On 24 August 2011, the organ transplant team at the National Taiwan University Hospital (NTUH) failed to identify that a donor had previously been diagnosed with HIV due to an error in recording the HIV test result in the donor’s blood report. As a result, five transplant recipients were exposed to the risk of infection. This incident was the first known case in Taiwan involving the transplantation of organs from an HIV-positive donor, shocking the nation and becoming a major news event. After the medical team administered preventive antiretroviral treatment, follow-up examinations showed that none of the affected patients had contracted HIV. However, the relationship between their immune responses and potential HIV activity remained undetermined. Following an investigation, the Control Yuan initiated impeachment proceedings against Ko Wen-je, who was the leading physician of the NTUH transplant team at the time. The impeachment announcement was made while Ko was abroad attending a conference and unable to return to Taiwan to respond, which triggered further controversy.
Background After a team led by Professor Lee Chun-jen of the National Taiwan University College of Medicine completed Asia’s first living-donor kidney transplant in 1968 and the first cadaveric kidney transplant in 1969, organ transplantation began to develop within Taiwan’s medical community. However, a comprehensive organ donation system had not yet been established at the time; hospitals independently sought donors and carried out transplant procedures on their own. In 2001, Chen Hsi-sheng, a professor in the Department of English at Tamkang University, suffered from fulminant hepatitis B, which resulted in liver failure. His students appealed online for an immediate organ transplant to save his life, drawing significant media attention. At the time, the law only permitted organ donation from relatives within the third degree of kinship. Minister of Health Lee Ming-liang publicly announced in the Legislative Yuan that he was willing to extend the limit to relatives within the fifth degree. However, no suitable liver donor could be found, and Chen passed away. In the aftermath, Minister Lee began working on establishing a formalized organ donation and transplantation procedure. In 2002, the Organ Donation and Transplantation Registry Center was established to oversee organ donations and transplant surgeries across Taiwan. Due to the absence of a functioning registration system, however, the center was initially unable to operate effectively. Ko Wen-je, then director of the Trauma and Emergency Center at National Taiwan University Hospital, was commissioned by the Department of Health’s Bureau of Medical Affairs to develop the organ donation registration system as a special project. In 2005, the organ donation and transplant allocation system was launched. The procedures for organ testing, the design of forms, matching rules, computer software and hardware, and the framework for organ procurement organizations were largely designed and coordinated by Ko. Taiwan’s organ donation and transplantation system was established on this basis. In 2011, the system faced its most serious medical error since its introduction. Due to a mistake made during the verbal reporting of laboratory results, the NTUH transplant team transplanted organs from a donor who had previously been diagnosed with HIV. The incident attracted intense media scrutiny and exposed weaknesses within Taiwan’s organ donation system.
… excerpt ends here. Continue reading the full article.
