William Cheng clearly remembers being close to death. He recalls stumbling around the streets one night almost two years ago, his body weakened by the hepatitis B that was destroying his liver. 'At that time, I did not want to face my family,' said the secondary schoolteacher. 'I was very weak and I knew that I could not live any longer.' His fears were compounded by the thought of not being around to provide for his family. But early this year, salvation came in the form of a phone call from doctors who said they had found a liver donor. Today Mr Cheng, 53, is healthy and lives a normal life, with the memory of the unknown donor spurring him to encourage friends and family to become organ donors. 'I am very lucky,' said the teacher, who a week from Sunday will receive the Scout Association of Hong Kong's highest honour, the Cross Badge, from Chief Executive Donald Tsang Yam-kuen. 'If I didn't get the donation, I would probably have passed away.' Three years ago, doctors discovered Mr Cheng had hepatitis B, which led to the deterioration of his liver. A year later, he had to go to hospital once every one or two weeks. By January this year, a liver transplant was the only thing that could save him. 'My health got worse,' he said. 'I had cramps, my face and eyes were yellow and orange, I got very tired and couldn't stand for more than 15 minutes. I usually had to sit and teach.' It was a distressing time for him and his family, and although his suffering showed, few people knew his real pain. 'The pressure inside [my body] and in my family was more painful,' said Mr Cheng. If he didn't get well, he wouldn't be able to financially support his family. 'My son had decided to quit university because of me, and he would have had to look for a job,' the teacher said. Mr Cheng struggled to continue a normal life. 'Usually, we have our family days on Saturday and Sunday, and in the past year, I made any excuse to get away,' he said. 'But in January, the hospital phoned me and said there was a liver waiting for me. I rushed to the hospital. I didn't even have time to tell my family. And, after 24 hours, I had a new liver.' Mr Cheng knows he is fortunate, especially in Hong Kong where the chance of receiving an organ donation is low compared with western countries. The Hospital Authority relies heavily on consent from the deceased's relatives, as only 1 per cent to 5 per cent of possible donors carry an organ donation card. In 2004, Hong Kong had 4.1 donors per million people, whereas Spain, the country with the highest donation rate in the same year, had 34.6 donors per million, according to an international organ donation registry. Organ donations come from the dead, or living donors who are generally the patients' next of kin. In Hong Kong, kidney, cornea, liver, bone, bone marrow, skin and heart transplants can be performed. If a cornea is donated, a plastic cap will be put on the eye of the deceased. When possible, the procedures will be performed on a part of the body that is covered at a funeral. Dr Beatrice Cheng Shun-yan, the authority's senior executive manager of professional services, said technology could ease kidney patients' wait for a donor organ. 'With kidney failure, patients can be sustained on dialysis, which replaces most of the kidney function, but not all,' Dr Cheng said. She added that with liver, heart and lung transplants, the number of patients on the waiting list was relatively low because many of the patients would die while waiting. 'We would like to do much more kidney, liver, heart and lung transplants but there simply aren't enough to meet the demand,' Dr Cheng said. Among those on the waiting list is 13-year-old Lam Yin-ting, whose plight has been highlighted in the media in recent months. The effort to boost Hong Kong's low donation rate is an ongoing battle. In 2004, a Hospital Authority study found 15 per cent of the refusals for an organ donation were due to the deceased not expressing their wish before death. In the same year, 26 per cent of the refusals were due to a lack of consensus within the family. Both of these issues are related to the fact that the deceased failed to make known their wishes about organ donation. 'Family is the most important factor towards our success in getting a donation from a deceased person,' Dr Cheng said. In Hong Kong law, the body of a dead person is owned by the next of kin. Therefore, the next of kin can object to an organ donation on a deap person's behalf, even if the deceased owned an organ donation card, or signed the organ donation register. In 2000, a survey conducted by the Department of Management Sciences at City University across Hong Kong showed 60 per cent of the respondents were willing to donate organs, but only 14.8 per cent had signed an organ donation card. 'I think, among the local Chinese, there is still the belief that keeping the body intact might be the reason why people are not willing to donate,' Dr Cheng said. But the majority of bodies in Hong Kong are cremated, a fact evidenced by the finding that last February the six government crematoria in Hong Kong could not cope with the increasing public demand for cremation. 'Keeping the bodies intact is really not a very big and significant issue,' Dr Cheng said. The relatives did not know how their loved ones feel, and they did not want to make a decision for them, she said. 'All [people] need to do is tell their loved ones that, 'If I die one day, I really hope my organs can remain in this earthly world rather than being buried or incinerated with my mortal remains',' Dr Cheng said. 'Once a relative knows how their loved one feels, then they will execute their will.' After 30 years in the classroom, Mr Cheng believes educating students is the key to promoting organ donation. 'I think the promotion [of organ donation] can start in school,' he said. 'In my experience, students know nothing about the donation of organs, and the effects, and how it can help others.' The Hong Kong Medical Association previously organised the Brighter Young Generation Scheme in which doctors volunteered to go to selected schools as advisers on a variety of topics such as organ donation. 'After Sars, we stopped this because not many people wanted to do the talks during the [outbreak], and now, if the school is interested, they can contact us on an individual basis,' said Dr Ho Chung-ping, chairman of the association's organ donation registry. In 2004, legislator Bernard Chan raised a question in the Legislative Council on the feasibility of inviting Hong Kong smartcard identity card holders, at the time of processing their card, to voluntarily indicate their consent to donate their organs upon their death. The proposal was rejected because of legal issues and technical and administration reasons. Opponents were concerned that consent would be given hastily and without proper thought. 'All I am asking for is a voluntary sign-up,' Mr Chan said. 'This is not a permanent thing. Even with the current practice [of using the organ-donation card], if the family does not agree, they will not go ahead with it. Once you have this identification, it will be easier for the Hospital Authority staff to say this deceased has these wishes.' The legislator said he hoped to sponsor a motion on this subject in the first quarter of 2006. 'But we also need to do more public education,' he said. 'We still need to make people aware of the importance of donating organs.' Dr Cheng said any means of getting organ donors was better than none. 'In Hong Kong, you can use the Hong Kong identity card as a means to borrow books, whether it can be used as a means of expressing consent on organ donation - as a medical professional - I would very much welcome this,' she said. The University of Hong Kong's chair professor of surgery, Lo Chung-mau, believes road safety, low violence and the absence of guns sold to the public reduces the number of organ donations because there are fewer brain-dead donors, or people with severe, isolated head injuries. In 1999, statistics show that the highest means of suicide in Hong Kong was 'jumping from a height' and the third-highest means was the use of 'solid, liquid or gaseous substances'. 'On the news, you sometimes see people who commit suicide leave a note saying they want to help other people after they die, but if they commit suicide by jumping from heights, or by carbon monoxide intoxication, how can we use the organs? There is no chance of using that,' said Professor Lo, former president of the Hong Kong Society of Transplantation. Dr Kwok Ka-ki, legislator for the medical sector, said it may be time to consider the 'opt-out' legislation, as used by Singapore, to collect organs from bodies unless they had signed a form to opt out of the donation. 'I don't think the opt-out system would be widely accepted in Hong Kong,' Mr Chan said. 'It will be very controversial, and it'll probably take forever to get this thing passed in Legco.' Professor Lo said the process would 'make organ donation, which is a very high moral act, into a very ugly practice'. And Dr Ho said: 'This is not the type of thing we would like to see in Hong Kong. In Singapore, they have a different political mindset.' But Hospital Authority spokesman Raymond Lo highlights the importance of organ donation. 'Donating is not just saving a life, it is saving a whole family, and maybe more than that,' he said.