Organ trade

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Organ trade is the trade involving inner organs (heart, liver, kidneys, etc.) of a human for transplantation. There is a worldwide shortage of organs available for transplantation,[1] yet trade in human organs is illegal in all countries except Iran. The problem of organ trafficking is widespread, although data on the exact scale of the organ market is difficult to obtain. Whether or not to legalize the organ trade, and the appropriate way to combat illegal trafficking, is a subject of much debate.

Contents

Legal organ trade

In the 1970s pharmaceuticals that prevent organ rejection were introduced. This along with a lack of medical regulation helped foster the organ market. Living donor procedures include kidney, liver, cornea and lung transplants. Most organ trade involves kidney or liver transplants.

Despite numerous past failures in organ trades due to lack of contractual and/or safety regulation, Dr. Truog of Harvard Medical School Department of Social Medicine addresses the lowered safety risks in transplant procedures with available modern medical technology, along with increased regulation in contracting of organ transplantation for individuals with more government interventions.[2]

Attempts to legalize

China

In China, organs are often procured from executed prisoners. Nicholas Bequelin, a researcher for Human Rights Watch, estimated that 90 percent of organs from China are from deceased prisoners.[3] Despite the legality of the process in the country, there is evidence that the government attempted to downplay the scope of organ harvesting through confidentiality agreements[4] and laws such as the Temporary Rules Concerning the Utilization of Corpses or Organs from the Corpses of Executed Prisoners.[5] Even with this lax regulation, China still suffered a shortage of organs for transplant.

The Chinese government, after receiving severe scrutiny from the rest of the world,[6] has passed legislation ending the legal sale of organs. No legislation currently prohibits the collection of organs from deceased inmates who sign agreements before execution. Recently, China has introduced new legislation in order to standardize its organ collection process. This legislation includes regulations stating which hospitals can perform operations and what the legal definition of brain-death is. Foreign transplant patients are no longer accepted. Since China has ceased the legal sale of organs, global prices are estimated to have risen 40%.[7]

India

Before the passage of the Transplantation of Human Organs Act in 1994, India had a successful legal market in organ trading. Low cost and availability brought in business from around the globe and transformed India into one of the largest kidney transplant centers in the world.[8] Several problems began surfacing during the period of legal organ trade in India. In some cases patients were unaware a kidney transplant procedure even took place.[9] Other problems included patients being promised an amount much higher than what was actually paid out.[10] Ethical issues surrounding contribution donating pushed the Indian government to pass legislation banning the sale of organs.[11] Despite these steps, loopholes still exist in current laws that allow non-related donors to give organs if they are emotionally close to the recipient. In many cases, the donor may not be from the same country as the patient, or even speak the same language.[5]

Iran

In Iran the practice of selling one's kidney for profit is legal. Iran currently has no wait lists for Kidney transplantation.[12] Kidney sales are legal and regulated. The Charity Association for the Support of Kidney Patients (CASKP) and the Charity Foundation for Special Diseases (CFSD) control the trade of organs with the support of the government. The organizations match donors to recipients, setting up tests to ensure compatibility. The amounts paid to the donor vary in Iran but the average figures are $1200 for kidney donation.[13] Employment opportunities are also offered in some cases. It has been argued that the Iranian system is in some ways coercive, as over 70% of donors are considered poor by Iranian standards.[14] There is also evidence of highly negative outcomes both in health and emotional wellbeing for Iranian donors.[15]

Philippines

The sale of organs was legal in the Philippines until a ban took effect in March 2008.[16] Prior to this, the Philippines was a popular destination for transplant tourists. The Philippine Information Agency, a branch of the government, promoted "all-inclusive" kidney transplant packages that retailed for roughly $25,000.[17] Since instating the ban on organ selling, transplants have dropped from 1,046 in 2007, to 511 in 2010.[18]

Current Restrictions

At present, Iran is the only nation that allows the legal buying and selling of organs. The market is contained within the country, that is foreigners are not allowed to buy organs of Iranian citizens. In an attempt to further limit transplant tourism, organs can only be transplanted between people of the same nationality, that is to say an Iranian cannot purchase a kidney from a refugee from another country.[19] The system is largely charity and volunteer-based, and those tasked with matching donors and patients are not paid for their work.[14] The Iranian system has been put up as an example of an effective and safe organ trading model by proponents of legalized donation.

