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The Declaration of Istanbul on Organ Trafficking and Transplant Tourism (2018 Edition) Introduction

Muller, Elmi, MD, PhD1; Dominguez-Gil, Beatriz, MD, PhD2; Martin, Dominique, MD, PhD3

doi: 10.1097/TP.0000000000002541
In View: Letter

1 Department of Surgery, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa.

2 Organización Nacional de Trasplantes, Ministerio de Sanidad, Consumo y Bienestar Social, Spain.

3 School of Medicine, Faculty of Health, Deakin University, Geelong, VIC, Australia.

Received 28 September 2018. Revision received 1 October 2018.

Accepted 12 October 2018.

The authors declare no funding or conflicts of interest.

Correspondence: Elmi Muller, Department of Surgery Groote Schuur Hospital University of Cape Town, Cape Town, South Africa. (

It is 10 years since the Declaration of Istanbul (DOI) on Organ Trafficking and Transplant Tourism was developed. Although not a legally binding text, the DOI has been profoundly influential upon national legal frameworks and professional codes of practice. The DOI represented the position of the international transplant community against practices that violate the fundamental rights of the vulnerable and tarnish the reputation of transplantation medicine.

An updated edition of the DOI was recently presented at the congress of The Transplantation Society in Madrid, Spain. The update was important after a decade of work, leading to a better understanding and conceptualization of these criminal practices. For example, in recent years, many groups have worked on updated definitions of organ trafficking and commercialization, with the most significant work produced by the Council of Europe, particularly its Convention on Action Against Trafficking in Human Organs. ( Because the DOI is now 10 years old, many of the definitions and issues need to be updated in the original document. Where the original document had 3 definitions of the terms, organ trafficking, transplant commercialism, and travel for transplantation/transplant tourism, the set of definitions in the 2018 edition has been expanded. Definitions now distinguish more clearly between organ trafficking and trafficking in persons for the purpose of organ removal. Furthermore, resident versus nonresident person is defined in the context of the declaration. The document also explains what is meant by self-sufficiency in transplantation and financial neutrality in organ donation.

The definition of transplant commercialism has been removed because this concept is now more clearly defined in the context of the definition of organ trafficking. The set of 6 complex original principles has been revised and expanded to 11 more concise principles.

Lastly, the section of the original text detailing proposals for potential implementation has been replaced by a separate commentary article in which the practical implications of the DOI are discussed and recommendations outlined in greater depth. The commentary article will be presented as a separate document to support the interpretation of principles and provide examples for their implementation in practice. This decision was made to make the actual document shorter and easier to read with a more detailed explanation in the commentary article.

One important difference between the 2008 edition and the 2018 edition is the process in which this document was formed. The first iteration of the 2008 edition was developed by an international multidisciplinary steering committee, followed by a workshop attended by 158 global representatives, including government officials, social scientists, and ethicists. This meeting took place in Istanbul, Turkey, between April 30, 2008, and May 2, 2008. The 2018 edition similarly began with an updated document drafted by an international working group of 42 individuals convened by the Declaration of Istanbul Custodian Group's Executive. This document and an accompanying draft of the commentary article were then made available for public consultation via an online platform for a period of 2 months. All societies and organizations which had endorsed the DOI, as well as Declaration of Istanbul Custodian Group members, were directly invited to participate in the consultation. Complete responses were received from 245 individuals, representing more than 64 countries, including 65 responses on behalf of professional societies or organizations. Comments expressed a positive overall support for the updated text. All feedback received was reviewed before a final version of the document was produced by the working group. At a 1-day preconference workshop in Madrid, the document was presented to the stakeholders—a well-attended workshop with more than 120 delegates.

The new edition of the DOI is more concise and provides greater conceptual clarity, which will enhance its value for those seeking to use it as a reference point for the development of ethical guidelines or policy at the local level. The 2018 document also aligns well with international norms and developments over the last 10 years. It remains an essential set of ethical standards articulating the responsibilities of health professionals and policy makers who must continue to combat unacceptable practices in donation and transplantation and strive to fufill the great promise of organ transplantation for people across the world.

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