hope to be able to find practical solutions
that can minimise or even eliminate the exploitation. Is that not a better outcome than the current situation?
Mr Speaker: Dr Lam. Keep your question short, please.
Dr Lam Pin Min (Ang Mo Kio GRC): Sir, I would like to thank the Minister for the comprehensive reply. I have three
supplementary questions.
(1) Under the current HOTA for altruistic living organ donations, is there a provision for employers to provide the necessary
support to the donors in terms of paid leave or even extended medical leave? If not, would it not be useful to mandate donoremployer support so as to minimise the sufferings and sacrifices of these living donors?
(2) By increasing the age limit of donor organ above the age of 60, is there any study to indicate the survivability of such
organs; and
(3) What is the cost of dialysis per patient per year? Will the legalisation of a kidney white market result in significant cost
savings and better usage of limited medical resources, in addition to the alleviation of pain and sufferings among kidney-failure
patients?
Mr Khaw Boon Wan: Sir, the lifting of age limit is something that is common in many countries. Our setting this arbitrary
limit of 60 is quite unique. I remember the history to this. We were breaking new grounds with a presumed consent
legislation, so for conservative reasons, my predecessor decided to set this age limit of 60. We can certainly study the
survivability or success of kidney transplants in other countries where elderly donors are involved. But the fact that in Norway
and Spain, for example, many donors are above 60 and their population life expectancy is not worse than ours suggests that this
is a very viable and practical option, going forward.
As for employer support, this is not covered under HOTA. My understanding is that employers are generally supportive of
Created by Laura Ng and Matthew Koh, February 2009.
employees who are donors, including insurers. I have checked on this point before, for example, whether insurance premiums
of donors will be affected, and the answer is "No".
I think I missed an earlier question from Mdm Halimah, which was on hospital ethics committee, and whether we should set up
other ethics committees to just look at unrelated organ donors. Our system is not unique. We have a National Ethics
Committee which provides guidance to the various hospital ethics committees, but we leave the decisions at the ground level to
the hospital ethics committee. It is their job to assess carefully the donors. There are two things they have to look out for:
(1) Are the donors well informed about the risks that they are going into; and
(2) Are they being pressured by financial considerations?
That is the arrangement we have in Singapore, which is also the system elsewhere. If we bring it to the Ministry of Health to
perform such a role, can we do a better job? I am not so sure. I spent many years running hospitals and I am used to listening
to the talks in the doctors' lounge or in the corridors, and often you get better information at the hospital grounds than far away
at the Ministry headquarters. So whether there are unethical practices happening on the ground, if you bring the committee to a
level which is much more remote from the ground, I do not think we are improving the situation.
ORGAN TRANSPLANTS PERFORMED IN SINGAPORE
3. Dr Lam Pin Min(Ang Mo Kio GRC) asked the Minister for Health if he will provide (i) the number of kidney, liver and
cornea transplants performed in Singapore over the past three years and their breakdown into cadaveric and live donor organs;
and (ii) the average waiting list for each organ type.
Mr Khaw Boon Wan: Sir, over the past three years, there were 228 kidney transplants involving Singaporeans, and 63% of
these were from deceased donors. During the same period, there were 33 liver transplants, 64% from deceased donors. There
were 271 cornea transplants, all of course from cadavers.
Currently, the numbers of patients waiting for cadaveric organs are 563 for kidney, nine for liver and 25 for cornea.
Dr Lim Wee Kiak (Sembawang GRC): Sir, I would like to ask the Minister whether, apart from the removal of the age limit
for cadaveric transplant, there are other measures that the Ministry would be looking into, eg, some form of bereavement fund
or financial compensation for the cadaveric donors' families to encourage more of these cadaveric donors.
The second point is that, with the current improvement in terms of technology, what kind of efforts has been put into more
research, so as to shrink the dialysis machine down to a small size enough to be implanted within the body. With the membrane
technology that we have now, are we pushing in this particular direction?
