Parliament is currently discussing the draft amendment to the Law on Donors. Senior specialist of Cell, Tissue and Organ Transplant Coordination Department of the Health Development Center B.Altantulga delves into the new provisions reflected in the bill in the following interview.
What new regulations are included in the draft amendment to the Law on Donors?
The Law on Donors was approved in 2000, amended in 2012 and revised in 2018. In accordance with the revised law, the Cell, Tissue and Organ Transplant Coordination Department was established in 2018. We developed a new draft amendment and submitted it to the Ministry of Health to address the key issues we have faced for more than four years. In December 2021, an open discussion on the bill was held. The amendment to the Law on Donors was re-drafted and supported by the Parliamentary Standing Committee on Social Policy last week. It will be discussed at the parliamentary plenary session soon. To re-draft it, comments were received from all teams involved in cell, tissue and organ transplantation and relevant organizations, as well as from citizens who have received this type of treatment.
Based on their comments, we believe that it is necessary to amend a number of important provisions in the law. Firstly, the minimum age requirement for organ donors, set out in Article 13.2 of the law, will be lowered from 25 years of age to 21 years of age. Secondly, living donors will be entitled to free treatment and service at a local sanatorium once a year. The bill also stipulates that the Social Insurance Fund will provide financial support for the funeral allowance of brain-dead organ donors. Moreover, a professional ethics committee will be established under the Ministry of Health to oversee cell, tissue and organ transplantation. In accordance with the draft amendment, the health minister will also be required to approve the procedure for a unified donor registration database.
Could you clarify the significance of lowering the minimum age for donors to 21?
It can be said that this is the most important provision to be amended. We have included this proposal in the draft law based on regular requests from patients, and cell, tissue and organ transplant teams. It is not easy to find a donor, so lowering the minimum age to 21 can increase the number of donors. Some suggested that the minimum age should be set at 18. However, we believe that it is difficult for an 18-year-old to make an independent decision to become a donor.
How do you expect the number of donors to increase by lowering the minimum age?
The revised 2018 law sets the minimum age for donors at 25. At that time, there were talks about making it 18 or 21. However, it was not supported during the parliamentary discussion. Therefore, Article 13.2 of the Law on Donors states that “a citizen of Mongolia who has reached the age of 25 may submit his or her decision to become a donor to any health care provider”. According to the National Statistical Office of Mongolia, there are about 300,000 people aged 21 to 25 nationwide. Thus, lowering the minimum age to 21 will widen the number of potential donors and save more lives.
In general, there are two types of donors: living and brain-dead organ donors. Living donors must be a member of the patient’s family. To clarify one thing, under the Family Law, spouses, legitimate, illegitimate and adopted children and immediate relatives, who are living with them, are considered family members. In reality, I think the Family Law cannot properly identify a family member eligible to be a living donor. Therefore, the law needs to be amended. For instance, relatives of the bride and groom are not considered family members. The law does not specify this in detail. Meanwhile, deceased donors are persons who are brain dead. Our officials meet with brain-dead organ donors’ families and request them to donate the patient’s organs or tissue.
There are certain criteria for becoming a donor. More specifically, according to the current law, donors must be 25 to 65 years old and not have chronic diseases, hepatitis B or C virus, tuberculosis, syphilis, or coronavirus infection. Since 2018, the families of 145 brain-dead patients have agreed to organ donations. However, only 46 of them passed the above criteria and became eligible to become donors as most Mongolians have chronic diseases. We met with 46 potential donor families and obtained approval from 26 of them. As a result, 29 people underwent kidney transplantation, 20 liver transplantation and 60 tissue transplantation. In other words, thanks to deceased donors, 49 lives were saved and the quality of life of 60 people was improved.
How do the families of brain-dead organ donors respond to your request?
It is very difficult to meet with the family of deceased donors and get permission. Brain death occurs when a person has an irreversible, catastrophic brain injury, which causes total cessation of all brain function. In other words, a person whose brain dead is legally confirmed as dead. Family members of these people are usually in a state of shock. At such a time, we meet the family and discuss whether they would donate their family member’s organs. When we make such a suggestion to them, there are people who understand it and there are those who do not. However, we have to get their permission as soon as possible. I would like to emphasize that the attitude of people has changed recently and that most of them view organ donations positively. In particular, in 2018, our officials were often turned down, but most of the families we met last year consented.
You mentioned the financial support for the funeral allowance of brain-dead organ donors. Does the draft law specify the amount of benefits?
