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Seeking to Close the Loopholes in Transplant Tourism and Organ Trafficking

Chapman, Jeremy R. AC, MD, FRCP, FRACP1

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doi: 10.1097/TP.0000000000001955
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The Declaration of Istanbul1 was the professional societies’ response to global organ trafficking and was designed to establish professional norms and principles in the same way as the World Health Organization’s Guiding Principles2 established norms and principles for governments and their health authorities. The Declaration of Istanbul was created by The Transplantation Society in partnership with the International Society of Nephrology in 2008 through a meeting of more than 150 individuals from more than 70 countries, from a variety of disciplines including ethicists, health professionals, and policy makers. The meeting was deliberately placed in Istanbul as the bridge between east and west, as well as the different religious traditions, to signal the global nature of the resultant professional standards.

In the mid 2000s, this focus on organ trafficking at both governmental and professional levels lead to a reduction in commercial organ transplantation. The international approbation heaped on China for use of executed prisoner organs as an export business also impacted, with a final ban on the use of executed prisoner organs by 2015.

A number of high profile arrests and prosecutions in Pakistan, India, and China were followed by visible and measurable actions taken by wealthy countries with poor organ transplantation rates. Israel, for example, legislated to stop use of health insurance to pay for illegal transplants overseas; Malaysia banned provision of immunosuppressants for patients returning to the country with transplants. Many countries turned, with varying success, to the task of increasing self-sufficiency through domestic deceased and living donor transplants, including European countries, Canada, United States, Australia, and Saudi Arabia.

Numbers of commercial transplants have increased again in the past 5 years, with major commercial programs in Egypt, Pakistan, India, Bangladesh, Sri Lanka, Cambodia, Vietnam, and Mexico. Ineffective legislative implementation, poor enforcement, and substantial profits have again driven illegal transplant numbers up in the past few years. Greater sophistication has been needed in definitions of organ trafficking, and reinvigorated legislation has thus become important.

Responding to the recrudescence of organ trafficking and transplant commercialism, the Council of Europe has created a treaty for international action,3 the Pontifical Academy of Science has considered organ trafficking in the context of human trafficking, and the Declaration of Istanbul Custodian Group has reviewed actions that might bring downward pressure to bear on the profit seeking clinical transplant programs.4 In this context the article: Management of patients who receive an organ transplant abroad and return home for follow-up care: Recommendations from the Declaration of Istanbul Custodian Group5 in this month’s issue, has addressed the question of what response nations might make to discourage people from seeking dangerous and illegal transplants in medical tourism destinations. In some countries, individuals can be prosecuted for undertaking illegal acts in foreign destinations—so-called extra-jurisdictional legislation. The core of the Declaration of Istanbul Custodian Group proposal is that this approach should be extended from instances of child sexual abuse to instances of commercial organ transplantation.

The practical complexity of successful prosecution of patients, who have received transplants overseas, and the ethical dilemmas that this places on physicians are of course the issues which spring to the mind of those of us who care for transplant patients. Very few such patients arrive in the clinic with a discharge summary and those that do fail to detail the donor. None admit to undertaking an illegal act, many claiming instead to have been transplanted from a nephew, niece, or other unspecified relative. The fact that doctors are not empowered as investigative agents does not stop countries from legislating mandatory reporting of certain infections or suspected child abuse, so why not require reporting of all overseas transplants? The difference for the physician is that reporting suspected child abuse is acting for, not against, the interests of your patient.

Advocating for an international set of principles for essential care for transplant recipients and respect of the donor who has been the source of organs is unarguable. Agreement on the detail and application to each nation would be an enormous task, which some will argue will fail to impact where it is most needed in the countries turning a blind eye to a profiteering medical establishment. That did not stop advocates for abolishing slavery, and it should not stop professionals now from standing up to the “iPad for a kidney” profiteers and bringing to attention organ trafficking.6


1. Steering Committee of the Istanbul Summit. Organ trafficking and transplant tourism and commercialism: the Declaration of Istanbul. Lancet. 2008;372:5–6.
2. World Health Organization WHO Guiding Principles on Human Cell, Tissue and Organ Transplantation. Transplantation. 2010;90:229–233.
3. López-Fraga M, Domínguez-Gil B, Capron AM, et al. A needed convention against trafficking in human organs. Lancet. 2014;383:2187–2189.
4. 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;95:1306–1312.
5. Domínguez-Gil B, Danovitch G, Martin DE, et al. Management of patients who receive an organ transplant abroad and return home for follow-up care: recommendations from the Declaration of Istanbul Custodian Group. Transplantation. 2018;1:e2–e9.
6. Widdop K. Desperate Chinese boy, 17, sells kidney for £2,000 to buy an iPad and iPhone. Daily Mail. April 6, 2012. Accessed Sept 14, 2017.
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