Chapter 2

REVIEW OF RELATED LITERATURE

 As the worldwide prevalence of end-stage renal disease increases it is important

to evaluate the rate of living kidney donation in various countries; however there is no

comprehensive global assessment of these rates. To measure this, Horvart reports in the

literature, and national health ministry’s from 69 countries and made estimates from

regional weighted averages for an additional 25 countries where data could not be

obtained. In 2006, about 27,000 related and unrelated legal living donor kidney

transplants were performed worldwide, representing 39% of all kidney transplants.  

The number of living kidney donor transplants grew over the last decade, with

62% of countries reporting at least a 50% increase. The greatest numbers of living donor

kidney transplants, on a yearly basis, were performed in the United States (6435), Brazil

(1768), Iran (1615), Mexico (1459), and Japan (939). Saudi Arabia had the highest

reported living kidney donor transplant rate at 32 procedures per million population

(pmp), followed by Jordan (29), Iceland (26), Iran (23), and the United States (21).

(Horvart, 2006). This situation has provided impetus for the search for various ways to

increase the kidney donor pool and has fuelled discussions regarding the establishment of

regulated organ markets. Although the debate among kidney donation and transplant

facility in the world rages is on, no country in the world has actually established a kidney

market. In the meantime, unregulated kidney markets have arisen at various time points

in developing countries such as India, Pakistan and the Philippines (Lippincott W. &

Lippincott W., 2009). Qualifying for a Kidney Transplant, doctors evaluate a patient to

determine if she will be a good candidate for a kidney transplant. When a donor kidney is

available, doctors run tests to verify organ compatibility. Once compatibility is verified,

the patient is brought into surgery.  

Kidney transplantation is the preferred treatment option for end stage renal failure

in terms of mortality , cost effectiveness, and improvement in quality of life. The average

dialysis treatment cost per life year saved is estimated at approximately $55,000-80,000 ,

while for kidney transplantation it is estimated at approximately $10,000 per life year

saved. Increased time on dialysis is related to higher rates of kidney failure twelve

months after transplantation , and to decreased survival of transplant recipients ,

(Symvolakis et. al,2009)

As of September 21, 2012, there are 100,045 registered candidates on the kidney

donor waiting list according to the Organ Procurement and Transplantation Network

(OPTN); however, only 93,952 kidney transplant candidates are active, which means able

to receive a transplant at the moment.1 With an overall tally of transplant waiting list

candidates equaling 115,666, it is easy to see how the kidney is a most sought after organ.

Age

  Living kidney donors usually range in age from 25-50 years, although there is

limited experience beyond this range. Donors below 18 years of age are considered

children and cannot usually provide informed consent without parental approval. In

addition, the prediction of adult (and familial) kidney disease may be problematic in

potential donors below 30 years of age, depending on the disease (ie, hypertension,

diabetes mellitus, polycystic kidney disease). However, kidney size and function are

acceptable in this age group; the cadaveric donor experience suggests that a child 6 years

of age or older can safely donate a single kidney into an average sized adult.In the older

population, physiologic age is more important than chronologic age. In the absence of

other medical problems, kidney donation can be safely performed up to age 55 routinely,

age 56-65 selectively, and over age 65 rarely. Aging results in a gradual decline in kidney

function such that the amount of transplanted kidney function becomes a limiting factor

after age 60 years.

According to John Hopkins research, Kidney transplants performed using organs

from live donors over the age of 70 are still safe for the donors and lifesaving for the

recipients. The study shines new light on a long-ignored potential source of additional

organs that could address a profound national shortage.Although the study found that

kidneys from older donors were more likely to fail within ten years of transplant when

compared with kidneys from donors ages 50 to 59 (33.3 percent failure rate vs. 21.6

percent), patients who received older donated kidneys were no more likely to die within a

decade of transplantation than those whose kidney donors were between 50 and 59.

Gender

Females were significantly less likely to be recipients, but more likely to be

donors of renal allografts, particularly if they were unemployed. Women generally are

known to be more empathetic and altruistic than men and are more than willing to donate

their organs. Our society expects women to excel at being caregivers, to their children,

and their community at large. It seems that this conditioning could be a large part of why

women donate more often. On the flipside, maybe men are prevented from donating as

often as women. This could be because they are traditional breadwinners of the family.

Doctors in city's leading hospitals and NGOs working to promote organ donation

estimate that more than 60% out of the total donors are females. Doctors say that when it

comes to organ donation, women step forward and show their kindness to help others.

(Times of India, 2013)

Religion

This perspective violating the human body, whether living or dead, is forbidden in

Islam. However, altruism is also an important principle of Islam, and saving a life is

placed very highly in the Qur’an—‘Whosoever saves the life of one person it would be as

if he saved the life of all mankind’ (chapter 5:32). In Christianity, faith appears to

generally endorse transplantation, although there are clearly different nuances in opinion.

