CQGR Organ Trafficking - Sage Publications

JULY 19, 2011

VOLUME 5, NUMBER 14

PAGES 341-366

WWW.GLOBALRESEARCHER.COM

Organ Trafficking CAN THE SMUGGLING OF HUMAN ORGANS BE STOPPED?

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eadline-grabbing arrests of kidney brokers and renegade doctors provide glimpses into a global black market in human organs that is thriving from South America to Asia. The World Health Organization estimates that 5-10 percent of the 100,000 organs transplanted each year have been purchased illegally, typically from poor people desperate for cash. In China, thousands of organs re-

portedly have been forcibly removed from prisoners to feed a lucrative “transplant tourism” business. The full scope

of the global organ black market remains unknown because transplant doctors and hospitals either don’t know the organs were trafficked or are complicit in the deals. Critics say hospitals should disclose the source of all transplant organs so illegal sales can be tracked. Some doctors say legalizing government payments to organ donors — as Iran has done — is the only way to eliminate trafficking, but the mainstream medical community says such payments would only exploit the poor. Artificial organs eventually could help satisfy the growing demand for organs, eliminating the black market.

Since 2000, four members of a Pakistani family have sold a kidney for about $1,200 apiece to pay off debts to their employer, who gives them each $12 a week to work in his Rawalpindi brick factory. Recent reports indicate a resurgent organ black market in Pakistan, despite a ban that became law in 2007. Shown displaying their surgery scars in 2009, are (from right) brothers Mohamed Riiz, 22, and Mohamed Ijaz, 25, and father, Karm Ali, 65. Ijaz’s wife Farzana, 20, (seated) also sold a kidney.

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ORGAN TRAFFICKING THE ISSUES

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• Is the global black market for organs growing? • Would legally paying donors discourage trafficking? • Should governments and hospitals do more to crack down on organ profiteers?

BACKGROUND

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The First Transplants A kidney was successfully transplanted in 1954.

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Foreign Variations Some countries make everyone an organ donor at death unless they “opt out.”

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Coercion and Bans Workers often sell a kidney to pay off debts.

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Transplant Gaps Spur Organ Trafficking Disparity between organ supply and demand fuels sales.

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Chronology Key events since 1901.

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Singapore Allows Reimbursements to Organ Donors But is additional cash paid under the table?

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Austria Leads in Per Capita Transplants Norway has second-highest rate.

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Legalizing Payments The transplant community is debating whether to sanction reimbursements.

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SIDEBARS AND GRAPHICS

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Rich and Poor Collaborate in Global Kidney Trade Kidneys usually travel from poor to rich countries.

Cover : AFP/Getty Images/Nicolas Asfouri

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CQ Global Researcher

MANAGING EDITOR: Kathy Koch

[email protected]

CONTRIBUTING EDITORS: Thomas J. Billitteri

[email protected]; Thomas J. Colin [email protected] CONTRIBUTING WRITERS: Roland Flamini, Sarah Glazer, Reed Karaim, Robert Kiener, Jina Moore, Jennifer Weeks DESIGN/PRODUCTION EDITOR: Olu B. Davis ASSISTANT EDITOR: Darrell Dela Rosa FACT CHECKER: Michelle Harris

A Division of SAGE

PRESIDENT AND PUBLISHER:

John A. Jenkins

At Issue Would regulated reimbursements discourage organ trafficking?

Todd Baldwin

FOR FURTHER RESEARCH

Copyright © 2011 CQ Press, A Division of SAGE. SAGE reserves all copyright and other rights herein, unless previously specified in writing. No part of this publication may be reproduced electronically or otherwise, without prior written permission. Unauthorized reproduction or transmission of SAGE copyrighted material is a violation of federal law carrying civil fines of up to $100,000.

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For More Information Organizations to contact.

CQ Press is a registered trademark of Congressional Quarterly Inc.

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Bibliography Selected sources used.

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The Next Step Additional articles.

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Citing CQ Global Researcher Sample bibliography formats.

OUTLOOK

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July 19, 2011 Volume 5, Number 14

DIRECTOR, REFERENCE SOLUTIONS:

Major Criminal Cases Several trafficking cases are pending.

Making Trafficking Obsolete Eventually, artificial organs could eliminate illicit sales.

U.S. Kidney Sellers Receive the Most Payments can run from $750 to $30,000.

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CURRENT SITUATION

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China Harvests Prisoners’ Organs Activists say China executes “on demand” to provide organs to foreigners.

Voices from Abroad Headlines and editorials from around the world.

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Organ Trafficking BY SARAH GLAZER

THE ISSUES

plant tourism,” in which patients from, say, the United States or Saudi Arabia travor 23-year-old conel abroad for a kidney or struction worker Luis part of a liver. As far as the Picado, it seemed like patients are concerned, opa way to realize the Amerierations in a reputable hoscan dream. Returning to his pital in India or Turkey may home in a slum in Managua, appear perfectly legal, and Nicaragua, one day in 2009, the hospital may assure the he told his mother he had patient that the procedure is met an American man who above-board. But the organ promised him a job and apartmay have come from an imment in New York if he’d poverished laborer who, undonate one of his kidneys. beknownst to the patient, has Three weeks later, Picado been promised from several came out of surgery at a Manhundred to several thousand agua hospital bleeding interdollars by a broker or unnally from an artery doctors scrupulous doctor. had severed in removing his It’s difficult for internakidney, according to medical tional health organizations records. Picado bled to death. and law enforcement agenMatthew Ryan, the Amercies to know which transican man who received the plants originated from an ilIn a high-profile case of coercive organ donation, transplant doctor kidney, did not fare much legal sale because medical Amit Kumar has been charged with illegally removing the kidneys better. Two months after confidentiality rules typicalof some 500 impoverished laborers and farmers in Gurgaon, India. receiving Picado’s kidney ly hide a donor’s identity Some of them allegedly were lured there by false promises of jobs and then forced at gunpoint onto the operating table. Several at the same hospital, the and bar access to medical police officers also were charged with extortion and accepting 68-year-old retired bus surecords. And transplant bribes in connection with the case, which is still pending. pervisor from New York died. tourism can be perfectly legal Prosecutors in Managua are if, for example, a Pakistaniinvestigating whether Nicaragua’s law ker for arranging such a sale. In Iran, American goes to Pakistan to receive prohibiting paying for an organ was such transactions are legal and fund- a kidney as a gift from a cousin there. ed by the government. 2 broken. 1 The Geneva, Switzerland-based The illicit organ trade continues be- World Health Organization (WHO), which Nicaragua is just one of the impoverished countries — along with cause knowing which transplants vi- oversees global organ transplant activiPakistan, India, Egypt and China — olate the law can be tricky. If a pa- ty, estimated in 2007 that 5 to 10 perwhere people from the United States, tient shows up at hospital with a cousin cent of the 100,000 organ transplants Japan, South Korea, Persian Gulf na- who says he’s willing to donate a kid- performed worldwide each year — 5,000tions and other wealthy countries go ney, for example, the transplant is pre- 10,000 such operations — are illegal. 3 to buy organ transplants. In many cases sumed to be legal in most countries. Most patients seeking transplants in the patients, most of whom suffer from But the hospital has no way of know- recent years have traveled from Saudi kidney disease, face the prospect of ing if the patient has written a big Arabia, other wealthy Arabian Gulf dying while waiting the typical five to check to his cousin to express his countries, Taiwan, Malaysia and South 10 years for a donated organ in their “thanks.” Or, the donor could be a Korea, often because their home counstranger, solicited by a broker and try lacks modern transplant facilities. 4 home country. The global black market in human masquerading as a devoted relative (See map, p. 344.) organs continues to thrive in many for an agreed-upon sum. No one knows how many AmeriThe possibility of illegal payments cans travel abroad for transplants (or countries, even though virtually every nation except Iran has banned buy- becomes more likely, but just as hard how many of the operations are illeing or selling organs or paying a bro- to trace, in cases of so-called “trans- gal). That’s because no one, including AFP/Getty Images/Prakash Mathema

F

www.globalresearcher.com

July 19, 2011

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ORGAN TRAFFICKING Rich and Poor Collaborate in Global Kidney Trade The illegal trade in kidneys from live donors generally flows from donors in poor, developing countries — such as Bolivia, India, Romania and China — to patients in rich, developed nations, such as Canada, the United States, Japan and Saudi Arabia. Affluent patients often travel to poorer countries overseas to buy kidneys because they can face up to 10 years waiting for a donated kidney in their home countries — if they live that long. On the Internet, medical tourism sites and hospitals offer cut-rate kidney transplants in India,Turkey and Latin America. In 2010, medical tourism was estimated to be a $100 billion industry, but no one knows how much of that business is based on illegal transplants.

