transplantation, brain stem, organ donation, India, organ transplantation, liver transplantation, Reeta Dar, Hindu marriage, transplant, Dar Reeta, HLA, Human Organs, living donors, organ transplant, child marriage, donor family, successful marriage, recipient, liver transplant, National kidney Foundation, internal environment, Srivastava Roli, Sunil Kumar Dar, Retrieved, Dowry Prohibition Act, Indian Journal of Psychiatry, recipient families, National Organ, Central Health Education Bureau, article attempts, Research Article Reeta Dar, International Research Journal of Public Health, immediate family members, organ donor, waiting list, brain dead, rigorous procedure, kidney transplant, Health Education
Reeta Dar, IRJPH, 2017; 1:4
IRJPH (2017) 1:4
International Research Journal of Public Health
Semblances of "Aangdan (organ donation)" with "Kanyadan (gift of a maiden)" under Hindu marriage
Reeta Dar (PhD Scholar)
Health Education Officer, Central Health Education Bureau , DGHS, MoHFW, GOI
This article seeks to draw parallels between various rituals and practices of the Indian wedding and the concept of organ dona-
tion and transplantation. The purpose of this article is to make it Donation, "Kanyadan", NOTTO,
easier for the layman to relate to the concept of organ donation NOTP, Organ Transplantation
and transplantation. The article attempts to liken
"Kanyadan" (giving away of a daughter in marriage) and
"Aangdan" (organ donation); makes comparisons between the two using parameters of legal age, importance of * Correspondence to Author:
love,search for a suitable match, appointment of middle men, financial investments and legal penalties etc. The article equates traditional match making on the basis of religion with the blood group matching in organ donation and
Reeta Dar (PhD Scholar) Health Education Officer, Central Health Education
transplantation. It further links the Guna Milap (Matching of Bureau (CHEB),
fate lines) of the prospective bride and groom with that of DGHS, MoHFW, GOI Human Leukocyte Antigen (HLA) matching in organ donation
and transplantation. It also highlights the significance of ensuring compatibility with internal environment
irrespective of How to cite this article:
best selected matches in both the cases. The engagement Reeta Dar. Semblances of
ceremony to grant social approval to a marriage is equated "Aangdan (organ donation)" with socio-legal approvals by "Authorization Committees" for organ donation and transplantation. Geography or spatial with "Kanyadan (gift of a
proximity also plays a crucial role in facilitating a marriage as maiden)"under Hindu marriage.
well as organ transplant. The article also concludes that a International Re-search Journal combination of sadness and jubilation is common in both these events. The post-event management in both the cases is of Public Health, 2017; 1:4.
a roller coaster ride full of apprehensions and anxieties and
needs more investments in terms of money, emotions and
care. The two however differ on the infrastructure issue; while
it's easy to perform "Kanyadan" at any place by priests or
pundits, availability of infrastructure and man-power is restricted
in case of "Aangdan". The author also draws parallel between eSciPub LLC, Houston, TX
some unusual marriages and unusual organ donation and USA. Website: http://escipub.com/ transplantations and warns people against commercial
donors. She also tries to counsel those feeling cheated and
resentful for not receiving organs for transplant despite their
names being on top in the waitlisted people for organ transplant.
The author underlines that based on this article a role play or
social drama could be prepared for conveying the nuances and
intricacies of organ transplant to common people.
Reeta Dar, IRJPH, 2017; 1:4
INTRODUCTION The term "Kanyadan" (1) meaning "gift of a maiden" is a term used when Hindu daughters are married and "Aangdan" (2) is a term used when organs are donated or gifted for transplantation. Both are considered to be the gifts of the highest order. "Kanyadan" is the combination of two Hindi words i.e., "Kanya" and "dan" similar to "Aangdan" i.e., "Aang" and "dan". While "Kanya" means "maiden" , "Aang" means "organ" and the word "dan" common to both means donation or gifting away (1,2).