Mr Khaw Boon Wan: Sir, as I said in an earlier reply, I have occasionally received requests from religious bodies and some
charities which wanted to promote altruistic donations. They said, "Can we be allowed to compensate the families, in the case
of cadaveric donors, including in dollar terms?" These are cautious people and they worry whether they will be flouting any
HOTA rules. I am studying this idea. I think we should encourage such third party, particularly if they are charities and
religious bodies who want to promote altruistic donations. I think the more you can break the direct relationship between the
donor and the donee, a lot of the unethical considerations can be minimised. This is a possible option that we should explore,
and I am studying it carefully with a view to doing so.
As for research on how to eliminate or reduce the impact of this problem, that is ongoing globally, including to a certain extent,
in Singapore. I remember the early day when I first joined the Ministry of Health when dialysis machines reminded me of
mainframe computers, big machines, but they have shrunk over the years and now there are a lot of efforts to shrink it further.
In parallel, there is also research ongoing to look at other non-human organ possibility and substitutes. We wish such
researchers early success but, meanwhile, the problem exists and I think the practical problem of this has to be resolved one
way or the other.
Created by Laura Ng and Matthew Koh, February 2009.
Should the Purchase and Sale of Organs for Transplant Surgery be Permitted? Gary
Becker - The Becker-Posner Blog
There were about 50,000 persons on the waiting list for kidney transplants in the United States in the year 2000,
but only about 15,000 kidney transplant operations were performed. This implies an average wait of almost four
years before a person on the waiting list could receive a kidney transplant. The cumulative gap between demand
and supply for livers was over 10,000, which implies an average wait for a liver transplant of a couple of years.
In 2000, almost 3000 persons died while waiting for a kidney transplant, and half that number died while waiting for
a liver transplant. Many also died in other countries while on the queue waiting for an organ transplant. Some of
these people would have died anyway from other causes, but there is little doubt that most died too early because
they were unable to replace their defective organs quickly enough.
If altruism were sufficiently powerful, the supply of organs would be large enough to satisfy demand, and there
would be no need to change the present system. But this is not the case in any country that does a significant
number of transplants. While the per capita number of organs donated has grown over time, demand has grown
even faster. As a result, the length of the queue for organ transplants has grown significantly over time in most
countries, despite exhortations and other attempts to encourage greater giving of organs.
In recent years the US has taken several steps to improve the allocation of available organs among those needing
them, such as giving greater priority to those who could benefit the most. These steps have helped, but they have
not stopped the queues from growing, nor prevented large numbers of persons from dying while waiting for
transplants. Some countries use an "opt out" system for organs, which means that cadaveric organs can be used
for transplants unless persons who died had indicated that they did not want their organs to be so used. A PhD
thesis in progress by Sebastien Gay at Chicago shows that opt out systems may yield somewhat more organs for
transplants than the "opt in" systems used by the US and many other nations, but they do not eliminate the long
queues for transplants.
To an economist, the major reason for the imbalance between demand and supply of organs is that the United
States and practically all other countries forbid the purchase and sale of organs. This means that under present
laws, people give their organs to be used after they die, or with kidneys and livers also while they are alive, only out
of altruism and similar motives. In fact, practically all transplants of kidneys and livers with live donors are from one
family member to another member. With live liver transplants, only a portion of the liver of a donor is use, and this
grows over time in the donee, while the remaining portion regenerates over time in the donor.
If laws were changed so that organs could be purchased and sold, some people would give not out of altruism, but
for the financial gain. The result would be an increased supply of organs. In a free market, the prices of organs for
transplants would settle at the levels that would eliminate the excess demand for each type of organ. In a paper on
the potential of markets for live organ donations, Julio Elias of the University of Buffalo and I estimate that the going
price for live transplants would be about $15,000 for kidneys and about $35,000 for livers. We recognize, however,
that the data are too limited to be confident that these numbers would be close to equilibrium prices that equate
supply and demand-they may be too high or too low. But even if our estimates were only half the actual equilibrium
prices, the effect on the total cost of transplants would not be huge since current costs for live transplants in the US
are in the range of $100,000 for kidney transplants and $175,000 for liver transplants.
An open market in organs would sharply curtail the present black market where some persons in need of
transplants have them in poorer countries like Turkey where enforcement against selling organs is slack. Since the
quality of the surgeons and hospitals in these countries is much lower than in advanced countries, this often greatly
reduces the quality of the organs used and how well they are matched to the organ types of recipients.
