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New Cannibal Markets

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Jean-Daniel Rainhorn
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Samira El Boudamoussi

Part 4. Organs for Sale

State of the Trade: World Transplant Tourism

Jacob A. Akoh

Texte intégral

1The General Agreement for Trade in Services (GATS) has led to liberalization of the international health-care market with consequent growth in medical tourism. Unlike general medical tourism, transplant tourism is associated with many ethical issues, as it is closely linked with organ trafficking and commercialization.

2About 114,690 transplants (77,818 renal) were performed throughout the world in 2012, representing approximately 10% of the global demand (WHO-ONT 2012). Transplant rates vary substantially around the world with important regional differences (Figure 1). This is likely due to differences in rates of end-organ diseases, economic differences in the ability to provide transplants, cultural differences that might support or hinder organ donation and transplantation, and reporting differences (Kasiske et al. 2013). According to Shimazono’s previous estimation (Shimazono 2007), between 3,800 and 7,600 (5%–10%) of the 77,818 renal transplants performed worldwide in 2012 were commercial renal transplants. The key stakeholders of commercial renal transplants include: patients on the waiting lists in developed countries or not on any list in developing countries; dialysis funding bodies; brokers: doctors; transplant centers; organ-exporting or-selling countries; and organ vendors. This chapter presents an overview of the state of transplant tourism in the world and the key challenges with such transplantation.

Figure 1. Regional differences in kidney transplantation (Data from the WHO-ONT Global Observatory on Donation and Transplantation 2012).

Figure 1. Regional differences in kidney transplantation (Data from the WHO-ONT Global Observatory on Donation and Transplantation 2012).

AMR The Americas, EUR Europe, EMR East Mediterranean, WPR Western Pacific, SEAR South East Asia, AFR Africa, Tx transplantation.

Types of tourism

3To address the growing problems of organ sales, a summit meeting was held in Istanbul bringing together more than 150 representatives of scientific and medical bodies, governments, social scientists and ethicists from 78 countries. According to the resulting Declaration of Istanbul (2008), organ trafficking entails the “recruitment, transport, transfer, harboring or receipt of persons, by means of the threat or use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power, of a position of vulnerability, of the giving or receiving of payments or benefits to achieve the consent of a person having control over another person, for the purpose of exploitation by the removal of organs, tissues or cells for transplantation”; and travel for transplantation becomes transplant tourism when it involves commercialization or organ trafficking or deprives the local population of their services. In most instances of transplant tourism, patients travel on their own to obtain organs through the organ trade or through other means that contravene the regulatory framework of their countries of origin. According to Shimazono (2007), transplant tourism takes various forms as depicted in Figure 2 (Akoh 2012).

Figure 2. Types of transplant tourism.

Figure 2. Types of transplant tourism.

Model I: Recipient (R) travels to country B where donor (D) and transplant center (TC) are.
Model II: R and D travel to another country for transplantation.
Model III: D travels to country C where R and TC are.
Model IV: D and R residing in different countries travel to another country (C) for transplantation.
(Culled from Akoh 2012.)

Ethical dilemmas

4Many clinical and bioethical concerns surround transplant tourism, with divergent views across the world. In some parts of the world, transplant tourism is associated with the practice of organ sales by entrepreneurs for financial gain through exploitation of the poor, for the benefit of the wealthy. Such practices denigrate human dignity by commodification or objectification of body parts—against World Health Organization (WHO) Guiding Principles on Human Cell, Tissue and Organ Transplantation (WHO 2010). Shroff (2009) opined that in many affording families, even when there are relatives in good health who could donate, the general argument that is often presented is “why donate and take any risks when you could buy a kidney?” Transplant tourism undermines altruistic donation of deceased organs, encourages exploitation of kidney donors by middlemen, and endangers the lives of donors undergoing nephrectomy in poor, unregulated conditions (Rizvi 2009).

5Consent to “donation” or, more appropriately, selling an organ can hardly be considered as informed as it is not known how much information prospective vendors are given and whether they have any access to redress if things go wrong. Many vendors cite family pressure as a reason for selling an organ—a clear case of coercion by family or significant others. Transplant tourism is associated with lack of appropriate assessment prior to “donation” and poor follow-up of vendors—considered to be unethical practices.

