It is estimated that there are around three million Nepalis who are suffering from kidney disease and around three thousand of them will annually require therapy in the form of either renal dialysis or renal transplant. On the other hand, there is no data on the prevalence of organ failure related to other vital organs like liver, heart, lungs, pancreas or intestine. The organ transplant service in Nepal is in its infancy. For a country like Nepal, which is battling hard to curtail infectious ailments like tuberculosis and malaria, the rapid rise in the number of people suffering from organ failure will further strain the health system.

Nepal witnessed its first successful renal transplant in 2008 at Tribhuvan University Teaching Hospital in Kathmandu. Currently, a few medical centres perform renal transplant, but the proportion of patients benefitting from this service is minuscule. Mostly, people in Nepal are either compelled to go abroad to seek an organ transplant or succumb to the disease. As such, it has become important to have a well-rounded transplant programme in the country. Apart from saving lives of thousands of ailing patients, such a programme will cut down millions of rupees spent on treatment in foreign countries, create more jobs domestically and help make the country self-sufficient in organ transplants.

Nepal’s policies

The government should take initiatives to relax rigid policies and replace them with pragmatic ones, or the programme will face a hitch. The primary task hinges on making necessary amendments to the prevailing law. First, the current law, which only allows living-organ donation from close relatives of patients, should be amended to allow organ donation from any willing individual on altruistic grounds. However, in developing countries like Nepal, impoverished or illiterate citizens often become a soft target and are likely to be exploited. Therefore, close monitoring is vital to prevent foul play.

Next, new laws should be introduced to permit deceased organ donation. A brain-dead individual can save up to eight lives. Cadaveric organ donation not only reduces the number of patients on the transplant waiting list by making organs more available but also helps to minimise the drawbacks intrinsic to live organ donation such as the risk of death and postoperative morbidity of the donor and commercialisation of organs. And as a live organ donor cannot donate organs such as heart, lungs, pancreas or intestine, patients needing these organs will benefit from a cadaveric donation.

In order to start a cadaveric organ donation programme, first, an introduction of a law on brain death, which elaborates the definition and criteria for declaration of brain death, is very important. Second, to enlarge the organ pool from cadavers, awareness among people about organ donation is critical. Spain has the highest organ donation rate in the world and its success to a large extent is attributed to improving the quality of available public information about organ donation. On the other hand, countries like Japan and South Korea have not been able to achieve their targets in organ procurement from cadavers due to prevailing social customs and beliefs among people about organ donation after death. As a result, they have more organs coming from live donors than from cadavers.

Finally, adopting policies to guard and strengthen the transparency of the system is crucial. The organ retrieved from a deceased donor should go to the patient at the top of the waiting list. Any sort of meddling with the process, as happened in Germany, could face a backlash, resulting in disruption of support from the public which is very important to sustain the programme.

Global context

Even the advanced countries with state-of-the-art infrastructure are failing to meet the demand in organ transplants due to a shortage of organs. Every day, 21 patients in the US and three in the UK die awaiting an organ transplant. The World Transplant Register shows that 118,117 transplants took place globally in 2014, a mere 12 percent of what was needed. To close the gap between demand and supply, as no solution seems imminent, organ transplant stakeholders are having debates on legalising organ commercialisation. Iran, for example, has legalised organ sale from an unrelated donor. Although it is generally being claimed as a successful model, ethicists have criticised it on the grounds that vulnerable groups have become an easy target.

Many countries in the world have adopted either of the two systems of cadaveric organ donation—“opt in” or “opt out”. In the “opt in” system, a person who is willing to donate organ(s) after death will actively sign up to  donate; in the “opt out” system, organ procurement takes place upon death of an individual unless they have opted out of donation before death.

In conclusion, Nepal could open an debate on adopting a system suitable for it. If the government sincerely heeds the tales of sufferers, formulates right policies and takes the stakeholders into confidence, organ transplant—something that is considered a sophisticated, unattainable and unaffordable medical “luxury”—can become a reality.

Gurung is a specialty doctor in Anaesthetics and Intensive care at Basildon and Thurrock University Hospital in Essex, UK