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Organ Trade

Knowledge, Awareness, and Nonlegislative Responses

Ambagtsheer, Frederike LLM, MSc1; Weimar, Willem MD, PhD1

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doi: 10.1097/TP.0000000000001063
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The trade in human organs is a hot topic that receives increasing scrutiny from international organizations [A], the transplant community [B], researchers, and the popular press. According to the Council of Europe, the trade is growing worldwide [C]. Governments, international organizations, and transplantation societies are establishing new laws against organ trade or tightening existing regulations.1,2 Organ trade however receives little consideration from law enforcement authorities, and only few successful convictions have taken place [D]. In addition, there are no partnerships between transplant professionals and law enforcement. The HOTT project (2012-2015) is a European Union-funded international research that addresses “trafficking in human beings for the purpose of organ removal.” The project has 3 objectives: to increase knowledge, raise awareness, and improve the nonlegislative response. The project is coordinated by Erasmus MC in collaboration with 3 cobeneficiaries and more than 10 associate partners [E]. This article collates online resources with relevance to the readership of Transplantation providing guidance on the current state of organ trade.

In 2007, the World Health Organization estimated that 5-10% of the approximately 60 000 kidney transplants performed annually around the globe occur via organ trade [F].3 In 2011, the Institute, “Global Financial Integrity” ranked organ trade in the top 10 of the world's most profitable crimes, with an estimated annual illegal profit of US $614 million to US $1.2 billion. [G]. How exactly these figures were established or validated is unclear.4 The World Health Organization indeed recognizes that the current state of organ trade remains obscure because of scarce data and acknowledges that figures should be regarded as “provisional and tentative.” The United Nations Office on Drugs and Crime also affirms that “due to an absence of reliable information, the global scale remains unknown” [F, H]. Estimated numbers of unknown cases are an inherent part of crime research: with the prohibition of a particular act, numbers often drop. Noteworthy, this relationship is not linked to a decline but rather to the development of a black market. As a result, real numbers remain hidden from law enforcement authorities. The scale of the human organ trade will thus be unknown as long as it remains prohibited.5













For these reasons, the HOTT project did not aim to establish how often organ trade occurs. Instead, we began our research by conducting a literature review on actors involved. The review, entitled, ‘Trafficking in human beings for the purpose of organ removal: a comprehensive literature review’ is based on a search of 5 databases in addition to screening more than 10 000 records. The review presents over 200 references on patients, donors, brokers, transplant professionals, hospitals, service providers, translators, and corrupt law enforcement officials who are involved in the network under which organ trade proliferates. The review describes, among others, how brokers recruit patients and donors, how much profit is made, where they travel to and from and to what extent organ sales constitute trafficking in humans. The review presents knowledge gaps due to a lack of ethnographic research into the experiences and motivations of patients that purchase organs and the modus operandi of trafficking networks. The authors conclude that “the scholarly research in this area is not well-developed” [I].

Subsequently, we conducted interviews with 22 patients from Sweden, The Netherlands, and Macedonia/Kosovo who purchased kidney transplants abroad. The aim of this study was to describe their motivations and experiences and to assess how their transplantations were facilitated. To date, this is the largest group of patients that has been interviewed on this issue. The patients provided information about their motivations for going abroad (eg, long wait time, dialysis-related complications, absence of a transplant programme, no living donor in domestic country, affiliations with destination countries, and so on). Practical arrangements that preceded their transplants mainly consisted of help from friends and family at home and abroad. The vast majority of recipients were satisfied with the care they received in the destination country. Nonetheless, 10 patients experienced severe complications ranging from a rupture of the bladder and perineal hematoma necessitating reexploration, severe rejections and infections (sepsis, Hepatitis C, tuberculosis and an infected kidney stone). Recipients, however, shared little information about whether their donors were paid and/or exploited. Thus, although this study has shed light on patients' motivations and experiences, we were not able to determine the potential illegal nature of their transplantations [J]. Therefore, we organized a case study research to acquire information about the modus operandi of organ trafficking networks and the facilitation of illegally performed transplants.

