As a consequence of the widespread shortage of organs and the increasing ease of Internet communication, organ trafficking and transplant tourism have become global problems accounting for an estimated 10% of organ transplants that are performed annually around the world.
Organ trafficking, transplant tourism and transplant commercialism threaten to undermine the nobility and legacy of transplantation worldwide because of the reality associated with these practices – the vulnerable in resource-poor countries (such as the illiterate and impoverished, undocumented immigrants, prisoners, and political or economic refugees) are exploited for their organs as a major source of organs for the rich patient-tourists who are prepared to travel and can afford to purchase organs.
These unethical practices were the subject of a Summit convened in Istanbul from 30 April 30 to 1 May 2008 by The Transplantation Society (TTS) and the International Society of Nephrology (ISN). The result of these deliberations was the Istanbul Declaration on Organ Trafficking and Transplant Tourism . The development of the Istanbul Summit and Declaration was derived from a direction by the World Health Assembly in 2004 as it adopted resolution WHA57.18 urging member states ‘to take measures to protect the poorest and vulnerable groups from transplant tourism and the sale of tissues and organs, including attention to the wider problem of international trafficking in human tissues and organs’ .
Although the World Health Assembly (WHA) 2004 resolution was unambiguous in its objection to trafficking and transplant tourism, a comprehensive description of these unethical practices was still needed. Organ trafficking, transplant tourism and transplant commercialism are now defined by the Declaration, and it provides principles of practice based on those definitions.
The Istanbul Declaration distinguishes transplant tourism from travel for transplantation. Travel for transplantation is the movement of organs, donors, recipients or transplant professionals across jurisdictional borders for transplantation purposes. Travel for transplantation becomes transplant tourism if
- it involves organ trafficking and/or transplant commercialism; or
- if the resources (organs, professionals and transplant centers) devoted to providing transplants to patients from outside a country undermine the country's ability to provide transplant services for its own population.
Not all recipients' travel to foreign countries to undergo transplantation is unethical. Travel for transplantation may be ethical if the following conditions are fulfilled:
For live donor transplantation:
- if the recipient has a dual citizenship and wishes to undergo transplantation from a live donor that is a family member in a country of citizenship that is not their residence;
- if the donor and recipient are genetically related and wish to undergo transplantation in a country not of their residence.
For deceased donor transplantation:
- if official regulated bilateral or multilateral organ-sharing programs exist between or among jurisdictions that are based on reciprocated organ-sharing programs among the jurisdictions.
The Istanbul participants emphasized that organ trafficking and transplant tourism should be prohibited because they violate the principles of equity, justice and respect for human dignity. The Declaration is also clear regarding the consequences of transplant commercialism. Because transplant commercialism targets impoverished and otherwise vulnerable donors, it leads inexorably to inequity and injustice and should also be prohibited. To be effective, these prohibitions must include bans on all types of advertising (electronic and print), soliciting or brokering for the purpose of transplant commercialism.
At this time, most of the countries from which transplant tourists originate, as well as those destinations to which they travel to obtain transplants, are just beginning to address their responsibilities to protect their people from exploitation and to develop national self-sufficiency in organ donation. The medical leaders who played major roles in the promulgation of laws and regulations within the past 2 years in China, Pakistan and the Philippines were participants in the Istanbul Summit meeting. The Declaration describes universal approaches to providing care for the living donor and also emphasizes the need for effective practices that support deceased organ donation.
The extent of organ trafficking and transplant tourism
Countries that have facilitated organ trafficking such as Pakistan and the Philippines do not release precise data (not surprisingly) regarding the numbers of foreign patients that travel to these countries for transplants. Despite its clandestine nature and the difficulties in obtaining national data, the extent of organ trafficking has become evident by visits to many countries around the world and by reports prepared for presentation at the WHO. The following provides a country-by-country description of current events that may impact the practice of transplantation internationally for the foreseeable future.