Countries of Origin for Kidney Buyers and Sellers

CANADA

MOLDOVA ROMANIA ITALY

UNITED STATES OF AMERICA

ISRAEL EGYPT

TURKEY IRAN SAUDI PAKISTAN ARABIA OMAN INDIA

CHINA

JAPAN

PHILIPPINES

PERU

BRAZIL

BOLIVIA AUSTRALIA

Countries of origin for those: Selling kidneys Buying kidneys Source: Organs Watch; news reports. Map by Lewis Agrell

U.S. hospitals that treat such patients on their return, is required to report these cases, according to Francis Delmonico, a Harvard Medical School surgeon and president-elect of the Montreal-based Transplantation Society, an organization of transplant specialists. Yet news reports and occasional arrests of large-scale traffickers reveal that ostensibly legal transplants in hospitals abroad depend on a thriving organ trade that preys on the

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poor. In Egypt, South Africa, Brazil and the Philippines, “international cabals of doctors and corruptible ethics boards have slowly transformed slums . . . into veritable organ farms,” investigative journalist Scott Carney writes in The Red Market: On the Trail of the World’s Organ Brokers, Bone Thieves, Blood Farmers and Child Traffickers, a new book about the worldwide illegal trade in organs and other body parts. 5

Meanwhile, some governments in developing countries have a strong incentive to look the other way: Medical tourism for all procedures, ranging from face lifts to transplants, brought in about $100 billion in 2010. 6 Popular images of the illegal organ market abound, but they’re often unrealistic. An example is the scenario portrayed in the 2002 movie “Dirty Pretty Things,” in which a criminal broker persuades desperate immi-

grants to have one of their kidneys removed in a hotel room and then passes the organs in a Styrofoam cooler to another kidney broker. “People don’t take out kidneys on kitchen tables,” says Gabriel Danovitch, medical director of the kidney transplant program at the David Geffen School of Medicine at the University of California Los Angeles. “For transplants to happen you need a decent hospital and well-trained surgeons.” Because organs last outside the body for only a few hours, recipients typically need to be in the same hospital with the donor. While rumors abound in developing countries of people being kidnapped for their organs, such cases are rare. However, there have been plenty of instances of bonded workers, particularly in Pakistan, being coerced into selling a kidney to pay off a debt. In Gurgaon, India, an alleged outlaw doctor charged with removing the kidneys of 500 impoverished laborers and farmers in 2008, some of whom had been lured there by false promises of jobs and then forced at gunpoint onto the operating table. Others were persuaded to sell. 7 In China, human rights activists say tens of thousands of imprisoned practitioners of the Buddhist spiritual discipline Falun Gong have been killed for their organs — largely at military hospitals, which offer foreigners a transplant in as little as a week. “It means next Tuesday somebody has to be executed so that an American can get an organ transplant,” says Delmonico. (See sidebar, p. 346.) But in most of the world, experts say, force is unnecessary. “It’s so easy to put an amount of money on the table that will bring in people that you don’t need to kidnap,” says Luc Noël, coordinator in essential health technologies at WHO. “The rumors and the urban myth of a person who wakes up in the hotel bathtub with a big scar and a


Poor Sellers vs. Rich Buyers The typical kidney seller in a developing country such as the Philippines is a male under age 30 with a family income of less than $500 a year. By contrast, buyers in developed countries such as Israel are much older and typically have family incomes above $50,000. Typical Kidney Buyers and Sellers in the Philippines and Israel Typical seller (Philippines)

Typical buyer (Israel)

Age: 29

Age: 48

Sex: Male

Sex: Male

Annual family income: $480

Annual family income: $53,000

Education: 7 years

Education: University degree

Source: Nancy Scheper-Hughes, “Organs Without Borders,” Foreign Policy, January-February 2005

kidney missing have never been proven,” he says. Often, studies find, a kidney broker pays much less than he promised, and the donor, typically poor and desperate, suffers both physically and psychologically from lack of follow-up care. “The seller is always a victim,” says Noël. In India’s Tamil Nadu province, Rani, the wife of an unemployed fisherman, agreed to sell her kidney to a broker to pay hospital costs for her daughter, who had tried to commit suicide by drinking pesticide. Rani was paid $900 up front to cover her daughter’s expenses and promised $2,600 more when the operation was over. But when she awoke, the broker had vanished. Months later, she said the pain in her side prevented her from getting the only work available to an unskilled woman: day labor on construction sites. “The brokers should be stopped,” she said. “My real problem is poverty — I shouldn’t have to sell my kidney to save my daughter’s life.” 8 “Transplant tourists” also face risks. Being poor and malnourished makes organ sellers more likely to be unhealthy, with no incentive to disclose their true health conditions. Delmoni-

co warns that people who get transplants overseas can contract an esoteric, new antibiotic-resistant bacteria — the superbug NDM-1 — or other infection, such as HIV. 9 Recently, some transplant surgeons have been urging Western governments to consider paying donors in order to eliminate the black market, reduce long waiting lists for donated organs and ratchet down health risks. Organ trafficking could be drastically reduced, says Benjamin Hippen, a transplant nephrologist in Charlotte, N.C., if “the incentives that allow it to be profitable” were eliminated. If American and Western governments paid domestic donors, he maintains, it would satisfy demand in the countries sending transplant tourists to poor countries for organs. The United States has more than 100,000 patients waiting for organs, and Europe has more than 56,000. 10 But proponents of payments remain a minority within the transplant community. Almost every international body opposes paying for organs, arguing that it would violate the existing altruistic system and turn human body parts into commodities. Poor donors would probably lie about serious medical condi-

July 19, 2011

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ORGAN TRAFFICKING tions, putting recipients at risk, opponents add. And paying donors likely would reduce the overall organ supply, they say, because family members would feel less obligated to donate an organ for a loved one. Nor would it increase the supply of organs other than kidneys, most of which come from cadavers.

“If you used every market incentive out there, we’d still have a shortage,” says Arthur Caplan, a professor of bioethics at the University of Pennsylvania and co-director of a United Nations study on organ trafficking. 11 Yet proponents of a regulated organ market point out that simply banning

the practice has only sent it into the shadows. In India, Pakistan, Iraq and Indonesia, transplants have “been driven underground, like abortion, to an underground basement,” says John Fung, director of the Cleveland Clinic’s Transplantation Center and a supporter of a legalized incentive payment

China Harvests Prisoners’ Organs Activists say China executes “on demand” to provide foreigners with organs. hinese government officials have acknowledged since July 2005 that up to 95 percent of the organs transplanted in China were harvested from convicted, executed prisoners — allegedly with their consent. 1 Yet in 2006, Canadian human rights activists reported that there weren’t enough executed prisoners or other donors to account for 41,500 transplants performed in China between 2000 and 2005. The report’s authors, human rights lawyer David Matas and former Canadian Parliament member David Kilgour, concluded that, rather than coming from executed criminals, most of the organs came from imprisoned practitioners of the Buddhist spiritual discipline known as Falun Gong, who were either shot first or died during the organ harvesting operation. 2 Since the government banned the practice of Falun Gong and declared it subversive in 1999, hundreds of thousands of practitioners have been arrested, and those who refused to recant disappeared into slave labor camps, according to Matas and Kilgour. The Laogai Research Foundation, a Washington-based advocacy group that exposes human rights violations in China, estimated that in 2008 between 500,000 and 2 million Falun Gong were being detained. 3 At least 62,000 were victims of organ harvesting operations from 2000-2008, according to Matas and Kilgour and Ethan Gutmann, an investigative journalist. 4 Matas and Kilgour, who were nominated for a Nobel Prize for their investigation, say the organs were then “sold” to foreign transplant tourists. Conducted mainly at military hospitals with access to prisoners, the transplants funneled $1 billion a year to the hospitals, which had lost most of their subsidies from the Communist government, according to Matas. The activists’ undercover reports include taped conversations with transplant doctors at Chinese hospitals promising foreign callers that they could receive a transplant in as little as a week — a process that usually takes months to years in most countries. “They’re clearly blood-typing and tissue-typing prisoners” — to match them to prospective recipients — “and then shooting them,” says Arthur Caplan, a professor of bioethics at the University of Pennsylvania. In 2008, advocacy groups and media reports charged that some of bodies and organs on display in the popular “Bodies” exhibit that traveled to several major American cities were

C

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those of executed Chinese prisoners. After Andrew M. Cuomo, then-attorney general of New York, investigated the allegations, the exhibitor admitted that it had received the bodies from the Chinese Bureau of Police and that, despite its prior denials, it could not verify that the human remains used in its exhibits had not come from executed Chinese prisoners. On May 29, 2008, Cuomo announced a settlement with Premier Exhibitions. The company agreed henceforth to obtain documentation demonstrating the cause of death of its bodies and disclose on its website that it could not confirm whether currently displayed bodies had come from executed prisoners. It also said it would refund ticket prices to prior visitors who requested it. 5 Perhaps in response to allegations of “execution on demand” policies and to allay negative publicity during the 2008 Olympic Games, the Chinese government in 2007 banned the harvesting of organs from living donors without their consent and outlawed the sale of organs. 6 Many websites advertising cheap transplants at Chinese hospitals suddenly disappeared. The government also ordered that Chinese patients waiting for organs be given priority over transplant tourists, and it limited donors to close relatives. John Fung, a Chinese-American transplant surgeon at the Cleveland Clinic who frequently visits Chinese hospitals as a visiting professor, says since China’s 2007 clampdown he no longer sees Saudi and Israeli patients in transplant wards. “I haven’t seen a Caucasian in five years,” he says. The number of organ transplants did dip in 2007, and some observers wondered if harvesting of prisoners’ organs was becoming a thing of the past. But since 2008, Matas maintains, overall transplants have returned to historic highs. Amnesty International estimates that changes in Chinese law have cut in half the number of criminal prisoners executed. But that just means even more of the approximately 10,000 annual transplants in China are coming from Falun Gong who have refused to recant their beliefs, Matas says. He estimates that the number of transplants harvested from Falun Gong members has risen from about 7,500 a year before 2007 to about 8,500 today. Matas acknowledges that “there’s a real downturn in transplant tourism in China. There used to be charters going from Taiwan to China organized by brokers, but the Chinese [gov-

to organ donors. “Once you ban something and the demand is there, you no longer have accountability.” Yet others find the idea of selling a body part — whether legally or illegally — morally repellant, even canni-


