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 ministrys 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 QuranWhosoever 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 Britains 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 ones 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 donors 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 members 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 individualsdecisions. 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 donors 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 QuranWhosoever 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 thats 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 nations 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.1awphilalf (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, HOPEs 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 Healths 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 "AntiTrafficking 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 recipients 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 recipients 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.