由宗教、醫學與教育觀點談器官捐贈

英文臺灣新聞/Taiwan News/Forum民意論壇/2001-02-24

Religious, medical, educational views on organ donation

INTRO.

        Supply and demand is unbalanced in Taiwan's market for organs; many people suffer, waiting for many years and never find a heart donor. The strange thing is, there are also many people who would like to be donors, but are unable to have their wishes carried out. What exactly is causing this unbalance between demand and supply? Religious factors? Flaws in the system? Or are there problems with the whole system of education about death in Taiwan? Focusing on the Taiwan's currently developing concept of organ donation, the Taiwan News held a forum, to which we invited Master Shih Chao-Fei, president of the Life Conservationist Association of the R.O.C.; Wen-Je Ko, SICV director at National Taiwan University Hospital's Department of Surgery; and Dr. Cheng-Deng Kuo, principal investigator and attending physician at the Veterans General Hospital's department of medical research and education. The forum was moderated by our Editor-in-Chief, Rex Wang.

        在台灣，器官市場是一個供需失衡的市場；許多人苦盼多年仍然等不到有心人捐贈；奇怪的是，也有很多人想捐贈卻無法如願。造成供需失衡的原因到底是什麼？是宗教因素？制度缺失？還是台灣整體上死亡教育出了問題？針對目前器官捐贈的觀念在台灣發展的情形，本報特別邀請關懷生命協會理事長釋昭慧法師、臺大醫院外科加護病房主任柯文哲，以及榮總教學研究部研究員兼主治醫師郭正典參予討論，座談會有本報總編輯王世榕主持。

GUESTS：

關懷生命協會理事長釋昭慧法師

Shih Chao-Fei, Founder and President, Life Conservationist Association

榮總教學研究部研究員兼主治醫師郭正典

Cheng-Deng Kuo, MD, Principal Investigator and Attending Physician, Dept. of Medical Research & Education, Veterans General Hospital

 臺大醫院外科加護病房主任柯文哲       

Wen-Je Ko, SICV Director, Department of Surgery, National Taiwan University Hospital

        主：我們先請柯醫師從醫學觀點切入這個議題。        

        Q: Let's start by asking Dr. Ko to approach this question from a medical viewpoint.

        柯：病人器官捐贈是從腦死病人開始的；腦死慣例起源於1960年代的法國，腦死病人若於腦死後兩年半時確定無法救治，就可以進行器官捐贈。台灣最有名的植物人是王曉明，到目前為止，她還存活著，因此不能列入器官捐贈的對象；醫學上並沒有把植物人列入器官捐贈條件的理由，只有確定已經無法救治的病人，才能列入器官捐贈的對象。

        Ko: Patient organ donation started with brain-dead patients; the convention of brain-dead people originated in the 1960s in France, where if, two and a half years after patient became brain-dead, there was no way of curing them, doctors could then carry out organ donation. Taiwan's most famous patient in vegetative state is Wang Hsiao-ming - she is still alive, and so she can't be put on the list of organ donors; medically speaking, there's no reason to put somebody in a vegetative state on the organ donors list, we only need to verify that there's no longer any possibility of curing the patient, then they can be put on the list of organ donors.

        主：現在台灣的情況如何？

        Q: What is the current situation in Taiwan?

        郭：基本上，我贊成器官捐贈，但我也重視器官捐贈者本身同意器官捐贈的一個「知」的權利。就我所知，有些器官捐贈者在進行手術取出臟器時，仍然有心跳加速的現象，但是大部分的醫生卻不管這些反應，仍不給捐贈者施打麻藥來降低他們的痛苦，因為施打麻藥會造成血壓下降，使器官的循環較差，而且移植到新的人體的存活率也會比較低，所以醫生通常能夠不給麻藥就不給。

      Kuo: Basically, I am in favor of organ donation, but I also respect the donor's right to know and consent to his or her organs being donated. As far as I know, when some organ donors go in to the operating theater to have their organs removed, the hearts still start to beat faster, but most doctors pay no attention to these reactions, and they do not administer anesthetics to the patient to reduce the pain, because anesthetics cause low blood pressure, and adversely affect the circulation of the organ, and when it is transplanted into the new body, the probability of survival is lowered - that's why doctors frequently avoid giving anesthetics if they can.

        雖然我贊成器官捐贈，但是站在人道的立場，應該要讓器官捐贈者在捐贈器官時毫無痛苦，如果在移植時人體有反應，多少要給一點麻藥。第二點，必須要獲得病人本身的同意才可以進行器官移植手術；徵求病人同意是世界潮流，也是合理的主張。        

        Although I am in favor of organ donation, from a humanitarian standpoint, we ought to allow the organ donors to give up their organs without pain, and if there is a physical reaction during the organ harvesting, we should give anesthetics in response. The second point is, we need to obtain the consent of the donor him or herself before we can carry out the organ transplant operation; soliciting the patient's request is a worldwide trend, and it's also a reasonable position to take.  

