Inter-State ramifications

Published : Oct 25, 2002 00:00 IST

Concerns remain about the large-scale migration of patients and potential donors from Kerala to Tamil Nadu owing to the comparative ease with which transplants are sanctioned and conducted there.

"Patients are all going to Tamil Nadu because it is much easier there. They go with a donor from here [or get a donor ther], do a transplant and come back to our hospital for follow-up treatment. Because there are no hassles there... It is the result, maybe, of the difference in public perception in Kerala and in Tamil Nadu [about commercial transactions in kidney donations]... Very soon Kerala society is going to realise that it is making a mistake."

THE above statement, from a reputed kidney transplant specialist in Kozhikode, Dr. Roy Chally, is an expression of a growing concern among doctors and hospital authorities in Kerala.

The Transplantation of Human Organs Act, 1994, a Central law meant to check the trade in human organs, was adopted by Tamil Nadu in 1995 and Kerala in 1996. It bans the buying and selling of human organs and makes commercial transactions in organs and their abetment a criminal offence. The Act allows only altruistic donations which, if made by non-relatives, should get the clearance of an Authorisation Committee after it is convinced that no commercial deals are involved (Frontline, April 12).

The migration of renal patients from Kerala is in itself not a new phenomenon, for until recently hospitals in the neighbouring State held out the only hope for those who needed transplants. The majority of them sought mercenary donors there, mostly through networks operating around the major transplant centres.

Frontline's investigation indicates that the situation has changed rapidly in the six years after the Act was adopted by the Kerala Assembly in April 1996. Before that only the private-sector Medical Trust Hospital in Kochi and the Government Medical College Hospital in Kozhikode offered transplant facilities. Kerala now has 13 hospitals, spread over six of its 14 districts, doing kidney transplants. The largest concentration of such hospitals is in the cities of Kochi and Kozhikode. More are being established, in various districts.

In Kerala, like anywhere else, the number of patients needing transplants far exceeds the number of altruistic donors. In the absence of efforts to popularise cadaver-based transplants (one of the goals of the new law) the patients' hope seems to rest solely on that vulnerable section in society for whom selling a kidney seems to offer life-altering possibilities. There appears to be a growing number of ``bystanders'' too, in and around Kerala's transplant hospitals, acting as links between needy patients and willing donors, helping them hoodwink the Authorisation Committee, and grabbing a share of the "price" of the kidneys.

The `demand' from patients, no doubt, was already there, but the growth in the number of transplant hospitals too has created the `need' for more transplants. A logical conclusion may be that inter-hospital rivalry may have increased the likelihood of such rackets and dubious networks developing. Dr. K. Vinodan, official spokesperson of Medical Trust Hospital, Kochi, which boasts of having performed the largest number (``nearly 600'') of kidney transplants in Kerala, told Frontline: ``Any private hospital would want to do such prestigious cases [transplant procedures]. And, definitely, there is competition among private hospitals. We would like to do more transplants because these are cases that bring in more prestige as well as money to the hospital.''

However, the authorities of the majority of hospitals disagree with the contention that competition between private hospitals could precipitate commercial organ trafficking. They argue that the demand for transplants in Kerala is much more than what the hospitals can meet and that hospitals do not need to run after patients or solicit agents.

Dr. K.M. Mehboob, medical director of the National Hospital in Kozhikode, where three major private hospitals started transplant facilities within a short span of time and which recently became the focal point of the first kidney racket in Kerala, said that ``there is absolutely no competition between private hospitals''.

Dr. K.G. Alexander, Director of the Baby Memorial Hospital, also in Kozhikode, said that his institution's way of dealing with competition was to have renowned doctors in its transplant unit. He said: ``In spite of that, we did only 54 transplants in the last two years, an average of one in two weeks. We could have done as many cases more if we wanted. We could have closed our eyes to all underhand dealings. We are not doing it. But it could be happening elsewhere. That should be inquired into.''

Dr. Thomas Mathew, Consultant Nephrologist at the hospital and a former Chairman of the Authorisation Committee, said: ``I do not think it is competition between private hospitals alone that you have to look into here [as the reason for possible rackets]. There are qualified nephrologists and urologists everywhere, and the ultimate personal interest in urology and nephrology is to do a transplant.''

In fact, the third major factor that has the potential to spread unlawful kidney transplants in Kerala is what every nephrologist and urologist and hospital director seem to be disturbed about, namely, the readiness of their own patients to go to transplant centres in Tamil Nadu whenever objections are raised by hospitals and the Authorisation Committees about the bona fides of the donors and the legality of the donation. Dr. K.M. Ashik, one of the directors of the National Hospital, told Frontline: ``We have any number of patients who were rejected here going to Coimbatore [the nearest transplant centre in Tamil Nadu] and getting it done there.''

