HOTA

The Human Organ Transplant Act (HOTA) provides an opt-out organ donation system that allows for the removal of kidneys, livers, hearts and corneas from Singapore citizens and permanent residents who have died, for the sole purpose of transplantation. Administered by the Ministry of Health (MOH), it also regulates organ donation by living persons. Enacted in 1987, it has since undergone three rounds of major amendments to extend its coverage so that more people can benefit from organ transplants.

History
Before HOTA was implemented, organ donation in Singapore was done only on a voluntary basis under the Medical (Therapy, Education and Research) Act, or MTERA in short. The current MTERA was enacted in 1972. It repealed a similar law that was passed by parliament in 1965, as this earlier legislation had been found to be flawed because of its ambiguities and stringent rules.

However, MTERA proved inadequate to meet the transplant needs of patients suffering kidney failure due to the lack of voluntary donations. Only 22 kidney transplants were performed between 1970 and 1978, and there were none between 1979 and 1981. This prompted then Health Minister Goh Chok Tong to suggest setting up an opt-out system of obtaining cadaveric kidneys. After extensive studies and public consultation, the government introduced HOTA in 1987 to allow for the removal of kidneys from non-Muslims who die from accidental causes.

The impact was significant. Between 1987 and mid-2004, 222 patients received kidney transplants under HOTA, an average of 13 per year. Since mid-2004, HOTA has been amended to widen the pool of cadaveric organ donors and thus benefit more people in need of transplants. In 2007 alone, cadaveric organs were used to perform 46 kidney transplants, 12 liver transplants, 4 heart transplants and 106 cornea transplants.

Key Changes Under the Human Organ Transplant (Amendment) Act 2004
(1) Inclusion of deaths resulting from non-accidental causes.
(2) Inclusion of livers, hearts and corneas in cadaveric organ donations.
(3) Regulation of living donor organ transplants.

Key Changes Under the Human Organ Transplant (Amendment) Act 2008
(1) Inclusion of Muslims.
(2) Provision of enforcement powers to give MOH the authority to investigate offences under HOTA.

Key Changes Under the Human Organ Transplant (Amendment) Bill 2009
(1) Removal of the 60-year upper age limit on cadaveric organ donors.
(2) Allowing donor-recipient paired matching. Put simply, this is a system whereby recipients who have medically incompatible donors exchange their donors so that each recipient receives a suitable organ. The exchange can be carried out across two or more donor-recipient pairs.
(3) Reimbursement of living donors in accordance with international and local ethical practices.
(4) Increased penalties for organ trading syndicates and middlemen.

Description
All Singapore citizens and permanent residents who are at least 21 years old and of sound mind are automatically included under HOTA, unless they opt out. Upon their death, their organs will be removed if the following conditions are met:
- they died in a hospital;
- their organs are suitable for transplant; and
- there are suitable recipients for the organs to be removed.

People who have not opted out of HOTA will have a higher priority on the waiting list should they need an organ transplant.

HOTA covers only kidneys, livers, hearts and corneas, but people may pledge to donate any of their other organs and tissues (e.g., lungs, bones and skin) upon their death, for the purpose of transplantation, education or research under MTERA. The minimum age requirement is 18 years old. Foreigners can also sign up as donors under MTERA.

Besides cadaveric organ donation, HOTA regulates living donor organ transplants. In such cases, HOTA allows for the removal of a kidney or any part of the liver of a living donor for the purpose of transplantation, provided there is written authorisation from the hospital's transplant ethics committee. Following the 2009 amendments, payments may now be made to living donors to reimburse them for the loss of earnings and other costs or expenses, including medical care and insurance protection, incurred as a result of the organ donation. Although the proposed amendments were eventually passed, this issue of reimbursement was the subject of a heated debate in parliament as some Members of Parliament were concerned that it could be a backdoor to organ trading.