Most Angelican Catholic and Protestant seem to agree that kidney donation is an act of

selflessness and endorse transplantation and donation .Other than any religious beliefs

Catholicism are more into the idea of kidney donation, more of them also support

donation and are kidney donors. Stevener (2010)

The largest religion in the world is Roman Catholic accounts for approximately

2.1 billion, in which 130 million is from Brazil largest Roman Catholic community in

the world, Phillipines has 60-80% of it`s population was Catholic. In addition Catholic

believes that organ donation is an extremely generous act and one that agrees with moral

law. With this statistical data he concludes that through the belief of the religion and the

span of control or influence, it most likely that this group will outnumber other religion in

terms of kidney donation.One act of support has gained particular publicity, namely the

fact that the current pope Benedict XVI has publicly announced that he carries a donor

card at all times. The previous pope, John Paul II, also publicly supported kidney

donation, not least in the encyclical letter Evangelium Vitae, in which he praised kidney

donation as a praiseworthy example of Christian love. When men of science conclude

that this normal process will no longer work and they suggest removing the kidney and

replacing it directly with another kidney from another human, this is simply a shortcut.

Those who submit to such operations are thus living off the flesh of another human. That

is cannibalistic. However, in allowing man to eat animal flesh Jehovah God did not grant

permission for humans to try to perpetuate their lives by cannibalistically taking into their

bodies human flesh, whether chewed or in the form of whole organs or body parts taken

from others.(Woywodt, 2010).

Meanwhile, even though Britain’s main religions – Buddhism, Christianity,

Hinduism, Islam, Judaism and Sikhism – do not forbid kidney donation, at least

seventeen percent of the people in Asian communities trust that their religions said NO

to it, and thirty percent are uncertain. Similarly, the Black people are averse to kidney

transplants because of fears, such as the fear of being used for experimentation, or having

an organ taken before one’s actual death (Macnair, 2009).

Education

The simplest and most obvious way to improve the ability of nurses to help

identify potential kidney donors and provide appropriate support to patients’ families in

the families’ decision making. Because behavior is the result of a complex interaction

among knowledge, beliefs, and attitudes, simply providing periodic classes or printed

materials will be insufficient to affect the quality of care. Like all aspects of nursing

education, end-of-life care is best addressed as a program, rather than with sporadic

activities, and planning must begin with a needs assessment. (Daly, 2006).According to

Emmanouil K SymvoulakKnowledge about organ donation was significantly associated

with education and socioeconomic status, here people expressed a high motivation to

donate.College graduates are more willing to donate their kidneys because of the

knowledge they have regarding kidney donation, next to them are undergraduates

because of the mere fact that money is always available in donation of their kidneys. He

also states that better knowledge may ultimately translate into the act of donation.

Effective measures should be taken to educate people with relevant information with the

involvement of media, doctors and religious scholars.

Civil Status

The study conducted by Khattaket. al, (2010) analyzed data about the patients

with ESRD aged ≥27 (mean age of first marriage in the US). The researchers analyzed

the frequency of marital status with an outcome of likelihood of donating kidney. After

adjustments for the included independent variables and compared to individuals single

(23.5%) and married (76%) civil status, it implies that married individual had a higher

likelihood of donating kidney. The researchers concluded that being married is associated

with better outcome of donating organ compared to those who were not.

Health Status

Health status of a certain living donor has also made a great impact, for a donor to

be valid in donating his or her kidney, a series of examination will be needed this must be

accomplished first to assure the safety of the recipient against communicable or

infectious diseases as well as to assure compatibility thus preventing kidney rejection.

(Kidney Organ donation and transplantation, 2012) Donors should be in good general

health. Donors do not need to be genetically related. Typically, someone who has cancer,

diabetes, kidney disease, heart disease, liver disease, sickle cell disease, HIV or hepatitis

will not qualify to be a donor. However, these diseases are not all absolute

contraindications to donation. Every donor will be considered on an individual basis

(University Of Maryland,2010).

  WHO, (2010) ensure that there are certain criteria that a donor must met and a

series of examination both physical and laboratory test to prevent organ rejection, donor

must be physically fit, and healthy, however if the donor has an underlying ailments it

must be address to the healthcare team and the team will weight things or correct the

problem if the operation will push through.

