Organ transplantation in the People's Republic of China

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Kidney transplants rose from about 3,000 in 1997 to 11,000 in 2004, falling to 6,000 in 2007. Liver transplants rose from a few hundred in 2000 to 3,500 in 2005, then dropped to 2,000 in 2007
Trend in kidney and liver transplants in the People's Republic of China (1997–2007)[1]

Organ transplantation in the People's Republic of China has taken place since the 1960s, and is one of the largest organ transplant programmes in the world, peaking at over 13,000 transplants a year in 2004.[2] China is also involved in innovative transplant surgery such as face transplantation including bone.[3]

Involuntary organ harvesting is illegal under Chinese law; though, under a 1984 regulation, it became legal to remove organs from executed criminals with the prior consent of the criminal or permission of relatives. Growing concerns about possible ethical abuses arising from coerced consent and corruption led medical groups and human rights organizations, by the 1990s, to start condemning the practice.[4] These concerns resurfaced in 2001, when The Washington Post reported claims by a Chinese asylum-seeking doctor that he had taken part in organ extraction operations. Further, in 2006, there were claims of harvesting of organs from live practitioners of the banned Falun Gong spiritual movement which led to a disputed report being compiled by former Canadian parliamentarian David Kilgour and human rights lawyer David Matas. While not revealing exact figures, the Chinese authorities have not denied the practice of taking organs from executed prisoners, and have taken steps to address international concerns regarding both the State's reliance on executed prisoners for organ donation and the illegal trading of these organs which in 2005 they acknowledged had occurred. They have consistently denied the allegations of removing organs from living Falun Gong practitioners. In 2007, China issued regulations banning the commercial trading of organs,[5] and the Chinese Medical Association agreed that the organs of prisoners should not be used for transplantation, except for members of the immediate family of the deceased.[6]

In 2008, a liver-transplant registry system was established in Shanghai, along with a nationwide proposal to incorporate information on individual driving permits for those wishing to donate their organs.[7] Despite these initiatives, China Daily reported in August 2009 that approximately 65% of transplanted organs still came from death row prisoners. The condemned prisoners have been described as "not a proper source for organ transplants" by Vice-Health Minister Huang Jiefu,[8] and in March 2010 he announced the trial of China's first organ donation program starting after death, jointly run by the Red Cross Society and the Ministry of Health, in 10 pilot regions.

Contents

Background

Globally, pioneering experimental studies in the surgical technique of human organ transplantation were made in the early 1900s by the French surgeon Alexis Carrel, and successful transplants starting spreading worldwide after the Second World War.[9] China herself began organ transplantation in the 1960s, which grew to an annual peak of over 13,000 transplants in 2004;[2] and, despite some deaths from infection and hepatitis, the transplant programme has been successful in saving many lives.[10] Though the number of transplants fell to under 11,000 annually by 2005, China still has one of the largest transplant programmes in the world.[2][4] China explores innovative surgery, such as the world’s first flesh and bone face transplant, performed by Professor Guo Shuzhong.[3] Organ donation, however, has met resistance, and involuntary organ donation is illegal under Chinese law,[11] as it is against Chinese tradition and culture, which attach symbolic life affirming importance to the kidney and heart.[12][13] China is not alone in encountering donation difficulties; demand outstrips supply in most countries. The world-wide shortage has encouraged some countries—such as India—to trade in human organs.[10][14] Reports of organs being removed from executed prisoners in China for sale internationally had been circulating since the mid-1980s, when a 1984 regulation made it legal to harvest organs from convicted criminals with the consent of the family or if the body goes unclaimed.[15] Development of an immunosuppressant drug, cyclosporine A, made transplants a more viable option for patients.[16]

Milestones

The first living related renal transplant was performed in China in 1972;[17] the first allogeneic bone marrow transplantation was successfully executed in an acute leukaemia patient[18] The first recorded clinical liver transplant from a living donor in China took place in 1995, seven years after the world's first was performed in Sao Paulo, Brazil.[19] Between January 2001 and October 2003, 45 patients received living donor liver transplantation (LDLT) at five different hospitals.[20] In 2002, doctors at Xijing Hospital of the Fourth Military Medical University described three cases of living related liver transplantation. In 2003 a landmark brain-death case involving switched off ventilation came to the attention of the public and made a big impact on medical ethics and legislation. The first successful brain-death organ donation soon followed.[17] From October 2003 to July 2006, 52 LDLT operations were conducted at the West China Hospital, Sichuan University.[21] In October 2004, Peking University People's Hospital Liver Transplantation Center executed two cases of living related liver transplantation involving complex blood vessel anatomy.[22] In 2002, the Chinese media reported surgeon Dr Zheng Wei successfully transplanted a whole ovary at the Zhejiang Medical Science University to a 34-year-old patient, Tang Fangfang, from her sister.[23]