         釋：台灣的佛教有很大的一部份是依循淨土宗的看法，而這些看法的確會影響人們器官捐贈的意願。很多人以為淨土宗的看法來自典籍，我在學佛的時候也以為是有經為據的。淨土宗的看法是，人死後有取識（執著生命的一種意識）不是立刻就離開屍體，而是慢慢地離開，這段時間是很痛苦的。神離開人體大概需要八個小時，所以這段時間不要去移動它的身體、打擾到它，讓它慢慢地離開身體。如果碰到它的話，會讓它生嗔、生惱，會有痛苦；佛家的看法是，人死的時候最好充滿著光明、快樂和希望，不要有痛苦、嗔惱。很多人覺得既然如此，倒不如等我到了西方淨土，修練到一定程度後再來幫助他們。這個看法的影響甚鉅。

         Shih: A large part of Buddhism in Taiwan is conducted in accordance with the views of Pure Land Buddhism, and these views certainly have an influence on people's wishes as concerns organ donation. Many people think that the ideas in Pure Land Buddhism come from ancient texts. From my own studies of Buddhism, I also think the classics are evidence of this. The viewpoint of Pure Land Buddhism is that after people die, sop?d?nasya vijn?na (an idea about the persistence of life after death) does not leave the corpse immediately, but very slowly, and this period of time is very painful. The spirit takes about eight hours to leave the body, so the body should not be moved or disturbed during this period, so as to allow the soul to leave the body slowly. If one collides with the soul, one could make it angry or unhappy, or cause it pain. The Buddhist view is, when people die, the best thing is to fill them with light, happiness and hope, not pain and vexation. Many people think that even so, rather than waiting until I reach the Western Land, I will discipline myself to a certain level and then help them. This view has an extremely strong influence.

         以佛教的觀點來看，人死後是否還有痛苦？究竟還會不會生嗔生惱呢？就典籍來看，人死亡之後，有取識（對於存在的一種執著）就會離開身體，身體就變成冰冷的屍體。這個過程會緩慢的由腳部慢慢到心臟，所以不是剎那間身體就馬上冰冷。但是在這個過程之中，並沒有明顯的證據支持它還會痛會嗔、會有神經傳導的情況，這樣的解釋不太符合佛經的看法。

         From a Buddhist viewpoint, can people feel pain after death? Can they, after all, feel angry or annoyed? According to the ancient texts, after people die, sop?d?nasya vijn?na (a kind of persistence in life) can leave the body, and the body then becomes a cold corpse. This process can start slowly from the feet and move on to the heart, so the body doesn't become cold all at once. But during this process, there is no clear evidence to support the idea that the body can still feel pain or anger, or that there are still neurotransmissions, this kind of explanation doesn't really tally with the Buddhist view.

         郭：有人以為：有些已經腦死的病人在接受器官移植時出現的心跳加速反屬於自主神經的反應，並沒有任何的意義。我想聽聽柯醫師的看法。        

         Kuo: Some people think that the quickening heartbeat of some people who are already brain-dead during the organ harvesting operation is on the contrary an autonomic [i.e. involuntary] nervous reaction, and has no significance. I'd like to hear what Dr. Ko has to say.

         柯：比方做動物實驗時，我們將青蛙的頭剪掉後，它的腳還是會繼續抽動；腦死的病人也是一樣，就算已經腦死，它的脊椎反射還是存在。不過，隨著器官的壞死，不消多久這些反應也會消失。所以，器官取出的時機只有在宣佈腦死與器官壞死的短短這段時間內取出。        

         Ko: When doing animal experiments, for instance, after we cut off the head of a frog, its legs will still continue to twitch; it's the same with brain-dead patients, it's as if they're already dead, their spinal column reflex is still there. However, not long after the necrosis of their organs, these reactions will disappear too. So, the critical moment for removing the organs is within a very short period between pronouncement of death and necrosis of the organs.

         其實最重要的還是要本人同意。在美國德州，駕照上就強制填上是否願意捐贈器官。其實台灣以前也想沿用這種做法，不過這種做法當時還無法被一般人接受。新加坡政府規定一定要接受死後捐贈器官，除非你有申請不捐贈，否則一律視為接受捐贈器官。

         Actually, the most important thing is still the consent of the person him or herself. On driving licenses in Texas, in the U.S., filling out whether or not you consent to donating your organs is mandatory. Actually, we in Taiwan did think about following this example in the past, but at the time, most people found this way of doing things unacceptable. The Singaporean government has stipulated that people must accept the donation of their organs after death: unless you apply not to be a donor, everybody is assumed to accept organ donation.

