Introduction
Living organ donors and transplant recipients are often required to travel to donate an organ or receive a transplant. The reasons for this could be multiple including financial, social or because of a lack of infrastructure or resources in the country where they live. However, it could also be because of an unethical reason, for instance the person is involved in organ trafficking (OT), human trafficking (HT) or human trafficking for the purpose of organ removal (HTOR).
Inadequate medical care before, during and after surgery is a problem, and this risk is higher if the patient travels for a transplant. Uncontrolled and illegal transplantation activities affect many patients by providing substandard or inadequate medical procedures to them with dismal results. In 2007 the World Health Organization estimated that more than 6000 kidney transplants per year are taking place in circumstances that pertain to organ trade and commercialization. (1)
Unethical reasons to travel for transplantation
Procedures that involve OT, HT or HTOR often require the patient to travel to a country where illegal organ trade is possible.(2) Organ trafficking networks will often target countries that are unable to provide a punitive response to these practices. These countries often have poor regulation and legislation, uninvolved health care authorities or a lack of professional oversight with inadequate professional vigilance, surveillance and guidelines. Because of this problem, OT, HT or HTOR often goes hand in hand with patients travelling: either the organ provider, recipient or both parties might travel to either supply an organ or receive a transplant in another country.(3, 4)
Medical tourism and travel for transplantation has the potential to not only impact on healthy organ providers, but also on the vulnerable recipients of these organs. In many places in the world, black market organ transplantation is still taking place. These processes can not take place without the cooperation of medical practitioners practising in these countries.(4) Countries who carry a high risk for organ trafficking rings are those that have a reasonable medical infrastructure combined with inadequate oversight.
Therefore, in order to prevent OT, HT and HTOR, medical practitioners should firstly be made aware of these risks. They often know that their patients are planning to travel for a transplant abroad, especially when they are treating patients who live in a country away from their country of birth.
Legitimate reasons to travel for a transplant are:
- The patient has a better social or family support system in the country he/she is traveling to.
- Financial support is available in the country where the patient will be traveling. This might involve medical insurance or state health insurance that might not be available to this patient in the country where he/she currently resides.
- There is a lack of medical and transplant-related infrastructure in the country where the patient currently lives. Another country might be willing to provide transplant services based on compassion.
- There is a lack of availability of organs in the country where the patient currently lives and there is a mutual arrangement between the country where the patient lives and the country where the patient is traveling. Often governments agree on a mutual exchange system or a reciprocal system between two countries. (5, 6)
Risk for organ trafficking and unethical transplantation practices
In many cases, patients and health care providers do not have the necessary infrastructure available to plan for the transplant abroad. As a result, the health care professional loses control over the recipient. Doctors often only get involved after the procedure had been done, and the patient returns to his/her home country.
A lack of documentation from both sides result in a higher risk to both donor and recipient and potentially no communication between the medical practitioners involved in patient care. With an official improved communication system between medical practitioners in different parts of the world, many problems and complications could potentially be prevented.
Potential donors who are exploited in organ trafficking rings are often unaware of their short and long terms risks, which is summarized in Figure 1. In the case of these practices, consent from the organ supplier could potentially be more focused on the financial or monetary gain, rather than on the medical procedure and the long-term implications of the operation.
Reciprocity
In many regions “support clusters” are needed to provide complex medical treatment to patients. If the option of a transplant is not available in one region, a collaborative model with a close-by area could be considered. However, these regional collaborations should preferentially be agreed upon beforehand by local governments and departments of health, rather than on an individual base between medical practitioners. In Africa, there are only a handful of countries who have the expertise and infrastructure to provide transplantation services. It is important for the people providing medical and legal services in Africa to work together on a plan for official reciprocity between countries, rather than patients traveling on an individual basis (which puts them at a high risk to become victims of organ trafficking).
Compassion
If deceased donors are being used in a country or region it should generally be for the patients of that region. If a deceased donor organ is provided to a recipient from a different region or country, this must be out of compassion, either because these organs are not available in the patient’s own country or the medical expertise/technical ability to do such a transplant is not available in the place where the patient lives. In this context, transparency is very important and governmental decisions are generally more transparent and open than decisions that are made by individuals or individual centres.
