Navigating Ethics and Rules: How a Kerala Government Hospital Saved a Nepali Woman’s Life

Arpana, known as Durga Kami,(22) waited for more than six months, clinging to the hope that the rules governing organ transplantation—rules that draw a hard line between locals, nationals and foreign citizens—would bend in the face of imminent death. Diagnosed with end-stage heart failure, she watched time run out as her condition worsened.

In September, when her case was deferred to prioritise a local patient in accordance with the prescribed norms, hope began to slip away. But now, after more than six months of waiting with bated breath, Durga Kami is recuperating at a government general hospital in Kerala, following a successful heart transplant. The donor heart was harvested from a brain-dead patient in Thiruvananthapuram, and the surgery was carried out after the Kerala High Court intervened to allow an exception to the rules.

Law and Ethics

Her survival story unfolds across multiple layers. It marks a medical milestone—the first heart transplant performed at a government district general hospital in the State. It also exposes a profound ethical dilemma embedded in the organ transplantation framework, which prioritises nationality at a time when life itself is hanging in the balance. And finally, it forces a larger question into public view: how should the law weigh citizenship when the difference is between life and death?

Durga Kaami,was living with her brother in an orphanage in Nepal. Her mother had died of cardiac disease, and about four years ago Durga Kaami herself began experiencing breathlessness and other symptoms of a serious heart condition.

Dr. Shajan Varghese first encountered her during a visit to Nepal last year. A friend had told him about the orphanage and asked if he could examine the inmates. “When I examined Durga Kaami, I realised her condition was quite serious,” Dr. Varghese recalled. “I prescribed some medicines, but that was all I could do at the time. She was suffering from a rare and serious heart condition called Cardiac sarcoidosis”

After returning to Kerala, Dr. Varghese was contacted again by a friend from Nepal, who asked whether anything more could be done for her. “I discussed the situation with my doctor friends here,” he said. “Around that time, the Ernakulam General Hospital was preparing to begin heart transplant procedures. The cardiologists there encouraged us to bring her to Kerala.”

Once Durga Kaami,arrived, she underwent a series of medical evaluations. Doctors found her to be medically fit for a heart transplant, setting in motion a process that would eventually culminate in a landmark surgery—one that would test not only medical preparedness but also the ethical and legal boundaries of India’s organ transplantation framework.

Durga Kaami,’s wait stretched on, indefinite and unforgiving. Each time news of a potential heart donation surfaced, a flicker of hope briefly eased her failing body. But when the rules took their course, that hope was repeatedly deferred, and the wait grew more excruciating. With every missed chance, the shadows over her survival deepened—because for Durga Kaami, only a transplant stood between life and death.

When Humanity Transcends Borders

Under Rule 31(4)(e) of the Transplantation of Human Organs and Tissues Rules, 2014 (THOTA), the sequence of organ allocation is clearly laid out: State list, regional list, national list, Persons of Indian Origin, and finally foreign nationals. The framework was designed to regulate organ transplantation while explicitly criminalising commercial dealings in organs.

The stringent provisions governing foreign nationals are rooted in past concerns over “transplant tourism” and media reports highlighting the exploitation of vulnerable Indian donors. To address this, the Union Health Ministry has, in recent years, taken steps to sensitise foreign nationals seeking organ transplants in India about the country’s legal framework. Last year, the Ministry wrote to the Ministry of External Affairs, emphasising the need to inform foreign nationals travelling to India of the existing laws. The move followed observations that India has emerged as a preferred destination for organ transplantation, owing to its world-class healthcare facilities and highly skilled medical professionals.

But these stipulations, made with good intentions, have nothing to do with Durga Kaami's lived experience; as an orphan, medical tourism was beyond her imagination. She came to Kerala not as a transplant tourist, but through the humanitarian intervention of a doctor who saw her condition deteriorating with time. As the clock ticked and her health worsened, the rules—rigid and impersonal—offered little room for compassion.

It was only through judicial intervention that her case found relief, reminding the system that while laws may recognise borders and categories, humanity does not.

The transplant was finally carried out successfully, giving a fresh lease of life to Durga Kaami. She received the heart of Shibu, 46, a resident of Kollam who was declared brain-dead. After his family—his mother, Shakunthala, and siblings—gave consent for organ donation, the heart was harvested at the Thiruvananthapuram Government Medical College and airlifted to Ernakulam.

The complex surgery was led by the General Hospital’s cardiothoracic surgeon, Dr George Vallooran, marking a milestone for both the hospital and Kerala’s public healthcare system. The Ernakulam General Hospital has thus become the first district hospital in the country to perform heart transplantation.

Doctors have confirmed that the patient is stable and will be under observation for about 72 hours.

Transplantations Spur Rise in Organ Donors

Two months ago, two heart transplants were carried out back-to-back at a private hospital in Kochi, underscoring the growing momentum in organ transplantation in Kerala. Data from the Kerala State Organ and Tissue Transplant Organisation (K-SOTTO) indicate that between 2012 and 2024, 83 heart transplants were performed in the State. Of these, 72 were conducted in private hospitals, whereas only 11 were conducted in government-run institutions.

According to Dr. Noble Gracious, Executive Director of K-SOTTO, the willingness to donate organs has increased steadily over the years. “Back-to-back transplantations, along with greater public awareness about what brain death means, have contributed to the rise in donors,” he said. “Once brain death is confirmed after due procedure, doctors inform the relatives. If they consent to organ donation, ventilator support is continued until the organs are harvested.”

He noted that improved communication with families and better understanding of brain death have played a crucial role in strengthening Kerala’s organ donation ecosystem.

At the same time, professionals involved in Durga Kaami’s case acknowledge the delicate balance the system must maintain. While there was an urgent desire to save her life through exemptions to the rules, they caution that loosening safeguards could open the door to exploitation of vulnerable people by those seeking organs. The ethical tension between compassion and regulation, they argue, cannot be resolved through blanket policies. Instead, it must be navigated carefully, case by case—where the law is tempered by humanity, without losing sight of why the law exists in the first place.