In April 2006, the Xijing military hospital in Xian carried out a face transplant operation covering the cheek, upper lip, and nose of Li Guoxing, who was mauled by an Asiatic black bear while protecting his sheep.[24][25] However, it was reported on 21 December 2008 that Li Guoxing had died in July in his home village in Yunnan Province. Prior to his death, the Discovery Channel filmed a documentary during which showed he had stopped taking immuno-suppressant drugs in favour of herbal medication. His surgeon, Dr Guo Shuzhong, suggested it to be a contributing factor to his death.[citation needed]

The first successful penis transplant procedure was performed in September 2006, at a military hospital in Guangzhou. The patient, a 44-year-old male, had sustained the loss of most of his penis in an accident. The transplanted penis came from a brain-dead 22-year-old male. Although successful, the patient and his wife suffered psychological trauma as a result of the procedure, and had the surgery reversed fifteen days later.[26][27] Following this, Jean-Michel Dubernard, famous for performing the world's first face transplant, wrote that the case "raises many questions and has some critics". He alluded to a double standard writing, "I cannot imagine what would have been the reactions of the medical profession, ethics specialists, and the media if a European surgical team had performed the same operation."[28]

International concerns

Transplantation first began in the early 1970s China, when organs were sourced from executed prisoners. Although other sources, such as brain-dead donors, had been tried, the lack of legal framework hampered efforts. Dr Klaus Chen said in 2007 that this was still the dominant pool.[17] Concerns that some poorer countries were answering donor shortages by selling organs to richer countries led the World Medical Association (WMA) to condemn the purchase and sale of human organs for transplantation at Brussels in 1985,[9] and at Stockholm in 1994.[10] In Madrid in 1987, the World Health Organization (WHO) condemned the practice of extracting organs from executed prisoners due to the difficulty of knowing if they had given consent.[29] Growing concern led other professional societies and human rights organisations to condemn the practice in the 1990s,[4] and to question the way in which the organs were obtained.[15] The WHO starting drafting an international guideline (WHA44.25) on human organ transplants in 1987[30] which resulted in the WHO Guiding Principles on Human Organ Transplantation being endorsed in 1991.[31] However, the wording did not allow the international community to draw up any laws preventing China from continuing to trade in human organs.[32]

The United States Senate Committee on Foreign Relations convened a hearing in 1995 on the trade in human body parts in China;[33] receiving evidence from various sources including statements from Amnesty International, the BBC, and Chinese government documents produced by human rights activist Harry Wu.[34]

The WMA, the Korean Medical Association, and the Chinese Medical Association reached an agreement in 1998 that these practices were undesirable and that they would jointly investigate them with a view to stopping them; however, in 2000, the Chinese withdrew their cooperation.[29] Amnesty International claimed to have strong evidence that the police, courts and hospitals were complicit in the organ trade, facilitated by the use of mobile execution chambers, or "death vans".[35] Amnesty speculated that this profitable trade might explain China's refusal to consider abolishing the death penalty, which is used on between 1,770 (official figure) and 8,000 (Amnesty estimates) prisoners annually. Corpses are typically cremated before relatives or independent witnesses can view them, fuelling suspicions about the fate of internal organs.[35]

In June 2001, Wang Guoqi, a Chinese doctor applying for political asylum, made contact with Harry Wu and his Laogai Research Foundation, who assisted Wang in testifying to the US Congress in writing that he had removed skin and corneas from more than 100 executed prisoners for the transplant market at the Tianjin Paramilitary Police General Brigade Hospital, and that during at least one such operation the prisoner was still breathing.[36] Wang, a 'burns specialist', said that he had also seen other doctors remove vital organs from executed prisoners; and the hospital where he worked sold those organs to foreigners. Harry Wu said that he had gone to "great lengths" to verify Wang's identity and that both the foundation and congressional staff members found the doctor's statements "highly credible."[37]

By 2005 the WMA had specifically demanded that China cease using prisoners as organ donors.[38] In December of that year, China's Deputy Health Minister acknowledged that the practice of removing organs from executed prisoners for transplant was widespread – as many as 95% of all organ transplants in China derived from executions,[39] and he promised steps to prevent abuse.[15][40] According to Time, a transplant brokerage in Japan which organised 30–50 operations annually sourced its organs from executed prisoners in China.[41] Edward McMillan-Scott, vice president of the European Parliament, said he believed that nearly 400 hospitals in China had been involved in the transplant organ trade, with websites advertising kidney transplants for $60,000.[42]