Many asylum seekers are now becoming eligible for transplantation on the basis of compassion while they are living in a different country. The worrying thing is not only the impact for local citizens but also the impact on illegal organ trade, increasing commercialism and unregulated transplantation as a result. The only way in which transplantation and travel could be regulated is if the practice is regulated by reciprocity and transparency.
Procedures
As big organizations like the World Health Organization have no regulative authority, it remains vital for governments to regulate transplantation practices in their own countries.
There is a very important consideration, and that is that all patients who travel for a transplant need to have a medical practitioner who refers them to this centre, with full documentation of their clinical condition. Furthermore, in the case of a living donor, the referring doctor needs to provide information where the donor came from, how the donor and recipient know each other and there should be full transparent paperwork available. Although centre-to-centre relationships are important, very often these referrals will have to be made between specific individual clinicians from the referring as well as the receiving team.
Results
We need medical practitioners who can evaluate, perform and follow-up patients in the ethical framework provided. Health authorities should be responsible for checking documentation for each donor and recipient who gets a procedure in their country. A working relationship with legal professionals is essential as many legal considerations are present in planning these procedures.
The implication of receiving a transplant abroad should also be important for insurance companies and governments who often have to carry the cost of immunosuppression and follow-up care for patients who return to their home countries. Without adequate transfer documentation that has a standardized reporting, patients might not be reimbursed or on-going expenses might not be covered. A referring physician can make sure a patient will be insured upon return by providing the recognized and appropriate information available before the transplant. If a donor is operated on after going through this approved network and standardized format, he/she should receive follow-up in the country they live in just like any donor who did not travel for the procedure. Care providers do not generally want to deny their patients’ care or treatment after an illegal transplant. However, governments can control these practices better by regulation and insurance discrimination as is already being done in countries like Israel.
It is easier to divide transplant procedures and follow-up care into two separate arguments. It is the objective of medical practitioners to treat people who donated their kidneys for the long-term problems they might encounter, and if a standardized set of documents will be part of these patients’ medical records, this process will be much easier. Medical practitioners need to identify donors from both a medical and ethical point of view and should also define where the patient will go back to and follow-up. For this, a full transfer of medical documents is needed. We are trying to achieve a situation where all donors who want to travel to donate an organ will receive an evaluation in their home country to make sure that this donation is voluntary, with full consent and free of commercial transactions. This screening needs to happen before the patient travels. Ethical evaluation should always start in the home country.
By providing an excellent set of tools for the healthcare worker and potential travelling patient, many unethical or illegal transplants can possibly be avoided. The objective was to focus on prevention, rather than responding to patients who already obtained a transplant through an illegal method.
References
1. Shimazono Y. The state of the international organ trade: a provisional picture based on integration of available information. Bulletin of the World Health Organization. 2007;85(12):955-62.
2. de Jong J, Ambagtsheer F. Indicators to Identify Trafficking in Human Beings for the Purpose of Organ Removal. Transplant Direct. 2016;2(2):e56.
3. Ambagtsheer F, Weimar W. Organ Trade: Knowledge, Awareness, and Nonlegislative Responses. Transplantation. 2016;100(1):5-6.
4. Ambagtsheer F, Van Balen LJ, Duijst-Heesters WL, Massey EK, Weimar W. Reporting Organ Trafficking Networks: A Survey-Based Plea to Breach the Secrecy Oath. Am J Transplant. 2015;15(7):1759-67.
5. Spasovski G, Busic M, Delmonico F. Improvement in kidney transplantation in the Balkans after the Istanbul Declaration: where do we stand today? Clin Kidney J. 2016;9(1):172-5.
6. Busic M, Spasovski G, Zota V, Codreanu I, Sarajlic L, Simeonova M, et al. South East European Health Network Initiative for Organ Donation and Transplantation. Transplantation. 2015;99(7):1302-4.
Figure 1 Risks for organ suppliers in organ trafficking rings.