AFP/Getty Images/Greg Wood

ernment] stopped them. There were whole wings of hospitals in northern China that had nothing but Koreans in them.” But the government crackdown and the scarcity of organs also have spawned an undercover black market, according to recent news reports. Each year, China has more than a million people waiting for replacement organs, but only 1 percent receive a transplant. 7 A voluntary donation program started by the government in 2009 has led to only 67 transplants in a country with cultural traditions that oppose organ donation. 8 Some Chinese-language websites still advertise illegal packages aimed at Chinese patients, including accommodations, meals and a kidney transplant. 9 In a highly publicized case reported this year, a 26-year-old welder, who changed his mind after agreeing to sell his kidney for $6,000, had his kidney forcibly removed at a grungy local hospital in Shanxi province. The brokers’ henchmen forced Hu Jie into the hospital where the recipient was waiting, and Hu Jie later woke up to find his kidney gone and $2,000 less in his bank account than the broker had promised, he said. 10 Despite recent public declarations from the health minister that the government intends to stop harvesting organs from prisoners over the next five years, it’s not clear that anything has changed yet, experts say. “It’s an attempt to answer criticism through a charm offensive, removing websites [advertising kidney transplants] as evidence for what they’re doing [without] actually improving the situation,” says Matas. Gutmann, an American investigative journalist whose estimates of the number of Falun Gong harvesting victims echoes those of Matas, says it’s hard to say what is happening now. He doesn’t trust Chinese government statistics. “Frankly, I don’t know if harvesting of Falun Gong stopped, stopped and then started again, or never stopped at all,” says Gutmann, an adjunct fellow at the Foundation for Defense of Democracies, a think tank in Washington. “My interviews with recent refugees yield only fragmented clues, and the Chinese health authorities are certainly acting as if they want to put the issue to bed.” It’s also unclear whether transplant tourism is still thriving in China. “For the past six months to a year it looks like it’s picking up again,” says Damon Noto, spokesman for Doctors Against Forced Organ Harvesting, an international group campaigning against forced organ harvesting in China. For military hospitals, where the bulk of transplants are done, Noto says, “their biggest source of income is organ transplant.”

Activists in Australia protest the reported practice in China of killing members of the banned Falun Gong spiritual movement, detained in labor camps, and harvesting their organs to sell to foreign transplant tourists. Websites advertising “transplant packages”disappeared after a government crackdown, but advocacy groups say prisoners still are being killed for their organs. Caplan concurs that transplant tourism is a big money-maker for China and other countries. “You’ve spent a lot of money to be prestigious by doing transplants, and you need kidneys and livers to transplant, but the only way you’re going to get them is through living donor purchase,” he says, or from prisoners in China’s case. “So the government condemns it but looks the other way.” — Sarah Glazer 1 David Matas, “Anti-rejection Drug Trials and Sales in China,” speech given at Doctors Against Forced Organ Harvesting Forum, May 1, 2011, Philadelphia, Penn., www.dafoh.org/Matas_speech.php. 2 David Matas and David Kilgour, Bloody Harvest (2009). 3 Matas, op. cit. 4 Scott Carney, The Red Market (2011), p. 82. Also see Matas and Kilgour, op. cit., and Ethan Gutmann, “ ‘How Many Harvested?’ Revisited,” East of Ethan blog, http://eastofethan.com/2011/03/10/how-many-harvested-revisited/. 5 “Cuomo Settlement with ‘Bodies: the Exhibition’ Ends the Practice of Using Human Remains of Suspect Origins,” press release, Office of the New York Attorney General, May 29, 2008, www.ag.ny.gov/media_center/2008/may29a_ 08.html. 6 “Ending Abuse of Organ Transplantation in China,” China Uncensored, Aug. 20, 2010, www.chinauncensored.com/index.php?option=com_content& view=article&id=249:ending-abuse-of-organ-transplantation-in-china&catid=36: organ-harvesting-in-china&Itemid=79. 7 Bo Gu, “Chinese man wakes up — minus his kidney,” NBC News, March 31, 2011, http://behindthewall.msnbc.msn.com/_news/2011/03/31/6382271-chineseman-wakes-up-minus-his-kidney. 8 Ted Alcorn, “China’s Organ Transplant System in Transition,” The Lancet, June 4, 2011, pp. 1905-1906. 9 “New Law Targets Organ Traders,” China Daily, Feb. 28, 2011, http://usa.china daily.com.cn/epaper/2011-02/28/content_12087280_2.htm. 10 Gu, op. cit.

balistic. “It’s not unlike slavery when you think you can own a part of another person,” says journalist Carney. As the debate over organ transplants continues, here are some of the key questions being discussed:

Is the global black market for organs growing? Because organ trafficking — the buying and selling of organs — is illegal, there are no reliable statistics on the extent of the practice. From the buyers to

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ORGAN TRAFFICKING U.S. Kidney Sellers Receive the Most People who illegally sell one of their kidneys can receive from as little as $750 to $30,000, depending on where they live, according to the most recent available survey of organ trafficking in selected countries. The asking price for an American kidney, for instance, is $30,000 — more than in any other country — because the buyers are wealthier. Kidneys sold in a developing country — such as India, the Philippines and Iraq — garner less than $2,000. Compensation for a Trafficked Kidney (in selected countries) $30,000*

United States

$10,000-$20,000

Israel Peru Turkey Brazil Moldova and Romania India Philippines Iraq (pre-war) 0$

$10,000 $7,500 $6,000 $2,700 $1,500 $1,500 $750-$1,000 5,000

10,000 15,000 20,000 (in current $US)

25,000

30,000

* Asking price Source: Nancy Scheper-Hughes, “Organs Without Borders,” Foreign Policy, January-February 2005

the surgeons, participants have every incentive to hide the transaction under the cloak of a legal operation in a mainstream hospital. Thus, what starts as an illegal sale of a kidney in one country often ends up in a transplant operation that is ostensibly legal in another. WHO — which does not regularly collect statistics on this activity — has not revised its 2007 estimate that 5-10 percent of transplants involve illegally removed organs. “We don’t know how many illegal transplants there are,” says the Transplantation Society’s Delmonico. “I receive anecdotal information,” he says, such as when “a colleague tells us an American has been here [at a foreign hospital] or someone from the Mideast comes to a U.S. center for an organ transplant” — which would be illegal if, say, the patient brought along a “friend” who had actually been paid or promised money. Although some ex-

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perts think the trade is decreasing, he says, “My colleagues from the Middle East tell me, ‘It’s business as usual.’ ” Transplant tourism has become “much less visible” since the World Health Organization’s 2007 report, and “because it’s gone underground” it’s more difficult to estimate the scope of the problem, says WHO’s Noël. “We speculate it has decreased to some extent,” despite some high-profile cases, such as the alleged 2008 coercion incident in Gurgaon, India. Recent bans on organ-selling in such countries as Pakistan, China and Egypt may account for more activity occurring under the radar. For example, India’s 1994 ban on the organ trade caused a drop in the number of foreign recipients but apparently spurred more foreigners seeking transplants to head to Pakistan or the Philippines. And after the ban was in effect for a few years, the underground market in

India appeared to bounce back, with about 2,000 Indians selling a kidney every year, according to the Voluntary Health Association of India. 12 Recent reports in the press and from medical experts indicate a resurgent organ black market in Pakistan, despite a government ban that took effect there in 2007. Pakistan once vied with India as the world’s illegal organ bazaar, performing kidney transplants for more than 1,500 foreigners a year. The new law appeared to halt the illegal donor trade, but only temporarily, according to the Sindh Institute of Urology and Transplantation in Karachi, which provides medical care to low-income patients. The ban is weakly enforced because authorities look the other way, according to the institute. At least 450 people in several villages have sold their kidneys since the ban took effect, according to an eyewitness account presented at an April press conference by Kishwer Zehra, a member of Pakistan’s parliament. Typically, these kidney sellers are bonded agricultural laborers whose indebtedness to their landlords makes them near-slaves. They sell their organs in a vain attempt to escape from lifelong debts but often end up worse off, a 2011 report on Pakistan’s organ black market said, because there is no postoperative care, medicines or follow-up. 13 “Entire villages in southern Punjab are selling their kidneys out of desperation of debt, poverty and landlord coercion,” with doctors “at the center of this trade,” said Adibul Hasan Rizvi, a physician and president of the Transplantation Society of Pakistan at an April press conference at the Sindh Institute of Urology and Transplantation in Karachi. “Pakistan is being dragged back to the era of illegal organ trafficking, spurred on by the unrelenting greed of the medical profession in collusion with the law-enforcing authorities.” 14

Would legalizing payments to donors discourage trafficking? Offer: $175,000 for your kidney. How many people would jump at that pay-


ment? Answer: Enough to eliminate the U.S. waiting lists for organs, Nobel Prize-winning economist Gary S. Becker estimated in 2002. Becker proposed paying both living and deceased donors (or their heirs) for any organ.