6There is intense debate about what to do with newly transplanted patients returning from abroad with complications (Cohen 2009). This issue challenges traditional professional principles of beneficence and non-judgmental regard. Adopting positions based solely on high moral grounds without consideration of the plight of the affected patients might not be appropriate (Schiano and Rhodes 2010). Not condoning transplant tourism does not abrogate a physician’s right to care for such patients. It is thought that ethical principles mandate transplant physicians to provide adequate care for returning transplant tourists.

Drivers of transplant tourism

7Transplant tourism is facilitated by several factors including inadequate/absent transplant services, ineffective measures to address organ shortage, ease of travel across the world, legal loopholes in different countries, difficulty in ensuring compliance with international law, competing cultural values, risk of death on the waiting list, and the widening gap between the rich and the poor (Kelly 2013).

Need for transplantation

8In developing countries, an ageing population combined with a high incidence of type 2 diabetes mellitus and hypertension has led to an increased burden of chronic kidney disease. Efforts at primary prevention are sporadic and the majority of those with established renal failure (ERF) die because of lack of funds, as few can afford regular maintenance dialysis or renal transplantation. Other reasons for the grim outlook include the lack of dialysis facilities close to home or the debilitating effects of frequent travel over long distances for dialysis. Rich patients living in such economies would be tempted to seek help elsewhere.

9In countries with developed transplant services, lengthy waiting times can contribute to increased risk for clinical deterioration, reduced quality of life, and in many cases, removal from the list. In the US, the median waiting time for transplantation increased from 2.7 years in 1998 to 4.2 years in 2008, and 20% of adult patients first listed for a kidney transplant in 2009 had either died or been removed from the waiting list by 36 months after listing (Matas et al. 2014). Some patients whose immediate prospects of being transplanted are low travel to other countries where they can acquire kidneys either from executed prisoners or live unrelated donors (Kennedy et al. 2005). Unlike many illegal markets, this one is driven by the need of desperate patients with established renal failure at risk of increased morbidity and mortality.

Inadequate organ donation

10The lack of legislation and infrastructure has prevented growth of deceased donor programs in developing countries, so living donors have continued to be the major source of transplantable kidneys. Even the most well-developed deceased donor programs like the Spanish program (with a deceased donor kidney transplant rate of 46.3 per million population [pmp] in 2011) can barely cover 50% of its waiting list (4,493 = 95.6 pmp) due to high demand for organs (WHO-ONT 2012). The establishment of live-unrelated-donor transplantation as a viable option has inadvertently allowed donor recruitment by illegal practices such as coercion or commercialization.

Competing interests

11Though commercial transplantation is prohibited in most countries (Kennedy et al. 2005), the practice of organ sales is common in some parts of the world. It is felt in some quarters that many WHO resolutions represent an imposition of the values and interests of Western countries and do not take into consideration the differing cultural and sociopolitical circumstances in a global economy. Barsoum (2008) controversially stated that certain cultures and developing economies perceive transplant tourism as a human-right that meets the demands of all stakeholders and should therefore be organized rather than declined in the interest of Western countries.

Economic inequality

12Commercial renal transplant is made possible because a high proportion of the population in developing countries live below the poverty line and some believe falsely that selling an organ can positively change their circumstances (Tong et al. 2012). It is not surprising therefore that the known major organ exporting countries (transplant tourism hubs) fall within the developing-economy category. This economic inequality is considered by some as a new form of slavery, as the vendor’s freedom of choice is compromised.

Miscellaneous

13Globalization along with easier communication and transportation enable traffickers to move their operations fluidly, taking advantage of legal loopholes that exist in various countries. As a result, enforcement in one country merely prompts traffickers to seek other countries with more favorable legal environments (Kelly 2013; Rizvi 2009). Also, manipulation of the Internet allows brokers to operate despite prohibitive laws.