When we meet the families of deceased donors, almost 95 percent of them ask if there are any benefits or financial support. Under the current law, this is not possible. So we explain to them that donation is a voluntary activity, not a for-profit one. When we say that, some families reject our offer. Therefore, we have included a funeral allowance in the draft law. In particular, the funeral expenses of brain-dead donors will be provided by the Social Insurance Fund. In the event of the death of a Mongolian citizen, the fund provides a one-time allowance of 1 million MNT for funeral expenses. We have proposed to increase the amount of funeral allowance for deceased donors by a certain percentage. In our country, an average of five to eight organ transplants are performed annually from brain-dead donors. We see that this number can be increased by lowering the minimum age and providing funeral allowances to the families of deceased donors.
The issue of human tissue and organ trafficking is raised in connection with organ transplantation. What measures are taken to prevent this?\
The Declaration of Istanbul on Organ Trafficking and Transplant Tourism was approved by the Transplantation Society and International Society of Nephrology in 2018. Mongolia joined the declaration in 2018. According to the declaration, organ transplants should not be a source of profit for anyone. That’s why we are talking about increasing the funeral allowance by a certain percentage, assuming that there should be no monetary relations for this type of treatment.
Are ethical violations common in organ transplant treatment?
Doctors and medical professionals involved in cell, tissue and organ transplantation in our country follow the ethical principles very well. However, we have developed and approved a Code of Conduct to prevent further risks. The draft law also proposes to establish a Professional Ethics Committee. In the event of any misconduct, the committee will discuss and monitor the issue. In specific, the committee will determine whether organ transplants are connected to human organ trafficking and whether living donors donated organs voluntarily. For example, someone may become a donor under pressure from family members. At present, our department regulates all issues.
You said that organ transplants from deceased donors are not frequent. So how many organ transplants are performed in our country from living donors?
On average, more than 60 organ transplants are performed in Mongolia every year. About 10 percent of these are organ transplants involve deceased donors. The rest are organ transplants from living donors. Internationally, it is believed that organ transplants should be performed only from brain-dead donors if possible. The International Liver Transplantation Society has made a similar recommendation. The Universal Declaration of Human Rights states that everyone has the right to life and liberty. However, the quality of life of a donor has been somewhat lowered than in the past. After surgery, donors may lose their ability to work for one to six months. They should not become a patient but be allowed to continue their work. Therefore, donors are screened once a year free of charge and their health is monitored. Transplant recipients suggested that donors should be allowed to rest at a sanatorium in the future. That is why it was decided to include such a provision in the draft law. It is estimated that 40 to 50 donors will rest in sanatoriums each year. Of course, we should try to perform an organ transplant from a deceased donor as much as possible. However, depending on the situation, our country is transplanting organs from living donors. The situation is similar in other countries. In South Korea, for example, less than half of all organ transplants are performed from brain-dead organ donors.
The special team plays an important role in detecting deceased donors. Are there enough special teams?
There are currently eight special teams in the country responsible for determining brain death. These teams work at the three state central hospitals, the National Trauma and Orthopedic National Center, the Uvurkhangai Regional Diagnostic and Treatment Center, and the Darkhan-Uul Province General Hospital. Moreover, this year, Songinokhairkhan District General Hospital and Khovd Regional Diagnostic and Treatment Center formed such a special team. These teams could expand the scope of brain-dead donor detection.
Due to the COVID-19 pandemic, Mongolia imposed a quarantine and restriction regime for the past two years. How has this affected organ transplant treatment?
According to a study, amid the pandemic, this type of treatment decreased by more than 10 percent internationally. It has also had a significant impact on our country. For example, the supply of surgical equipment, substances, and immunosuppressive drugs was disrupted. In addition, there was a high incidence of COVID-19 infection from donors. In some cases, transplant recipients died from infection. They must take immunosuppressive drugs for the rest of their lives. Therefore, their immunity is very weak and the risk of infection is high. For these reasons, the organ transplant treatment was stopped for six months and resumed in September 2021. Now it is back to normal.
How many people have underdone organ transplants this year? How many people need surgery now?
Since January this year, two kidney transplants and one liver transplant have been performed from one deceased donor. There are currently about 500 people on the waiting list for liver and kidney transplants. If a deceased donor is found, there are specific criteria and regulations that determine whether or not to perform surgery, taking into account the patient’s blood type, tissue and cell compatibility, age, and physical condition. In order to improve this regulation, the draft law provides for the establishment of a unified registration and database. As a result, organ donation regulations will be improved and the system will automatically select patients if a donor is found.