The Malaysian medical fraternity added another feather in its cap recently with the historic heart transplant performed by a team of cardiothoracic surgeons cardiologists, anaesthesiologists and other supporting staff of the National Heart Institute.

The effort was a culmination of the heart transplant programmed set up by the institute two years ago. It also provides hope for one percent of the estimated 20 000 Malaysians who experience heart failure every year and require a transplant.

The notion of transplantation has been around for the last few millennia. Susruta Sanhita, and old Indian document written around 700 B.C., contains elegant descriptions of methods for repairing defects of the nosed and ears using autografts from the neighbouring skin.

According to legend, miraculous surgeons like Pien Chi’iao and Hua T’o who practised in China two thousand years ago, performed transplants on heart patients without inflicting the slightest pain. The Roman Catholic saints, Cosman and Damian, were said to have risen from dead to replace the cancerous foot of a devout Christian with a transplant from the cadaver of an Ethiopian.

It was narrated that during the battles of Badr and Uhud in A.D. 624 and 625 respectively, Prophet Muhammad (peace be upon him) himself re-attached the detached eye of Qatada ibn Noman, and the severed hands of Muawith ibn Afra and Habib ibn Yusof. Muslim jurists, such as Al-Imam Nawawi and Asshirbini, are known to have sanctioned transplantation of teeth and bones. Intra-species (allograft) and inter-species (xenograft) transplantation of most organs were also permitted.

Organ transplantation is a mode of treatment for serious and life-threatening diseases which has been proven to be successful, and hence should be continued. Recent advancements in surgical procedures and the availability of anti-rejection drugs have contributed tremendously to the success of organ transplantation.

The primary source of organs for transplantation is a dead body. As the process of death sets in, the organs of the body begin to putrefy rapidly. Thus, if possible, organs must be retrieved from a dead body whose vital functions are being sustained artificially.

Such bodies are often patients who die after a trauma that destroys their brain but leaves other organs intact. The term “brain-death” or cadaveric is used to describe these bodies. Return to life is considered scientifically and medically impossible. Very strict brain-related criteria are used to certify that a patient is brain dead. And these criteria have been internationally accepted and widely practised.

The first successful transplant was carried out at Boston’s Peter Bent Brigham Hospital in 1954 by a surgical team, led by the Nobel laureate Dr Joseph Murray. A kidney from one identical twin was transplanted to his brother. Ever since then, transplantation has become the treatment of choice for kidney failure patients. Kidneys harvested from living and cadaveric donors are suitable for transplantation.

Lung transplantation was first carried out in 1962. The same year marked the first successful liver transplant procedure at a hospital in Denver, Colorado in the Untied States. Although the majority of livers for transplantation are obtained from cadavers, partial liver transplant from living donors has now become possible.

On Dec 3, 1967, in the Schur Groot Hospital, in Capetown, South Africa, Dr. Christiaan Barnard transplanted a living heart from the chest cavity of a presumable dead person into a patient suffering from end-stage heart disease. The patient survived for 18 days.

One month later, Dr Barnard attempted the same procedure to save the life of Dr Philip Blaiberg, who lived for 18 months. This procedure has been developed to a stage where the survival rate for heart transplant patients is 90 per cent for the first post-operative year, 75 percent for the fifth, and 55 percent for the tenth.

Due to the shortage of cadaveric donors, the first heart transplant in Malaysian could only be carried out on Dec 18 last year. Organ donors are indeed a rare breed in this country. In fact, in the last 22 years, there have been only 17 cadaveric donors, the majority being foreigners who died in traffic accidents.

Nevertheless, the Ministry of Health must be commended for its effort to encourage the public to pledge their organs for donation. The first thing the ministry did was to obtain the sanction of the religious authority on the permissibility of the Organ Transplantation Treatment.

The matter was discussed at the National Fatwa Committee meeting on June 23 and 24 in 1970. The committee, assisted by a panel of medical experts, made the decision to allow organ transplantation based on acceptable juridical principles.

The first is the principles of “choosing the lesser of two evils if neither can be avoided.” Since the saving of life is a necessity that carries more weight than preserving the integrity of the body of the donor or cadaver, and inflicting injury on the body of the donor is less evil compared with letting the patient die, therefore organ transplantation is sanctioned.

It goes without saying that the procedure should not pose any danger to the living donor as far as medically ascertainable. Here, the main principle of medical ethics, namely: primum non nocere is automatically invoked. Donation must cause no harm or a minimal increased risk to the health of the donor.

The second is the rule of “necessities overrule prohibitions.” Basically, mutilating the human body, whether living or otherwise, is against the precepts of Islam. Prophet Muhammad rebuked a man who broke the bone of a deceased which he found in a cemetery and said: “Breaking the bones of a dead man is similar to breaking the bones of a living man.”

Due respect should be accorded to the dead body as exemplified by Prophet Muhammad who stood in veneration for a funeral procession of a Jew, at a time when Jews were his companions exclaimed: “It is only a funeral of a Jew!” The Prophet answered: “Is it not a human soul?”

Nevertheless, under very special circumstances, juridical prohibitions can be waved. Allah says in the Holy Quran in Surah Al-Baqarah verse 173: “But if one is forced by necessity, without wilful disobedience, nor transgressing due limits, then he is guiltless. For Allah is Oft-Forgiving and Most Merciful.” A similar decree is stated in Surah Al-Maidah, verse 3 and Surah Al-An’am, verse 145.

Thus, Muslim jurists allow the use of non-permissible materials in medicine if it is deemed indispensable for cure and prescribed by a competent Muslim physician.

Less than eight hundred years age, Zakaria Al-Qazwini, a grand Qadhi of Iraq (A.D. 1203-1283) noticed that porcine bone graft functioned more efficiently than other xenografts. If that were the only available treatment to save the life of the patient, Muslim jurists would exonerate both the patient and surgeon from any blame.

Donating an organ is not an act of mutilation. Mutilation is done with malice and vengeance and serves no good purpose, while donation of an organ is an act of charity and benevolence as it can save a human life. In Surah Al-Maidah, verse 32, Allah says: “if anyone saves a life, it will be as if he saves the life of all mankind.”

The third principle which supports organ transplantation is contained in verse 185, Surah Al-Baqarah: “Allah intends every facility for you. He does not want to put you to difficulties.” Islam considers a disease as a natural phenomenon. However man should seek remedy, Allah, who causes ailments, also brings cure and redemption. Muslims are therefore encouraged to search for new modes of treatment and should apply them if proved successful.

A literature scan indicates that the major religions of the world do not object to organ donations. The Roman Catholic and Jewish traditions consider giving up a body part for the benefit of another as moral justifiable. While abhorring mutilation of the body, Buddhism permits donation after death if the explicit consent of the donor has been obtained before death.

Despite the unequivocal sanction for organ donation by the various religious authorities, there is still a severe shortage of organs for transplantation. Malaysians are still reluctant to pledge their organs for donation. In a study carried out in Kuala Lumpur a few years ago, only 20 per cent of the respondents indicated the willingness to donate their organs. The figure for potential Muslim donors is only 10 percent.

Every year, thousands of Malaysians in dire need of an organ transplant die before a donor can be found. Nevertheless, the success of the national Heart Institute is set to usher in a new age of organ transplantation in the country.

Let us hope that the same event will spur more Malaysians to pledge to donate their organs. A noble option indeed as a new year resolution!