We studied prosecuted cases in South Africa, Kosovo, Israel, and the United States by performing 37 interviews with 49 persons (police, prosecutors, lawyers, transplant professionals, government representatives, and so on). The aim was to describe how police and prosecution discovered each case, how they performed their investigations, what the modus operandi of the networks were, under what laws the prosecutions took place, what the successes and obstacles of law enforcement authorities were, and what the judgment in each case was. This study revealed, among others, sophisticated and subtle methods that trafficking networks use to recruit patients and donors facilitating illegal transplants. This case study also illustrated the difficulties that police and prosecutors experience in convicting networks and in proving that donors were exploited. They in particular encountered difficulties with prosecuting transplant doctors [K].

We presented the project's research results at its international symposium which was held at Europol's headquarters in The Hague, The Netherlands, in November 2014. The event was attended by more than 230 participants. We invited police and prosecutors from the United States, Kosovo, South Africa, and Israel to share their prosecution experiences. One day before the symposium, we organized a “Writers' Conference” where we invited 40 experts to formulate recommendations to improve the nonlegislative response to the crime. Experts convened in 4 groups and developed recommendations that addressed ethical and legal obligations of health care providers,6 the protection of victims,7 strengthening cross-border collaboration in criminal cases,8 and stimulating partnerships between transplant professionals and law enforcement.9 These recommendations highlight, among others, the need for transplant professionals to collaborate more closely with law enforcement. In particular, the transplant community can help improve the nonlegislative response by reporting organ trafficking networks to law enforcement authorities.10

The project's final report is a list of indicators for transplant professionals, law enforcement, and victim support workers based on the project's empirical data. Indicators aim to differentiate legal from illegal transplant activities and to support data collection and identification of trafficking in human for organ removal. The report identifies legal and illegal services provided for each step of the criminal process: recruitment, transport, entrance, documents, housing, transplant, aftercare, and finance.11

The project's reports have been sent to over 1000 of its stakeholders. They have also been posted on the project's website and will be published in a book of which 1000 copies will be distributed.

In conclusion, the HOTT project has contributed to an increase in knowledge and awareness of trafficking in humans for organ removal among law enforcement and transplant professionals. Yet, creating awareness among these groups can only be done by ensuring that evidence-based information about the crime is made easily accessible and readily available. Moreover, an effective nonlegislative response cannot be successfully established if transplant professionals and law enforcement authorities do not collaborate. In addition to scholarly literature, a set of valuable online resources exist on the topic.


1. The declaration of Istanbul on organ trafficking and transplant tourism. Transplantation. 2008; 86 (8): 1013–8.
2. Danovitch GM, Chapman J, Capron AM, et al. Organ trafficking and transplant tourism: the role of global professional ethical standards—the 2008 Declaration of Istanbul. Transplantation. 2013; 95 (11): 1306–12.
3. Budiani-Saberi DA, Delmonico FL. Organ trafficking and transplant tourism: a commentary on the global realities. Am J Transplant. 2008; 8 (5): 925–9.
4. Columb S. Beneath the organ trade: a critical analysis of the organ trafficking discourse. Crime, Law Soc Change. 2015; 63 (1–2): 21–47.
5. Penney TL. Dark Figure of Crime (Problems of Estimation). The Encyclopedia of Criminology and Criminal Justice: Blackwell Publishing Ltd; 2014.
6. Caulfield T, Duijst W, Bos M, et al. Trafficking in human beings for the purpose of organ removal and the ethical and legal obligations of healthcare providers. Transplant Direct. DOI: 10.1097/TXD.0000000000000566. In press.
7. Pascalev A, Van Assche K, Sandor J, et al. Protection of human beings trafficked for the purpose of organ removal. Transplant Direct. DOI: 10.1097/TXD.0000000000000565. In press.
8. Holmes P, Rijken C, D'Orsi S, et al. Establishing trafficking in human beings for the purpose of organ removal and improving cross-border collaboration in criminal cases. Transplant Direct. DOI: 10.1097/TXD.0000000000000571. In press.
9. Capron AM, Muller E, Ehrlich G, et al. Trafficking in human beings for the purpose of organ removal: stimulating and enhancing partnerships between transplant professionals and law enforcement. Transplant Direct. DOI: 10.1097/TXD.0000000000000567. In press.
10. Ambagtsheer F, Van Balen LJ, Duijst‐Heesters W, et al. Reporting organ trafficking networks: a survey‐based plea to breach the secrecy oath. Am J Transplant. 2015; 15 (7): 1759–67.
11. De Jong J, Ambagtsheer F. Indicators to identify trafficking in human beings for the purpose of organ removal. Transplant Direct. DOI: 10.1097/TXD.0000000000000568. In press.
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