All other nations have some form of legislation meant to prevent the illegal trading of organs, whether by an outright ban or through legislation that limits how and by whom donations can be made. Many countries, including Brazil, Belgium, and France, use a system of presumed consent to increase the amount of legal organs available for transplant.[20] In the United States, federal law prohibits the sale of organs, however the government has created initiatives to encourage organ gifting and to compensate those who freely donate their organs. In 2004, the state of Wisconsin began providing tax deductions to living donors.[21] Worldwide, the trend has been to move towards increased regulation of organ trading. This is seen in the tightening of policies after countries like China and India came under scrutiny for human rights violations related to their organ procurement process.

Illegal organ trade

According to the World Health Organization (WHO), illegal organ trade occurs when organs are removed from the body for the purpose of commercial transactions.[22] The WHO justifies these actions by stating that, “Payment for…organs is likely to take unfair advantage of the poorest and most vulnerable groups, undermines altruistic donation and leads to profiteering and human trafficking.”[23] Despite these ordinances, it was estimated that 5% of all organ recipients engaged in commercial organ transplant in 2005.[24] Research indicates that illegal organ trade is on the rise, with a recent report by Global Financial Integrity estimating that the illegal organ trade generates profits between $600 mill and $1.2 billion per year with a span over many countries, including but not limited to

Poverty and loopholes in legislation contribute to the illegal trade of organs.[25] Poverty is seen in all countries with a large black market for organs. This, however, is not the only factor affecting illegal organ markets - some of the poorest countries in the world do not engage in organ trade. Legislation is another contributing factor in the illegal organ trade, especially legislation with loopholes. For example, India's Transplantation of Human Organs Act (THOA) requires that an organ donor must be a relative, spouse, or an individual donating for reasons of "affection." Oftentimes, claims of "affection" are unfounded and the organ donor has no connection to the recipient.[26] Monetary transactions for organs are illegal in India currently, but there are no laws concerning funds given to a spouse. The spousal inclusion provides a loophole for illegal trade; in some cases organ donors marry the recipient to avoid legal penalty.[27]

History

The international community and national governments have been trying to find stable, ethical systems to deal with the high demand for organ transplants. In 1968, the United States implemented the Uniform Anatomical Gift Act of 1968, which gave individuals the right to donate their organs after their death. Following, the U.S. enacted the National Organ Transplant Act of 1984, which established a national online registry for organ donors and prohibited the buying or selling of organs in the U.S. The most recent efforts of the United States to combat high organ demand include the revision of the Uniform Anatomical Gift Act in 2006 and the 2007 Charlie W. Norwood Living Organ Donation Act [22]

Numerous other countries have passed laws aimed at ending illegal organ trade. In 1994, India passed the Transplantation of Human Organs Act, which banned both the sale of human organs and organ transplants between non-relatives. South Africa adopted the Human Tissue Act of 1983, which outlaws the transfer of tissue (including flesh), bone, organ, or bodily fluid in exchange for payment.[26] In May 2007, China adopted the Human Transplantation Act banning organ commercialism.[28]

Prosecuted cases

Though claims of organ trafficking are hard to substantiate due to lack of evidence and reliable data, cases of illegal organ trade have been tried and prosecuted in the past. 42% of organs are from illegal human trafficking[29]

In 1993, Bombay police exposed a kidney sale and transplantation operation run by a man known as Santosh Raut. Eleven people, including Raut and two nephrologists, were arrested, but Raut managed to escape capture. Authorities believe that Raut went on to establish similar illegal kidney centers across many Indian cities. In February 2008, another kidney transplant center, run by a man called Amit Kumar, was discovered by police in Delhi and nearby Gurgaon. Due to technological advances in fingerprinting, Kumar and Raut are now believed to be the same perpetrator, who has gone by many aliases throughout years of illegal activity. In addition to the two instances mentioned above, Kumar alias Raut is facing charges for his decades of involvement in illegal organ trade, which includes over 600 kidney transplants and the involvement of at least two hospitals.[30]