“To me it’s horrifying that the area of medicine I’ve devoted my life to may be responsible for atrocities around the world,” says transplant nephrologist Hippen, who has been a prominent advocate of government payments

AFP/Getty Images/Adek Berry

Earlier this month, three doctors were apprehended as they were about to perform an illegal kidney transplant for a Somali man in a private house in the Pakistani provincial capital of Lahore. According to law enforcement authorities, 40 kidney operations had been carried out mostly on Arab and Middle East clients, while most of the kidney sellers were from poor Pakistani families. 15 Demand for kidneys is growing in both wealthy and developing countries for several reasons. Developing countries are building transplant facilities and offering transplants for less than they cost in wealthy countries. New immunosuppressive drugs have improved transplant survival rates, and doctors are adding older, sicker patients, who now have a better chance of survival, to transplant lists. 16 In countries such as Japan, South Korea and Taiwan, demand for transplants has increased as the population has grown wealthier. If China follows the same pattern, its waiting lists for kidney transplants could double in 15 years. 17 That global growth — in both demand and transplants — is likely pushing up demand for trafficked organs, some observers say. “Why wouldn’t the criminal market be growing?” asks journalist Carney. Declining costs for transplants have been driving up global demand for them, he writes in The Red Market. “We’re seeing people more comfortable with medical tourism. And medical tourism is definitely growing,” he points out, adding that countries such as India are aiming to reap billions from the industry. India’s Council on Medical Research predicts that medical tourism could generate $2.3 billion in annual revenue by 2012. 18 India’s medical tourism industry predicts growth of around 17 percent annually. 19

Cash-strapped Indonesians reportedly are selling their organs online, exploiting a loophole in local laws and fueling a dangerous and illegal trade in human body parts. “I want to sell my kidney to buy a house for my mother, thanks call me,” reads the online ad. Such ads on Indonesian personal websites offer kidneys for as little as 50 million rupiah ($5,860).

If governments or health insurance companies could legally make such payments, it “would essentially knock out the black market,” he argued. With an increased supply of organs stimulated by financial incentives, patients would no longer have to travel overseas for a transplant, Becker concluded. Legalization also would reduce the advantage wealthy patients enjoy over poorer patients, who can’t afford to jump the queue by paying cash for a quick, illegal transplant. 20 In recent years, some kidney transplant physicians have embraced the idea of a government-regulated organ market. Financial incentives to live donors would bring in enough kidneys to satisfy demand, they say, and save the lives of those who otherwise might die while on a waiting list. It also would put unscrupulous brokers who exploit the poor out of business.

for organs. “I don’t see another way to fix that.” Arthur J. Matas, a professor of surgery at the University of Minnesota, calculated in 2004 that U.S. society could break even by paying $90,000 to a live kidney donor, because it would save the cost of months or years on dialysis (funded by Medicare, Medicaid or health insurance) while the recipient waited for a donated kidney. 21 Today, he estimates that break-even point could be as high as $500,000, if one includes the benefits from the patient’s improved quality of life. He adds, “If everyone could have a transplant in an aboveboard market, who would go abroad to get an illegal transplant?” Matas does not think donors should necessarily be paid in cash, however. “It could be a tax deduction, a small amount that the donor gets each year to come back for a check-up, college

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ORGAN TRAFFICKING Transplant Gaps Spur Organ Trafficking More than 105,000 people were on organ transplant waiting lists in the United States in 2009, but there were fewer than 15,000 donors. Such gaps between supply and demand in wealthier countries such as the United States help to explain why affluent patients often travel to poorer countries for transplants, fueling the black market in organs. (No. of people)

120,000 100,000

No. of Organ Donors and People on U.S.Transplant Waiting Lists, 1989-2009

80,000 60,000

Donors

40,000

Waiting list

20,000 0

1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009

Source: “The Gap Continues to Widen,” U.S. Department of Health and Human Services, www.organdonor.gov/DLINK-gapgraph.asp

tuition or assistance with getting a job,” he says. Proponents often cite Iran’s experience in paying donors for organs. After legalizing government payments to donors in 1988, Iran claims to have eliminated its organ waiting lists and avoided transplant tourism by prohibiting transplantation to foreigners. It also boasts good postoperative health for organ recipients, although some studies show sellers often experience deteriorating health. 22 (See Background, p. 357.) But critics say middlemen continue to exploit the poor in Iran, and UCLA’s Danovitch doubts that Iran’s waiting list counts every kidney patient who needs a transplant. Nancy ScheperHughes, an anthropologist at the University of California, Berkeley, who studies the organ trade, has reported, “When the government took over responsibility for managing the black market kidney trade, the so-called brokers and kidney hunters were rebranded as ‘transplant coordinators.’ But they’re still just thugs who troll the streets and homeless shelters for people to donate on the cheap.” 23

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Besides a fixed government fee of $1,200, each Iranian kidney donor also may receive a “rewarding gift,” negotiated between donor and recipient under the auspices of a patientrun kidney foundation, which matches donors with compatible recipients. The gifts can run as high as $5,000, according to Nasrollah Ghahramani, a transplant nephrologist at Penn State College of Medicine in Hershey, Pa., who practiced medicine in Iran for a decade. However, Ghahramani, who visited Iran recently, says Scheper-Hughes’ picture of brokers trolling the streets is not accurate. “Most people in larger metropolitan areas with access to the media are aware that . . . they can go directly to the patient advocacy group” to find a match, he says. But he worries that under the so-called gift exchange, the donor and recipient can contact each other. “Nothing says they can’t meet and potentially coerce one another into higher or lower bargaining” under the table, he says. That’s exactly what’s happening, says Scheper-Hughes. “More affluent trans-

plant patients demand healthier, stronger, better-off kidney donors, and are willing to pay for a ‘higher quality’ and ‘more educated’ organ. Rather than replace the black market, the government of Iran has legalized it,” she has argued. 24 “A government-regulated program will not end the black market,” argues Debra Budiani-Saberi, executive director of the Cairo, Egypt- and Washingtonbased Coalition for Organ-Failure Solutions, which works with organ sellers victimized by the black market trade. “People will go where the price is cheaper, and it will always be cheaper somewhere.” “Under the circumstances, where developing countries have almost no mechanism of regulation, to think that the government could run a regulated [market] program is idiotic,” says Farhat Moazam, chairperson of the Sindh Institute’s Centre of Biomedical Ethics and Culture. She points out that even in the United States a Brooklyn kidney broker was arrested in a 2009 FBI sting in New Jersey after allegedly arranging for purchased kidneys to be transplanted at reputable U.S. hospitals for years without being discovered. Market supporters Matas and Hippen, however, say they are proposing a regulated market only for the United States — and perhaps Western Europe — where law enforcement is more trustworthy. And by satisfying demand in wealthy countries, the trafficking in poorer countries almost could be eliminated, they argue. However, Danovitch doubts such a market could be contained within U.S. borders. In the age of Twitter, he predicts, “Within three seconds flat there will be twice the U.S. price offered in Singapore or somewhere else.” International bodies such as the WHO and U.N. and pillars of the medical world, such as the U.S.-based Institute of Medicine, all oppose the payment idea, largely on moral grounds. 25 “Most people wouldn’t want to live in a

Should governments and hospitals do more to crack down on organ profiteers? Who profits most when organs are trafficked? “They’re called ‘doctors’ — and that’s why they’re untouchable,” says journalist Carney. “You don’t go to a Mafia don in Bangalore to get a kidney,” he says, “You go to a hospital.” “It’s mainstream elite hospitals and doctors,” adds bioethicist Caplan, who co-chaired a U.N. investigation of trafficking in 2009. “It’s not gangs of thugs; they’re around, but they’re not the driver.” 27 Indeed, white-coated doctors are the real brokers at the end of an illegal chain, says Carney, either by directly purchasing organs or just turning “a blind eye to something they know about.” When the FBI sting operation in 2009 uncovered a criminal ring that paid Israelis to donate organs to American patients, the surgeries were being performed at reputable New York City hospitals, according to Scheper-Hughes, who had investigated the kidney broker who was arrested. (See Current Situation, p. 360.) A combination of medical prestige, corruption and cronyism helped pro-


AP Photo/Mel Evans

society where the government paid the poor to be organ supplies,” BudianiSaberi says. International groups contend that paying donors would reduce the overall organ supply because fewer relatives would donate an organ. But proponents point out that while donations dropped sharply after payment was legalized in Iran, paid organs more than made up for the difference. 26 Many opponents of outright payment say they would support reimbursements for things such as transportation to the hospital, accommodations and medical expenses, which are not always covered by health insurance in the United States. In Britain and Europe donor expenses for surgery and follow-up care are generally covered.

Levy Izhak Rosenbaum, of Brooklyn, N.Y, was arrested in 2009 as part of an FBI sting and charged with conspiring to broker the sale of an Israeli citizen’s kidney — for $160,000 — for an American transplant patient. Rosenbaum allegedly had been brokering kidney sales for 10 years. Critics of the organ transplant process say look-the-other-way hospital policies foster the illegal trade.

tect doctors behind India’s largest recent organ-selling scandal. In Tamil Nadu province, a refugee camp for survivors of the 2004 tsunami had so many people selling their kidneys that it became known as Kidneyvakkam or “Kidneyville.” After local newspapers began covering the scandal in 2007, the Department of Medical Services discovered that 52 Indian hospitals were involved in transplanting sold organs from thousands of impoverished refugees. Those who sold a kidney were typically offered the equivalent of about $3,000 by brokers, but most received only a fraction of that after their pro-

cedure. Although brokers took a cut of what recipients paid for a kidney transplant — typically $14,000 — doctors and hospitals profited the most, according to Carney. Even though paper trails linked dozens of surgeons to more than 2,000 illegal transplants, authorities let the doctors off with a lecture, forcing only two small nursing homes to close. 28 In Pakistan, rural villagers and bonded laborers view doctors as the likely purveyors of their kidneys, Farhat Moazam, chairperson of the Sindh Institute’s Centre of Biomedical Ethics and Culture, discovered in 2007 while

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ORGAN TRAFFICKING conducting interviews in the countryside. She was shocked when poor villagers approached her colleagues wearing physicians’ garb and asked if they could help with selling a kidney. 29 To the extent there are criminal rings in Pakistan, Moazam says, “You can call it a kind of Mafia . . . connected to certain doctors and certain hospitals.” Although the middlemen take a cut, black market brokers can be quite poor themselves, while “the surgeons and hospitals make a whole lot of bucks out of it,” she contends. Several Pakistani transplant surgeons involved in this illegal activity are wellknown, according to Moazam, but no physicians have been jailed even though the law calls for up to 10 years in prison for selling or buying organs. “There’s quite a strong lobby among transplant surgeons in Punjab,” she says. In Pakistan, police arrested doctors earlier this month, charging them with running an illegal kidney transplant ring in Lahore using kidneys bought from poor Pakistanis and sold to foreign patients, yielding an estimated $1 million. 30 Carney says hospitals should be required to provide the identity of every organ recipient and donor. “It isn’t legal to sell stolen cars, nor is it legal to sell ones that are sure to break down,” he writes. The same standards should apply to body parts, he says. Some countries, such as Switzerland, allow authorities — including foreign authorities and international organizations — to examine medical records in order to expose illegal organ trafficking. “Every country’s transplantation laws should allow this form of disclosure and traceability,” Canadian human rights lawyer David Matas has urged. 31 Yet many members of the medical community resist revealing donors’ names. Caplan would like to “hold the transplant centers accountable for where they get organs” but says this can be done without violating patient confidentiality.

