A problem that is more than skin deep

Here is the irony: Skin is the largest organ in the human body, yet it is not covered under the 21-year-old Human Organ Transplant Act (Hota). The law, which provides for an opt-out organ donation system allowing the removal of kidneys, livers, hearts and corneas for transplantation, had gone through three major amendments. Still, skin - something doctors, especially plastic surgeons, and sympathetic MPs have been calling for, for some time - was not included on the list.

Hota was enacted in 1987 to harvest the kidneys of those who died in accidents, to be used for transplants unless the victims had earlier opted out. It underwent three major changes to extend its coverage to include livers, hearts and corneas so that more people can benefit from organ transplants. The third amendment was made this month, to allow the reimbursement of costs and expenses to living donors. The Singapore Medical Association is supportive of the call to include skin donation under Hota.

Its spokesman, Dr Tan Sze Wee, said Singapore faces a severe shortage in its skin bank and it has had to get help from countries like the United States and Australia, whose own supplies are running low. Skin donations remain rare because people do not know how useful donated skin is. It is used as a temporary dressing in cases of severe burns involving 40 per cent of the body or more, to reduce the growth of bacteria and the patient's loss of vital fluids.

It is usually discarded in three weeks. By then, new skin which had been cultivated from the patient's own cells would have grown enough to be used as a replacement. As skin is not covered by Hota, Singaporeans who want to donate their skin would need to do so under a separate Act - the Medical (Therapy, Education and Research) Act, or MTERA. Unlike Hota, MTERA is an opt-in system where people pledge their organs to be used for transplants, education or research after they die. As at the end of last year, there were a total of 46,800 MTERA pledgers.

But if there is no opt-in from the person, hospital staff will have to ask the deceased's family to consent to a donation. The problem here is that the answer from grieving loved ones is often 'no', primarily because people still mistakenly believe donating skin will disfigure the dead. This, in turn, will mean a closed coffin, and loved ones will be unable to bid a last goodbye face-to-face. The reality is that in skin donations, only the outermost layer, between 0.25mm and 0.4mm thick, is taken from flat surfaces like the thighs and back. This is thinner than a piece of tissue paper. Moreover, these areas will be concealed by clothing and will not mar the donor's appearance. One reason the Health Ministry had for not including skin in Hota was the apprehension that it could result in a high number of Singaporeans opting out.

The same inhibition had clouded cornea donations as well - the dead leaving without their eyes is anathema in Chinese culture. But its inclusion in Hota has not provoked a hue and cry. Associate Professor Colin Song, who heads the country's biggest burns unit at the Singapore General Hospital (SGH), said the shortage of skin donation here is a longstanding issue, but people shying away from the thought of donating the skin of a loved one who has died is not peculiar to Singapore. It is a problem worldwide.

Since 2006, Canada has been desperately short of skin donations that can be used to treat patients with severe burns. Skin banks in Calgary, Edmonton and Halifax are near empty. Last year, the Canadian government approved a C$35 million (S$42.9 million) funding for a national organ donation registry through the national blood donor agency. Prior to this, Canada was the only developed country without a national transplant system. Last year, The New Zealand Herald reported that American skin is being used on New Zealand burns victims because of a substantial shortage of skin donated for grafts. The shortages meant that about 10 New Zealand victims of major burns were not able to have the best treatment - human skin - for their wounds in that time. Currently, New Zealanders can indicate their wish to donate their organs on their driver's licence. The donation can proceed unless the decision is reversed or when the family does not consent.

To alleviate Shanghai's skin shortage, its Changhai Hospital developed a compound of modified cells from the cuticle and used that as a skin graft two years ago on a woman with 85 per cent burns. Singapore had only two donors to the National Skin Bank last year. One was three-month-old Ryan Wong, who died from complications following surgery for a cleft lip. The other donor is unknown. So far this year, there has been one donor - triad leader Tan Chor Jin, 41, better known as 'one-eyed dragon', who was hanged in January. He also donated his kidneys and a cornea.

Although the 60,000 sq cm of skin - or skin from 30 adult donors - in the SGH Skin Bank may be enough to meet initial needs should a mass casualty situation occur, any prolonged tragedy would have doctors scraping the bottom of the skin barrel. Perhaps when Hota comes up for review again, the scope of the Bill could be expanded to include skin. Singapore has already become a forerunner in upping the stakes of organ donation by allowing recipients to reimburse their donors - if they wish - to cover the financial losses incurred by their donors. The country could take a step further when it comes to skin donation. After all, giving is more than merely skin deep.

March 2009
By Judith Tan