Relationship to the Recipient

Another factor is the degree of consanguinity of the donor and recipient, the

relationship between the donor and the recipient often has a bearing on the donor’s

motivation for giving a kidney organ. The living related donor is genetically related to the

recipient and more relationship lies in being theirsiblings. Siblings are usually the best

medical match for the kidney recipient and, as a result, are not only preferred, but also

most often used as live donors. They are also more likely than other family donors to

express positive reactions to the donation process (Stiller et. al, 2005).Of note, while

living kidney donor matches from siblings last on average at the highest rate of 20 to 35

years, living kidney donor matches, overall, begin functioning in the recipient at a rate of

97 percent after transplant. Exactly, who are those non-related living donors who

contribute? Unrelated living donors have included a wide spectrum from spouses to

friends, neighbors to classmates, colleagues to teammates, and perfect strangers. Half of

living donors fall between the ages of 35 and 49 with the majority of living kidney donors

being female. In addition, duties and obligations associated with family relationships and

roles often weigh heavily on the decision to donate, as do emotional bonds within the

family, because the living related donor is usually also an emotionally related one as

well. Major ethical concerns about kidney donation by living related donors focus on the

possibility of undue influence and emotional pressure and coercion. By contrast, the

living unrelated donor lacks genetic ties to the recipient. The living unrelated donor and

recipient may be emotionally related (e.g., a spouse). Financial hardship appears to be a

barrier to support for living donors. Those who have difficulty paying their bills are more

likely to talk about this subject or to give their consent to donation of their own kidneys

or those of a deceased close family member. Living donors who are exposed to financial

risk are more likely to donate their kidneys just to pay their hospital bills. ( Kidney Organ

donation and transplantation, 2012)

Family Influences

Spouse, children, parent, or person with a significant relationship with the donor

of either the donor or recipient can be either supportive or coercive. Family members are

an integral part of the decision-making process they will be affected regardless of

whether the decision is to donate or not to donate. The decision not to donate could

impact another family member’s fate, while the decision to donate could have a direct

impact on the donor and his or her immediate family.(ANA,2004).Views regarding organ

donation were often shaped by theparticipants’ families. Such influences could have

either apositive or, more often, negative influence on individuals’decisions. This is the

most integral part that impactly affects an individual to either donate or not. Some felt

they had to ask permission from family members.Some also felt that a definite decision,

from familymembers regarding donation, would ensure that loved oneswere not burdened

later with a difficult choice. Some feltthat organ donation would interfere with the

grieving process forfamilies.(Irving et. al,2011).

In the study made by the kidney organ donation and transplantation (2012), the

result only shows that Filipinos has strong intact of family relationship, furthermore

Filipinos are well known for being a family oriented individuals. Factor under family

influence base on the degree of consanguinity of the donor and recipient, implies that it

has a bearing on the donor’s motivation for giving a kidney organ. The living related

donor is genetically related to the recipient. In addition, duties and obligations associated

with family relationships and roles often weigh heavily on the decision to donate, as do

emotional bonds within the family, because the living related donor is usually also an

emotionally related one as well.

Socio Economic Status

Of the many socio-economic factors that have been associated with willingness to

donate kidney, education attainment is consistently one of the most explanatory.

Education might stand as a proxy for knowledge about health related issues. In UK, more

affluent individuals are less likely to donate while higher income is associated with

higher willingness to donate in Canada. Wakefield et al. found that females, younger

potential donors, and those with higher knowledge levels were more likely to have

attitudes that favored kidney donation. They also found that a potential donor who

described themselves as having stronger religious beliefs and those with poor knowledge

had less favorable attitudes towards kidney donation.(Kidney Organ donation and

transplantation, 2012). According to HOPE(2005), the government approved a 'gratuity

package' for not related donors. This consisted of Php (Philippine peso) 100 000 for

reimbursement of lost income for 4 months, PhP 75,000 for livelihood assistance, a

PhP100 000 life insurance, 10-year membership with the government health insurance

system and free annual check up for 10 years. Compensation for lost income is generally

accepted to be within ethical boundaries, but PhP 175,000 for lost income and livelihood

assistance exceeded the national average income for the whole family for an entire year

that was reported to be PhP 172 000 in 2006. Therefore, this amount is valuable

consideration indeed for the average Filipino family.(Medical Observer, 2010).             

Journal of the American Society of Nephrology, (2013) Income status was strongly

associated with living kidney donation: low income populations had higher rates of living

kidney donation compared with higher income populations among both African

Americans and Whites. "These results suggest that for African Americans,

socioeconomic status is a more important barrier to living kidney donation than any other

factors. The findings are surprising and will have significant implications on strategies to

increase living kidney donation in the United States. Specifically, efforts to increase

living kidney donation should target the barriers that are specific to lower socioeconomic

populations.

In the survey conducted by Saleemet. al, (2008), about kidney vendors d in

Punjab, Pakistan showed that 34% were living below the poverty line. Most of these

kidney vendors were illiterate; 69% were bonded laborers. Their monthly income was

US$ 15.4 ± 8.9. Ninety three percent of these individuals had vended their kidneys for the

purpose of debt repayment . Another study reported the various aspects of 104 kidney

vendors in Pakistan; 67% were bonded laborers earning < $ 50 per month. Hepatitis B

and C positivity was seen in 5.7% and 27% respectively . According to estimates, paid

donation makes up 50% of all transplants in Pakistan .Wider public awareness of this

Ordinance is important for its reinforcement and implementation. Organ trade is an

important emerging issue that should be tackled with appropriate legislation. According

to World Health Organization (WHO), organ trafficking may be accounting for up to 5–

10% of the kidney transplants performed annual.

