Kerala's highly celebrated deceased donor transplant programme, Mrithasanjeevani, was already fighting for life when the latest controversy surrounding the alleged mishandling of a donor kidney happened at the Thiruvananthapuram Medical College on June 19.
The number of donors has shown a steep fall since 2016. If in the initial years of 2013, 2014, 2015 and 2016, the number of deceased donors were 36, 58, 76 and 72, it fell to 18 in 2017. In 2018, the number dropped further down to eight.
The subsequent years saw a slight revival -- 19 (2019), 21 (2020) and 17 (2021) -- but these were far below the promise the Mrithasanjeevani project held when it began. This year, while nearing the half way mark, the number of donors is just six.
The organs of one deceased donor – heart, liver, kidney, lungs, pancreas and even hand -- are shared with multiple, three to five, recipients. Therefore, beneficiary numbers, too, have fallen proportionately. It touched a low of 29 in 2018, when donors were just eight. The highest was 218 in 2015, when the number of donors was also the highest at 76.
Doctors as murder suspects
It is a fact that pop culture tools like cinema have ingrained in the public a certain level of suspicion about organ transplant. Popular films, say for instance 'Joseph', have given the impression that organ donation is part of some big mafia racket.
But more than the common man's fears related to organ donation, it is the reluctance of doctors to certify brain-stem death that has punctured the life out of Mrithasanjeevani. “No doctors are willing to certify brain death,” said Dr Noble Gracious, the nodal officer, Kerala Network for Organ Sharing (Mrithasanjeevani).
According to him, the society has badly antagonised neurologists and neurosurgeons who are supposed to first report brain death. “They are constantly told, through litigations and popular forms of entertainment, that they are accomplices in murder,” Dr Gracious said.
The potential for legitimate organ harvesting, which would save the lives of thousands, is huge in Kerala. But the 'once bitten twice shy' attitude of the doctors is holding the organ sharing project back. “There are over 4000 traffic deaths happening in Kerala annually. Yet, there are less than 10 donations a year,” Dr Gracious said.
The WHO defines brain death as “irreversible cessation of cerebral and brain stem function, characterised by absence of electrical activity in the brain, blood flow to the brain, and brain function as determined by clinical assessment of responses.”
Organs can be harvested only from the brain-dead because in them, though they are clinically dead, cardiopulmonary functions can be artificially sustained for some time.
Visit from the police
In 2017, there were two instances of police interrogating doctors in Ernakulam who had certified brain death in their respective hospitals some five or six months before.
“They were questioned for the brain dead certifications they had carried out some five or six months before. It was made to look like they had done some serious malpractice when in reality they had done everything strictly according to protocol. This had seriously traumatised the medical community," said Dr Easwar H V, professor and head of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum.
After this, the then DGP, Loknath Behera, had issued an order prohibiting the police from subjecting doctors to any kind of interrogation or harassment in the name of brain death certifications. By then it looked like doctors had collectively made up their mind.
Next year, in 2018, the number of deceased donors fell to eight. “Neurologists on duty in ICUs even stopped making the first step towards organ donation, which was informing the hospital superintendent or the person in charge of the brain death of a patient,” Dr Gracious said.
A neurologist in a private hospital told Onmanorama on the condition of anonymity that his management had told him not to certify brain deaths. “It was official policy. They did not want to get into trouble and invite bad publicity,” he said.
Dr Gracious said that if at all some organ transplants still take place in Kerala it is only because the close relatives of the dead person want the organs donated. “The initiative will rarely come from a doctor,” he said.
Dread of court cases
Doctors and private hospitals are also wary of litigation. The one that gained wide publicity was a public interest litigation filed in the High Court by a Kollam-based doctor named S Ganpathy, again in 2017. He told the court that doctors were wrongly declaring a patient brain dead so that the organs could be harvested for huge commercial gains. The PIL was dismissed but since it was filed by a doctor himself, it nearly confirmed fears that organ donation was a deadly business.
Nonetheless, while dismissing the petition, the High Court asked the government to be cautious.
Saving doctors from guilt
The LDF government sought to resolve the growing indifference of doctors by issuing a government order on January 19, 2020, that sought to free a doctor from any ethical dilemma s/he might face while certifying brain-stem death.
As per the January 2020 order, a doctor should declare a patient brain dead, whether there is organ donation or not, if certain clinical procedures and tests attest to irreversible brain damage. This was the first such doctor-empowering order in the country.
The order defined the certification of brain-stem death as an act of justice. Here is what the order said: “Allowing the brain-dead to continue on ventilators may lead to potential harms which include mistreatment of the dead, deprivation of dignity, provision of false hope with resultant distrust, and prolongation of the grieving process.”
Three-step certification process
A thorough three-stage protocol was laid down in the order.
Step 1: Rule out any chances of coma reversal before subjecting the patient for brain stem death confirmation.
Step 2: Assessment of brain stem reflexes. This involves a series of seven tests done by four doctors and these essentially assess the reflexes and stimuli of the brain-dead. Each of these tests will have to be repeated after an interval of six hours, so that what was recorded during the first series of tests are either confirmed or invalidated. One doctor in the panel has to perform the test and it is mandatory that other panel members have to witness and interpret these tests.
Step 3: The apnoea test, the last brain stem reflex test. This should not be done if any of the earlier tests confirm the presence of a reflex. On top of this, all of this will be videographed.
Even after such a fool-proof protocol, under which no doctor could be singled out for negligence, the medical community has not been persuaded. “The fear still lingers. Leave alone the public, I don't think lot many doctors are aware of such an order,” Dr Easwar said.
Doctors Onmanorama talked to said even if they were, the latest organ controversy that led to the suspension of two doctors would further hold the community back from fully committing themselves to the organ sharing project.