Francis L. Delmonico, M.D.
Organ transplantation is a lifesaving and cost-effective treatment for organ failure but there is an insufficient supply of transplantable organs available worldwide to address those in need. In 2016, approximately 136,000 organ transplants were performed throughout the world. Most of these transplants are performed for either kidney (approximately 90,000) or liver approximately 30,000 candidates. Most of these transplants (greater than 60%) are performed from deceased donors but there are locations of the world such as Japan and India, in which there are either relatively few or no deceased donors (Egypt and the Philippines).
With a world population of over 7 billion, it is estimated that there are approximately 60 million deaths annually. From that proportion of those dying there is a total of only 30,000 deceased donors worldwide for a rate of 0.05% donors per deaths. To accommodate the need which is 10 times the number of annual transplants performed, the rate of deceased donation must increase to 0.5% donors per deaths. The inadequate supply of organs has led to a desperation by patients to obtain organs through illegal or unethical ways – victimizing the poor as a source of organs.
Organ trafficking is occurring day by day throughout the world in economically underdeveloped countries with the destitute selling their kidneys to provide for themselves or for their families. Organ trafficking is a form of human trafficking and a violation of human rights. The migrants fleeing from Syria or along the Nile corridor are selling their organs in Turkey and in Egypt. The media reports regarding these illegal activities are current. But organ trafficking is not limited to those locations. It is the experience of transplantation in India. It is the experience of transplantation in Mexico when a wealthy journalist can travel from Germany accompanied by a young man from Africa to sell his kidney. It is the experience of a Syrian woman compelled to sell her kidney so her children can reach an environment free of war.
The doctors who perform these procedures are trained but do so in locations that are not monitored by proper governmental oversight. Although the doctors rationalize the concern for a patient with organ failure in need of a transplant, that rationale is discredited by the reality of greed. Money is the motivation. Organ trafficking is now defined by the Council of Europe as a monetary transaction as the basis for the organ transplant. Monetary gain is the objective of the vendor who sells an organ; monetary gain is the objective of the doctors who enable the transaction. The vendor is exploited. A large sum of money is provided to a broker and to the doctor but in contrast virtually nothing to the donor vendor. The vendor is stigmatized within his or her own culture – illustrated by the organ market in Iran. However, the motivation of the vendor in obtaining money usually does not achieve the reason needed for the money. The vendor remains destitute with one less kidney. There is no sustained care of the vendor if complications arise – and they do. There is no awareness of a donor death; if the donor dies, it is only the family that has to reconcile the loss.
Organ transplantation is a societal event – different than any other practice of medicine. It requires the oversight of society to protect the well being of the living donor and to make certain of the equitable distribution of organs that derived from the deceased. Governments are not exercising their responsibility to provide a sufficient number of organs from the deceased within their jurisdiction nor are they monitoring the practices of transplant doctors in exploiting vendors for their organs. As a result, patients in need are traveling to locations in which organs are readily obtainable – economically underdeveloped countries where the source of organs is plentiful. Alternatively, patients in need will secure a donor and travel with that individual to a location that has no ethical framework to prohibit the exploitation. The demand for organs will continue unless governments act to achieve self-sufficiency for their own patient populations who are otherwise compelled to participate in organ trafficking.
The World Health Organization
The issue of organ trafficking has been a concern of the WHO for three decades, expressed initially in 1987, but reaffirmed by the adoption of a World Health Assembly Resolution (WHA63.22) on 21 May 2010 to promote “principles of human dignity and solidarity which condemn the buying of human body parts for transplantation and the exploitation of the poorest and most vulnerable populations and the human trafficking that result from such practices”.
The WHO has also urged Member States “to strengthen national and multinational authorities and/or capacities to provide oversight, organization and coordination of donation and transplantation activities, with special attention to maximizing donation from deceased donors and to protecting the health and welfare of living donors with appropriate health-care services and long-term follow up”.
The 2010 Resolution of the 63rd World Health Assembly (WHA) that embraced the Guiding Principles of the World Health Organization set forth the following objectives to be accomplished by Member States:
- to improve the safety and efficacy of organ donation and transplantation by promoting international best practices;
- to promote a system of transparent and equitable allocation of organs, guided by clinical criteria and ethical norms, as well as equitable access to transplantation services in accordance with national capacities, which provides the foundation for public support of voluntary donation;
- to strengthen national and multinational authorities to provide oversight, organization and coordination of donation and transplantation activities, with special attention to maximizing donation from deceased donors and to protecting the health and welfare of living donors with appropriate health-care services and long-term follow up;
- to collaborate in collecting data including adverse events and reactions on the practices, safety, quality, efficacy, epidemiology and ethics of donation and transplantation.