Ethico Moral

In the study of Woywodt, (2010),this perspective violating the human body,

whether living or dead, is forbidden in Islam. However, altruism is also an important

principle of Islam, and saving a life is placed very highly in the Qur’an—‘Whosoever

saves the life of one person it would be as if he saved the life of all mankind’ (chapter

5:32). In Christianity, its faith appears to generally endorse transplantation, although

there are clearly different nuances in opinion. Most Angelican, Catholic and Protestant

scholars seem to agree that kidney donation is an act of selflessness and endorse

transplantation. One act of support has gained particular publicity, namely the fact that

the current pope Benedict XVI has publicly announced that he carries a donor card at all

times. The previous pope, John Paul II, also publicly supported kidney donation, not least

in the encyclical letter Evangelium Vitae, in which he praised kidney donation as a

praiseworthy example of Christian love.

According to National Kidney Institute, (2007), Kidney donation by living donors

clearly saves lives, improves transplantation outcomes under some circumstances, and

reduces recipients’ waiting times. But some donors specially the oppressed individuals

(those who are in part of Northern Mindanao) has another motives aside from donating

their kidney they also sell it in exchange for the incentive either cash or special grants

that will be given by the recipient, to make this possible donors personal data will be

falsified and present that they are at least on the 4th degree of consanguinity and this act

is considered immoral by the catholic church.

Saleem, et. al, (2009), organ transplantation has recently drawn attention as a

bioethical issue for robust debate in Pakistan. Emerging concerns intertwined with it

include the burgeoning trend of transplantation, lack of legislation to govern it and

exploitation of human rights. These efforts led to the promulgation of an Ordinance in

2007 to regulate the transplantation of human organs and tissues This ordinance mentions

living donors of at least eighteen years of age. Any close relative can be a donor

according to it but must donate voluntarily and without duress or coercion. Almost 60%

believed that the basic aim of organ donation is to save someone's life. Some people

responded that organ donation can be done out of compassion/sympathy while others

cited monetary benefits as the leading motivation behind organ donation. Still some

others though that organs are donated as a responsibility

Communication

This is a critical element of supporting patients’ families and rendering health care

services, including decisions about kidney donation, particular attention must be paid in

helping nurses develop and improve skills in this area. This step requires more than

didactic sessions. Role playing, feedback on performance, and planned opportunities to

observe expert clinicians in meetings with patients’ families are essential for learning and

will not occur without a well-developed educational plan Numerous factors can act as

barriers to kidney donation. Among the most widely acknowledged are failure on the part

of healthcare professionals to identify potential donors and initiate the referral and

request process and beliefs and attitudes of the families of potential donors. In 2008

American Medical Association Council on Scientific Affairs for physicians’ intended to

address failures on the part of healthcare professionals specially in establishing a

therapeutic communication to persuade potential donors to donate their kidneys. Past

research on communication during donation requests has overwhelmingly been

conducted in settings examining kidney donation. These studies have indicated that

families of potential kidney donors are more likely to consent to kidney donation when

transplant coordinators are specifically trained to provide information and support the

family during the decision-making process.Rodriguez and colleagues conducted

interviews with families after the donation request and found that although most

respondents felt that the requesters were caring and compassionate, those who consented

were more likely to describe the requester in this way and were more likely to report

being satisfied with the request. About 15% of those who declined to donate cited

negative perceptions of the request/donation process as a contributing reason for refusal.

Siminoff and colleagues used observational coding of the interaction between the

requester and the donors as well as post request interviews with donors about their

perceptions and recall of the request. They found that donors were more likely to consent

if physician discussed key topics such as costs associated with donation and ability to

have an open casket funeral after donation, and donors were less likely to donate when

they held incorrect or negative assumptions about donation. Regarding persuasion,

donors were more likely to consent when requesters used specific types of persuasive

statements, such as establishing credibility or referring to how donation could potentially

help others, although the total number of persuasive statements was not a significant

predictor of consent. Finally, donors were more likely to consent to donation when they

perceived the requesters as being more caring and concerned, being less controlling,

using a higher quality of communication, and using more conformational messages, such

as providing reassurance, expressing empathy, or making statements aimed at building

partnership between themselves and donors. (Stephens,2004)

Altruistic Behavior

Despite decades and decades of public education about the virtues of organ

donation, the waiting list just gets longer, and the time to transplantation just gets longer.

