A helpless authority

THE office of the Director of Medical Education (DME), which has been designated by the Kerala government as the Appropriate Authority (the top body in the State to monitor kidney transplants and to ensure that proper facilities are available and norms are followed in the transplant hospitals), has now been rudely awakened from its sleep.

Since the DME's office is already overburdened with the task of monitoring of the volatile medical education sector, the legal and ethical intricacies of human kidney transplants had so far been the least of its anxieties. At best, what it did for the proper conduct of kidney transplants was to satisfy the basic legal requirement of constituting three-member Authorisation Committees once in a while and leave it to them to sanction or disapprove kidney donations and inspect hospitals seeking to establish transplant facilities.

Dr. K.A. Kumar, the DME who took charge in June soon after the kidney trade scandal was exposed by the media, said: ``Kidney transplantation was till now a non-issue in Kerala. But we cannot be complacent any longer. We are going to be very serious about it.''

Immediately after reports of the racket appeared in the media, it constituted two more Authorisation Committees in the State, in place of the only one that functioned in Kozhikode. Now there is a committee, each with five members, for three regions of the State in Kozhikode, Ernakulam (Kochi) and Thiruvananthapuram. So far, this has been the only felt change on the ground.

Says Dr. Kumar: ``We do not have anything more here in place for the continued working of the system. We have no money even to call the committee members for a meeting, or to ask one of them to conduct an inquiry into the kidney racket. But to try and ensure that such rackets will not happen in the State again, we are now going to prepare a comprehensive scheme to structure the organ transplant monitoring agencies in the State in a proper manner.''

According to him, a decision has been taken to streamline the functioning of the authorisation committees. An important decision is to ask the three committees to ``concentrate'' on ensuring that every donation involving a live-unrelated donor is voluntary and altruistic and done only after proper verification of the identity and whereabouts of the donor. Dr. Kumar said: ``We are going to make psychiatric evaluation of the donors mandatory. Now pscychaitric evaluation is done by hospitals. But we are going to insist that if the committee feels so, it should refer the donor to a government psychiatrist to ensure that the donation is voluntary.''

Regarding the identity of the donors, the DME said that if the committees had a doubt about the bona fides of a person presented as a donor, they would now be required to insist on his producing a certificate from the executive officer of the respective local body gram panchayat, municipality or corporation. The committees will also have the option of seeking the help of the police, if it has a doubt that any foul play is involved.

Dr. Kumar said that at present the authorities disappeared from the scene once the transplant was approved by the committee. He said: ``We have no idea now about what happens afterwards, even whether the surgical procedures do take place at all. From now on hospitals will have to provide the Authorisation Committee with all these details.''

Dr. Kumar said that at a meeting of the committee members held in August, a consensus emerged that the Appropriate Authority had totally neglected the issue of the welfare of the kidney donors. ``Very soon, after some more discussions, we shall make the medical supervision and care of the donors, for at least until one year after the operation, the responsibility of the transplant hospitals.'' The meeting also felt that the unhealthy practice of the committees, which at times held interviews with the donors at the hospital where the transplant was done, needed to be discontinued.

He said that inspections of hospitals that conducted transplant operations would be made more regular and frequent. ``At present, inspections are held only to give the initial permission and when licences need to be renewed.''

For the first time since the adoption of the Transplantation of Human Organs Act, 1994, by Kerala in 1996, the Appropriate Authority has also constituted a sub-committee to formulate detailed rules governing the transplantation of human organs based on the Act. ``We are going to specify the standards and are in the process of preparing a handbook of the dos and don'ts for transplant hospitals,'' Dr. Kumar said.

The DME said that the Authority's position was that if organ trading was taking place, it had to be stopped, its operations detected and contained. At the same time a genuine live-unrelated donor should be able to do a transplant without any hassles.

Dr. Kumar said that since the Act did not have financial provisions incorporated into it, the Authority faced the problem of paucity of funds. The Authorisation Committees have been functioning on the benevolence of its members, who are not even paid their travel expenses, not to mention remuneration. In order to address the problem, a proposal is under consideration ``to involve a token fee'' to be paid by the hospitals.