During calendar year 2006, it was estimated that at least 4000 prisoners were executed to provide approximately 8000 kidneys and 3000 livers for mainly foreign patients purchasing these organs. In March 2007, the Regulation on Human Organ Transplantation was approved by the State Council of the People's Republic and implemented on 1st May 2007 . Currently, 87 institutions have full approval from the Ministry of Health to perform transplants whereas 77 additional institutions have provisional approval to comply within a year. The number of transplant centers has been reduced from approximately 600 institutions performing transplants in 2006. Transplant tourism has been markedly curtailed.
Vice Minister of Health, Jiefu Huang, has taken courageous action as a result of information submitted by the Istanbul Steering Committee directly to the Ministry of Health. Three hospitals have been sanctioned and closed for at least 1 year as a result of information furnished to Chinese authorities. It is recognized that the Chinese government does not have complete control over all hospitals, for example, military hospitals. Thus, we are aware that patients are still going to China to obtain organs from executed prisoners.
There may be over 400 deceased organ donors available in Colombia annually for transplantation. That number is evidently more than what is needed for Colombian patients; but there is no transparency as to the number of foreign patients that undergo mainly liver transplantation. Patients from Israel and Japan (at least) take advantage of the system that was intended to provide a priority for Colombian patients. There is much skepticism about Colombian patients not having access to the list because there has been no assessment by the Colombian Government to confirm otherwise.
The Indian government is continuing to monitor illegal activities and has renewed its opposition to commercialization following the Gurgaon scandal of January 2008; kidneys were from those deceived into thinking they were going to participate in a program that would give them employment (http://en.wikipedia.org/wiki/Gurgaon_kidney_scandal). Unrelated ‘altruistic’ donation is now subjected to more stringent examination by transplant centers. The Transplant of Human Organs Act of India is now being revised, and it will maintain a prohibition of organ sales.
The Knesset has outlawed illegal transplants in destinations outside of Israel. Funding of transplant tourism by insurance agencies is being withheld. Brokers can anticipate criminal prosecution. The legislation enacted in March 2008 also permits up to 18 000 shekels as a reimbursement for donor expenses provided as a fixed onetime payment and what was estimated as the financial loss associated with the donor evaluation process (travel expenses and loss of workdays) and the immediate consequence of the surgery (loss of wages) (http://www.israelnationalnews.com/News/News.aspx/125675). The regulatory authorities of Israel have not implemented this provision of the legislation. The Istanbul Steering Committee will ask the regulatory authorities to individualize the reimbursement of expenses, of course not exceeding the limit noted above.
Living unrelated donors (LURDs) constitute the major source of renal allograft in Iran. LURD transplantation is performed in a program assisted by the Dialysis and Transplant Patient's Association (DATPA) that was intended to be controlled; but it is widely known that ‘regulation’ has not been realized. Under-the-table payments by the recipient family to the vendor's broker are customary and well known. The Iranian model is considered to be in violation of the Istanbul Declaration.
There have been more than 20 000 kidney transplants performed in Iran over the past 15 years from unrelated donors. There is little known about those vendors, and most donors do not have enough knowledge about possible in-hospital and long-term complications of kidney donation. As a result, relatively few may not participate in regular follow-up after operation. A current study by the group in Tehran of over 400 vendors has provided a candid reflection of the social circumstances of those that sell a kidney. The vendors have experienced a job loss or a substantial reduction of income or the loss of a family member – suggesting they could be depressed.
Parting with a kidney is no remedy for depression. The Iranians are clearly disturbed to write ‘changes should be made before presenting (the Iranian Model) as a successful model to the rest of the world’ .
Since the changes in China and the Philippines that prohibit foreign transplants, patients from the Gulf countries have been going to Cairo to purchase kidneys. It is estimated that at least 1000 kidney transplants are done in Egypt each year. Countries such as Saudi Arabia and Kuwait have deceased donor programs that are expanding to address the needs of the patients. These efforts are timely because changes are underway in Egypt.