· Post marriage phase which is possible only if one is lucky to find a partner(4), otherwise once the marriageable age is over the person goes into nonmarriageable phase (usually after 40 years of life). A time comes when it is felt that suitable age for marriage is over and people stop looking for a suitable match. Likewise the three phases for organ transplantation can also be divided into
Marriage and Organ transplantation are needs of human beings
the former arising from the need for permanent companionship in addition to procreation and sexual needs and later arising from organ failures like Kidney, Liver or Heart Failures under specific pathological conditions(3). Incidentally, the processes involved in organ transplantation are somewhat similar to that of a marriage. After marriage a daughter shifts permanently from its parental house
to husband's house. In organ transplantation too there is a permanent shifting of an organ from its original body to another body. The marriage requires a gamut of emotions like love, affection, tension, patience and caring in addition to manpower, material and finances (4).Vast number of ceremonies and rituals are performed before the actual marriage which are usually stressful and time consuming(1, 4). The same holds true for organ transplantation. Let us see how? THREE PHASES OF MARRIAGE / ORGAN TRANSPLANTATION There are three phases of marriage akin to organ transplantation. The three phases for marriage of a person can roughly be divided into · Pre-marriageable phase i.e., up to 18 and 21 years for girls and boys respectively (5); · Marriageable phase (roughly up to 40 years) and
· Pre-transplant phase, · Transplant phase and · Post-transplant phase. A person who needs an organ does not need it instantaneously. An individual usually goes through pre-transplant phase and copes with the failing organ with the help of medicines for some time. As the disease progresses, a stage comes when the person needs an organ transplant (3). Requirement for an organ transplant is determined by a team of specialized doctors based on signs and symptoms including medical investigations of the patient. For example a person can be registered for a deceased donor kidney at National Organ and Tissue Transplant Organization (NOTTO) only if he is a case of End Stage Renal Disease with maintenance dialysis for more than three months (6).The body needs a new organ which has to come either from a living donor or a brain stem dead donor in India. This phase is known as the transplant phase which brings a lot of turmoil within the body of ailing individual and his family as well. There is a limited period within which a person can be transplanted an organ and unfortunately in most of the cases the people waiting for an organ die before receiving it. Therefore a time comes when the transplantation phase can be over like that of one's marriageable age because the physical and biological state of the recipient at that time becomes non-conducive for organ transplant. However, in case of successful organ transplantation the individual has to make lot of adjustments akin to marital adjustments in post-transplant phase. LEGAL AGE FOR MARRIAGE / ORGAN DONATION AND TRANSPLANTATION
Reeta Dar, IRJPH, 2017; 1:4
A certain age is always viewed as suitable All such recipients of organs are usually
for marriage. Legally marriageable age for a unrelated and unknown to the donor. There is
groom and bride is not less than 21 and 18 no monitory gain to the donor family as a result
years re-spectively in India (5). Age also plays of such donation. A brain stem dead donor can
an import-ant role in organ donation and give new lease of life to 7-8 persons by
transplantation. None can pledge to donate donating two kidneys, two lungs, heart, liver,
organs before 18 years of age and no living pancreas and very rarely intestines (10).
donor can donate an organ who is less than 18 years of age (7). However there is usually no restriction of age for donation of organs from brain stem dead donors in India.
However, in a praiseworthy and landmark decision recently, Directorate General of health service
s (DGHS) favoured a family whose one son was declared brain stem dead and another was
LOVE IN MARRIAGE / ORGAN TRANSPLAN- on the waiting list for kidney transplant
. Their ail-
ing 47 year old son , advocate by profession was
Love, affection and care are important aspects of marriage and same is essential in organ transplantation as well.
allocated one of the kidneys of his brain stem dead brother after bypassing 3000 patients on the waiting list. DGHS felt that by taking this decision they prevented double deaths in the family
Incidentally, love and affection are much more (11).
important in organ donation and transplant as SEARCH FOR A SUITABLE MATCH IN compared to marriage. In fact, love is of primary MARRIAGE / ORGAN TRANSPLANTATION importance in organ donation from living donors
in India. In India, it is mandatory for living organ A rigorous search for a suitable match is required
donors to donate organs out of pure love, affilia- in both the cases of marriage and organ trans-
tion and affection (7).