Its past time to face the fact that altruism is just not enough. Many people need more of

an incentive to give. And that’s why we need to be able to compensate people who are

willing to give a kidney to a stranger, to save a life.(Satel, 2012)For some donors, it was

an altruistic and natural decision meant to improve the recipient's health and quality of

life but this decision could also be more philosophical or spiritual in nature.Under

altruistic behaviour is Good Samaritan donation. The donor is giving to a stranger. Most

recently, Good Samaritan donors have begun initiating chains which are facilitating

hundreds of additional living donor transplants at much higher compatibility levels.

Chains are a way for one Good Samaritan donor to help many patients get transplants

instead of just one person. Chains are a major breakthrough in transplantation and are

revolutionizing the process by eliminating incompatibility as a barrier to donation and

providing a way for all recipients to find very well matched donors.

In the recent study of Laura (2013), donors mostly offered a kidney motivated by the

progression of the recipients’ disease and/or the prospect of dialysis in the (near) future

(45%). However, they also stressed their personal benefits in donating a kidney; they

hoped the transplantation would make the recipient less dependent and thus could

participate more in household activities and family life. Attitudes towards donation were

generally positive, with nearly two-thirds of participants either agreeing or strongly

agreeing with donating an organ for transplantation and almost 90% agreeing or strongly

agreeing with receiving one.

The importance of understanding attitudes derives from a rich body of empirical,

theory-based literature which substantiates a positive relationship between attitude

toward a voluntary behavior and behavioral performance. Unlike other voluntary health

behaviors, translating favorable attitudes toward organ donation directly into acts of

donation is not acutely possible in cases other than living donation. Thus, approaches to

influence a favorable attitude toward donation have measured key intermediate behaviors

such as family discussion about organ donation and donor registration.

R.A 7170 “ORGAN DONATION ACT OF 1991”

An act was enacted by the Senate and House of Representatives of the Philippines

8TH Congress under the administration of the late president Corazon Aquino called R.A.

7170 also known as "Organ Donation Act of 1991."This act aims to widened or extend

the coverage of the donors, by precisely defining the concept of organ donation in the

nation, considering the statistics from DOH that living donor accounts for almost 95%

while deceased donor is only 5% it means that healthy and useful organ that supposed to

be procured for future transplant was wasted and buried and this is one of the reasons in

formulation of this act. With the nation’s rapid population explosion, deceased donor is

the key to compensate the increasing need of organ donors .An act authorizing the legacy

of donation of all or part of a Human Body after death for specific purposes.

SECTION. 1.   Title.- This Act shall be known as the "Organ Donation Act of 1991."

SEC. 2.   Definition of terms

a) "Organ Bank Storage Facility" - a facility licensed, accredited or approved under the

law for storage of human bodies or parts thereof.

(b) "Decedent" - a deceased individual, and includes a still-born infant or fetus.

(c) "Testator" - an individual who makes a legacy of all or part of his body.

(d) "Donor" - an individual authorized under this Act to donate all or part of the body of a

decedent.1awphilŸalf

(e) "Hospital" - a hospital licensed, accredited or approval under the law, and includes, a

hospital operated by the Government.

(f) "Part" - includes transplantable organs, tissues, eyes, bones, arteries, blood, other

fluids and other portions of the human body.

(g) "Person" - an individual, corporation, estate, trust, partnership, association, the

Government or any of its subdivisions, agencies or instrumentalities, including

government-owned or -controlled corporations; or any other legal entity.

(h) "Physician" or "Surgeon" - a physician or surgeon licensed or authorized to practice

medicine under the laws of the Republic of the Philippines.

(i) "Immediate Family" of the decedent - the persons enumerated in Section 4(a) of this

Act.

(j) "Death" - the irreversible cessation of circulatory and respiratory functions or the

irreversible cessation of all functions of the entire brain, including the brain stem. A

person shall be medically and legally dead if either: May be confirm by the attending

physician and consulting physician. The death of the person shall be determined in

accordance with the acceptable standards of medical practice and shall be diagnosed

separately by the attending physician and another consulting physician, both of whom

must be appropriately qualified and suitably experienced in the care of such parties. The

death shall be recorded in the patient's medical record.

SEC.3: Person Who May Execute Legacy. - Any individual, at least eighteen (18) years

of age and of sound mind ,may give by way of legacy, to take effect after his death, all or

part of his body for any purpose specified in Section 6 hereof. 

SEC.4: Person Who May Execute a Donation

1)  Spouse; 

2) Son or Daughter of legal age: 

3)  Either parent; 

4)  Brother or sister of legal age; 

5)  Guardian over the person of the decedent at the time of his death.

SEC.5:Examination of Human Body or Part thereof:

For purposes of this Act, an autopsy shall be conducted on the cadaver of accident,

trauma, or other medico-legal cases immediately after the pronouncement of death, to

determine qualified and healthy human organs for transplantation and/or in furtherance of

medical science.

SEC.6:Persons Who May Become Legatee or Donee:

Any hospital, physician or surgeon

Any accredited medical or dental school, colleges or university.