Commercial kidney donors

14The risks associated with living kidney donation, such as surgical complications, deterioration of remaining kidney function, and death (Mjøen et al. 2014; Tong et al. 2012), also apply to commercial kidney donors. A recent report from Norway, a country with a well-established living-donor program with adequate follow-up, has highlighted significant long-term risks in non-commercial kidney donors. Mjøen et al. (2014) compared long-term renal function, cardiovascular, and all-cause mortality in 1,901 living kidney donors (median follow-up of 15.1 years) with a control group of 32,621 individuals who would have been eligible for kidney donation between 1963 and 2007. They showed that the hazard ratio for all-cause mortality was significantly increased to 1.30 (95% confidence interval 1.11–1.52), cardiovascular death was 1.40 (1.03–1.91), and the risk of established renal failure was 11.38 (4.37–29.6) for donors. The outcome of commercial kidney donors may in fact be worse than for altruistic donors reported by Mjøen et al. (2014) due to the suboptimal care experienced by organ vendors.

15Naqvi et al. (2008) conducted a cross-sectional survey of 104 kidney vendors in Pakistan, comparing them to 184 matched living related kidney donors from their center and reported a higher rate of hypertension (17% versus 9.2%, p = 0.04), lower glomerular filtration rate (70.94 +/–14.2 versus 95.4 +/–20.44, p = 0.0001), and higher hepatitis C positivity (27% versus 1.0%, p = 0.0001) respectively. Several studies show deterioration in the health of commercial kidney donors possibly due to insufficient donor assessment and pre-existing compromised health conditions, and lack of economic benefit from the sale of an organ (Budiani 2006; Goyal, Mehta, Schneiderman and Sehgal 2002; Naqvi et al. 2008; Zargooshi 2001).

16Public attitude to commercial kidney donors is in sharp contrast to altruistic living kidney donors who were supported by a public anxious to ensure their health and well-being (Tong, Chapman, Wong, Josephson, and Craig 2013). Tong et al. (2012) reviewed seven studies involving over 676 commercial kidney donors that identified: desperation (the participants’ decision to sell their kidney was forced by poverty or to fulfill a family obligation), despair (shame and secrecy, loss of livelihood, and regret), and debasement (deception by brokers and recipients, victimization by the hospital, stigmatization by community, and rejection by family) as the major issues in commercial kidney donation. Budiani reported that 91% of 142 vendors in Egypt expressed social isolation about their donation and 94% regretted donating (Budiani 2006). Furthermore, a kidney sale does not solve the most frequently given reason for being a commercial kidney donor (Budiani 2006; Goyal et al. 2002; Tong et al. 2012; Zargooshi 2001). A long-term financial disadvantage is reported following nephrectomy from a compromised ability to generate the prior income level.

Transplant recipient outcomes

17There are numerous reports indicating that transplant tourism is associated with a high incidence of surgical complications, acute rejection, and invasive infection including the transmission of HIV and hepatitis B and C viruses, which cause major morbidity and mortality (Table 1) (Alghamdi et al. 2010; Ivanovski et al. 2011; Kennedy et al. 2005; Krishnan et al. 2010; Kwon, Lee and Ha 2011; Salahudeen et al. 1990;

Table 1. Outcome for recipients of commercial kidney donation (Akoh 2012).

Table 1. Outcome for recipients of commercial kidney donation (Akoh 2012).

AR acute rejection; CMV cytomegalovirus; HBV hepatitis B virus; HCV hepatitis C virus; GS graft survival; PS patient survival; T tourism; H home country.

18Tsai et al., 2011). Invasive fungal infections, frequently originating at the graft site, have emerged as a serious complication of commercial renal transplants and are associated with high rates of graft loss and death. Nineteen incidences of invasive fungal infections occurring in 17 patients resulting in graft loss or death in 13/17 (76%) of patients and overall mortality of 59% (10/17) have been described (Shoham et al. 2010).

19In discussing the consequences of organ trade in Pakistan and of a regulated paid donor model in Iran on transplant activities in these countries, Rizvi et al. (2009) showed that recipients of commercial kidney donor had poor outcome and high infectious complications in Pakistan, whereas graft survival rates were similar to those for living related donors in Iran. A comprehensive review of commercial renal transplantation performed in several developing countries showed patient and graft survival were generally inferior to internationally accepted standards (Sajjad, Baines, Patel, Salifu, and Jindal 2008). However, some studies report survival figures comparable to local standards (Table 1).