In November 2010, the South African National Direct of Public Prosecution found St. Augustine's Hospital, owned and operated by the private company Netcare Kwa-Zulu (Pty) Limited guilty of 102 counts of activity relating to illegal kidney transplant operations. Convicted along with the private company were four transplant doctors, a nephrologist, two transplant administrative coordinates, and a translator. The charges against the parent company, Netcare, and its CEO Richard Friedland were dropped in order to obtain an admission of guilt from the hospital. The private company pleaded guilty to 109 illegal kidney operations performed on Israeli, Romanian, and Brazilian citizens between June 2001 and November 2003, including five minors. These citizens received cash following their surgeries, while the private company was paid up-front for its involvement in the operation.[31]

In 2007 a man in the United Kingdom became the first person convicted under the Human Tissue Act 2004 by trying to sell his kidney online for £24,000 in order to pay off his gambling debts.[32]

In April 2010, six Israelis were charged with suspicion of running an international organ trafficking ring and breaking promises to donors to pay for their removed kidneys.[33] According to police, one of the arrested suspects is a retired Israeli army general. The traffickers offered up to $100,000 per kidney, but in at least two cases didn't pay the donors after the organs were surgically removed, police said.[33]

In November and December 2010, Israelis and a Turkish national were reported to be involved in organ trafficking in Kosovo.[34][35]

Media portrayal

Illegal organ trade and organ trafficking have been depicted throughout the years in the media. The 1977 fictional novel Coma by Robin Cook, made into a movie by Michael Crichton, tells of unsuspecting medical patients who are put into a coma in order for their organs to be removed. Similarly, the 1993 book The Baby Train by Jan Brunvand reveals the mythical story of a man who wakes up in his hotel room with a missing kidney the night after flirting with a woman at a bar.[29] In addition to books and films, the stories of organ trafficking are often depicted through television, tabloid magazines, emails, and the Internet.[36] Moreover, many of the organ trafficking tales depicted in the media report unsubstantiated claims. An example is the 1993 British/Canadian T.V. program "The Body Parts Business", a series of episodes investigating alleged organ and tissue trafficking in Guatemala, Honduras,Argentina, and Russia. The series made many claims about organ trafficking that later proved to be false. One such claim includes the story about Pedro Reggi, in which "The Body Parts Business" reported that his corneas had been removed without consent during his stay in a mental facility. Pedro Reggi later came forward and dispelled this claim by saying that his corneas were still intact, and he was just suffering from an acute eye infection.[36]

Critics[who?] argue that this sensationalized view of organ trafficking, often depicted as an urban myth, delegitimizes the illegal organ trade. They call for increased scientific research for illegal organ trade, so that organ trafficking legends can be replaced by scientific fact. Silke Meyer argues, "Only then will [organ trafficking] be taken seriously by all governments affected and will the results constitute a solid ground for the field of policy-making."[29]

Current state

According to the most recent Bulletin of the World Health Organization on the state of the international organ trade, 66,000 kidney transplants, 21,000 liver transplants, and 6000 heart transplants were performed globally in 2005.[24] Another article reports that in 2008 the median waiting time for the U.S. transplant list was greater than 3 years (with projections to increase in the next few years), while the United Kingdom reported a lack of organs for 8000 patients, with the rate increasing at 8%.[22] In response to the high demands and long waiting times, the illegal organ trade has been expanding. Currently, it is estimated that about 10% of all transplants occur illegally, with the Internet acting as a facilitator.[37] For 2006, it was estimated that at least 4000 prisoners were executed to supply approximately 8000 kidneys and 3000 livers for foreign buyers.[37] In 2007, 2500 kidney transplants were bought in Pakistan, with foreign recipients making up two-thirds of the purchases.[22] As of 2007, the Voluntary Health Association of India estimates that approximately 2000 Indians sell a kidney every year. And in Canada and the United Kingdom, experts estimate that about 30 to 50 patients illegally purchased organs abroad.[24]

Transplant tourism

The United Network for Organ Sharing defines transplant tourism as "the purchase of a transplant organ abroad that includes access to an organ while bypassing laws, rules, or processes of any or all countries involved."[28] The term transplant tourism describes the commercialism that drives illegal organ trade, but not all medical tourism for organs is illegal. Examples include when both the donor and recipient of the organ travel to a country with adequate facilities to perform a legal surgery or a recipient travels to receive the organ of an abroad relative.[28] Transplant tourism raises concerns because it involves the transfer of healthy organs in one direction, depleting the regions where organs are bought. This transfer typically occurs from South to North, developing to developed nations, females to males, and from people of color to whites, a trend that experts say "has exacerbated old...divisions."[30]