Any organ bank storage facility.

Any specified individual.

SEC.7:Day of Hospitals

-  A hospital authorized to receive organ donation or to conduct transplantation shall train

qualified personnel and their staff to handle the task of introducing the organ donation

program in a humane and delicate manner

SEC.8:Manner of Executing a Legacy

(a)  Legacy of all or part of the human body under Section 3 hereof maybe made by will.

The legacy becomes effective upon the death of the testator without waiting for probate

of the will. If the will is not probated, or it is a declared invalid for testamentary purposes,

to the extent that it was executed in good health, is nevertheless valid and effective

SEC.9:Manner of Executing a Donation

(a)  A member of the team of medical practitioners who will affect the removal of the

organ from the body; nor 

 (b) The physician attending to the recipient of the organ to be removed; nor 

 (c) The head of hospital or the designated officer authorizing the removal of the organ.

SEC.10.  Person(s) Authorized to Remove Transplantable

Organs. - Only authorized medical practitioners in a hospital shall remove and/or

transplant any organ which is authorized to be remove and/or transplanted pursuant to

Section 5 hereof. 

SEC.11:Delivery of Document of Legacy or Donation

If the legacy or donation is made to a specified legatee or donee, the will, card or other

document, or an executed copy thereof, maybe delivered by the testator or donor, or his

authorized representative , to the legatee or donee to expedite the appropriate procedures

immediately after death

SEC.12:Amendment or Revocation of Legacy or Donation

(1) The execution and delivery to the legatee or donee of signed statement to that effect;

(2) An oral statement to that effect made in the presence of two or other persons and

communicated to the legatee or donee; or 

 (3) A statement to that effect during a terminal illness or injury addressed to an attending

physician and communicated to the legatee or donee ; or 

 (4) A signed card or document to that effect found on the person or effects of the testator

or donor.

SEC.13:Rights and Duties after Death.

The legatee or donee may accept or reject the legacy or donation as the case may be. If

the legacy or donation is a part of the body, the legatee or donee, upon the death of

testator and prior to embalming, shall effect the removal of the part, avoiding

unnecessary mutilation. After removal of the part, custody of the remainder of the body

vests in the surviving spouse, next of the kin or other persons under obligation to dispose

of the body of the decedent.

(b)   Any person who acts in good faith in accordance with the terms of this Act shall not

be liable for damages in any civil action or subject to prosecution in any criminal

proceeding of this Act.

SEC.14:International Sharing of Human Organs or Tissues. -  Sharing of human organs

or tissues shall be made only through exchange programs duly approved by the

Department of Health: Provided, that foreign organs or tissue bank storage facilities and

similar establishments grant reciprocal rights to their Philippine counterparts to draw

human organs or tissues at any time.

SEC.15:Information Drive. -  In order that the public will obtain the maximum benefits

from this Act, the Department of Health, in cooperation with institutions, such as the

National Kidney Institute, civic and non-government health organizations and other

health related agencies, involved in the donation and transplantation of human organs,

shall undertake a public information program. 

 The Secretary of Health, after consultation with all health professionals, both

government and private, to make an appeal to human organ donation.

SEC.16:Rules and Regulations. -  The Secretary of Health, after consultation with all

health professionals, both government and private, and non-government health

organizations shall promulgate such rules and regulations as may be necessary or proper

to implement this Act. 

 SEC.17:Repealing Clause. -  All laws, decrees, ordinances, rules and regulations

executive or administrative orders, and other presidential issuance inconsistent with this

Act, are hereby repealed amended or modified accordingly. 

SEC.18:Separability Clause. -   The provisions of this Act are hereby deemed separable.

If any provision hereof should be declared invalid or unconstitutional, the remaining

provisions shall remain in full force and effect. 

 SEC.19: Effectivity. - This Act shall take effect after fifteen (15) days following its

publication in the Official Gazette or in at least two (2) newspapers of general

circulation. (Philippine Laws and Jurisprudence Databank ,1991)

Agencies that regulate organ donation

HOPE (Human Organ Preservation Effort)

Initially, HOPE’s thrust was focused on deceased organ recovery. But as the

dilemma of the scarcity of donors continuously haunt the entire nation, it now considers

and screens living donors, who voluntarily donate their kidneys to patients on the list in

the spirit of true altruism. In this aspect, it works closely with the Renal Disease Control

Program (REDCOP) following strict implementing guidelines set by the Department of

Health’s Philippine Organ Donation Program(PODP)

The Renal Disease Control Program (REDCOP)

This is the office in-charge of implementing the NKTI's public health projects on

the prevention and control of renal and other related diseases. It plans, implements and

monitors projects for research, advocacy, training, service and quality assurance.

REDCOP's activities are done mostly on a national scale through its network of Regional

Coordinators throughout the country.

