The recent death of 19-year-old Jamella Lo after a heart-rending and fruitless two-week wait for a double lung transplant has again highlighted the urgent need for Hong Kong to champion organ donations. Around 3,000 patients are on waiting lists for transplants of organs and other body tissues. Many die before a donor is found. Only around 174,000 people - just 2.4 per cent of the local population - are registered as potential donors on the government's Centralised Organ Donation Register. Hong Kong's donation rate is 5.4 patients per million population, compared with 20.4 in the United Kingdom and 27.02 in the United States last year, according to the International Registry in Organ Donation and Transplantation. Everyone agrees the city should find ways to boost its organ donation rate as soon as possible. The health minister came up with one suggestion - make all Hongkongers potential donors unless they opt out. Such a presumed-consent scheme, adopted by many countries such as Singapore, Sweden, Spain and Austria, would have to be implemented through legislation. Under such a law, all deceased Hongkongers would automatically donate their usable organs, unless they had expressed a wish not to be a donor. The current opt-in system requires an individual to join a voluntary scheme by registering online or to carry a pink card if they wish to donate organs. But medical professionals must still approach relatives on donations - the family makes the final decision, regardless of the deceased's intentions. Those in favour of a presumed consent law believe it is more respectful and fair because it leaves the choice to the donor, the deceased person, rather than their relatives. According to the World Health Organisation, countries with opt-out systems have donation rates that are 25 to 30 per cent higher. With the tragic memory of Lo still fresh in people's minds, Secretary for Food and Health Dr Ko Wing-man believes now is a good time for such a discussion, and the government will consult the public to gauge opinions. However, Dr Chau Ka-foon, former president of the Hong Kong Society of Transplantation, believes an opt-out donation law would be a highly controversial step in traditional Chinese culture as many people still consider organ removals as "desecrating a corpse". Even without a cultural factor, legislation has triggered widespread concern in many Western countries. A debate over the law was initiated in the UK in 2008 amid a similar shortfall of organs, but the subject is so controversial that only Wales has introduced it so far. Those opposed believe the legislation removes power from the hands of families - ignoring their wishes and creating tensions with medical practitioners. The fear is that if families cannot trust doctors, people may question whether doctors are providing the best care for family members at the end of their lives. Cooperation is vital in the organ donation process, as families are often more aware of their relatives' medical history - a crucial factor for doctors who have to make often agonising decisions to minimise potential risks for recipients. For the organ donation law to work, there has to be mutual trust and understanding between both parties. The principle of presumed consent also poses ethical questions. Research conducted by Johns Hopkins University School of Medicine in the US suggests it could challenge the relationship between the transplant community and the public - and increase hostility towards those in need of a transplant. Other scholars regard it as more akin to a totalitarian ideology that has no respect for the individual. Legal advice also suggests that a presumed consent law may be open to challenge under the European Convention on Human Rights - especially the right to respect for family and private life under Article 8. However, an article published in a WHO periodical last year defended the principle of opting out as being consistent with the view of "a fair concept of justice" that calls for reciprocal altruism. It says that organs may be considered "a scarce societal resource". The author, Alejandra Zuniga-Fajuri from the University of Valparaiso in Chile, believes that the willingness to be a donor in exchange for eligibility to receive an organ is "a basic moral requisite". He concludes that the law can lead to desirable cultural changes and help bring about more caring and responsible societies. As the debate continues, a veteran doctor in Hong Kong who does not want to be named reminded the government it should not see the law as the only factor affecting organ donation rates. In Hong Kong's public hospital system, identification of potential organ donors is usually performed by intensive care specialists. But some viable organs are never made available for donation due to administrative and manpower problems, the doctor says. "Although many doctors are very supportive towards organ donation, they may not be able to report every potential donor prior to their death due to the complex situations they have to handle and the huge workloads at hospitals," says the doctor, who works in an intensive care unit. "In hospitals, everything happens in haste. The doctors are too busy saving lives and then moving on to the next patient. They do not often have time to consider whether the patient's organs could be used and contact the transplant coordinator to follow up." After a specialist does report a potential donation, it is then the job of a transplant coordinator to manage the request process and counsel the families involved. This raises another issue - there are only nine coordinators to serve the seven geographical groups of public hospitals scattered across Hong Kong. The doctor also points out that many countries, such as the US, have not adopted presumed consent legislation yet have impressive rates of donation. In fact, the US has a higher donation rate than that of Sweden, which has implemented opt-out legislation. An article by Simon Bramhall, consultant liver transplant surgeon at Queen Elizabeth Hospital in Birmingham, England, suggests that the US has a heavily invested, well-staffed and extensive network of organ donor coordinators and systems in place, under which hospital costs on organ donation is reimbursed to increase incentives. By law, all medical staff must identify every potential donor - such as those who are very likely to be brain-stem dead - to the organ donor organisation. Bramhall believes these factors contribute a great deal to a high donation rate without the need for opt-out legislation. Hong Kong lawmaker Kwok Ka-ki says the government is not doing enough to educate and gain consent from the public. After the tragic death of Lo, health minister Ko said public hospitals should review whether they were putting enough resources and manpower into organ donations, and vowed to enhance public education on the right course of action. But Kwok says: "The Hong Kong government has long been putting too few resources into organ donations. "While I agree with the presumed consent practice in principle, the change would not work if the government does not boost its efforts in educating the public, training medical professionals and winning a public mandate," he says. "It will take time for the public to accept the idea, and the government should start working on it now if they really want to push ahead with the legislation." 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