plantation. Generally it is the responsibility of
The prerequisite of love in organ donation from living donors has given birth to new expectations from female members within a family. Females are required to part with a segment of their liver or a kidney usually for male members to show their love for them. Females in certain cases also donate to unknown people illegally to rescue their families in financial crisis
the family to find a suitable match for their family member (4). Likewise the responsibility to find an organ donor also rests on a family (3). The processes in both the cases are tedious, time consuming, stressful and full of roller coaster rides. The rigorous procedure of finding the most suitable match in both the cases aims at ensuring long lasting harmonious existence.
in medical technology
has encroached into bi- In the case of living organ donation, it is possible
ological boundaries of human beings that lay to follow a rigorous procedure of finding the most
down expectations on people to donate organs suitable match (7) which may not be possible
for transplantation into other people. Incidentally, when it involves donation of organs from a brain
females are usually the ones who are trapped or stem dead donor. It is because organs from a
go the extra mile to prove their loyalty by donat- brain dead donor are required to be transplanted
ing organs especially for male recipients (7, 8). among waiting recipients within a short duration
It is worth mentioning that there is no importance of time (10).
of love and affection for family members
or relatives when it comes to donation of organs from a brain stem dead donor. It is presumed that an
APPOINTMENT OF MIDDLE MEN IN MARRIAGE /ORGAN TRANSPLANTATION
individual loves his own countrymen irrespective In order to get rid of inherent troubles and pains
of their gender, caste, socio-economic or reli- associated with match finding, the families pre-
gious status after death. The organs of the brain fer to involve middlemen or seek help of matri-
stem dead donor are given to any person with monial/organ donation cum transplantation sites
whom the organ matches the best among the that indirectly do the job of finding a suitable
waiting list of patients or as per organ match in both the cases.
allocation criteria laid down by a national
network like NOTTO or a State network (9, 10).
Reeta Dar, IRJPH, 2017; 1:4
However, the middle man for organ transplant could be legal or illegal. The middle men for illegal transplants are people who indulge in organ trade to make organs available from living donors. They purchase organs from underprivileged people and charge hefty amounts from recipient family for the purchased organ (8). They trap poor people; give them inadequate or incor-rect information regarding procedure of organ retrievals and importance of organs in their own bodies etc. They survey villages for probable donors, whom they sometimes lure with money and a false as-surance of a job in the city or a better socio-eco-nomic life. Officials of National Organ Transplant Programme (NOTP) are often being alerted to various forms of organ trade like kidnappings for organ retrievals, posting of advertisements on websites and seeking donors in lieu of money. Also the people from the neighbouring country Nepal are enticed to sell organs in India to re-build their homes after the recent earthquake in their own country (12). The middlemen for legal organ transplants are hired by hospitals called Organ Transplant Coordinators (10). It is mandatory for an organ retrieval or transplant centre to have an Organ Transplant Coordinator in place (13). They counsel families for donating organs of their brain stem dead relatives on ventilators to make organs available for the waiting recipients. FINANCIAL INVESTMENTS IN MARRIAGE / ORGAN TRANSPLANTATION
which is punishable under the Act(5).In the same way, meagre availability of organs for transplantation has led to illegal child trafficking for organ retrievals from children below 18 years (12), which is punishable under the law(13, 14). In marriage dowry demand attracts penalties in the form of imprisonment and fine (15). Similarly selling of organs or commercial dealings of organs for transplantation is not permitted legally and attracts penalties in the form of imprisonment and fine (13, 14). MATCHING RELIGIONS IN MARRIAGE / BLOOD GROUPS IN ORGAN TRANSPLANTATION Matching is a tedious process in both the cases. Incidentally we have four major religions
i.e. Hindu, Muslim, Sikh and Christian akin to four blood groups that are A, B, AB and O. In marriage, preference is always given to same religious match akin to blood group matching in organ transplantation. It is medically mandatory that Blood group of the recipient be best matched with that of an organ donor (16).The following blood types are compatible for organ donation and transplantation:
PERSON WITH CAN DONATE CAN RECEIVE
BLOOD TYPE ORGAN TO RE- AN
CIPIENTS WITH FROM BLOOD
BLOOD GROUP DROUP
A and AB
A and O