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Delmonico notes that in Israel, where religious objections traditionally keep donation rates low, insurance companies used to pay for overseas transplants. But Israel recently banned insurance payments if the overseas operations were illegal. “I would hope the U.S. government would take the same approach,” says Delmonico. Carney, in his book, cites health insurance companies that have touted transplant operations abroad as cheaper than at home. “Their websites say they will only cover things that are legal in the [United] States,” he says. But would they actually cover an illegal transplant? That’s an open question, he says: “It’s not difficult in India to make an illegal transplant look legal.” In Chennai, India, the committee responsible for authorizing transplants admitted to Carney on tape that it was taking bribes. Even reputable hospitals “won’t look harder than they’re legally forced to,” he says, partly because they benefit financially from performing operations with “donated” organs, which may actually have been purchased under the table. In the United States, doctors say that when a patient shows up at the hospital with a purported friend or relative wanting to donate a kidney, it is difficult to determine whether an illegal organ sale has occurred. The hospital’s social workers and psychiatrists probe the donors about their real motives, but a question often remains: “Is the motivation really ‘I want to help someone’ . . . or get $1,000?” asks New York University transplant surgeon Thomas Diflo. 32 “The transplant community can do a lot to control black markets and exploitation, but they just haven’t chosen to do it,” says Caplan. He urges doctors to boycott conferences if they involve transplant research in China based on organs from executed prisoners. And Danovitch urges journals not to publish similar articles. “If you make pariahs of people who engage

in the behavior, you could get behavior to change,” Caplan says. But Carney sees these as only halfmeasures. “It seems like doctors don’t want to reevaluate their own role,” he says. That will only happen, he says, if the profession agrees to make the supply chain transparent.

BACKGROUND The First Transplants n unfettered market in human tissue and blood was both common and legal in the United States and other countries for nearly threequarters of the 20th century. The discovery in 1901 of four separate blood types ushered in an era of blood transfusion, permitting more extensive surgeries. Selling blood was legal and increasingly in demand in the United States. After World War II, blood collection clinics sprang up in skid row neighborhoods of every major city, endangering the blood supply with blood sold by alcoholics, drug users and others suffering from hepatitis and other blood-borne diseases. 33 This market approach changed radically with the publication in 1970 of a highly influential book by Robert Titmuss, a British social researcher and professor of social administration at the London School of Economics. In The Gift Relationship: From Human Blood to Social Policy, he argued that selling blood and human tissue is exploitative and that an “altruistic” approach, in which people donate their blood, would yield a safer and more ample supply. When people can sell their blood, he argued, the desperately poor lie about drug use or prostitution and the

A

Continued on p. 354

Chronology 1900s-1950s Sale of blood and organs is legal in many countries. 1901 Discovery of four blood groups allows transfusion-aided surgery. Dec. 23, 1954 Doctors in Boston perform first successful kidney transplant. •

1960s-1970s First lung, heart transplanted; states adopt organ donation laws, which make it easier for individuals to donate their organs after death, specifying it is a “gift.” 1963 First lung transplant performed in Jackson, Miss. 1967 First heart transplanted, in South Africa. 1970 British social researcher Robert Titmuss publishes The Gift Relationship, urging altruism as the basis of organ donation in U.S. and U.K. 1971 All 50 states have adopted the Uniform Anatomical Gift Act, giving individuals the right to donate their organs after death with a simple document or donor card; some interpret law as barring incentives for living donors. •

1980s

New immunosuppressive drug makes organ


transplants safer, sparks rise in demand, raising concern about distribution and safety of organs. United States, other countries ban organ sales. 1983 Anti-rejection drug cyclosporine approved in the United States. . . . Reston, Va., doctor announces kidney exchange to buy/sell kidneys, arousing concern in Congress. 1984 Congress passes National Organ Transplant Act banning organ sales. •

1990s

India, the world’s organ bazaar, bans organ sales; Iran legalizes payments. European Union (EU) is empowered to harmonize member states’ laws governing blood, organ distribution. 1994 India bans organ sales; illegal sales continue.

in India, New Jersey and Istanbul, but trafficking continues in Pakistan, Egypt, China. 2006 Two Canadian human rights lawyers report China is harvesting organs from Falun Gong prisoners and selling them to “transplant tourists.” 2007 WHO estimates 5-10 percent of organ transplants are illegal. . . . Pakistan bans organ sales. . . . China bans organ sales, gives Chinese citizens priority for transplants over foreigners. 2008 Declaration of Istanbul condemns organ selling. . . . EU formulates Organs Directive for members, emphasizing organ donations must be unpaid, requiring traceability of organs. 2008 Amit Kumar, a doctor in Gurgaon, India, arrested for 500 illegal transplants.

1998 Iranian government begins paying living donors for their organs.

2009 Brooklyn man charged with brokering organ from Israel for U.S. patient.

1999 Iran claims to have eliminated its kidney waiting list. . . . EU gets new powers to harmonize members’ laws governing organs.

2010 Pakistan’s ban becomes law. . . . Egypt bans trafficking. . . . EU finds Kosovar politicians ran organ smuggling ring.

•

2000s

Medical groups condemn organ trafficking, Chinese organ harvesting from prisoners; debate over legalizing payment for organs heats up. Organ traffickers are arrested

2011 Turkish doctor arrested for alleged involvement in Kosovo organ smuggling ring. . . . Pakistan’s illegal trade returns. Aug. 27, 2012 Deadline for EU states to adopt the Organs Directive.

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ORGAN TRAFFICKING Continued from p. 352

supply is at risk for blood-borne diseases. Based on a comparative study of blood supplies in England and the United States, he concluded that England, where most blood donations came from unpaid volunteers, had a safer supply than did the United States. 34 Titmuss’ altruism concept eventually became the dominant ethical principle, not just for blood but also for organ distribution in the United States and most other Western countries. The first successful kidney transplant was conducted on Dec. 23, 1954, in Boston, and the first lung transplant in 1963 at the University of Mississippi in Jackson. On Dec. 3, 1967, newspapers across the world splashed front-page head-

lines about the first successful heart transplant, in Cape Town, South Africa, by surgeon Christiaan Barnard. 35 A few months later the National Conference of Commissioners on Uniform State Laws produced a framework for standardizing organ and tissue donation laws in the United States, and by 1971 the model Uniform Anatomical Gift Act of 1968 was adopted in nearly identical form by all 50 states. 36 It made it easier for people to donate their organs for medical purposes after death. In 1983, the Food and Drug Administration’s approval of cyclosporine, a revolutionary anti-rejection drug, promised improved transplant survival rates and sparked a huge increase in

transplants. It also spurred concerns about how to distribute available organs, which fell short of demand. In 1984 lawmakers passed the landmark National Organ Transplant Act (NOTA), which makes it “unlawful for any person to knowingly acquire, receive, or otherwise transfer any human organ for valuable consideration” — a vaguely-defined term that has been the subject of legal debate. A violation of the ban is punishable by a $50,000 fine, five years in prison or both. 37 But it exempts “reasonable payments” to donors to cover travel, housing and lost wages incurred by the donation. 38 Similar bans were adopted in other countries. The sale of blood and tissue is now illegal in most countries.

Singapore Allows Reimbursements to Organ Donors But is additional cash paid under the table? ingapore retail tycoon Tang Wee Sung had a net worth estimated at more than $170 million. He also had endstage kidney disease. 1 But even Tang couldn’t count on getting a legal kidney in Singapore, where the wait for a donated kidney is up to nine years. In 2008 he was convicted of offering to pay an organ broker the equivalent of $244,558 for a kidney from an Indonesian man. 2 Tang served a day in prison and was fined about $14,000. 3 The highly publicized case spurred a debate in Singapore over how best to control the illegal organ trade. During a parliamentary hearing on proposed legislation, health minister Khaw Boon Wan said the Southeast Asian city-state should consider legalizing payments to kidney donors. “We may be able to find an acceptable way to allow a meaningful compensation for some living, unrelated kidney donors without breaching ethical principles or hurting the sensitivities of others.” However, Singapore didn’t go quite that far. It did allow donors to be reimbursed for donation-related costs, such as medical care, loss of income, travel and lodging. It also extended the prison sentences of anyone convicted of buying or selling organs, to up to 10 years. 4 The law, which took effect in 2009, came in for harsh criticism from some legislators, who charged it would lead to an organ trading market. The law not only permits foreigners who donate an organ in Singapore to be reimbursed but also allows foreigners to receive a transplant there after agreeing to pay a donor’s costs.