The kidney is the most sought after organ in transplant tourism, with prices for the organ ranging from as little as $1300[30] to as much as $150,000.[28] In fact, reports estimate that 75% of all illegal organ trading involves kidneys.[38] The liver trade is also prominent in transplant tourism, with prices ranging from $4000[39] to $157,000.[40] Though livers are regenerative and thus not fatal to remove from donors, liver donations are much less common due to an excruciating recovery period that deters donations. Other high-priced bodily organs commonly sold in the organ trade include corneas ($24,400) and unfertilized eggs ($12,400), while lower-priced bodily commodities include blood ($25–$337 ), skin ($10 per square inch) and bones/ligaments ($5,465). While there is a high demand, and correspondingly a very high price, for vital organs such as hearts or lungs, transplant tourism and organ trafficking of these parts is very rare due to the sophisticated nature and the state-of-the-art facilities required for such transplants.[40]

Global reaction

In light of the increasing activity of the illegal organ trade and transplant tourism, the international community has issued many ordinances and declarations against the selling of organs. Examples include the 1985 denouncement of organs for commercial use by the World Medical Authority, the Council of Europe's Convention on Human Rights and Biomedicine of 1997 and its 2002 Optional Protocol Concerning Transplantation of Organs and Tissues of Human Origin, and the Declaration of Istanbul on organ trafficking and transplant tourism.[26] The World Health Organization has played a prominent role in condemning the illegal organ trade. The WHO first declared organ trade illegal in 1987, stating that such a trade violates the Universal Declaration of Human Rights.[23] In 1991, it approved nine guiding principles for human organ transplant at the 44th World Health Assembly, clearly stating among the guidelines that organs cannot be the subject of financial transactions. On May 22, 2004, these guidelines were slightly amended at the 57th World Health Assembly and are intended for governments.[22] These global initiatives have served as a helpful resource for establishing medical professional codes and a legal framework for the issue, but have not provided or declared necessary sanctions to enforce their decrees.[28]

Declaration of Istanbul

The Declaration of Istanbul on organ trafficking and transplant tourism, drafted by the international transplant community, defines transplant commercialism, organ trafficking, and transplant tourism[23] and denounces the practices based on violations to equity, justice and human dignity.[37] The declaration aims to invoke and promote ethical practices in organ transplantation and donation on an international level.[23] The declaration is nonbinding, but over 100 transplant organizations support its principles, including countries such as China, Israel, the Philippines, and Pakistan, who have strengthened their laws against illegal organ trading after release of the declaration.[23]

Impact on the poor

Demographics

Data from the World Health Organization indicates that the primary group targeted by the illegal organ trade is impoverished individuals in developing nations. In a study of organ donors in India, it was found that 71% of all donors fell below the poverty line.[41] Tales of organ theft usually characterize the victims as unemployed males between ages 20–40 who are seeking work and are taken out of the country for operations.[42] This is seen in the case of Makbuba Aripova, whose husband left Uzbekistan for a job in Canada. His corpse and those of family members traveling with him were found several days later with missing organs and bags of money believed to be the proceeds from an organ sale.[5] While men feature prominently in anecdotes on the organ trade, impoverished women are also frequent victims.[41] However most data show that women are rarely the recipients of purchased organs.[15]

Reasons for donating

Considering the poor status of most donors, one of the primary stated reasons for organ selling is to pay off debt.[42] Those who are poorest are frequently seen as more reliable targets for transplant tourists because they are the most in need of money. It has been argued that by providing compensation to donors, the organ trade is helping to lift some people out of poverty. However evidence of this claim is still being debated.[14] In some cases, organs are sold to other family members, either from parents to offspring, or from adult children to parents. This is more frequent in nations where waiting lists are less formal and among families that cannot afford to leave the country for transplants. The trend of younger people donating to their more aged relatives is relatively new, and has been criticized for placing greater value on kidneys from live donors.[43]