Lot of money is spent in marriage right from finding a match. However one usually accommodates the marriage expenses within their own budget (1). Same holds true for organ transplantation (7). While interviewing a liver transplant recipient in India who was lucky to get a brain stem dead donor's liver transplanted in a Government Hospital with minimal financial inputs revealed that the total cost
of liver transplant in various private hospitals ranged between 24 lakhs to 60 lakhs but she was the luckiest, having invested not more than Rs. 50000/-in a Government Hospital. LEGAL PENALITIES IN MARRIAGE /ORGAN TRANSPLANTATION Unfortunately there are people who indulge in marrying before the legal age i.e., child marriage
B and AB
AB (UNIVERSAL AB only RECIPIENT)
0 ( U N I V E R S A L A, B, AB and O DONOR)
B AND O A, B, AB and O O
However, Rh factor is not generally regarded as important in matching organs for transplantation (17). It is usually seen that some people simply marry after finding a compatible religious match. No other matches are done. The same is the case with liver or heart transplant usually. For these two transplants the other elaborate matches are not required usually (17).
MATCHING GUNA (GUNAMILAP)
MARRIAGE AND HUMAN LUKOCYTE
Reeta Dar, IRJPH, 2017; 1:4
Matching religion or matching blood group alone does not suffice for marriage or transplantation especially in the case of kidney transplant. The second matching that is done is "Gunamilap" for marriage (18) and "Human Leukocyte Antigen" (HLA) matching for transplant (16). "Gunamilap" is a tradition followed under Hindu marriage to judge the compatibility of the couple who are entering into wedlock. According to Vedic astrology, compatibility of two people is a pre-requisite for tying a nuptial knot. It involves precise astrological calculations to find the compatible gunamilap of the horoscopes of the two individuals. This horoscope matching method is based on scoring points that are supposed to influence marriage. More points mean that there are more chances of a successful marriage. Gunamilap can yield a maximum score of 36 points. A couple has to score a minimum 18 points for a compatible marriage. If the score is less than 18, marriages are rejected. Guna score of 18-24 are considered average scores for marriage. Guna score of 25-32 is considered a perfect match. A score of above 32 is technically excellent but could be a problem as both counterparts could be of the same nature and are viewed as unfavorable for a sustainable relationship (18).
an important role (18) for a fruitful relationship. Is the environment conducive for sustenance of future relationship - is a question that haunts the families before proceeding further in the relationship even after ensuring horoscope compatibility.To ascertain the same, a meeting of the two families, meeting of the couple, and even a visit to groom's house are undertaken to see whether the internal environment is conducive for the bride or not. The outcome of such interactions decides the fate of marriage. Similarly in organ transplantation, in order to determine whether the internal environment of the recipient body is conducive for the donor organ, a Serum Cross Match is done which is a blood test that takes about 4-5 hours. The cells of the donor are incubated into the serum of the recipient and if the donor cells die as a result of higher concentration of antibodies in the serum of recipient the transplant can't take place. It shows that recipient shall reject the organ if transplanted (16). In case of second marriage especially after divorce the family of the bride is suspicious of the internal environment and becomes extra cautious with such marriages. Extra efforts are done to ensure compatibility.
Akin to gunamilap in marriage "Tissue Typing" Similarly in certain cases like previous trans-
or HLA Matching is an important aspect of or- plants, blood transfusion
s etc., the recipient
gan transplant as it is found that the best tissue body is exposed to various foreign antigens and
matched transplants give better post-transplant develops antibodies to them. In such cases, to
results. There are six Human Leukocyte Antigens determine internal environment a laboratory test
and the best match for any kidney recipient is to called Panel Reactive Antibody (PRA) is done to
have all his six antigens matched with that of the identify the levels of antibodies in the recipient
donor. For finding HLA compatibility, a blood test body because higher the percent of these
is done in a laboratory to find if the tissues of the antibodies, higher are the chances of rejection
donor are compatible with that of the recipient. of the new organ. People with high PRA are
If less than two HLA match with the donor, the called sensitized. These sensitized people pose
donor is rejected for donation of kidney. Matches a higher rejection risk to the organ and if
above two HLA are accepted for donation (16). transplanted, need higher doses of
The situation is considered the best when there immunosuppressant medicines and have
are zero mismatches. It is only in identical twins shorter transplant survival (16).