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Lawmaker Halimah Yacob expressed fears that foreign laborers might “become a ready, vulnerable pool of organ donors to be exploited and abused.” 5 Unlike transplant procedures elsewhere, in Singapore the prospective donor and recipient apply as a pair for the transplant and usually know one another. The law also permits the recipient to pay whatever reimbursement costs he chooses, which must be approved by a three-person ethics committee, composed of two doctors and a layperson. Jacqueline Chin, who teaches medical ethics at the National University of Singapore’s Centre for Biomedical Ethics and has reviewed eight such cases as a member of a transplant committee, says the system has flaws. Under the law, the committee must reject the transplant if it suspects money has changed hands. If an employee is donating his kidney to his employer, she says, “Those things get our antennae up.” But, she observes, “We have no expertise or powers to investigate” whether there’s been a cash exchange under the table. By the time a foreign donor-recipient pair shows up on Singapore’s shores, the recipient has presumably already paid for the donor’s airfare and possibly promised other compensation. Ideally, to prevent an under-the-table sale of an organ, there should be a third party who collects the money from the recipient and passes it on to the donor, Chin says. Currently, Singapore’s National Kidney Foundation offers up to 5,000 Singapore dollars ($4,100) in lost income to organ donors. The ethics committee also has no way to enforce the recipient’s promise to pay for the donor’s operation or follow-up

medical care. “If we have any doubts that the recipient is not sincere about reimbursing, we’ll not authorize the transplant,” she says. But what if the recipient just walks away without paying? “Lately, I’m concerned about this. I ask the hospital and physicians if they are intending to pursue the donor for payment.” Singapore’s system, for all its flaws, is intended to follow international guidelines specifying that donations should be an “altruistic” gift, not an exchange for money or valuables. But sometimes those lines become blurred, especially if the donor is a poor relation or an employee in a wealthier cousin’s familyowned business. If the family patriarch dies, the poor employee might be out of a job, Chin points out. Might not a poor person want to donate an organ to a rich employer “to put some food on the table, give my children a better education, get some health insurance?” she asks. Critics of the new law question why the government didn’t prohibit foreigners from receiving transplants and reimbursements in order to crack down on the international organ trade. Singapore, like Thailand and Malaysia, is heavily committed to medical tourism — which attracts all types of patients, not just those seeking transplants. In 2003, Singapore’s government set up an agency just to attract foreigners to its up-to-date hospitals, which are some of the finest in Asia. At some of Singapore’s best private hospitals, foreigners account for a third of the patients — and up to 40 percent of revenue. 6

(It remains legal in the United States for donors to sell blood plasma, a product extracted from blood, and women’s eggs as well as sperm.) But the law did not eliminate profits from the organ business, Red Market author Carney points out. In fact, the donation requirement allowed U.S. hospitals to acquire organs virtually for free while charging up to $500,000 for their transplantation. That system, plus medical privacy rules that forbid public scrutiny of donors, masks the true nature of the supply — including illegal transactions — “behind a curtain of ethics,” he writes. 39 NOTA has been challenged only once in the United States, when Pennsylvania in 1994 enacted its Burial Benefit Act, providing funeral expenses from


“I think Singapore wants to establish a reputation for transplantation expertise,” Chin says. “To do that, you have to do a lot of operations.” As for the tycoon Tang, he finally got a kidney. In January 2009 he received one from organized-crime boss Tan Chor Jin, known as the “One-Eyed Dragon” because he had lost an eye. Tan, who was hanged for murdering a nightclub owner, reportedly donated his kidney voluntarily. 7 — Sarah Glazer 1 “Tang Wee Kit,” Forbes, Aug. 24, 2006, www.forbes.com/lists/2006/79/06singa pore_Tang-Wee-Kit_JU3W.html. 2 Peter Ritter, “Legalizing the Organ Trade?” Time, Aug. 19, 2008, www.time.com/ time/world/article/0,8599,1833858,00.html#ixzz1QyTcaZIK. 3 “Tang Wee Sung Gets 1-day Jail,” Channelnewsasia.com, Sept. 3, 2008, www.channelnewsasia.com/stories/singaporelocalnews/view/373494/1/.html. 4 See “Human Organ Transplant Act (HOTA), FAQs,” Singapore Ministry of Health, www.pqms.moh.gov.sg/apps/fcd_faqmain.aspx?qst=2fN7e274RAp%2bbUzLd EL%2fmJu3ZDKARR3p5Nl92FNtJie8pByIMium%2b96IFsmAcEka%2bpIKxFLl%2bbs TxHVE3%2fpFsXIkii%2bakrP9JvTq0g9m%2fgz6kkbcvQptk23HEACXM9FNn0UQ qJ%2fPlcO17qN9e7L%2b43g4GT9QiZGWWvdvoB4Vi%2bNy6oZpxAfJtcAR% 2fEIKqmp2YAozrd9VgIg%3d.. 5 David Gutierrez, “Singapore to Legalize Financial Compensation for Organ Donors,” Natural News, July 14, 2009, www.naturalnews.com/026619_Singa pore_organ_donor_WHO.html. 6 Ritter, op. cit. 7 Gutierrez, op. cit. Also see Jessica Jaganathan and Teh Joo Lin, “Tang gets kidney, believed to be from ‘One-Eyed Dragon,’ ” The Straits Times (Singapore), Jan. 10, 2009.

a state-administered fund for those who agreed to donate organs after death. Questions about whether the law violated NOTA led the state to specify that the funds should be used to pay only for food, travel, lodging and lost wages — already authorized by NOTA. In European countries, deceased donors’ families commonly are reimbursed for funeral expenses. 40 In 2003 the first tax incentive to encourage organ donation was adopted in Wisconsin, allowing donors to claim a $10,000 state deduction to cover lost wages and expenses for travel, lodging and medical care. 41 Since then, 15 states have adopted similar laws. 42 By 2008, many states had passed other laws aimed at offering inducements or removing disincentives for donating an

organ. At least 30 have provided paid or unpaid leave for bone marrow or organ donors who are state employees. At least eight states have required companies to provide a leave of absence for employees who donate. 43 In 2007, questions arose about whether NOTA’s ban on “valuable consideration” was being violated by socalled paired donations, in which donor-recipient pairs who were not a good transplant match swapped kidneys with another incompatible pair so that each patient received a suitable organ. In 2007 the U.S. Attorney General’s office said the approach did not violate NOTA. On Dec. 21, 2007, the Living Organ Donation Act was signed, clarifying that NOTA did not outlaw paired donations. 44

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ORGAN TRAFFICKING Foreign Variations rgan shortages vary dramatically across the European Union, a difference that many experts attribute to differences in national laws and policies governing how organs are donated. For example, deceased-donation rates range from a low of 14.7 per million people in Britain to a high of 34.4 million in Spain. 45

AFP/Getty Images/Raveendran

O

consent law, organ donation rates started to rise only after Spain created a coordinated hospital-based policy of encouraging consensual donation, known as the “Spanish model.” 46 Under the policy, every hospital appoints as donation coordinator a senior physician with special training in talking with families of dying patients. By contrast, in Britain, a very junior staff member, typically untrained in how to sensitively approach this difficult sub-

Activists from India’s main opposition Bharathiya Janata Party demand an investigation of a kidney black market uncovered in New Delhi in February 2008. Although India banned organ sales in 1994, police have seen a resurgence in the underground organ market, with about 2,000 Indians selling a kidney every year, according to the Voluntary Health Association of India.

Spain is one of several EU countries with a policy of “presumed consent,” in which organs are taken after death unless a person “opts out” before death or the family objects. By contrast, Britain — like the United States — has an “opt in” system, in which a donor must specify on a driver’s license or other directive a desire to donate an organ after death. Many experts suggest countries without presumed consent could eliminate their organ shortfalls by following Spain’s example. While Spain’s high donation rate might be attributed to its presumed

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ject, raises the issue with the family, says Margaret Brazier, a law professor at the University of Manchester. “Perhaps we could avoid radical changes” such as legalizing payments to donors, “by just having a thoroughly good system for encouraging consensual donation,” she says, citing Spain as “the shining example.” In 1999, the EU gained new powers to adopt measures aimed at “harmonizing” member states’ measures governing blood, human tissue and organ donations. Members have until Aug. 27, 2012, to adopt the EU’s Or-

gans Directive, formulated in 2008, the first legally binding international regime imposing legislative requirements on organ donation. Among other measures, it draws on the Spanish approach of appointing specially trained coordinators at hospitals to speak with families about donating. 47 However, the directive says little about organ trafficking except that the EU will monitor the situation — a vagueness due in part to the lack of data on how extensive trafficking is in Europe. 48 That information may be uncovered by the directive’s requirement that members begin verifying donor identities and the origins of organs — not just within donors’ own countries but also in organ exchanges with other countries. 49 Under the directive, EU nations must ensure that donations are voluntary and unpaid, although this does not prevent living donors from being reimbursed for expenses or loss of income. However, in an analysis published this year, Anne-Maree Farrell, a senior lecturer in law at the University of Manchester’s Centre for Social Ethics and Policy, criticized the directive for failing to acknowledge the “longstanding academic and policy debate” over legalized payments and other alternative incentives for donations. She blames the EU’s avoidance of this crucial issue on “a largely technocratic mindset.” 50 Live donor rates in the EU also vary widely — low in Spain but much higher in Scandinavia. Only 17 percent of organ donations across Europe come from living donors. 51 In Britain, live donations have been controversial, partly because of concerns about possible abuses, according to David Price, professor of medical law at Britain’s De Montfort University in Leicester. But legislation in Britain in 2004 and 2006 explicitly endorsed such donations and regulated them. 52 Britain and many other European nations are “actively promoting living organ donation to help boost trans-