Outcomes

Reports by the World Health Organization show decreased health and economic wellbeing for those who donate organs through transplant tourism. In Iran 58% of donors reported negative consequences for their health status. In Egypt, the number rose as high as 78%, and 96% of donors stated that they regretted doing so.[41] These findings are relatively consistent across all countries; those who sell their organs on the market tend to have lower overall health. Substandard conditions at the time of transplant can also lead to transmission of diseases like hepatitis B and C and HIV. The poor health of donors is further exacerbated by depression and other mental illnesses brought on by the stress of donating and insufficient care after surgery.[42][44]

Impoverished donors' economic outcomes are no better than their health outcomes. In a study of Indian donors, it was found that 96% of donors sold a kidney to pay off debts, however 75% of all donors still had this debt after a period of time.[41] Organ brokers frequently do not pay the full amount promised to the donor. Cash that is received for the donation is often quickly spent on post-surgery care that is not provided by the buyer.[17] In a study of Iran, the only nation that has legalized payment for organs, it was found that 66% of donors reported lower financial status. While the Iranian model does provide better compensation for donors and has subsidized the cost of immunosuppressant drugs, it has been argued that the non-negotiable price of a kidney drastically devalues the donor at the expense of the patient.[42] Donors in all countries often report weakness after surgery that leads to decreased employment opportunities, especially for those who make a living through physical labor.[17]

Scholarly debate

The issue of organ trade, both illegal and legal, has been and continues to be the subject of much debate from a wide range of scholars representing diverse perspectives. These debates have resulted in many different solutions addressing the high demand for organs and the rise in illicit trading, including but not limited to a free market for organs, increased legislative regulations and sanctions against illegal organ trading, and implementation of "presumed consent" laws for organ donations.[45] These proposed solutions stem from a large field of academic perspectives, discussed below.

Academic perspectives

Criminal justice perspective

The criminal justice perspective considers the functioning of organ trade from a legal, judicial viewpoint. Though many statutes regarding organ trade exist, law officials have failed to successfully enforce these mandates. One barrier towards enforcement includes a lack of communication between medical authorities and law enforcement agencies. Oftentimes, enforcement officials' access to information regarding individuals involved in illegal organ transplants is hindered by medical regulations such as confidentiality. Without the ability to review medical records and histories to build an effective case against perpetrators, officials cannot fully enforce organ trade laws.[29] Many critics state that in order to achieve effective prohibition of illegal organ trading, criminal justice agencies must collaborate with medical authorities to strengthen knowledge and enforcement of organ trade laws. Critics also support other criminal justice actions to meet this goal, such as prioritization of organ trafficking with local level judicial and legislative bodies, multidisciplinary collaboration in cross-border offenses, and further police training in dealing with organ trafficking crimes.[23]

Economic perspective

Many scholars advocate the implementation of a free market system to combat the economic shortage of available organs for transplant that helps drive illegal organ trade.[45] This illegal status of organ trade creates a price ceiling for organs at zero dollars. This price ceiling affects supply and demand, creating a shortage of organs in the face of a growing demand.[46] According to a report published by the Cato Institute, a US-based libertarian think tank, the elimination of the price ceiling would eliminate the shortage.[14] However, the idea of organ "scarcity" had been opposed by Ivan Illich and other authors who argued that "scarcity" is an "artificially created need". There is not a real shortage of organs, but "excess and wasted" organs. Scarcity only exists for some groups of people—those who were denied the organs, and those who could not afford them. So what needs to be regulated, according to these authors, is organs procurement and distribution practices.[47]

Currently, with little incentive to donate an organ approximately 6,000 people die yearly waiting for a transplant organ. It has been argued by David Holcberg that the regulation of organ trade could solve the organ shortage and create safer, fair practices for donors.[48] Supporters of regulation argue that by implementing a regulated market system, prices for organs would actually be lower than current black market values since an increased supply drives prices down. These lowered organ prices could result in a disincentive to engage in black market organ trading, since illegal brokers would have less of a monetary gain. Additionally, the increased supply would result in lower waiting periods for transplant recipient, which would reduce hospital costs.[45]

However, other critics state that such a market would only increase already high prices for organs, creating an imbalance: only wealthy individuals would be able to purchase these organs. They also argue that such a free market system for organ trade would encourage organ theft through murder and neglect of sick individuals for a financial gain. Advocates for the free market of organs counter these claims by saying that murder for money (e.g. cars, jewelry, etc.) already happens; sanctions against such acts exist to minimize their occurrence, and with proper regulation and law enforcement, such incidents in a legal organ trade could be minimized as well.[45]

