On responsibility and “standing in line for life”

The news that Ukraine’s Ministry for Public Health has drawn up and submitted to the relevant parliament committee a bill that simplifies the procedure of posthumous donorship (it is suggested that the presumption of disagreement to organ transplantation after death, now in force, be replaced with the presumption of agreement) has stirred up the public. Under the bill, everyone who has not written a waiver in their lifetime automatically becomes a donor after death. Social networking sites immediately began to display collages and demotivational posters about “organ hunters” and “improvement right today” – the claim is that nobody will, of course, have their organs cut out on the street, but doctors will not be exactly hurrying to save the life of a seriously sick patient if there are orders for certain organs. Tetiana Bakhtieieva, a Party of Regions MP, chairperson of the Parliamentary Committee for Public Health, has made a statement consonant with the public mood: she said in an ICTV channel live program that Ukraine is today absolutely unprepared for a law on the presumption of agreement to posthumous organ transplantation and that this initiative may harm, rather than improve, things.

The reaction of people to this draft law has clearly shown society’s profound mistrust towards doctors, law-enforcers, the state as a whole, and any official initiatives and bills which promise to improve the grassroots’ life. Ukrainians do not trust the state and are trying, in fear, to trace some hidden benefits “for them” and potential dangers “for us,” which is only natural. In the minds of many, such things as donorship and organ transplantation are closely associated with negative connotations. “Most of the people consider a transplanter as a horror-story doctor who unlawfully cuts something out to enrich himself. But, in reality, a transplanter is, above all, a doctor who saves the life of and gives hope to patients,” reflects Oleksandr VAKULENKO, Police Colonel, a department chief at the Main Investigation Directorate of Ukraine’s Ministry of the Interior. But what he says can be denied by the numerous stories of illegal transplantation, such as, for example, the detention of Israeli surgeon Michael Zis in 2007 in Donetsk, who was charged with preparing and conducting illegal surgery to transplant donors’ organs in Ukraine. Or take the trial of the Chernihiv Regional Postmortem Bureau medics who excised body fragments from corpses without permission of relatives. The media have been full of this kind of stories in the past few years.

Obviously, such controversial and socially objectionable initiatives cannot be successful in a situation of total mistrust. Experts believe that what is really needed is a systemic populace-oriented effort that includes propaganda of donorship, measures to boost the social responsibility of people, and guarantees of complete social protection in these matters. Besides, the Ukrainian mass media only increase the fear, mistrust, and unwillingness to become a donor by printing sensational stories instead of deeply analyzing the problems and the likely ways of their solution. Will an individual wish to become a donor after reading such newspaper headlines as “Ukrainians to Be Dismembered after Death,” “Black Transplantation: Will Ukraine Turn into Kosovo?” and so on? Everybody, including the media, must be aware of their responsibility in such a complicated and subtle question as donorship.

HOW CAN SOCIETY BE REANIMATED? A “PRESCRIPTION” FROM THE MINISTRY OF PUBLIC HEALTH

“It is not a draft law but sort of a concept to develop a transplantation service in Ukraine. It was drawn up by a group of experts formed in accordance with a Ministry of Public Health instruction. This concept is not yet a draft law – it has only been put to a public debate,” Ruslan SALIUTIN, director of the Coordination Center for Transplantation of Organs, Tissues, and Cells at the Ministry of Public Health, said in an attempt to pacify the public. Saliutin emphasizes that this concept focuses on “the establishment of a single coordination service that would deal with everything that relates to the transplantation of organs, cells, and tissues. It is not a question matter of the presumption of agreement or disagreement.”

According to Saliutin, Ukraine has opted today for the so-called “insular system of transplantation.” Things are scattered over various Ministry of Public Health departments, and there are in fact no logistical chains. Nor is there a single coordinating system of transplantation and an effective system of transportation and control. There should be a supervisory board composed of representatives of the law-enforcement bodies, religious and non-governmental organizations. We must see to it that this activity connected with rather subtle spiritual and social matters should be open and transparent so that we never again have instances of the so-called black transplantation,” the director of the ministry’s Coordination Center for Transplantation of Organs, Tissues, and Cells explained.

In Mr. Saliutin’s words, the question of replacing the presumption of disagreement with that of agreement was supposed to “reanimate the public.” As we can see, the reanimation turned out to be so strong that all the other problems of transplantation in Ukraine and the likely was of their solution in society have receded far to the background.