Global reality

20The global reality is that demand for transplantation far outstrips supply of organs throughout the world (WHO-ONT 2012). ERF patients are desperate for transplantation and some die on the kidney waiting list (Matas et al. 2014). In many developing countries, there are no deceased-donor programs and no dialysis facilities. It is thought that transplant tourism functions according to market laws and is profit-driven, as opposed to the legal organ-exchange programs in Europe and the US, which are non-profit and patient-oriented. The WHO, in collaboration with The Transplantation Society and the International Society of Nephrology, has produced several resolutions aimed at curtailing transplant tourism, facilitating transplantation and national self-sufficiency (WHO 2010; The Madrid Resolution 2011) with varying uptake among the 194 WHO member states. Several countries have laws prohibiting transplant tourism and consequently, where this practice takes place illegally, it is unregulated. Given the desperate desire of patients to undergo organ transplantation, the risk of exploitation should not be underestimated.

Way forward

21It is widely acknowledged that widespread criminalization of transplant tourism, worldwide development of organ donation and transplant services, and achievement of self-sufficiency in organ donation by nation states would provide the most potent antidote to transplant tourism (Matas et al. 2014; WHO 2010; The Declaration of Istanbul 2008; The Madrid Resolution 2011). Matas et al. (2014) opined that to effectively address this problem, the international community must craft a new binding instrument that uniformly criminalizes organ trafficking while simultaneously encouraging domestic legislation to address the organ shortage. Meanwhile other options should be considered.

Legalized market

22Proponents argue that vendors ought to be allowed respect of their autonomy to do as they wish with their own organs. They point out that patients from countries with Western moral standards quickly lose these when they become desperate for transplantation. They believe that allowing a legalized market would eliminate many of the negative effects of the organ trade. The main arguments against a legalized market relate to concerns about justice and fairness as well as disproportionate rewarding of the better-off (Demme 2010). It can also be argued that commercialization of living kidney donation does not serve the interests of the donors but endangers the health of recipients and undermines healthy development of international transplantation.

23Hippen (2005) and Clemmons (2009) argue that a regulated market in organs from living vendors would ensure: safety for both vendors and recipients, transparency regarding the risks to vendors and recipients, and institutional integrity regarding guidelines for managing vendors. Further arguments against commercial kidney donation such as “exploitation” of “vulnerable” vendors, and “violating human dignity” (The Declaration of Istanbul 2008) are regarded by proponents of a legalized market as in fact against the effects of an unregulated market.

Financial incentives

24Due to the ethical problems associated with a regulated legalized market and the fears that it would be difficult to properly control it, others have advocated regulated financial incentives for kidney donation (Berman, Lipschutz, Bloom, and Lipschutz 2008). A good example is the Iranian model (Ghods and Savaj 2006). The Iranian government pays all of the hospital expenses for renal transplantation, provides essential immunosuppressive drugs, and gives an award and health insurance to live unrelated donors in addition to a rewarding gift from the recipient or one of the charitable organizations. The program is under the close scrutiny of the transplant teams and the Iranian Society for Organ Transplantation regarding all ethical issues. To prevent transplant tourism, foreigners are neither allowed to undergo renal transplantation from Iranian live unrelated donors nor permitted to volunteer as kidney donors to Iranian patients. The Iranian model cuts off the middlemen and the risks of exploitation.

25Development of a regulated system of incentives might be the most effective means of crippling the core economic support for transplant tourism. Starzl and 18 transplant colleagues (2009) stated that simply making organ trafficking illegal will not make it go away and called for a regulated trial of incentives for donation, to determine whether such incentives would increase the number of available organs while preserving the health, well-being, and dignity of donors and their families.