Philippine Organ Donation Program (PODP)

PODP sets up policies, guidelines and ethical principles whereby the act of organ

donation and conduct of transplantation from living non-related organ donors (LNRDs)

shall be managed and regulated. This Program supports a rational, equitable, ethical, and

accessible renal health care program in the country.It is there to ensure that Filipino

patients are prioritized in the organ-recipient waiting list, the safety of both donor and

recipient are guaranteed, payment for kidney donation and selling of kidneys through

organ vendors are prohibited, and kidney transplantation is not offered as a form of

medical tourism.

NKTI(National Kidney and Transplant Institute)

Organ transplantation is an accepted life saving therapy for patient with end stage

organ diseases. To date, in many countries, almost all vital organs can be successfully

transplanted: kidney, liver, heart, pancreas, lungs, and small bowels.The Department of

Organ Transplantation of the National Kidney and Transplant Institute is dedicated and

grounded in a patient-centered philosophy in helping patients with end stage renal

diseases and other end stage organ failures through transplantation. The department was

first established in 1983, and has pioneered kidney, liver, kidney-pancreas transplantation

in the country. Almost 2500 transplant (living related, non-living related and cadaver

donors) to date were performed and still counting; undoubtedly the center for

transplantation in the country.Aside from the foregoing activities in transplantation, the

department actively participates in various advocacy programs of the Institute, in

promoting organ donation. Hand in hand with 

Human Organ Preservation Effort (HOPE) and Renal Disease Control Program

(REDCOP), the department assists to increase the public awareness in organ donation

and the acceptance of organ transplantation as a therapeutic modality in all key cities and

provinces in the country.

Local Literature

For the year 2010, almost 14,000 Filipinos suffer from end-stage renal disease (8th

leading cause of death of Filipino) and are undergoing dialysis and 1 Filipino die each

week due to Kidney failure. According to the Annual Report of the PRDR, 2000 and

2007 kidney transplantation activity in the Philippines has shown a continuous upward

trend - the total number of kidney transplants has jumped from just 276 in year 2000 to

1046 in year 2007 Living donors have consistently accounted for over 95% of all kidney

transplants. Although the Organ Donation Act was passed in 1981 to pave the way for

deceased organ donation, the deceased donation program has never taken off, and in

2007, there were only 29 kidney transplants using a deceased organ, representing 0.34 per

million population per year. In contrast, deceased donation rates in Europe and North

America are in the vicinity of 30 per million population per year. (Eyes Under Pressure,

2010). Unfortunately, kidney disease often cannot be cured, but fortunately, it can be

prevented.  Early detection and prevention of kidney failure is vital, as is the need to

ensure that acute cases avoid, if possible, the progression to Chronic Kidney Disease.

Prevention and early management, although very extensive can achieve significant

benefits for the public. This has generally become a responsibility for the Human Organ

Preservation Effort. Human Organ Preservation Effort (HOPE) Asia`s leading kidney

transplant formerly the Cadaver Organ Retrieval Effort (CORE) was established in 1983.

It is the organ retrieval arm of the Institute tasked to advocate organ and tissue donation

and to source out transplantable organs from deceased organ donors thru its network of

various government and private hospitals in the country. It recovers mainly kidneys,

pancreas and liver but may include other vital organs like the lungs, heart when the

proper program is put in place. It also provides a network for tissues such as corneas,

bones, heart valves, and skin. The recovered organs are placed among patients in the

waiting list.

Manila, a call came from the Department of Health, as it formally established a

national program for the "sharing of organs from deceased donors. "The program aims to

serve the needs of mainly 9,000 Filipinos suffering from kidney failure each year,

according to Health Secretary Esperanza Cabral. The DOH initiative was made "in

response to the Philippine commitment to the 2008 Declaration of Istanbul on Organ

Trafficking and Transplant Tourism and the 63rd World Health Assembly Resolution on

Organ Donation for governments to take appropriate actions in increasing the transplant

of kidneys and other organs from deceased donors. We seek not only to improve an

important service to many patients in need of organ transplantation, but also to assure that

the illegal traffic of organs that has victimized many of our countrymen for many years

will not be repeated," Cabral said.

The DOH head issued an administrative order on the program, which she said

"shall set the policies and guidelines for a deceased donors program for our country that

will be feasible, equitable and ethical."Cabral expressed confidence that "with this

program, the international medical community will once again recognize that our country

is indeed serious in curtailing illegal organ donation and at the same time, strengthen our

deceased donors program which has been known to be effective in other countries.” Here,

the non-government group Human Organ Preservation Effort, or HOPE, has launched

what it calls "Organ Donor Card Project." A HOPE donor card is the "equivalent of a

legal consent document" allowing an individual to donate any of his body organs shortly

after his death. Before a person can become a cadaver donor, he or she must be certified

as brain dead. Among the organs that can be harvested from such a donor are the kidneys,

the liver, bone marrow, pancreas, lungs, cornea, and the heart. The only organs that can

be donated under "living-related organ donations" are one kidney, bone marrow and a

part of the liver, provided they would not cause any danger to the donor's life or cause

any alteration to his physical activities.On Thursday Cabral noted that "patients with

kidney failure who need a transplant are increasing all over the world."

