At first glance, it might appear that with such limited resources and the prevalence of global health problems (such as malaria, HIV/AIDS, and tuberculosis), the World Health Organization (WHO) should really not be dealing with the issues of cell, tissue and organ transplantation—fields that only benefit a few hundred thousand people annually, mostly in the developed world. Two obvious reasons can be offered to justify WHO’s interest.
First, in allotransplantation, the question of the buying and selling of organs raises profound questions of justice and human rights in the health care domain, and health care is WHO’s territory. Second, in the case of xenotransplantation, the potential for infections spreading into the community when a recipient of an organ from a nonhuman animal becomes the nidus of infection is a legitimate concern of WHO. In the case of organ selling and the related issues of trafficking and transplant tourism, WHO has in the past condemned these practices, as have other organizations, and many countries have passed laws against them. And yet these practices continue to grow both in terms of kidneys transplanted and in terms of transplant centers and countries involved (1). We haven’t done a good job of parsing these practices. It is difficult to see how this particular resolution will make any significant difference, other than to lend moral weight to the discourse that others can draw upon when arguing against these practices.
It is interesting that this resolution advocates extending living donations. This is a complete reversal of the spirit of the 1991 WHO Guiding Principles, which were very negative about living donations and considered them only ethically acceptable as a last resort. My colleagues and I have consistently argued in favor of increasing living kidney donations, including from unrelated donors with legitimate relationships with the recipient (2). There are those who have argued that encouraging living donation will encourage commercialization, but those who took this position, in my view, never really understood the realities of developing countries, nor the fact that cadaveric donation would never adequately satisfy the growing need and demand for organs in almost all countries in the world.
WHO was represented at the recent Amsterdam Forum to consider the issues around the care of the living kidney donor. It could use its good offices to help countries implement the Amsterdam recommendations and support us on the Ethics Committee of the (international) Transplantation Society as we work to do the same (3).
What the WHO can do well is collect data; this resolution does talk about data collection in the context of revising the 1991 WHO Guiding Principles on Human Organ Transplantation. It is noteworthy that the WHO Task Force on Organ Transplantation, of which I was a member during its existence in the mid-1990s, made the same recommendation to revise those outdated guidelines; somehow, that did not occur. We hope things will be different this time. When the revisions are made, it will be crucial to have wide representation of different informed stakeholders, particularly from the developing world, where organ transplantation is likely to experience its fastest growth rates in the future.
As for xenotransplantation, there are a number of ethical issues (4), but for WHO the real issue is the risk of xenogeneic infections spreading to the public. This resolution makes very sensible suggestions. These suggestions are similar to those made in the report of the WHO Consultation on Xenotransplantation that I chaired in 1997 (5). The recommendations of this resolution are more likely to be implemented because of the very fact that there is a resolution and because the last item in the resolution requests the Director General of WHO to report “at an appropriate time” to the Health Assembly, through the Executive Board, on implementation of this resolution.
Having worked with WHO in several capacities over the years, currently in a WHO Collaborating Center, I have come to understand some of the ways that WHO works, and its strengths and weaknesses. It really has some incredibly talented people working for it: this resolution would not have made it to the Executive Board or the World Health Assembly without the years of diligent hard work by Luc Noel from the Department of Essential Health Technologies and Alex Capron, the first Director of Ethics, Trade, Human Rights, and Health Law. It is well meaning, as we can see from the Herculean task it has set itself to implement: the “3×5” program which aims to get 3 million people living with HIV/AIDS in developing and middle income countries on antiretroviral treatment by 2005, which is seen as a step towards the goal of providing universal access to treatment for all who need it as a human right.
WHO sometimes pulls off incredibly difficult feats, such as helping to eradicate smallpox and now heading towards the eradication of polio. It can, on occasion, undertake challenging and controversial tasks very rapidly and mobilize the world and its resources, as it did during the SARS crisis. However, it is underresourced for the work it is trying to do globally, particularly in developing countries, and has been terribly bureaucratic, although there are indications recently that it has improved in this respect.
The fact that the resolution requests the Director General to report on implementation of this resolution means that some day the Director General will report to the Executive Board—the bureaucracy of the institution will ensure that. I am pretty sure that report will reach the World Health Assembly. I doubt, however, if the World Health Assembly will really feel very excited about organ transplantation, mainly because the majority of the countries will consider this of marginal importance to them. But if WHO at least does manage to revise the 1991 guidelines, establish a really good database, and work with the Transplantation Society to implement some of the Amsterdam recommendations, then all the good work that Luc Noel and others have done over the years will be worth it.
1. Daar AS. Money and organ procurement: narratives from the real world. In: Daar AS, Gutmann T, Land W, eds. Ethical, legal and social issues in organ transplantation. Munich, PABS Publishers, in press.
2. Daar AS, Land W, Yahya TM, et al. Living donor renal transplantation: evidence-based justification for an ethical option. Transplant Reviews
1997; 11: 95.
3. Ethics Committee of the Transplantation Society. The Consensus Statement of the Amsterdam Forum on the Care of the Live Kidney Donor. Transplantation
2004; 78: 491,
4. Daar AS. Ethics of xenotransplantation: animal issues, consent, and likely transformation of transplant ethics. World J Surg
1997; 21: 975.
The Xenotransplantation Guidelines of the Council of Europe
Regulatory Guidelines of the World Health Organization
The WHO Report on Xenotransplantation
Madrid Meeting, October 2003
WHO May 2004 World Health Assembly Resolution
Note: The views expressed on these sites are independent and do not necessarily reflect the opinions of the authors or Editors of this forum.