Limitations

26A review of this nature has several important limitations. The culture of secrecy surrounding transplant tourism means that it is impossible to fully understand the effects of this activity. Reported outcomes of commercial renal transplant may not be reliable because commercial transplantation is illegal, recipients of such transplants return to their native countries soon after the operation and may not have access to follow-up, and it may not be in the interest of practitioners to publish poor results. Furthermore, data on such activity is often based on reports by returning patients to home transplant centers or units for continuing care. Perioperative deaths and defaults from treatment may not be included in published results. Published results are liable to selection bias, publication bias, and underreporting. The “ethical” practice by certain transplant journals in not accepting to publish results of work including commercial kidney donation causes significant publication bias. A recent meta-analysis of commercial kidney donors only included 676 donors (Tong et al. 2012) despite an estimated global rate between 3,800 and 7,600 per year!

Recommendations

27The complex nature of globalization indicates that multiple approaches are required to address the increasing problem of transplant tourism. There is need to improve or develop transplantation services all over the world including enforceable professional guidelines for organ donation and transplantation. Concerted efforts must be continued to curtail transplant tourism by:

  • Expanding education—targeting potential commercial donors and governments.
  • Collecting information—setting up an international registry for transplant tourism. It should become mandatory for details of transplants performed outside any country to be reported to a central national registry.
  • Effectively criminalizing organ trafficking—This requires the enactment of more effective and binding laws such as extraterritorial criminal frameworks against organ trafficking (currently patients who travel abroad to purchase organs experience no legal repercussions upon their return).
  • Encouraging ethical practices—Several international resolutions and standards have been developed to encourage the development of ethical practices in organ donation and transplantation and to prevent trafficking in humans and organs (WHO 2010). The WHO needs to create a unit solely tasked with lobbying governments to accept and enact these resolutions into their national laws in order to ensure better compliance.

Conclusions

28Legislation does not address the root cause of transplant tourism and altruism has proved inadequate in ensuring an adequate supply of organs for transplantation. As attempts to increase donation have not been universally successful and transplant tourism seems to be growing, alternative options are required. It is now time to re-examine intrinsic attitudes to transplant tourism bearing in mind the cultural and economic realities of globalization. Several options need to be pursued by nation states in their drive to national self-sufficiency in organ donation and transplantation. A critical intervention would be devising an effective way of transforming internationally agreed resolutions, standards and protocols into binding national laws. Meanwhile alternative strategies must be considered in the form of reactivating research into xenotransplantation or grafts generated by tissue engineering.

Bibliographie

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Table des illustrations

Titre Figure 1. Regional differences in kidney transplantation (Data from the WHO-ONT Global Observatory on Donation and Transplantation 2012).
Légende AMR The Americas, EUR Europe, EMR East Mediterranean, WPR Western Pacific, SEAR South East Asia, AFR Africa, Tx transplantation.
URL http://books.openedition.org/editionsmsh/docannexe/image/10770/img-1.jpg
Fichier image/jpeg, 78k
Titre Figure 2. Types of transplant tourism.
Légende Model I: Recipient (R) travels to country B where donor (D) and transplant center (TC) are.Model II: R and D travel to another country for transplantation.Model III: D travels to country C where R and TC are.Model IV: D and R residing in different countries travel to another country (C) for transplantation.(Culled from Akoh 2012.)
URL http://books.openedition.org/editionsmsh/docannexe/image/10770/img-2.jpg
Fichier image/jpeg, 82k
Titre Table 1. Outcome for recipients of commercial kidney donation (Akoh 2012).
Légende AR acute rejection; CMV cytomegalovirus; HBV hepatitis B virus; HCV hepatitis C virus; GS graft survival; PS patient survival; T tourism; H home country.
URL http://books.openedition.org/editionsmsh/docannexe/image/10770/img-3.jpg
Fichier image/jpeg, 246k

Auteur

MBBS, FMCS, FRCSEd, FWACS, FRCS (Gen), FICS, is a consultant general/transplant surgeon at Derriford Hospital, Plymouth. He is also associate professor of surgery with University of Plymouth and a member of the Training Committee of the British Transplantation Society (BTS). He was a member of BTS Council, director of the South West Transplant Centre and clinical director of the Surgery and Renal Services, and is an examiner for the Intercollegiate Specialty Board in General Surgery. He is a member of many medical societies and has published many articles and co-edited a book on dialysis access. He is an expert referee for the Health Technology Assessment program.

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