Still, despite these strong arguments in favor of allowing commercial markets in organs, I do not expect such
markets to be permitted any time in the near future because the opposition is fierce. Some critics simply dismiss
organ markets as immoral "commodification" of body parts. More thoughtful critics suggest that allowing organs to
be bought and sold might actually reduce the total number of organs available for transplants because they claim it
would sufficiently lower the number of organs donated from altruistic motives to dominate the increase due to those
sold commercially. That scenario, however, is extremely unlikely since presently only a small fraction of potentially
useable organs are available for transplants. Compensating persons either for allowing their organs to be used
Created by Laura Ng and Matthew Koh, February 2009.
after their death, or for kidneys and livers to be used while they are alive, would enormously widen the scope of the
potential organ market.
Another set of critics agree with me that the effect on the total supply of organs from allowing them to be purchased
and sold would be large and positive, but they object to markets because of a belief that the commerciallymotivated part of the organ supply would mainly come from the poor. In effect, they believe the poor would be
induced to sell their organs to the middle classes and the rich. It is hard to see any reasons to complain if organs of
poor persons were sold with their permission after they died, and the proceeds went as bequests to their parents or
children. The complaints would be louder if, for example, mainly poor persons sold one of their kidneys for live
kidney transplants, but why would poor donors be better off if this option were taken away from them? If so desired,
a quota could be placed on the fraction of organs that could be supplied by persons with incomes below a certain
level, but would that improve the welfare of poor persons?
Moreover, it is far from certain that a dominant fraction of the organs would come from the poor in a free market.
Many of the organs used for live liver or kidney transplants are still likely to be supplied by relatives. In addition,
many middle class persons would be willing to have their organs sold after they died if the proceeds went to
children, parents, and other relatives. Although this is not an exact analogy, predictions that a voluntary army would
be filled mainly with poor persons have turned out to be wrong. Many of the poor do not have the education and
other qualifications to be acceptable to the armed forces. In the same way, many poor persons in the US would
have organs that would not be acceptable in a market system because of organ damage due to drug use or various
diseases.
Still another criticism of markets in organs is that people would be kidnapped for their organs, and that totalitarian
governments would sell organs of prisoners. This would happen, but not likely on a significant scale since the
source of organs offered for sale could be determined in most cases without great difficulty.
A criticism particularly of a commercial market for live transplants is that some persons would act impulsively out of
short run financial needs, and that they would regret their decision to sell a kidney or allow their liver to be used for
a transplant if they had taken more time. I do not know how important such impulsive behavior would be, but it
could be sharply reduced by having a month or longer cooling off waiting period between the time someone agrees
to supply an organ and the time it can be used. They would be allowed to change their mind during the interim.
Many of the arguments against the sale of organs indirectly stem from an influential book in 1971by the British
social scientist Richard Titmuss, The Gift Relationship: From Human Blood to Social Policy. He argues against
allowing blood to be sold for transfusions, and compares the British system, which did not allow the purchase of
blood, with the American system, which did allow its purchase. Titmuss basically ignored that the American system
in fact was getting more blood per capita than the British system. Instead, he concentrated on the quality of the
blood. Since a significant fraction of the American blood came from individuals with hepatitis and other diseases
that could not be screened out, the blood given under the British system tended to be healthier. In the absence of
effective screening techniques, perhaps shutting down the commercial market was an effective way then to
improve blood quality.
But that is no longer the case as highly effective methods have since been developed to determine whether blood
is contaminated with various types of hepatitis, the HIV virus, and other transmittable diseases. Under present
screening technology, a market in blood yields much more blood, and with enough diligence its quality can be
maintained at a high level.
My conclusion is that markets in organs are the best available way to enable persons with defective organs to get
transplants much more quickly than under the present system. I do not find compelling the arguments against
allowing the sale of organs, especially when weighed against the number of lives that would be saved by the
increased supply stimulated by financial incentives.
Created by Laura Ng and Matthew Koh, February 2009.
Created by Laura Ng and Matthew Koh, February 2009.