EGYPT: Giving Life After Death

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Giving Life After Death
A decade after it was first proposed, the much-debated Organ Harvesting and Transplant Act is nearing approval
By Ethar El-Katatney

In 1997, Sheikh Al-Azhar Mohammed Sayed Tantawi dropped a bombshell by announcing that he would donate his organs after his death, sparking a decade-long controversy that only now seems to be reaching a conclusion.

The debate revolved around the Islamic definition of death, and whether or not it is even permissible to harvest organs from non-living donors. The debate picked up steam and then ground to a standstill when the highly revered Egyptian cleric Sheikh Mohammed Metwali Al-Sharawi responded to Tantawi’s announcement that “a human being should neither surrender nor replace any part of his or her body because it is a gift from God.”

Even if the influential Al-Sharawi, who died in 2000, had said organ transplants were religiously permissible, Tantawi’s words at the time were essentially symbolic, for there was no law permitting transplants using organs from non-living donors.

Organ donation advocates such as Tantawi and Dr. Hamdi El-Sayyed, chairman of both the Doctors’ Syndicate and the People’s Assembly’s (PA) Health Committee, have spent nearly a decade trying to change the public mindset and legal framework to give those in need of transplants that second chance at life.

In March, Tantawi appeared on popular TV talk show Al-Bayt Baytak and restated — as he has been doing for years — that donating your organs after death was not only an act of sadaqa (charity), but the ultimate act of ethar (altruism). “Everything is owned by God,” said Tantawi, “including the chair I’m sitting on right now, but God, though I am His creation, has given me the right to deal with His creation as long as it’s within the boundaries of virtue. Ethar is a virtue and what bigger act of ethar can there be than giving away your organs? <> I don’t understand why people are afraid of death and what happens to their body after their death. I see that what is taken from a person’s body after his death <> is halal, halal, halal.”

Their efforts are paying off. The ‘what constitutes death’ debate is almost fully resolved and a complete Organ Harvesting and Transplant Act — first introduced to parliament in 2001 — has been referred to the PA for final discussions this month.

Wanted: Organ Traffic Cops

Sanctioned organ transplants are currently being done under the guidelines endorsed by the Doctors’ Syndicate and Ministry of Health (MOH), which stipulate that both donor and recipient be Egyptian and ‘alive’ — essentially limiting the organs that can be donated to kidneys and portions of the liver. Organs and body parts that could be transplanted from a non-living donor include eyes and corneas, the heart, lungs, intestines, pancreas, skin, bone, tendons and certain large veins.

Considering that only three percent of organ transplants worldwide are from living donors, with the remainder coming from non-living donors, demand has always eclipsed supply in Egypt. The result? Organ trafficking, with desperate people literally maiming and killing each other in order to steal organs. Organ trafficking is big business globally, but in Egypt the stakes are even higher as hopeful recipients resort to extreme measures to obtain organs amid a host of restrictions.

A 1996 MOH edict that hoped to minimize ‘organ tourism’ — where wealthy foreigners come to coerce or rob the poor out of their organs — forbade transplants except between Egyptians and family members up to the fourth degree. Nevertheless, there is no way to enforce syndicate or ministry guidelines, because no section of the Egyptian Penal Code deals with organ trafficking. The theft of an organ is currently regarded as a misdemeanor assault with a one-year minimum sentence, and no penalty for organ brokers.

Approximately 4,000 organs are trafficked in Egypt each year, according to a 2008 report by the World Health Organization (WHO). A 2003 WHO report noted that trafficking became a severe problem in Egypt in the 1970s and estimates that in Egypt, 98 percent of all kidney transplant operations — a booming business over the past few decades — are made possible through trafficking. In September 2006, Egypt Today reported in its cover story “My Doctor, My Butcher?” that a single kidney brings in $1,000-5,000 to the donor, and newspapers are filled with stories of young Egyptians who have been persuaded or tricked into losing their kidneys.

In 2006, the MOH assigned a special department to monitor medical centers and private hospitals in Egypt, where most illegal organ transplants take place. According to the ministry, in 2007 there was a slight decline in the number of illegal transplants, but then a rise in 2008.

In November 2008, local media reported that a MOH campaign, which included surprise inspections of hospitals, found several hospitals allegedly conducting illegal transplants, most notably Al-Marwa hospital in Dokki, where 21-year-old psychiatric patient Ahmed Abdel Ghany was reportedly talked into selling his kidney for LE 13,000.

