the gp classroom

Iranian carpet trader Mohsen Fadaei has called Singapore home for the past three years. The 35-year-old runs a thriving business selling Persian rugs at his store in Arab Street. But should he ever have kidney failure, Mr Fadaei will have no qualms about returning to Iran.

The reason? Any sick Iranian who needs a kidney will be able to get one in two to three months because of a government-sanctioned kidney ’sharing’ scheme. Other countries continue to debate the ethics of organ trading, but for the last 11 years, the Iranian government has been paying citizens who are willing to give up a kidney.

It is the only country in the world to legalise kidney sales, and has been cited in the current debate over whether Singapore should consider legalising the organ trading.

The issue will be raised in Parliament by two MPs tomorrow. One of them, Dr Lam Pin Min, deputy chairman of the Government Parliamentary Committee (GPC) for Health, will ask if the Health Ministry would consider legalising the sale of organs as many kidney patients wait nine years on average for a transplant.

But what exactly is the Iranian model?

The Sunday Times spoke to Iranian nephrologist Alireza Mehdizadeh from the Mashad University of Medical Sciences, in the city of Mashad in north-eastern Iran, and referred to medical reports by the country’s top renal specialists to understand the situation.

The revolutionary set-up has its roots in 1997, when United States-imposed sanctions – in place since 1979 when the Iranian government stormed the American Embassy in Teheran – limited the supply of dialysis equipment into Iran.

The country’s eight-year war against Iraq had also taken a toll on the people’s health. With no cadaveric donations and few living donors, Iranian kidney patients had to either get a transplant abroad or die. Said Dr Mehdizadeh: ‘There was a big difference in the number of people waiting for a kidney and the number of kidneys available. We needed to find a way to save thousands of lives.’

The government introduced a new system where kidney patients who cannot find a living related donor can get one from a stranger.

The donor gets a compensation of US$1,200 (S$1,620) – the equivalent of a year’s salary for the average Iranian – and free health insurance from the government.

He also receives an additional gift, usually extra cash, from the kidney recipient.

The Iranian government runs the entire operation with the help of the Iranian Society for Organ Transplantation, a voluntary organisation run by kidney patients.

The organisation screens potential donors, matches donors to recipients and arranges for doctors to perform the transplant. The government bears the full cost of the transplant.

This ensures that even the poorest in society can have a transplant, said Dr Mehdizadeh.

There are supposed to be no private players. The doctors are government employees and there are no middlemen or brokers, ensuring that only the donor and recipient benefit from the exchange.

Potential donors are banned from advertising their kidneys or approaching kidney recipients directly.

Only Iranians are eligible to receive a donated kidney.

Dr Lam told The Sunday Times that the Iranian way of compensating donors with cash and insurance could possibly work.

‘The cash is not meant to be payment for the organ but compensation for the downtime and possible loss of income during the period the donor is recuperating from the transplant. The kidney is donated, not sold,’ he said.

Although it is too early to identify the best system for Singapore, the Government can form a work group to look into the various issues relating to organ trading, he suggested.

But the Iranian system is not without its loopholes.

Because the government pays relatively little for a kidney, donors usually try to wrangle recipients for more money before the transplant. This sum will be in the guise of a gift.

Here, market forces come to play.

Donors with rare blood types, such as AB, can fetch ‘gifts’ of as much as US$10,000 (S$13,520), said Dr Mehdizadeh. Older, less healthy donors have less bargaining power.

Organ ethicists worldwide have criticised Iran’s system, saying governments should not put a price on human organs.

But Iran insists it is not engaging in organ trading.

Said Dr Mehdizadeh: ‘It is organ sharing, not organ trading, even if some money is transferred during the exchange. It is very nice to share your organ with others.’

In a 2006 article, Iranian nephrologist Ali Nobakht Haghighi wrote: ‘It is unfortunate that some…use the terminology ’sale of kidneys’ instead of ‘donation of kidneys’. In our view, they have preferred to view the glass as half empty, rather than half full.’

But carpet trader Mr Fadaei says there is nothing altruistic about the kidney-sharing system in Iran.

‘People do it for the money. The inflation rate in Iran is 25 per cent every year. Many Iranians have financial problems because the value of their money is shrinking so quickly,’ he said.

By 2006, more than 16,000 Iranians had sold a kidney.

Studies by Iranian doctors found 84 per cent of kidney donors were poor. The majority were men who were unemployed or working as labourers.

With kidneys easily available, kidney patients would rather buy one than ask a family member to give up theirs, said doctors who oppose the system.

Ms Nancy Scheper-Hughes, director of Organs Watch, a United States-based group which investigates the organ trade, told The Sunday Times from Berkeley, California: ‘Medical critics of the system say that easy access to the bodies of poor people…has eroded kidney donation among loving family members.’

Often, kidney sellers are treated as ‘anonymous suppliers of much needed medical material’, she added.

Iran does not keep records of its kidney donors or do follow-up checks, said Professor A. Vathsala, director of the adult renal transplantation programme at the National University Hospital (NUH) here.

‘There is no donor follow-up data at all. So, to date, there is no assurance of the safety of the donor in such a system,’ she said.

A study by Iranian urologist Javaad Zargooshi on 300 kidney donors six months to 11 years after their transplant found that two in five, mostly manual labourers, lost their jobs because they were scared of overexerting themselves.

While ethicists argue that such outcomes are reason enough to continue banning organ sales, a few choose to view the situation differently.

American law professor Lloyd Cohen thinks that kidney sellers are no different from people in dangerous jobs.

Speaking to The Sunday Times from Texas, he said: ‘There are many dangerous things that people do for money, such as deep sea fishing for Alaskan crabs….

‘And all that society gets from crab fishing are crabs to eat, whereas selling kidneys saves lives.’

Dr Mehdizadeh could not agree more, pointing out that the health risk of donating a kidney is very low compared to other procedures such as renting a uterus.

As much as ethicists abhor Iran’s regulated kidney-for-profit system, it cannot be denied that a regulated system is better than no system at all.

He said: ‘As long as some people are determined to obtain kidneys and others are desperate enough to sell them, the trade will be impossible to stop.

‘It makes better sense to regulate the business than to drive it underground.’

ndianah@sph.com.sg