         主：釋大師有什麼看法？

         Q: Master Shih, do you have a view on this?

         釋：佛教裡的菩薩講的是犧牲奉獻的精神，我們可以自我期許成為這樣的菩薩。但是並非代表你一定要成為菩薩，所以我不贊同新加坡的做法。

         Shih: In Buddhism, when we talk about bodhisattvas, we mean that by the spirit of sacrificial dedication, we can expect to become this kind of bodhisattva. But this doesn't mean that you will definitely become a bodhisattva, so I don't agree with what they're doing in Singapore.

         我覺得腦死似乎是為器官捐贈量身打造的一個名詞。由於器官市場的供需失調，需求大於供應，瀕死的一方便成為弱勢。可是器官長在他們身上，他們有絕對的權利決定要不要捐。

         I think that brain-dead is a word created especially for organ donation. Demand outstrips supply on the organ market. Those on the verge of death have become the oppressed side. But the organs have grown in their bodies, and they have the absolute right to decide whether or not to donate them.

         柯：家屬與本人原本就有捐與不捐的選擇權。我們不會強迫人們捐贈。

         Ko: The person and his or her family members have the right to decide whether or not to donate organs. We can't force people to donate.

         主：但是站在神學、佛學與哲學的立場來看，「能把死前最後一點東西貢獻出來」這種觀念是值得提倡的。

         Q: But from theological, Buddhist and philosophical standpoints, the concept of "being able to offer the very last thing before death" should be advanced.

         柯：我再補充一點，全世界器官捐贈率最高的是西班牙加泰隆尼亞，他們的心態是：今天我捐贈出來給有需要的人，同樣的，有一天我的親友需要器官時，也會有同胞願意捐贈給他們。他們已經把整個國家當作生命共同體。事實上，一個國家器官捐贈率的高低可以看出一個國家道德文化的高低。

         Ko: I'd like to add something, the highest organ donation rate in the world is in Catalonia, in Spain, and their attitude is: today, I will donate something to somebody who needs it, and in the same way, if one day, one of my family or friends needs an organ, there will be a fellow countryman who is also willing to donate to them. They have already turned their entire country into a community of life. In actual fact, how high or low the rate of organ donation in a country is can be seen from how high or low their culture of ethics and morals is.

         政府目前沒有一個機構專門負責器官捐贈的事宜。基本上做器官捐贈時，還要做血液的檢查；器官從拿出來到移植，之間也只能有四個鐘頭的間隔時間，這樣的過程必須有很大的組織來執行，然而台灣沒有這樣的系統。其實台灣也有不少人願意捐贈他們的器官，但是想捐的人還必須自己到醫院去捐；像不久前還有由家人藉由捷運推到醫院去掛號的，可是人已經死了怎麼掛號？

         At present, the government does not have a body with special responsibility for matters concerning organ donation. Fundamentally, when we carry out organ donation, we still have to carry out blood tests; there can only be four hours between harvesting the organs and transplanting them into recipient's body, and carrying out this kind of process requires a big organization. However, Taiwan doesn't have this kind of system. Actually, Taiwan also has many people who are willing to be organ donors, but the people who would like to be donors still need to go to the hospital themselves to donate. For instance, not long ago, there was a case where the body of a dead person was taken by her family to the hospital by MRT to register, but since the person is already dead, how could she register?

         主：師父您週遭接觸的人看法如何？

         Q: Master, what do the people you commonly come into contact with think?

         釋：我所接觸的佛教徒都很開明，或許因為我們比較能夠了解生命必然面臨的死亡。器官市場供需失調，有些人從動物身上下手，甚至想複製人的器官來使用，這是錯誤的道德觀念。佛教有個很重要的觀念就是：人不能為了一己之私，就妄從別的動物身上去獲取。如果今天你移植了一隻豬的器官在身上，那你到底算人還是算豬？

         Shih: The Buddhists I am in contact with are all very enlightened, perhaps because we all have a better understanding that life must inevitably face death. Demand exceeds supply on the organ market, and some people want to take organs from the bodies of animals, they would even like to harvest organs from human clones, this is a mistaken ethical concept. There's a very important concept in Buddhism, which is that people cannot presumptuously take something from the body of a living creature for their own selfish purposes. If today you transplant an organ from a pig into your body, are you a human being or a pig?