“ROAD ACCIDENT VICTIMS ACCOUNT FOR ABOUT 3,000 KIDNEYS, 1,500 LIVERS AND HEARTS A YEAR”

The Ministry of Public Health’s chief transplanter Oleksandr Nykonenko furnished the following statistics to journalists: there is an annual need in about 2,000 kidneys, 1,000 livers, and 500-700 hearts for transplantation in Ukraine. “However, last year all the centers transplanted as few as 86 kidneys, 14 livers, and just one heart, Nykonenko said. As long ago as in April, when the concept was still under discussion, the chief transplanter announced that about 1,000 annual surgeries could be performed in Ukraine. “We have seven centers that use the necessary equipment and employ well-trained specialists who can successfully transplant livers, kidneys, hearts, as well as the pancreas and the spinal cord,” Nykonenko pointed out. But what hinders the process is the imperfect law, especially the presumption of disagreement to posthumous donorship. “It is forbidden in today’s Ukraine to remove healthy organs from corpses without permission of relatives. And this permission should be obtained in the shortest possible time while the organ is still fit for transplantation. But, as a rule, relatives do not give this permission.”

“Road accidents annually claim the lives of 5,000 to 7,000 people, and 25 to 30 percent of them are diagnosed as having experienced brain death. It is about 1,500 people a year, that is, 3,000 kidneys, 1,500 livers and hearts. This number fully meets Ukraine’s need in donors’ organs. Nobody will be removing donors’ organs just to be with it – the law-enforcement bodies will keep an eye on this,” Saliutin explains. He is sure there will be no abuses because a brain death can only be diagnosed by a council of five or six doctors. “You can bribe one, but not several, doctors,” the specialist assures us.

“The concept says that we are all potential donors a priori, but it is impossible to excise an organ in some cases. The first is when the donor himself did not agree to excision in his lifetime and his notice was entered into the register. The second is when relatives categorically disagree to the removal of organs when the patient is in the clinic. And, thirdly, it is not allowed to remove organs and tissues from unidentified people,” Saliutin explains. He also reminds us that Ukraine has signed the Declaration of Istanbul, under which “organs of a country’s citizens should only be used for the citizens of this country” and, hence, will not be carried abroad. In addition, Saliutin kept on saying there would be strict public and law-enforcement control, but it is still unknown how this mechanism will function.

The Ministry of Public Health can respond to all the questions and doubts of the public – all the responses sound quite convincing, but they apply to a rule-of-law state. Conversely, the Ukrainians do not believe that this country’s law system will not offer “loopholes” for those who need these. And it is next to impossible in Ukraine to prove the guilt of doctors in one question or another, which the law-enforcement bodies also agree to.

“It is very difficult to bring a doctor to justice. It is common knowledge that there is corporate protection in the medical milieu. So everything should be regulated by the current domestic law: who, how, and when gives permission, etc. As long as there is no clear-cut procedure, there will be crimes in this field,” Oleksandr Vakulenko explains. He disclosed the following statistics: in 2007-11, prosecutors investigated eight illegal transplantation cases. Six cases were submitted to courts, five were tried and sentences were passed. In three cases, the court offered the defendants an amnesty.

WE WENT A WRONG WAY…

The presumption of agreement is applicable today in Russia, Austria, Belgium, Spain, the Czech Republic, Belarus, the UK, Hungary, and some other countries. The presumption of disagreement is valid in the US, Canada, Germany, France, Portugal, the Netherlands, and Ukraine. Ruslan Saliutin says the number of transplantations is approximately the same in both categories of countries. “The question is not in the law but in the health care and transplantation systems and, what is more, in the system of social security, public information, and control,” he explains. This is exactly what Ukraine lacks. Besides, replacing the presumption of disagreement to posthumous removal of organs by that of agreement changes the very approach to the human body – the latter becomes state property after the death of a human. This model functioned in the Soviet health care system. But this approach does not suit many people because in this case everything is done to meet the needs of the state rather than to allow people exercise their right to dispose of their body and make a donorship decision, a voluntary and deliberate decision, on their own. But in this case, too, one must remember that when one becomes a donor, he or she donates their organs to concrete people, not to an abstract state.