that tissues are the same, rest everyone has ENGAGEMENT IN MARRIAGE / ORGAN
different tissues from everyone else's. Hence TRANSPLANTATION
organ donation from identical twins is the best
match for the recipient (19).
After finding these compatibilities the engage-
ment ceremony is performed in presence of
ASCERTAINING WHETHER INTERNAL family members of the groom and bride to give
ENVIRONMENT IS CONDUCIVE OR NOT IN social approval to the marriage (18). The
MARRIAGE /ORGAN TRANSPLANTATION
marriage can be called off even at this stage if
In case of marriage, the family environment plays dowry is demanded. Providentially any kind of
Reeta Dar, IRJPH, 2017; 1:4
ILQDQFLDOgains are not accepted in both the cases be it marriage or organ donation.
organs are transported via aircraft to far off places such procedures involve huge cost(21).
As organ failures are usually caused by lifestyle SADNESS AND JUBILATION INSEPARABLE
diseases that affect the rich mostly, the possibil- IN MARRIAGE / ORGAN DONATION
ity of exploitation of the poor always exists (12). AND TRANSPLANTATION
In order to safeguard people such surgeries cannot be done without the prior approval by an An aura of sadness in a bride's home is unavoidofficial committee/ authority in case of living able at the time of her departure from parental organ donation. As per THOT rules 2014 living house. Her parental family can't hold back the organ donors can only be known people like rolling tears. For them the only convincing factor "Near Relatives" or "Other than Near Relatives " is that the girl has found a good life partner (4, who have a connection of true love and affection 18). The same event in groom's house on the
with the recipient (3,20).It is believed that such other end leads to an aura of jubilation where individuals may not mind sharing their organs she makes her entry. The bride's family at the
to save the lives of their loved ones. THOT- time of departure are also seen saying to the
Rules, 2014, permit donation of organs for near groom's family "you have taken my heart: please
relatives like spouse, mother, father, brother, take care of my heart" or "I am parting with my
sister, son, daughter, grandfather, grandmother own piece of liver, please take care of her".
and grand-children after approval by the "Competent Au-thority". When the donation of organs from other than near relatives like friends, uncles, aunts, cousins etc., is involved ,love has to prevail and requires official
In organ transplantation, the donor organs like liver, kidney, heart literally leave the original body with an intention to serve other bodies that otherwise may perish soon. The organs leaving the
verification by the "Authorization Committee" of a body of a brain stem dead donor is also accom-
hospital, a district or a State(7). A lot of time stress is involved in verifying love for
panied with tremendous grief in donor family and jubilation in recipient families. The donor family
in such situations convince themselves, saying
The socio-legal sanction for organ transplant is that the person is not dead but living in so many
usually accorded in the hospital premises under recipients or his death did not go in vain as even
"Competent Authority" or "Authorization Com- at death he gave life to many needy people (3).
mittee" members who look at the documents, interview the donor and recipient families .This is a very crucial phase as most of the commercial
ADJUSTMENTS AFTER MARRIAGE / ORGAN TRANSPLANT
donors who are thoroughly prepared by middle Marriage involves a sustainable relationship be-
men to pass the scrutiny, hold their breath till the tween two families. All attempts are made to
time donor recipient pairs pass the video record- ensure stability of marriage respecting social
ed tests of these committees. The decision of values, customs, traditions (18) and even legisla-
these committees may or may not accord legal tion. The bride is showered with gifts throughout
sanction to these transplants (7).