By 1999, Iran said its kidney waiting list had been eliminated. More than 78 percent of kidneys transplanted in Iran come from living donors unrelated to recipients. 56

Coercion and Bans ven though it banned organ sales in 1994, India became a major destination for Western organ tourism in

E

ied by a research team at The Johns Hopkins School of Public Health had sold a kidney in hopes of paying off debts, three-quarters were still in debt six years after the organ was removed. 57 In Egypt, poor kidney sellers who have been cheated on the price quoted by a broker or who suffer physical ailments after the surgery are frequently afraid to report their exploitation for fear of arrest, according to the Coalition for Organ-Failure

Chicago Tribune/McClatchy Tribune via Getty Images/Laurie Goering

plant rates,” according to Price. In Britain, the National Health Service now funds transplants of liver sections from living donors, in addition to kidneys. The legal framework also allows swaps of kidneys between pairs or within groups of pairs. 53 Under the Human Tissue Act of 2004, which took effect in England in 2006, an independent agency must approve procedures where there could be abuses, such as paired swaps or donations by children or vulnerable adults. 54 Consensus documents from medical professional groups around the world increasingly establish guidelines to ensure voluntary and informed consent of donors. They frequently recommend psychological and psychosocial evaluation of donors to ensure there has been no pressure to donate. However, Price points out, there is no legal requirement in Britain to follow this guideline. 55 Since the 1980s, many countries have banned compensation for organs. Iran’s compensation system evolved in a war-torn country without the facilities to perform organ transplants for its citizens with kidney disease. Between 1967 and 1988, the number of Iranians on dialysis steadily increased, but only 100 transplants occurred. In 1980, the health minister allowed Iranians to get transplants abroad, paid for by the government. The lack of a deceased-donor program meant the country had no other source of organ donations. Between 1980 and 1985, more than 400 traveled abroad for transplants, and by 1988 there were long waiting lists for overseas transplants. Faced with the rising cost of operations abroad, the government in 1988 introduced a plan to subsidize organ transplants at home. Currently the government pays donors $1,200, which can be supplemented by payments from recipients for associated expenses. After the program began, the number of transplant teams in Iran jumped from two to 25.

Marsha Payne and her husband James — “transplant tourists” from South Florida — traveled to New Delhi’s premiere Apollo hospital, where she donated half her liver for James’ liver transplant in 2008. The operation, plus the couple’s 10-week hospital stay, cost the uninsured former investment banker $58,000 — a fraction of the $450,000 he was quoted in Florida for the same procedure. The $100 billion global medical tourism industry is helping to reduce the cost of transplants and increasing the demand for organs, but it is often difficult for hospitals to determine whether “donated” organs have been purchased.

the 1990s, and by 2002 sales through corrupt brokers were commonplace, according to a widely cited study. The law permitted nonfamily members to donate an organ if they signed a form saying they had not been paid, so brokers persuaded impoverished people to lie. Frequently, local moneylenders demanded that debtors sell a kidney to pay off debts and refused additional credit to those who still had both kidneys. Although 91 percent of organ sellers stud-

Solutions. The group says men from western Sudan’s troubled Darfur region have been recruited for jobs in Cairo, where they were forced to work without pay, accumulated rent debts and then were lured into selling a kidney to pay the debts. 58 Black market sellers are frequently financially and physically worse off. Of 32 Pakistani laborers who sold a kidney to pay off debts to their landlords, none received the amount they

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ORGAN TRAFFICKING were promised, and most remained in debt after the sale, according to a study by Moazam, of the Sindh Institute’s Centre of Biomedical Ethics and Culture. Three years later, all complained of symptoms related to their operations, and all said they could not work as hard as before. 59 Similar after-effects, including high rates of depression and worsened financial situations, have been found among organ sellers in India and the Philippines. Strikingly, most sellers in Iran have experienced deteriorating health, and many have expressed regrets similar to those of illegal sellers in other countries, according to several recent studies. Many said they’d been stigmatized by their families and communities for selling a kidney. 60 In 2008, the international Transplantation Society and the International Society of Nephrology, meeting in Istanbul, adopted the Declaration of Istanbul on Organ Trafficking and Transplant Tourism, a document condemning policies “in which an organ is treated as a commodity, including by being bought or sold or used for material gain.” 61 Since then, Pakistan and Egypt have banned organ-selling, but the bans have only “curbed” the organ trade, according to the Coalition for Organ-Failure Solutions’ Budiani-Saberi. They have “by no means ended it.” In Egypt, organs traditionally were distributed through sales, although most recipients were not foreigners. As recently as 2009, some 80-90 percent of living kidney donors in Egypt had no family link to the recipients. In February 2010, Egypt banned organ trafficking, and, for the first time, permitted transplants from deceased donors. 62 But the law has not been aggressively enforced, according to BudianiSaberi, whose organization works with Egyptian victims of organ trafficking. And with the current vacuum in the government following this spring’s ouster of President Hosni Mubarak,

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Austria Leads in Per Capita Transplants Austria has the world’s highest per capita organ transplant rate, with 95 transplants each year for every million residents. Kidney transplants are the most common. Most transplants are performed in the United States, followed by China, say experts who caution that Chinese statistics are unreliable. Top 20 Organ Transplanting Countries, 2011 (based on number of transplants per million population)

Austria Norway United States Portugal Spain Belgium France Sweden Netherlands Canada Switzerland United Kingdom Croatia Denmark Ireland Czech Republic Germany Italy Malta Australia

95.24 91.88 90.38 87.55 86.16 83.80 71.94 71.61 64.85 64.45 62.11 61.47 60.23 59.45 58.00 57.62 57.45 56.81 55.00 53.62

Source: Global Observatory on Donation and Transplantation, World Health Organization, www.transplant-observatory.org

enforcing the transplant law is not a high priority, she observes. “Trafficking could flourish again, because it’s a vulnerable moment,” she warns. 63

In Pakistan, reports of organ sales by impoverished people surfaced in April, and again just this month in the arrest of several Lahore doctors charged with transplanting purchased kidneys, despite the ordinance criminalizing organ-selling. 64 The Chinese government’s 2007 regulations prohibiting organ trafficking and removal of organs from the living without their consent were aimed at discouraging transplant tourism. The government also began giving Chinese citizens priority for organs and in 2009 limited donors to close relatives. 65

CURRENT SITUATION Major Criminal Cases everal high-profile cases against organ-traffickers are pending around the world, including those against: • Alleged renegade doctor Amit Kumar, in Gurgaon, India, who is in jail awaiting the resolution of his trial. 66 He is charged with illegally removing the kidneys of some 500 day-laborers, farmers and rickshaw drivers. 67 Several police officers also have been charged with extortion and accepting bribes. 68 • Brooklyn, N.Y., resident Levy Izhak Rosenbaum, arrested in 2009 on charges of conspiring to broker the sale of a human kidney for transplant at a cost of $160,000 to an American buyer. According to the complaint, filed in the U.S. District Court of New Jersey, Rosenbaum had been brokering kidney sales for 10 years. He allegedly instructed an undercover buyer to pretend to be a relative or friend

S

Continued on p. 360

At Issue: Would regulated reimbursements discourage organ trafficking? yes

BENJAMIN HIPPEN, MD

GABRIEL DANOVITCH, MD

TRANSPLANT NEPHROLOGIST CHARLOTTE, N.C.

MEDICAL DIRECTOR, KIDNEY TRANSPLANT PROGRAM, DAVID GEFFEN SCHOOL OF MEDICINE, UNIVERSITY OF CALIFORNIA LOS ANGELES

WRITTEN FOR CQ GLOBAL RESEARCHER, JULY 2011

WRITTEN FOR CQ GLOBAL RESEARCHER, JULY 2011

r

egulation probably would discourage trafficking. But issuing broad generalizations about illegal, underground organ trafficking in developing countries is a hazardous proposition. Published information about the workings and outcomes of organ trafficking around the world is piecemeal and often second- or third-hand. The information we do have indicates that it typically involves the transfer of organs from the very poorest to the comparatively very rich, and that those purchasing organs on the black market do so because the opportunities for transplantation in their native country are limited. For the last decade, the core strategy of most transplantation opinion leaders has been to aggressively condemn organ trafficking; identify and apply public pressure on high-level government functionaries in the worst-offending countries and encourage the development of robust deceased-donor programs in the developing world. It’s impossible to know whether this strategy has had any meaningful impact on the prevalence of organ trafficking, though there is ample room for doubt. Pakistan, for instance, passed the Human Organ Tissue Transplant Act (HOTTA) to great acclaim and trumpeted its success in the media and in at least one bioethics journal last year. Although the law banned the sale of organs, reports now are surfacing of a resurgence of illegal underground trafficking. More specifically, this anti-trafficking strategy fails to address the fundamental social and economic allure of organ trafficking: desperation. When a person’s very life depends on a new organ, he suddenly finds himself willing to pay exorbitant sums to individuals he knows nearly nothing about; risk his life (and the lives of others); violate established laws in a country where he is a visitor, and undertake a major surgical procedure in sometimes substandard conditions. The flourishing of organ trafficking in developing countries is caused by the manifest failure of organ procurement policies in developed countries to meet the growing demand for organs. It is the current system that is, and has been, morally complicit in the existence of organ trafficking. It is time to accept that this strategy has been insufficient to the challenge. A regulated market may or may not cure much of what ails global organ transplantation. But, correctly structured, such a market would assuredly remove the incentives for recipients of means to provide key economic support for organ trafficking. And, it is a reasonable hypothesis that, absent this crucial economic support, organ trafficking will wither and die.