The Declaration of Istanbul
On April 30, 2008 The Transplantation Society (TTS) and the International Society of Nephrology (ISN) convened in Istanbul, Turkey a Summit Meeting of more than 150 representatives of scientific and medical bodies, government officials, social scientists, and ethicists from around the world to take a stand on the urgent and growing problems of organ sales, transplant tourism, and trafficking in organs. The meeting adopted the “Declaration of Istanbul on Organ Trafficking and Transplant Tourism”, which has since been endorsed by 130 medical societies, government bodies, and other groups involved with organ transplantation. Although the Declaration was widely disseminated in medical journals and online beginning with a seminal article published in The Lancet on July 5, 2008. TTS and ISN were determined that the Declaration would be more than merely a statement reported in the medical literature. Therefore, in 2010, they created the Declaration of Istanbul Custodian Group (DICG) as a means of actively promoting, sustaining, and monitoring the implementation of the Declaration’s principles.
The Pontifical Academy of Sciences Summit on Organ Trafficking and Transplant Tourism
In February 2017 PAS convened a Summit on the topic of organ trafficking by the direction of Pope Francis. A definitive statement was made by participants from throughout the world (inclusive of China) that all nations and all cultures recognize human trafficking for the purpose of organ removal and organ trafficking, which includes the use of organs from executed prisoners and payments to donors or the next of kin of deceased donors as crimes that should be condemned worldwide and legally prosecuted at the national and international level. Organ trafficking is a crime against humanity.
The participants also emphasized that nations provide the resources to achieve self-sufficiency in organ donation at a national level with regional cooperation as appropriate by reducing the need for transplants through preventive measures and improving access to national transplant programs in an ethical and regulated manner.
Development of WHO Task Force on Organ and Tissue Donation and Transplantation
To fulfill the WHA commitment to disseminate WHO Guiding Principles, that would ensure ethical practices of organ and tissue donation and transplantation worldwide, the Delegation of People’s Republic of China proposed at the 70th World Health Assembly of 2017 that the WHO establish an Organ and Tissue Donation and Transplantation Task Force to implement the WHO Guiding Principles in Member States with organ and tissue transplantation services.
Countries have a responsibility to provide a national supply of transplantable organs by ethical and legal practices. The role of government is now clear to support organ and tissue transplantation:
- Enact legislation to define death that enables recovery of organs and tissues;
- Enact legislation to support ethical, efficient and sustainable tissue donation, banking and transplantation;
- Establish National Agency that:
- oversees the practice of organ donation and transplantation;
- oversees the practice of tissue donation, banking and transplantation;
- certifies transplant centers, training programs and transplant personnel;
- certifies organ and tissue procurement agencies and personnel;
- certifies histocompatibility laboratories;
- certifies tissue processing and distribution facilities;
- develops registries for donors, potential recipients and transplant patients;
- reviews outcome data;
- reviews the burden of disease that necessitates organ and tissue transplantation.
The Challenges Ahead
Scientists and scientific policymakers must be engaged to develop a common understanding of death to enable a sufficient supply of organs to be available. National authorities must regulate donation and transplantation activities, maximizing donation from deceased donors and to protecting well-being of living donors with appropriate health-care services and long-term follow up.
Governments must promote a system of transparent and equitable allocation of organs and tissues, guided by clinical criteria and ethical norms, as well as equitable access to transplantation services in accordance with national capacities, which provides the foundation for public support of voluntary donation. Governments must also address the disproportionate use of dialysis as renal replacement therapy impeding access to kidney transplantation which is comparatively cost-effective and improves the quality of life. Governments must also combat the trafficking of human organs defined by the Council of Europe as commercialization – the buying and selling of organs; and human trafficking for organ removal which is a human rights abuse of exploitation of the poor.
The national agencies overseeing organ transplantation must collect data to evaluate the practice, safety, quality, efficacy and ethics of organ donation and transplantation and promote organ donation as a standard of end-of-life care.