On the eve of a state visit to the United States by President Hu Jintao, the 800-member British Transplantation Society also criticised China's use of death-row prisoners' organs in transplants, on the grounds that as it is impossible to verify that organs are indeed from prisoners who have given consent;[41] the WMA once again condemned the practice on similar grounds.[43] A BBC news report by Rupert Wingfield-Hayes in September 2006 showed negotiations with doctors in No 1 Central Hospital in Tianjin for a liver transplant.[44]

In 2006, claims of harvesting of organs from live practitioners of the banned Falun Gong spiritual movement at a research hospital led to an investigative report being compiled by former Canadian politician, David Kilgour, and human rights lawyer David Matas.[45] The findings of their investigation were controversial as the conclusions were based on circumstantial evidence,[46][47][48] and investigations, including by dissident Harry Wu, and the U.S. State Department, failed to find evidence to support the allegations,[40][49][50][51][52] though Kirk C. Allison, Associate Director of the Program in Human Rights and Medicine in the University of Minnesota, (2006) and Tom Treasure of Guy's Hospital, London (2007), considered the report "plausible from a medical standpoint" based on the numerical gap in the number of transplants and the short waiting times in China compared with other countries.[53][54][55] In May 2008 two United Nations Special Rapporteurs reiterated their previous request for the Chinese authorities to adequately respond to the allegations,[56] and to explain the source of organs which would account for the sudden increase in organ transplants in China since 2000. China has repeatedly denied the organ harvesting allegations in the report.[57]

Developments since 2006

In March 2006, the Ministry of Health issued the Interim Provisions on Clinical Application and Management of Human Organ Transplantation, which stipulated that medical centres must meet new requirements for transplant services; the provinces were made responsible for plans for clinical applications. Establishments performing transplantation were thereby obliged to incorporate considerations for ethics, medical and surgical expertise, and intensive care. In April 2006, the Committee of Clinical Application of Human Organ Transplantation Technologies was created to standardise clinical practice; a national summit on clinical management took place in November 2006 which issued a declaration outlining regulatory steps.[2] Professor Guo Shuzhong conducted a series of face transplant experiments in Xijing hospital, leading in April 2006 to the world’s first face transplant that included bone.[3][58] The donor had been declared brain-dead before the operation.[59]

In May 2007 the Regulation on Human Organ Transplantation came into force, banning organ trading and the removal of a person's organs without their prior written consent,[60] and this has been favourably received by the World Health Organization and The Transplantation Society.[2][4] To curb illegal transplants, doctors involved in commercial trade of organs will face fines and suspensions; only a few hospitals will be certified to perform organ transplants.[61] As a result of a systematic overhaul, the number of institutions approved for transplants has been reduced from more than 600 in 2007 to 87 as at October 2008; another 77 have received provisional approval from the Ministry of Health.[2]

To further combat transplant tourism, the Health Ministry issued a notice in July 2007 in line with the Istanbul Declaration, giving Chinese citizens priority as organ recipients.[2] In October 2007, after several years of discussions with the WHO, the Chinese Medical Association agreed to cease commercial organ collection from condemned prisoners, who would only be able to donate to their immediate relatives.[6][62] Other safeguards implemented under the legislation include documentation of consent for organ removal from the donor, and review of all death sentences by the Supreme People’s Court. Transplant professionals are not involved until death is declared. A symposium among legal and medical professionals was held in April 2008 to discuss the diagnostic criteria for brain death for donors of transplant organs.[2]

A liver-transplant registry system was established in Shanghai, in 2008, which allows the monitoring of the after-care of liver recipients; at the same time a nationwide proposal was announced that would allow people to note on their driving licence that they wish to donate their organs.[7] Despite these initiatives the China Daily newspaper reported in August 2009 that approximately 65% of transplanted organs still came from death row prisoners,[8] which has been described as "not a proper source for organ transplants" by Vice-Health Minister Huang Jiefu.[5] China's first posthumous organ donation system was jointly launched in March 2010 by the Red Cross and the Ministry of Health.[2] Huang Jiefu announced that the scheme, which will allow people to express their wishes on their driver’s licences, would be trialled in 10 pilot regions including the cities of Tianjin, Wuhan and Shenzhen.[5] Funds will be made available for the families of people who voluntarily donate their organs. Chinese authorities say they hope the pilot program's success will reduce the need to take organs from death row prisoners and stem the tide of black market organs.[8] In 2012 China officials stated they plan to phase out organ harvesting of death-row inmates.[63]

In September 2012, a report published on the US's House Committee on Foreign Affairs website showed: " Medical doctors outside China have confirmed that their patients have gone to China and received organs from Falun Gong practitioners".[64]

See also

References

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