Representatives of the Istanbul Declaration met with the Egyptian Minister of Health and Egyptian Society of Nephrology leaders in Cairo in 15 October 2008. The Minister assured the Istanbul Representatives that government action to curtail foreign patients from undergoing transplantation in Egypt will be initiated. The Egyptian Society of Nephrology presented a detailed plan to support the Ministry and the Istanbul Declaration. President Mubarak has subsequently addressed the Egyptian Parliament to stress that the organ donation legislation that has been stalled for more than a decade must be enacted.
President Musharraf signed an ordinance in 2008 prohibiting foreign patients from going to Pakistan to purchase kidneys before he departed from office. As recently as November 2008, a patient from India underwent transplantation in Lahore Pakistan at the Aadil Hospital. Thus, the ordinance has not been completely effective. Istanbul is represented by two outstanding leaders from Karachi, Adib Rizvi and Anwar Naqvi, so there is confidence that the ordinance will prevail despite the unsettled political climate and attempts by brokers selling kidneys from bonded laborers to rescind it .
Payment for donors for non-Filipinos is now prohibited by a directive from President Arroyo promulgated in April 2008. The Philippine Society of Nephrology reports that foreign patients no longer have easy access to purchase kidneys. Manila has been a site for the worst abuses of organ trafficking, and continued vigilance by the Istanbul leadership will be needed.
The Istanbul Steering Committee is concerned that Minister of Health Minister Khaw Boon Wan has suggested compensation for the loss of a kidney to be acceptable. Impoverished individuals from Myanmar, Vietnam, Indonesia, the Philippines or from Malaysia may be departing Singapore with one kidney after a government-instituted program of sales. Istanbul will not accept such practices if that is determined to be the reality.
USA and Canada
Patients are still returning from China and Egypt with kidneys obtained from vendors. The Istanbul Steering Committee is now in receipt of reports regarding this activity with indisputable evidence including billing documents from the transplant hospitals.
The immediate future
The implications of the Istanbul Declaration definitions, principles and recommendations are profound. They call for a legal and professional framework in each country to govern organ donation and transplantation activities. They call for a transparent regulatory oversight system that ensures donor and recipient safety and enforces the prohibitions of unethical practices. Governments should ensure the provision of care and follow-up of living donors be no less than the care and attention provided for transplant recipients. Professional societies should not continue to enable membership status for those individuals that violate the principles of the Declaration. Pharmaceutical companies and public and private funding agencies must affirm the Declaration in their consideration of clinical research support.
The Istanbul Declaration is not just about saying ‘no’ to live donation. It supports the care of the live donor with programs that would make the experience for the donor not a monetary burden, and thus, cost neutral. Istanbul also emphasizes that the hard work of deceased donation cannot be set aside by a complacency that only uses the living donor. The Istanbul Declaration is underway to preserve the goodness of the act of organ donation without victimizing the poor of the world that are otherwise have been used as the source of organs for the rich.
I thank Eytan Mor for his review of the manuscript.
References and recommended reading
Papers of particular interest, published within the annual period of review, have been highlighted as:
• of special interest
•• of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (pp. 211–212).
2 Steering Committee of the Istanbul Summit. Organ trafficking
and transplant tourism
and commercialism: the Declaration of Istanbul. Lancet 2008; 372:5–6.
3 Huang J, Mao Y, Millis JM. Government policy and organ transplantation in China. Lancet 2008; 372:1937–1938. This article is an important testimony of the People's Republic of China to improve the ethical practices of transplantation by curtailing foreign patients undergoing transplantation from organs recovered from executed prisoners.
4 Nejatisafa AA, Mortaz-Hedjri S, Malakoutian T, et al
. Quality of life and life events of living unrelated kidney donors in Iran: a multicenter study. Transplantation 2008; 86:937–940. This article is an important acknowledgment by the Iranian leaders as to the limitations of Iranian model.
5 Naqvi SAA, Ali B, Mazhar F, et al
. A socioeconomic survey of kidney vendors in Pakistan. Transpl Int 2007; 20:934–939.