her life to keep the marriage going. The first year
GEOGRAPHY AN IMPORTANT FACTOR IN MARRIAGE AND ORGAN TRANSPLANTATION
being very crucial for the adjustments, the bride is often showered gifts by her parental family not only for herself but for her other immediate family members too to enable her to have a peaceful
Very few like to get their daughters married to a coexistence within the family. The ultimate aspiperson living far off. In organ transplantation also ration of marriage is to keep the family integrated the organs cannot be sent to far off places be- and avert its breakdown.
cause of varying ischemic time. The heart needs to be transplanted within 4 hours, the liver within 12 hours
and kidney within 24 hours after their retrieval from a brain stem dead donor as these organs cannot survive outside human body beyond this time(10).Even when the retrieved
The same holds true for organ transplantation. Akin to gifts post marriage, immunosuppressant's play the trick in organ transplantation. To assist in internal adjustments immune-suppressants are pumped into human beings after the
Reeta Dar, IRJPH, 2017; 1:4
transplant. With time, the number and quantity of immune-suppressants decreases but continue throughout life (22) akin to gifts post marriage. DESIMILARITIES IN INFRASTRUCTURE AND MANPOWER IN MARRIAGE/ORGAN TRANSPLANTATION Marriages usually require places like community centres, banquet halls, hotels etc. and they are in abundance all over the country. But as per the records available with NOTTO there are 301 designated transplant centres/ hospitals in different states in the country (23). Also there is no shortage of priests or pundits required for solemnizing marriages in India but it is pertinent to state that there is paucity of transplant surgeons in this country. OUTCOME OF MARRIAGE /ORGAN TRANSPLANT Irrespective of all the efforts and money put by family in marriage or organ transplant none of the two end like a fairy tale
. No one lives happily forever in both the cases. Disturbances, minor disruptions, adjustment and coping problems may erupt and vanish with intangible internal and tangible external support. The threats of separation prevail till the end in both the cases. Some eventually end up in legal separation i.e., divorce- when internal and external mechanisms to keep the couple together in harmony fail (24). Similarly the transplanted organ can be rejected anytime and second transplant done with another organ usually in case of kidney transplant (25).
kidney transplant usually. In certain cases a person needing a transplant may have a family member willing to donate kidney but donor kidney may not be compatible with him. The kidneys of two such willing non- compatible donor recipient pairs are swapped to ensure best kidney match in two recipients in two different families .This is called Swap transplant and has been legalized in India (26). 2. SHARING BRIDE AMONG BROTHERS / SPLIT LIVER TRANSPLANT In very rare cases there is polyandry in marriage due to scarcity of girls in some pockets of this country when a single woman is married to many brothers (27).Akin to this, shortage of organs in certain cases has resulted in split liver transplants (28) when a single brain stem dead donor's liver is divided between two recipients of liver transplantation. 3. SAMUHIK VIVAH (MASS MARRIAGE CEREMONY)/ ORGAN DONATION FROM A BRAIN STEM DEAD DONOR Sometimes community marriages called Samuhik Vivah in Hindi are performed among a number of couples in one go (29). Akin to this 7-8 organs like liver, two kidneys, heart, two lungs, pancreas and intestines from a single brain stem dead donor are transplanted among a number of waitlisted organ recipients within a single day (30).
UNUSUAL MARRIAGES AND TRANSPLANTS
At times some unusual marriages are performed in our society and same holds true for organ donation and transplantation. A few examples are given below:-
1. SWAP MARRIAGE TRANSPLANT
There are some instances when daughters are exchanged in two willing families through marriage. The daughter of one family gets married to the son of other family in exchange for their daughter getting married to the son of first family. There is a possibility of such exchange in case of
Conclusion-Organ donation and transplant involves almost similar processes akin to marriage of a daughter. A person needs to understand the steps involved in organ transplant which is full of roller coaster rides quite similar to marriage of a daughter. Future scope of this article- This article is a benchmark and can be referred for development of Information Education & Communication (IEC) material, audio visual spots, script for role play or social drama to make people understand the nuances and intricacies of organ transplant in a simplified language. References
Reeta Dar, IRJPH, 2017; 1:4
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