Medical ethics perspective

The debate on ethics and morality of organ trade remains a hot topic in today's society. Everyday, the supporting evidence is changed due to the dynamic nature of our technological advancements in medicine and our understanding of ethics itself.[30] At the moment, although organ trade is illegal in almost all countries, it is still difficult to provide a solid conclusion in the field of business ethics without a bias based on one's basic beliefs, culture, or religion. Particularly, religion plays a major role in the topic of bodily autonomy in regards to organ trade. Bodily autonomy is defined as the "ability to make choices about how [one's] body is to be treated by others."[45] Many religious activists and theorists say this idea of bodily autonomy treats the body as property, which goes against many religious views that the body and self are one entity. Therefore, from a religious stance selling a part of your body is analogous to selling your inner self, or soul, which is regarded as a violation of human dignity in many religious communities [49]

Advocates for bodily autonomy argue that the freedom to make decisions about one's body does not violate one's dignity but actually increases a person's sense of control and empowerment. By exercising their right to choose what to do with their body, they will be further empowered and effectively increase their bodily autonomy. Additionally, advocates of bodily autonomy support their arguments by citing examples of activities in today's society that pose risks analogous to organ trade. For example, the ability to endanger one's body by joining the military, acting as a surrogate mother, and/or engaging in medical experiments are all accepted in today's society fueled by financial incentives. By these standards, they argue, the right to choose whether to sell an organ should be supported.[45]

Legalization of organ trade

Legalization of human organ trading is opposed by a variety of human rights groups like the Organs Watch, a group established by medical anthropologist Nancy Scheper-Hughes who was instrumental in exposing illegal international organ selling rings. Much like the Organs Watch, the World Health Organization seeks to protect and benefit the poverty-stricken individuals who participate in the illegal organ trade out of necessity.[50] However, the act of selling oneself (or a portion of oneself) for monetary gain is still viewed as a lucrative opportunity.[44] Indeed, much academic debate is leaning towards the decriminalization and regulation of organ trade as a viable solution for organ trafficking.[37]

Proposed solutions

Several solutions have been put forward to both increase the amount of legally available organs and staunch the flow of illegal trafficking around the globe. Policies of presumed consent have been successful in various countries such as Brazil, the United States, and several nations of Europe. These policies can be either opt-in or opt-out. In a nation with an opt-out policy, consent for organ donation is presumed upon death, although one can choose not to donate by submitting documentation. Research shows a 25-30% increase in the amount of available organs in opt-out countries.[42] In nations with an opt-in policy, like the United States or France, a person may choose to donate their organs during their lifetime. In opt-in countries, families have on occasion succeeded in overturning the decision of the deceased to donate.

Presumed consent programs cut down on organ trafficking in many ways. These laws help increase the amount of available organs, decreasing the reliance of patients on the black market. At the same time, the increased amount of organs cuts the financial cost of a transplant, decreasing the need for medical tourism.[5]

Another method that has been recommended is to enact laws that would hold doctors accountable for not reporting suspected organ trafficking. Medical anthropologist Nancy Scheper-Hughes has written extensively on the issue of doctors knowingly performing illegal operations with illicit organs.[15] While it can be argued that expecting doctors to come forward violates doctor-patient privilege, their legal obligation to the patient, according to Scheper-Hughes, is superseded by public interest in ending alleged medical violations of human rights. If accountability measures were imposed, doctors would be liable as accomplices if they knowingly performed operations with black market organs.[5]

Many in the United States believe that adopting a system for regulating organ trading similar to Iran's will help to decrease national the shortage of kidneys. By promoting accountability, ensuring safety in surgical practices, employing vendor registries, and providing donors with lifetime care, it has been stipulated the US could adopt similar policies. Arguments have been made that private insurance agencies would be invested in providing such care for donors, as the procedure would become relatively standard given the long waitlist for organs. Alternatively, laws could be enacted that make long-term care an intrinsic part of any donation agreement.[14] By legalizing and incorporating organ trade into the domain of government, poverty could be eliminated and the necessity of a black market for organs would be mitigated.

See also

References

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