While visiting her father's grave last week before the Qingming Festival, Ruan Xiaocong felt bad because she hadn't fulfilled her father's last wish, which was to donate his body to help others.
Several years before his death, the senior had told the family that he wanted to donate his body, but his wife and both daughters, including Ruan Xiaocong, strongly objected to the idea. The senior had been a financial clerk at the city's port, dying at age 88. He had wanted to donate his corneas for transplant and donate his body for scientific research to a medical school.
"After some time, we managed to talk him out of the idea," Ruan says. "My mother was really unhappy about it since she thought my father wanted to donate because he didn't want to be with her in the next life. After that, my father never mentioned donating his body again."
Three years after her father passed away, Shanghai-native Ruan says she feels remorse.
"Every time I see news about body donation and organ transplants on TV, I think of my father," the 50-year-old woman says. "He must be sad we didn't support him."
Ruan's family is not a special case when it comes to donating bodies, organs or corneas for transplant. Although the number of people willing to donate has increased in the city in recent years, there is still a great need of organs and corneas, as well as cadavers for medical schools.
The shortage is acute and China is setting up a nationwide organ transplant system that is supposed to be comprehensive, fair and transparent, matching donor organs with the most needy recipients.
The former Ministry of Health has said it plans to move to a voluntary national organ transplant network by around 2015, phasing out reliance on organs from executed prisoners. (After restructuring, the National Population and Family Planning Commission and the Ministry of Health have been combined.)
Every year more than 300,000 people around China need an organ transplant, but only around 10,000 actually receive one, according to the former Ministry of Health.
In 1982, Shanghai became the first city on the Chinese mainland to permit and encourage donation of bodies and corneas.
Since then, 33,814 people have registered to donate their body or corneas, resulting in 6,679 donations, according to the Shanghai Red Cross.
Last year nearly 2,490 people in Shanghai donated corneas or their bodies, an increase of around 50 percent over 2011, the Red Cross said.
The lack of donations stems partly from the traditional Chinese concept that body must be interred intact in order to enter the afterlife. It's also partly due to inadequate laws and questions about fairness in organ distribution. For example, there's no law to protect the interests of donors and their families; this sometimes results in conflicts between donors' families and recipients.
Many Chinese believe it is very inauspicious, horrible in fact, to donate the body for anatomical studies or organ donation, even the corneas. It is considered a "bad death" if a body is cut after death, or an organ is missing. It is believed by many people that the imperfect boy will follow the soul to the next world, and will affect reincarnation since the missing body parts may still be missing in the next life.
"To be honest, when my father told us about the donation, I couldn't even bear to think of people cutting into his body for research," says Ruan. "That image in my mind would leave me mentally scarred."
Another reason for the lack of bodies and organs for transplant is the lack of laws that recognize brain death in addition to cardiac death. The former Ministry of Health reported last year that of the 465 cases involved in an organ donation trial project all over the country, 47.5 percent were donations after cardiac death and 43.5 percent were donations made after both cardiac and brain death. Organ donations after brain death accounted for just 9 percent of the total.
Brain death, though accepted in more than 90 countries worldwide, is not legally acknowledged in China. Traditionally, Chinese people determine a person's death based on cardiac death.
"Donations after brain death should become the mainstream for organ donations," says Yuan Xiaopeng, an organ transplant expert with the No. 1 Affiliated Hospital of Sun Yat-sen University in Guangzhou, capital city of Guangdong Province.
Meanwhile, according to city regulations on body and organ donation, prospective donors must receive permission from immediate families, including spouses, parents and children before the recipients can sign an agreement with them. If the prospective donors' families change their mind and refuse to go along after the prospective donor's death, there is no penalty. The agreements, more like letters of intent, are not legally binding.
"Some registered donors were unable to make a donation after their death because their family disagreed," says Zhou Xianglan, director of volunteer department of the Shanghai Red Cross.
Another problem is the lack of tracking and loss of donors' contacts after they sign a letter of intent. Some prospective donors moved or changed telephone numbers, so the Red Cross was not able to contact them.