Demand for organs shows no sign of slowing: The high prevalence of Hepatitis C in the country, for example, means an estimated 300,000-500,000 Egyptians will need liver transplants in the next three years.

As one of six countries on the WHO’s list of the world’s leading providers of trafficked organs — China, India, Pakistan, Brazil and the Philippines being the others — and one of four countries with increasing rates of illegal organ transplants, Egypt has been dubbed “the Brazil of the Middle East.” A hotspot organ tourism location, where the poor are seen as spare parts for the rich, Egypt is also the only one of only four countries with no framework to regulate organ transplants. Eighteen Muslim countries — including Saudi Arabia — already have organ transplant laws in place.
A Comprehensive solution

In a nutshell, Dr. El-Sayyed says, the new Organ Harvesting and Transplant Act has been drafted with three aims in mind: “Increase the supply by allowing the harvesting of organs from non-living donors, regulate organ transplants, and stop organ trafficking.”

The highly detailed 18-article law drafted by 13 medical specialists stipulates that living organ donors have to be willing, in command of their mental capacities and unpaid. For non-living donors, proof that they gave permission to have their organs used must be given. The definition of death is clearly explained, as are the conditions that must be fulfilled before a hospital-appointed committee of three experts who have no invested interest in the case — an intensive care specialist, a brain specialist and a cardiologist — declare the donor brain dead.

Organs harvested from non-living donors, says Dr. El-Sayyed, “will be given to potential recipients according to a waiting list arranged according to need, ignoring their looks, age, color, religion” — as long as both donor and recipient are Egyptian.

In the case of living donors, however, the law restricts organ transplants to not only Egyptians but to fourth-degree family members, to impede organ tourism. In cases of non-Egyptian family members, only second-degree family relatives would be allowed to donate. Inter-faith donations — initially forbidden in an earlier draft of the law, an issue that in August 2008 caused outrage in the Christian community — are allowed.

Licenses to perform organ transplants will be issued to hospitals and medical centers by a soon-to-be-formed institute created to regulate organ transplants. A committee headed by Dr. Mahmoud Al-Mateeny, surgery professor in Ain Shams Medical University, set the criteria for hospitals and surgeons that wish to perform organ transplants as well as every detail regarding the definition of brain death. Licenses will only be issued once the conditions are fulfilled, including one that states equipment needs to be updated every three years and hospitals must submit reports for every operation.

The new institute will be responsible for maintaining a national waiting list, screening and approving potential organ recipients according to their needs, establishing a national organ bank and monitoring and evaluating hospitals and surgeons.

Articles 12-16 of the law deal with penalties for illegal transplants, which differ according to whether the donor is alive or non-living, and if alive, whether he was forced, paid or seriously injured. Doctors performing illegal transplants face jail sentences of 15 years and fines of up to LE 500,000; hospitals may be fined up to LE 1 million, lose their licenses and possibly be shut down.

Tantawi issued a controversial fatwa (religious edict) in mid-March, saying that the ten men sentenced to execution for gang-raping a woman should have their organs harvested without their permission, asserting that a person sentenced to death does not have a right to his body. Both advocates and critics of the proposed transplant law have rejected that fatwa.

One of the proposed law’s critics, Sheikh Ahmed Omar Hashem, head of the PA’s Religious Committee and former president of Al-Azhar University, believes that fatwa goes against human rights. “We cannot take someone’s organs without their permission,” says Hashem, “regardless of whether they are a criminal.” Dr. El-Sayyed notes the proposed law protects all potential donors. “We’ll take an organ from a non-living donor with the same respect as a living one.”
How Dead is Dead?

Dr. El-Sayed and Dr. Al-Mateeny have been working together for the past decade on the Organ Harvesting and Transplant Act. The reason it took so long, they say, was because the inclusion of non-living donors meant a clear, legal definition for death had to be made, and that took a lot of time.

Globally, the medical community has two ways of defining death. The definition approved by the American Medical Association in 1980 and by the American Bar Association in 1981 states, “An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem is dead.” In the latter, commonly known as brain death, the heart and lungs can continue to function with mechanical aid. For major organ harvesting from non-living donors to be successful, brain death must be considered as ‘absolute’ death, since many organs are rendered unfit for transplant once the heart stops beating.