THIS, perhaps, is the crux of the problem. When professionally ambitious doctors in competing hospitals discourage their patients from going elsewhere, what do they offer them in return? Is it why ``they all wink at borderline cases'', as one urologist in Kozhikode put it, under the pretext of upholding the patient's interest and saving a life? Several doctors indicated in their conversations with Frontline that it was always a ``terrible dilemma'' for them to decide between the need of a patient for a kidney and the legal implications of a patient actually buying one for survival.

Dr. Mehboob said: ``It is a social dilemma, not the doctor's alone. It is difficult for us too to give an opinion on that. Because our opinion will be in favour of the patient. If the law permits it, it is fine with us... Everything is not fair in this. What transpires between the donor and the recipient, the hospital really does not know.''

However, opinions do vary. For instance, Dr. Vinodan said: ``I am not in favour of a person selling a kidney... It is below the dignity of a person to ask somebody for his organs. If it is done out of love or compassion, that is something else. It takes place because poverty is the main problem and I think it is definitely not right.''

However, the view expressed by Dr. Thomas Mathew, the one that blinks at ``reasonable transactions'' and frowns at ``outright sale'' of organs, seemed to be the counsel of the majority of specialists in Kerala, including the ``personal views'' of the chairmen of the three Authorisation Committees, in Kozhikode, Kochi and Thiruvananthapuram. It is here, perhaps, that the distinction between ethics and compassion (or professional ambition) becomes blurred.

Georgy K. Ninan, Consultant Nephrologist at the PVS Memorial Hospital, Kochi, and a member of the transplant team that performed all the four cadaver transplant surgical procedures done in Kerala until recently (at the Medical Trust Hospital), said that the consensus solution to this dilemma was the promotion of cadaver transplant.

A favourite contention of hospital authorities is that the cost of a kidney transplant operation in Kerala (over Rs.50,000 in government-run medical colleges with additional ``hidden costs'', and between Rs.80,000 and Rs.1.5 lakhs, according to various private hospital authorities) is still low when compared to that in hospitals across the border. On the other hand, they also argue that the revenue from performing transplant operations is not that high between ``Rs.10,000 and Rs.15,000,'' according to one of them.

Doctors say that when so much money is involved, there will be middlemen facilitating the process. Says Dr. Chally: ``I do not see how you can in the near future do away with middlemen. But they should not be there, ideally.'' There are doctors who maintain that it is not the professionals who have brought kidney transplants into disrepute, but the middlemen. However, Dr. Chally believes that the basic reason for commercial transactions between patients and unrelated donors should not be overlooked. He said: ``It is the prevailing economic and social condition in the State... There may be a commercial transaction, for that matter, even within the immediate family, when members donate.''

They also think that whether a racket develops or not actually ``depends on the individual doctors and the patients concerned''. Dr. Vinodan said: ``It all depends on the environment in each hospital. The management and the professionals make sure that there are no middlemen... That is the only way.''

BUT where is the line to be drawn? Who decides which hospital management or doctor has crossed the limits and which ones have not? Actually, what are the limits, if they are not the ones drawn by the law of the land? Who decides how much the law can ``reasonably'' be watered down? Doctors merely smile and fudge answers to such questions.

Significantly, the most ``convenient'' assertion one hears in hospitals is the one that puts the onus of deciding the legality of a donation solely on the Authorisation Committee. Dr. Kasi Visveswaran, former Chairman of the Authorisation Committee and now Consultant Nephrologist at the Cosmopolitan Hospital, Thiruvananthapuram (which did its first transplant in June 2002), echoed the views of several other doctors whom Frontline met when he said: ``Hospitals can't be expected to do all these inspections. A person brings a donor, he says he is a relative or a friend, he has all the papers, he is medically fit and he has given proper, informed consent. All these data are submitted to the Authorisation Committee. If the Committee says yes, we go ahead.''

However, Dr. M.R. Chandran, Chairman of the Authorisation Committee in Kozhikode (until June the only such body functioning in the State), said that the committee had no mechanism to find out whether a donor was truly altruistic, or about his or her whereabouts. The hospitals are ``better-placed'' to monitor patients. The hospitals have to be careful because ``they know from where the donor is coming, and they present an altruistic donor before us as per their system. And we try to check whether that is true or not''.

Dr. C.R. Soman, chairman of the Health Action By People, a voluntary agency, believes that this is where moral dilemmas come in once again. He asked: ``How do you judge actually? What are the mechanisms by which the so-called expert panel can judge that this man is telling the truth about his altruistic motives? They have no vested powers to look into the motives and, therefore, for the purposes of record they would try to believe his statement. And beyond that they just do not have any conflict of conscience. This is the problem.''

