The use of transplantation as treatment for patients with terminal organ failure is gradually increasing. However, patient access to organ and tissue transplantations varies widely around the globe (1). Transplantation was first established as a part of routine health care in North America, Australia, and many parts of Europe. These countries are now struggling with increasing waiting lists due to a large gap between the number of available organs and the demand. The main reason for the increase in recent years is a growing number of procedures carried out in developing regions. Complete international statistics of transplantation procedures are lacking and the World Health Organization (WHO) is presently collecting data worldwide. However, it has become obvious that the People's Republic of China (referred to as China in the following text) now has one of the largest transplant programs in the world, with about 11,000 organ transplantations performed in 2005.
Since the late 1980s, there have been multiple indications that executed prisoners are the main (and, more or less, only) source of organs and tissues in the Chinese transplant programs. This has now also been officially acknowledged by a representative of the Chinese government. The Transplantation Society (TTS), as well as other professional societies and human rights organizations, previously condemned this practice in the 1990s; the membership statement of TTS has long stipulated that no member should be involved in obtaining or transplanting organs procured from executed prisoners.
There are many reasons for this position. TTS considers it a basic requirement that the act of donation is voluntary. Moreover, the decision to donate must be based on relevant and sufficient information and made without external pressure or coercion. Even if a death-sentenced prisoner and his family were given such information, the situation makes it impossible to ascertain whether the decision was independent and free. Furthermore, in accord with the position of many medical societies, including the American Medical Association, a physician—as member of a profession dedicated to preserving life—should not participate in a legally authorized execution (2).
Another problem is the commercialization of transplantation procedures that has occurred at least in some parts of the Chinese health care system. The first reports on transplantations in foreigners who paid to obtain kidney transplants retrieved from executed prisoners were published more than 15 years ago (3, 4). During recent years, several hospitals have placed advertisements on the World Wide Web to attract transplant recipients from abroad. The information has emphasized the short waiting times and, in some cases, has guaranteed a second transplant within a few weeks in case the first graft fails. No statistics are available on the number of foreign citizens undergoing transplantations in China, but it seems obvious that the increased transplantation activities have not been solely directed towards the own population. The financial gain for the parties involved raises concern that money may become an incentive to increase the number of organs available for transplantation, and that this might affect the use of death sentences or the number of crimes for which such sentences can be applied.
The Need for Guidelines
The ethical issues were highlighted during the World Transplant Congress in Boston, July 2006. During this meeting, a new Ethics Committee of TTS was appointed. The chairman of the previous committee, Dr. Francis L. Delmonico, remains as a committee member and was also appointed Director of Medical Affairs. One of the first tasks for the committee was to revise the Membership Statement of TTS to further underline the importance that all donations and transplantations should be performed within a legal and ethical framework that protects living donors and ensures that organs from deceased donors are recovered only when consent for donation has been obtained (5). As previously, the statement condemns the buying and selling of organs. Every new member must agree not to be involved in the transplantation of organs from executed prisoners or other donors where there is a risk that an autonomous consent for donation is lacking. The positions of TTS are further described in the Society's new Policy and Ethics Statement (6).
The political developments in China, with more openness towards the international community, have increased the number of requests and invitations to collaborate with Chinese transplant programs in various ways. The Transplantation Society Council found that specific guidelines are needed for interactions with China. The Ethics Committee chose to develop a statement formulated as responses to the most common questions. After approval of the TTS Council, the document was distributed to its membership. The complete document is shown in Figure 1.
The main aims were to support the positive developments in China, but at the same time stress that their present policies were considered unacceptable, and to maintain international pressure towards a change. For these reasons, doctors and health care personnel involved in obtaining or transplanting organs and tissues from executed prisoners cannot become members of TTS. Likewise, scientific presentations from such transplant centers involving patient data or samples from recipients of organs from executed prisoners cannot be accepted for presentation at TTS meetings and TTS members should not collaborate in such studies. However, to promote dialogue and insight into international practice, doctors and health care personnel from China may be accepted as registrants at TTS meetings. TTS members can also accept invitations to lecture in China and provide expertise if the activity favors the development of Chinese transplantation programs towards TTS standards of practice. Clinical and preclinical trainees from China should be accepted only if they are educated in appropriate alternatives to the use of executed prisoners and agree to comply with TTS standards of practice throughout their careers.
After lengthy discussions, it was finally decided to recommend that international registers accept data about patients transplanted with organs or tissues from executed prisoners. The reasons for this decision were the need for transparency and the collection of correct demographic data. However, the fact that the organs and tissues were obtained from an executed prisoner should always be clearly stated and such data should not be used for scientific registry studies. This document undoubtedly fails to deal with all possible situations. However, if one is uncertain about collaboration with representatives of a Chinese transplantation program, one should always be guided by the principle that TTS supports collaboration that contributes to a development towards internationally accepted standards of care.
In July 2006, a report on the alleged harvesting of organs from practitioners of Falun Gong in China attracted major international attention (7). The authors were two Canadians: David Matas, an immigration, refugee, and international human rights lawyer; and David Kilgour, former member of Parliament and a former Secretary of State for the Asia Pacific region. The investigation was done from outside China and was based on interviews and the assessment of available written information. It is alleged that organs have been obtained from many unwilling Falun Gong practitioners and that the individuals were not executed, but instead killed during the course of the surgical recovery. The Chinese authorities deny that any such activities have occurred. TTS considers this report alarming but has no possibility to further investigate the accusations. Instead, TTS has made a formal request to the WHO that the United Nations Commission for Human Rights investigates these charges.
During 2006, TTS established an official collaboration with WHO. One important task is to cooperate with government agencies and create national legal frameworks that comply with TTS standards of practice and guiding principles of the WHO. In China, TTS together with WHO works directly with the Vice Minister of Health. According to the Vice Minister, the Chinese government now intends to create a legal framework for national oversight, ban the purchase and sale of human organs, and prevent organ trafficking and transplant tourism. Credentials for Chinese transplant officials will be established, only selected centers will be allowed to perform transplantations, and transplantations on foreign citizens will be subjected to special regulations. The Chinese government also states that deceased organ donation based on brain death criteria will be established with the intention of achieving a national self-sufficiency that includes deceased and living donors.
TTS endorses this development and looks forward to the implementation of these new policies in China. The establishment of deceased organ donation from donors with total brain infarction and a careful expansion of live donor programs hopefully will create a basis for reevaluation of the practice of using executed prisoners.
1. Council of Europe. International figures on organ donation and transplantation activity. Newsletter Transplant 2005; 10: 5–22.
2. Current Opinions on Capital Punishment. Chicago: The Council on Ethical & Judicial Affairs of the American Medical Association, 1989.
3. Guttman R. On the use of organs from executed prisoners
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1992; 6: 189–193.
4. Cheng IKP, Lai KN, Au TC, et al. Comparison of the mortality and morbidity ration between proper and unconventional renal transplantation using organs from executed prisoners
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