         柯：我再舉個器官捐贈的例子。于楓上吊自殺後，她的家人將送她到榮總時，醫生宣佈腦死。之後家屬將她帶到臺大醫院，希望可以將她的器官捐出，但是醫生卻說願意盡力救救看，家屬當然同意了。於是醫生用了大量的類固醇之類的藥品，為病人做最後的努力，結果死後器官都已經內出血，臟器也不能使用了。所以其實在台灣，不能接受病人死亡的是醫生，而不是家屬。

         Ko: I'll give another example of organ donation. When [the actress] Yu Feng hanged herself, her family took her to the Veterans General Hospital, and the doctors pronounced her dead. Afterwards, her family brought her body to National Taiwan University Hospital, in the hope that they could donate her organs, but the doctors said they were willing to do their best to see if they could bring her back to life, and of course the family gave their consent. Thereupon, the doctors used large quantities of steroids, to make the last possible efforts for the patient, and the result was that after her death, all her organs were bleeding, and not even her internal organs could be used. So actually, the people in Taiwan who can't accept death are the doctors, not the families.

          台大醫學系畢業所要修的學分在270-290之間，但是有關生死學的學分只有1個，台灣的醫學教育裡沒有死亡學的教育。這就造成一個很有趣的現象：一個每天在處理生死的醫生不知該怎麼面對生死這個問題，這是很可悲的。當醫生到癌症病房巡視時，病人家屬問還有多少日子可活，醫生卻要家屬不要胡思亂想，好好安心養病。醫生被認為是無所不能的，怎麼樣都要全力一救。台灣器官捐贈的比率為什麼那麼低？因為一個瀕臨死亡的人亟需外界的關懷，但周圍的醫生和護士卻沒有接受「如何面對這些人」的教育，器官捐贈的情形只是冰山一角。

        Graduates from National Taiwan University's medical department need between 270 and 290 credits, but only one mark of these credits is related to life and death studies. Medical education in Taiwan doesn't really contain any education on the study of life and death. This creates a very interesting phenomenon: a doctor who has to deal with life and death on a daily basis does not know how to face the issues of life and death, which is a great pity. When a doctor makes the rounds of the cancer ward, the patient's family asks how many more days the patient can be expected to live, but the doctor tells the family not to imagine such silly things, they must be assured that the patient will be cured. The doctor is thought to be omnipotent, but how can he or she save everybody? Why is the rate of organ donation so low in Taiwan? Because a person on the verge of death urgently needs the care of the outside world, but the doctors and nurses around him or her haven't been taught "how to face these people," and the situation with organ donation is just the tip of the iceberg.

         中國人深受儒家的影響，「未知生，焉知死」的觀念使我們從小到大沒有接受任何有關死亡的教育。

        Chinese people are deeply influenced by Confucianism, and the concept of "if you don't understand life, how can you understand death?" means that from childhood we cannot accept any education related to death.

         郭：其實醫生也裡外不是人，因為他們如果在救治的過程中有所遲疑，可能還會被家屬告；法院也規定醫生救人一定要救到底。在救治的過程中，哪來的精神談臨終關懷？

        Kuo: Actually, doctors can't win either way, because if they hesitate in the process of saving someone, they may be sued by the family, and the courts also stipulate that a doctor must do his or her utmost to save a life. In the process of saving someone, where is the energy to care for the dying supposed to come from?

         主：對於教育方面大家有沒有什麼意見？

        Q: Does anyone have any ideas about the education side of things?

         柯：我在想，醫學的教育與一般的國民義務教育中，應該加入如何面對死亡的問題。

        Ko: I was thinking, in both medical education and general compulsory education, we should add how to face the question of death.

         郭：社會教育也要有生死學的教育。就連佛教對於死也不說死，卻說成「往生」。

        Kuo: Social education also needs an element of life and death studies. Even Buddhism doesn't call death "death", they call it "going towards life."

         釋：按照佛教的說法，死是另一種生命的開始。這個概念屬於淨土宗的部分。

        Shih: According to Buddhism, death is a kind of beginning of life. This concept is part of Pure Land Buddhism.

         主：除了剛才所談的教育部分之外，還有什麼要談的？

        Q: Apart from what we've just said about education, is there anything else we want to say?

         柯：在身分證、駕照或健保卡上面應該有標示，這方面的工作可以由衛生署執行。倘若哪天後悔了可以再登記取消。

        Ko: We should have a mark on our ID cards, driving licenses or national health insurance cards, and this task could be undertaken by the Department of Health. And if we then change our minds again, we could register to cancel this mark.

全文完

The end

編輯李美儀/英文翻譯何麗薩
Compiled and edited by Tina Lee/Translated by Elizabeth Hoile