"Organ traders have long learned that putting together patients desperate for a

kidney transplant and persons desperate enough to sell a kidney can be a lucrative

business," said Cabral. In 2008, Cabral, then social welfare and development secretary,

coordinated with the Department of Justice and DOH in strengthening the implementing

rules and regulations of Republic Act No. 9208, otherwise known as the "Anti-

Trafficking of Persons Act of 2003." The regulations "stopped organ trafficking in its

tracks and were seen by international organizations as an important step in the fight

against organ trafficking and transplant tourism."

The same regulations "became our protection against attempts to exploit our

countrymen, such as bogus marriages between foreigners and Filipinos just the locals can

be kidney donors," according to Cabral. The report on the proposed “international

standards” for financial incentives for organ donation in the February issue of the AJT 

stated that “until there are trials, we have no means of knowing under precisely what

circumstances such a proposal would best succeed”. Permit us to report that a regulated

system of incentives for living organ donors was already implemented in the Philippines

from 2002 to 2008. The program offered a sizable “gratuity package” while mandating

systems and procedures for transparency, creation of ethical guidelines, monitoring of

transplant facilities and a donor registry, much like what this article proposes. The reality

was different from the intended outcomes. The black market was not eliminated and

organ brokers continued to be involved (Roberto Tanchanco et al., unpublished cohort

study, 2011). A regulation that transplants to foreigners should comprise no more than

10% of total transplants proved unenforceable and transplant tourism flourished . Donors

were not protected, as there was failure of informed consent, lack of economic

improvement in the donors’ lives and poor rate of medical follow-up (Roberto Tanchanco

et al., unpublished cohort study, 2011). A study limited to the donors within the

government-regulated program reported better economic outcomes, but this was hardly

convincing as poor follow-up allowed reporting of data in only 81 of 164 participants

(Romina Danguilan et al., unpublished cross-sectional study, 2010). Thus, our experience

leads us to believe that the Matas article underestimates the problems related to the

approach they recommend. A system of incentives for living unrelated donors which is

difficult to differentiate from a disguised organ market is totally inappropriate for a

country like the Philippines, where many patients have a potential related donor but

cannot afford to pay for a transplant, where the deceased donor program is still very

infantile, where the poor have been exploited in organ trafficking before and a large

sector of the population remains vulnerable.

In Region 1, Pangasinan, Dagupan City - The first kidney transplant in region 1

Medical Center was performed last September 30, 2012 on Maria Govinda Onruvia, 29

year old nurse from Bonuan Gueset, Dagupan City. The kidney donor was Isagani

Patungan, the recipient’s 32 year old cousin. The successful operation was spearheaded

by Dr. Joseph Roland Mejia, R1MC Medical Center Chief, and was led by the following

doctors: Dr. Adolfo Parayno of the transplant vascular team, Dr. Abraham Coquia of the

perfusion team and Dr.Paquito Fuentes of the donor team. Region 1 Medical Center

started the first step to becoming an organ transplant facility last year by sending five

selected nurses namely FroilanFabia, Manuelito Fernandez, Christy Palaganas, Susan

Parayno and Alicia Viloria to attend the Specialty Program on Organ Procurement and

Transplantation on January 10-March 5, 2011 at the National Kidney and Transplant

Institute, Quezon city. After the traning, the five nurses started to assist Dr.Parayno and

Dr.Coquia in cadaveric organ retrievals from organ donors. The retrieved organs were

transported to Manila for transplantation. The hospital was accredited by the Department

of Health as an Organ Procurement Organization last March 9, 2012 which allows R1MC

to do cadaveric retrievals for organ transplant. Two months after, R1MC was accredited

as a transplant facility by the DOH through the Bureau of Health Facilities and Services

on May 24, 2012.(The Podium2012).

Meanwhile, Ilocos Training and Regional Medical Center first performed and

organ transplant and procurement on kidney in 1997 to 2006 were a total of 44 cases was

recorded, donors are usually recipient’s family members. The researchers believe that

various factors may contribute to decision process of kidney donors. Therefore there is a

need to explore the complex interplay of these factors in this arena. Kidney donation has

evolved significantly from an experimental procedure to acceptable medical treatment for

terminal illnesses. Despite these contemporary advances, there has been a relatively slow

progress in the supply of kidney for transplantation. This has resulted in global shortage

of organs available for transplantation. There is a paucity of literature about the

relationship between knowledge and attitudes toward organ kidney. If barriers to the

willingness for kidney donation can be identified, these items can be targeted for change.