Asked about such a predicament, Dr. Chandran said: ``[Personally, as a doctor] I do not think it is totally wrong if one donates a kidney and takes some money. For blood transfusions, one gives blood and takes the money that is paid officially. Similarly, if a person gives a kidney and takes money there may not be anything totally immoral in it. But then it becomes selling an organ. That may be unethical [illegal] but there is no way we can find out..."

What would the committee do when it has a doubt that a monetary transaction has taken place? Dr. Chandran said: ``There was no occasion when we had reason to suspect there was money transaction. But we know that, invariably there would be money transactions. There is no way of finding out.'' It is here, perhaps, that the distinction between the law and compassion too becomes hazy.

Another problem is the largely disinterested government establishments, the institutional mechanisms that are meant to monitor the implementation of the Act. Frontline found that as one moves up the ladder from hospitals, Authorisation Committees, the Appropriate Authority and the government departments right up to the Health Minister, awareness about the stringent conditions laid down in the Act decreases steadily.

Dr. K.A. Kumar, the Appropriate Authority (the Director of Medical Education), who assumed charge in June, well after the kidney racket made headlines, told Frontline: ``So far kidney transplants were a non-issue in Kerala. There is no system in place that can effectively monitor or police the transplant scene in the State. There is neither the manpower nor the resources to do it. The State has not even formulated the proper rules to implement the Act effectively. The government merely adopted the Act and entrusted the responsibilities to a few offices and government doctors''.

Are Kerala's transplant centres providing fertile ground for a nexus between doctors and middlemen to develop? Says Dr. Alexander: ``That can happen. That may be happening.''

According to Dr. Soman, professional ethics and morality are the victims of the unbelievable rise in the levels of specialisation and availability of technology. He said: ``They go hand in hand. There are any number of business-oriented persons in Kerala now who are investors, and some doctors who have, in turn, become investors and are willing to put in so much of money for the kind of sophisticated technology available now. This has resulted in one having a business culture in this noble profession. That has already seeped into the subconscious mind of every successful doctor.''

Significantly, doctors are now concerned that the expose and subsequent efforts under way to streamline the functioning of monitoring agencies and make the approval process more strict will only accelerate the transplant `tourism' in Tamil Nadu. Dr. A.K. Unnikrishnan, Director of the West Fort Hospital, Thrissur, told Frontline: ``We have a strong suspicion that the `Coimbatore lobby' [hospitals in Coimbatore] has a prominent role in raking up the present controversy in Kerala because the setting up of more and more transplant centres in Kerala has proved to be a setback for their business interests that depended a lot on patients from Kerala."

Dr. Chally likened the situation to the misguided public perception in Kerala a few decades ago that demanded that education should be free and that there should be no self-financing (read capitation fee) educational institutions, ``when actually what was needed was the proper pricing of educational facilities''. He said: ``But over a period people in Kerala came to realise that their students were making a beeline for capitation-fee professional colleges that had sprouted in the neighbouring States based solely on the demand from Kerala. The State is slowly realising its folly now and is beginning to establish such colleges here.'' Dr. Chally says that in a similar manner ``people will get fed up and will come to realise that they are being exploited by other States in this instance too''.

However, another trend is emerging in the State that could prove such optimism wrong. It is acknowledged that Kochi is the foremost transplant centre in Kerala, with three major specialty hospitals doing the largest number of transplants in the private sector. But, significantly, transplant hospitals in Kochi have for some time noticed a new pattern of patient migration. Doctors say that once their patients realise it is difficult for them to get an unrelated transplant done there because of legal and ethical hurdles, many of them seek a new, ``easy'' destination, apart from Coimbatore or Chennai Kozhikode.

Says Dr. Francis George, Consultant Nephrologist at Lissie Hospital, Kochi: ``We know a lot of people who go from here and get their transplants done in Kozhikode. They come back here for follow-up treatment, but will not tell us anything about how they managed to do it there. I have worked in CMC [Christian Medical College], Vellore, and now in Lissie. In both places I have found that despite the committee, people go and find donors, obviously for money, at places such as Chennai and Kozhikode and get it done.''

The reality and the attitudes of the doctors, hospital authorities and monitoring agencies as revealed in this investigation fly in the face of claims that the situation in Kerala is ``comparatively much better'' than that in Tamil Nadu or Karnataka. If Kerala had been free of such large-scale kidney trade rackets for a long time, it may have only been because there were only two hospitals doing mostly live-related transplants in the State. Now there are 13, with more being established.

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