But even though Tantawi said in 1997 that brain death was absolute death, the nation’s highest Islamic authority, Al-Azhar’s Islamic Research Academy (which, ironically, reports to Tantawi) defined death to be the “complete deportation of life from the human body that is preceded by the failure of all of the organs of the body.” It did not recognize brain death as absolute death.

The decision of what state constituted death was then handed over to the medical community, says Ibrahim Negm, official spokesperson of Grand Mufti of Egypt Aly Gomaa. “Doctors themselves are not in consensus about this issue,” says Negm. “The scholars told them that the ball is in your court and that they have to choose what constitutes death. The stance of Shariah is that if the doctors say it’s death then Shariah follows accordingly.”

In October 2008, the PA was set to conclude the debate on Islam’s definition of death. PA Speaker Fathy Sorour left the decision to the Health Committee, excluding the PA’s Religious Affairs Committee from the discussions, since, as Negm pointed out, the definition of death is a medical and not religious one.

The meaning-of-death debate was seemingly settled a couple of months later in January, when the State Council finally defined death as either respiratory and circulatory failure or brain death, as determined by a hospital-appointed, independent panel of medical experts.

The council then approved the new organ transplant draft law and referred it to the MOH, who announced that until a final decision was made, any current living donors and recipients had to get approval from the MOH and the Doctors’ Syndicate before they could proceed with operations. The MOH passed the law to the PA in mid-February, something the Doctor’s Syndicate has been trying to do since 1996.

Putting an end to any further religious objections, the Islamic Research Academy in March reversed its earlier opinion with the announcement that brain death constituted ‘absolute’ death. “Once the academy says yes, Dar Al-Ifta follows,” says Negm. “The opinion of the Grand Mufti of Egypt Aly Gomaa is the same as the Islamic Research Academy.”

Nevertheless, many religious leaders, including sheikhs in Dar Al-Ifta and some MPs, are still unhappy with the decision. Hashem of the Religious Affairs Committee disagrees with the definition of death. “Absolute death is when life ends completely, but if there’s a pulse then the patient is not dead. Sometimes people are washed for burial and they wake up. These things are only in God’s knowledge, so how can we take someone’s organs when they could wake up?”

Dr. El-Sayyed says that the definition of death now stated in the draft law, freely available to all, is not up for discussion, although religious institutions must accept the definition for death, “since the Constitution says Shariah is a principal source of laws. The Islamic Research Academy, the highest legal authority, has said brain death is absolute death, which means the religious aspect shouldn’t be discussed anymore and the religious committee shouldn’t play a role in this decision.”

Al-Mateeny is less circumspect: “I think it’s ridiculous we’re still discussing the religious angle. that Sheikh Al-Azhar, the Grand Mufti, Baba Shenouda and the Islamic Research Academy have all said their bit, the public should shut up with this issue. Twenty years is long enough to have spent talking, it’s time to forge ahead.”

That said, Al-Mateeny acknowledges that religion is not the critics’ only cause. “Some people are against the law not because of the religious or cultural issues,” he says, “but because of the worry that might abuse the law. But we put the most stringent laws in place and even included that the punishment could be higher if the law sees fit to increase it. We didn’t put the penalties, but if it was up to me I would have wanted execution for violators.”

He also points out that that doctors will have little opportunity to wrongly declare a patient brain dead, because the independent panel must confirm the diagnosis. “Everything will be recorded, reports will be written. There will be no opportunity for kosa .”

The PA is set to discuss the law this month. “I expect the discussion will take 15-20 days of arguments, and everyone who wants to ifty will do so,” says Al-Mateeny, wryly.

And will the PA approve the law? Everyone seems to hope so, though Hashem is not so optimistic: “I predict that my opinion is the one the PA members, as humans, will be able to live with comfortably — that we can’t take an organ from a person who is still alive, whose heart is still beating. Haram.”

Pointing to the Islamic Research Academy’s acceptance of brain death, Dr. El-Sayyed dismisses that argument as a moot point. “The way of thinking has to change,” he says. “As long as there are people asking questions that aren’t rational or logical and lack concepts of humanity and ethics, it will be difficult to get people to see organ transplants for the blessing they are. Our job is to change the thinking of society about what it means to transplant organs and introduce them to the spirit of ethar Al-Azhar is talking about.”

-- http://www.egypttoday.com/article.aspx?ArticleID=8461