The Red Cross says that several years ago it tried to send New Year's cards to the donors, but around half the cards were returned because the prospective donors had moved and all contact was lost.
The organization has started to reorganize donor's contacts in their computer system.
One result of the lack of donations is the lack of cadavers for dissection in medical schools throughout China. Medical schools everywhere complain that many students must share a body in anatomy courses, or worse, students do not take anatomy lab courses and learn to dissect; instead they watch detailed films prepared for anatomy students. But there's no substitute for first-hand experience.
According to the Shanghai Medical College of Fudan University, a medical student should dissect a body during undergraduate studies, but usually eight students must share a cadaver.
"Students need to acquire basic knowledge of the human body through anatomy and also study pathology through anatomy - both involve lab work and dissection," says Tan Deyan, an anatomy expert with Fudan University.
According to the Red Cross, every year all the medical schools in Shanghai need 600 to 700 cadavers, but they receive only around 400. Still, the situation in Shanghai is better than in other Chinese provinces on the mainland.
Liu Li, a student at Shandong University School of Medicine, says they take both general and specialized anatomy covering various organ systems. They cannot dissect in the general course but can only watch models being dissected. In the specialized courses, 10 students share a specimen for dissection.
"The specimens are mostly old, preserved in formalin for years," says Liu. "The sources of cadavers are drying up."
During instruction, students must compete for operation of dissection opportunities; otherwise, they would never have a chance to do lab work. "Even the women rush to grab the bodies," she says.
According to long-standing rumors on the Internet, many cadavers and specimens for medical schools are from executed prisoners, but the schools in Shanghai have denied the reports. Most of the specimens are donated freely by people who are not in prison, they have said.
Meanwhile, the country's reliance on organ transplants from condemned prisoners will end within two years, as a human organ donation trial project has proven successful, the former Ministry of Health said recently.
From March 2010 to the end of September 2012, the trial involved 465 donation cases, which resulted in 1,279 organs being donated by members of the public, according to the former Ministry of Health.
Systematic organ donation is expected to become a reality. The severe shortage of organs needed for transplant is forcing change. In 2007 the State Council has issued a regulation on human organ transplant, which banned trade in organs for transplant. Organs are to be donated freely and without compensation.
Last December hospitals in Shanghai have started to distribute pamphlets on organ donation to inform the public. Local health authorities have begun drafting detailed rules and regulations, but the city still has a long way to go to meet patients' needs for donated organs.
Ten senior officials with Zhongshan Hospital in Shanghai recently signed a letter of organ donation intent. They are expected to issue a call for the public to accept the concept of donation to save people's lives.
"At our hospital, around 400 to 500 people are waiting for organ transplants, including more than 300 who need kidneys," says Zhu Yutong, deputy director of the hospital. "The latest figures show that in China the proportion of organ supply to demand is 1:30, but I say that figures it too optimistic."
Ruijin Hospital officials also express concern about the severe shortage. "Patients with heart or liver diseases pass away before finding matching donors for transplant," says Zhu Zhecheng, a liver transplant expert at the hospital.
Doctors says 70 percent of organ transplants are done among families. Although many more people are willing to donate organs while they are alive, they don't know how and the paperwork is daunting.
"The whole procedure of organ donation is too complicated," says Zhu Yutong. "People have to fill in several forms, going to notary office for notarization, then send the forms to receiving/recipient organizations. I hope the procedure can be simplified."
Shanghai is participating in the pilot program of a national organ donation system. In December this year, the first group of 17 major, city-level hospitals will begin to collect and transplant organs.
That will mark the city's official participation in the national organ donation system.
Under the system, all information about donated organs and patients with organ failure will be put into a national distribution and sharing database network to ensure organs go to the patients with the greatest need on the waiting list.
According to law, those trafficking in human organs can be fined and sentenced to around five years' in jail. The former Ministry of Health recently said the country still needs a third-party authority to monitor donations to ensure fairness and making sure the neediest patients get the organs first - not the richest and most influential.