t

yes no

he 2008 Declaration of Istanbul on Organ Trafficking and Transplant Tourism (www.declarationofistanbul.org) and the Guiding Principles endorsed by the World Health Organization (WHO) have helped to reduce the venal exploitation of vulnerable organ donors intrinsic to organ trafficking. The widespread endorsement of these pronouncements represents an unprecedented consensus against all forms of organ commercialism. Though organ trafficking still occurs, distinct and measured progress has been made in countries previously designated as “hotspots” by the WHO. Plus, several countries that traditionally have “exported” transplant tourists have taken measures to reduce the trade. For example, Japan passed brain-death laws that enable it to start addressing its citizens’ transplant needs, and Israel prohibited insurance reimbursements for citizens who travel abroad for transplants. Commercialization of organ (typically kidney) donation has been shown to undermine the very fabric of the organ transplant endeavor, which is based on mutual benefit and trust — both in the diagnosis of death and in the welfare of living donors and their recipients. The outcome for kidney sellers is worse than for altruistic donors — from both a medical viewpoint and a psychosocial one. Recipients are also put at greater risk as the mutual caring that underlies successful living donor transplantation is displaced by financial considerations. Furthermore, a “regulated organ market” is an oxymoron. In Iran, where such a system has been in place since 1970, “under the table” payments to “supplement” the regulated government payment are near universal. The transplant community has documented the inferior outcomes for vulnerable donors and is struggling to unburden itself from a system that has hampered the development of related living donation and voluntary deceased donation. Moreover, it is facile to think that commercial organ donation would somehow “solve” the organ donor shortage. Experience has shown that paid donation comes at the expense of and not in addition to voluntary donation. Countries and regions must strive to become self-sufficient in answering their citizens’ transplant needs. We must redouble our efforts to prevent end-stage organ failure and do our utmost to remove the economic, educational, legal and cultural disincentives to organ donation, so both the living and deceased can manifest the humanity that is the core of a safe, successful and effective organ transplant endeavor.

no


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ORGAN TRAFFICKING Continued from p. 358

It further claimed that Kosovo Prime Minister Hashim Thaci, a former Kosovo Liberation Army leader, headed the faction that controlled illicit criminal enterprises, including the organ trafficking. Thaci has denied the charges. The report suggested the organ trafficking continued after the war, and that there was a link between the ring and the Kosovo clinic where Sonmez was working in 2008. 70

AP Photo/Ibrahim Usta

of an Israeli donor-seller he would bring to New York City for the transplant operation. Rosenbaum was arrested as part of an FBI sting that charged 44 people — including New Jersey politicians and rabbis — with a variety of crimes including international money laundering. 69 A trial date has not yet been set.

Police escort Turkish doctor Yusuf Ercin Sonmez to a court in Istanbul, Turkey, on Jan. 12, 2011. He was arrested in January and charged with organ trafficking at a Kosovo clinic in 2008 and has been implicated in an organ smuggling ring based in Kosovo in 1999.

• Yusuf Ercin Sonmez, a Turkish doctor arrested in January for alleged involvement in an organ smuggling ring based in Kosovo, described in a recent Council of Europe * investigation. According to the 2011 report, Kosovar politicians stole organs when the Kosovo Liberation Army was fighting Serbian forces in the late 1990s. Their criminal faction detained Serb prisoners in Albania and killed them in order to extract organs for shipment abroad, the report alleges. * The council is an organization of 47 countries in Europe that seeks to ensure human rights and democratic principles.

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Legalizing Payments roposals to allow payments for organs are being vigorously debated in Europe and the United States. “There has been in general a willingness to look at the issue again,” says Brazier, the British law professor. The Nuffield Council on Bioethics, an influential British think tank, is scheduled to release a report this fall considering various incentives to encourage organ donations, including cash payments, priority on the transplant waiting list for previous donors and payment of funeral expenses of deceased donors. 71

P

Nadey Hakim, surgical director of the transplant unit at London’s Hammersmith Hospital, said he became interested in a regulated market after presenting a news program on organ trafficking for a British television station. Since then, he says, more colleagues have begun to support the idea. “Instead of abusing patients in Third World countries and offering them peanuts for their kidneys, we ought to legalize organ payments in the United Kingdom so at least it’s well-organized,” he says. But he would pay only British donors. Despite the renewed interest, the debate so far has been more theoretical than legislative. In the United States, in 2008 former Sen. Arlen Specter, then a Republican from Pennsylvania, drafted a bill that would have allowed federal, state or local governments to provide donors with in-kind rewards. 72 However, the bill — expected to face fierce opposition from medical groups — was never introduced. Nevertheless, the once-taboo idea of providing donors with financial incentives, or at least reimbursement, appears to now have the support of a sizable proportion of American transplant doctors, according to a 2009 survey by the Society of Transplant Surgeons. It found that most members support providing living donors with coverage for lost wages, guaranteed health insurance and an income tax credit. For deceased donors the poll showed support for paying funeral expenses. But most oppose providing lump-sum cash payments. 73 UCLA’s Danovitch notes that U.S. organ donation rates have been declining slightly in recent years, which he blames on the recession. People worried about holding onto their jobs are reluctant to take time off from work, another reason to consider reimbursing them for lost wages and other expenses, he says. In China, with its low donation rate, the health minister has said the government should consider providing

funeral costs, tax rebates, medical insurance, hospital costs or tuition waivers for donors’ family members. 74

OUTLOOK Making Trafficking Obsolete ome experts think medical advances — such as the use of regenerative medicine to produce artificial organs — could kill the black market in organs by reducing the need for transplants. Although the use of artificial organs on a mass basis may not happen for at least another decade, many experts say, surgeons in Sweden have just given a cancer patient a new windpipe, made with stem cells from the patient’s bone marrow, the BBC reported on July 7. It was the first transplant of a synthetic organ that did not require a donor. 75 “Thanks to nanotechnology, this new branch of regenerative medicine, we are now able to produce a custommade windpipe within two days or one week,” said Paolo Macchiarini, chairman of the Hospital Clínic at the University of Barcelona in Spain, who led the transplant team. “This is a synthetic windpipe. The beauty of this is you can have it immediately. There is no delay.” In addition, “This technique does not rely on a human donation.” 76 He said many other organs could be repaired or replaced in the same way. Other research aims to use stem cells to repair defective organs or create hearts and livers from a patient’s own cells by growing cells on plastic or natural scaffolds. 77 “If we pushed, we could see cell replacement in 10 years,” says bioethicist Caplan, which he says will be far more effective in ending organ trafficking

S


than politically charged market proposals. “You’re not going to get a solution to the needs of people in organ failure by arguing about markets,” he says, noting that millions of patients aren’t even on a transplant list “because there’s no transplant center where they live in Bolivia or Mozambique.” Other experts see an even simpler way to reduce black market demand: better disease prevention so patients don’t need a replacement organ. A growing epidemic of obesity and the resultant growth in diabetes is a major driver of the increasing demand for kidney transplants. In addition, “there are about to be several dramatic improvements in treating hepatitis C — a major cause of end-stage liver disease,” which could “dramatically reduce the need for liver transplants,” says UCLA’s Danovitch.

Otherwise, he says, the poor half of the world will continue selling organs to the wealthier half.

Notes 1

Michael Smith, “Kidneys at Hub of Deadly ‘Transplant Tourism,’ ” Bloomberg News, in The News Tribune, May 15, 2011, www.thenews tribune.com/2011/05/15/1665819/kidneys-at-hubof-deadly-transplant.html. 2 For background, see Barbara Mantel, “Organ Donations,” CQ Researcher, April 15, 2011, pp. 337-360. 3 Yosuke Shimazono, “The State of the International Organ Trade: A Provisional Picture Based on Integration of Available Information,” Bulletin of the World Health Organization, December 2007, pp. 901-980, www.who.int/bulletin/ volumes/85/12/06-039370/en/#. Also see, Council of Europe/United Nations, “Trafficking in

“Entire villages in southern Punjab are selling their kidneys out of desperation, . . . debt, poverty and landlord coercion. Pakistan is being dragged back to the era of illegal organ trafficking, spurred on by the unrelenting greed of the medical profession in collusion with the law-enforcing authorities.” — Adibul Hasan Rizvi, President, Transplantation Society of Pakistan

Waiting times for heart transplants have already declined, he points out, because treatment of heart failure has improved over the past five to 10 years. “Prevention,” Danovitch maintains, “is the best way and the only solution” to stem the shortage-driven black market and the inevitable flow of organs from poor to rich countries.

Organs, Tissues and Cells and Trafficking in Human Beings for the Purpose of the Removal of Organs,” 2009, www.un.org/apps/news/story. asp?NewsID=32521&Cr=&Cr1=. 4 D. A. Budiani-Saberi and F. L. Delmonico, “Organ Trafficking and Transplant Tourism,” American Journal of Transplantation, 2008, p. 927, www.cofs.org/COFS-Publications/Budi ani_and_Delmonico-AJT_April_2008.pdf. 5 Scott Carney, The Red Market (2011), p. 65.

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Smith, op. cit. Amelia Gentleman, “Poor Donors Duped by Organ-Transplant Racket in India,” The New York Times, Jan. 9, 2008, www.nytimes.com/2008/01/ 29/world/asia/29iht-kidney.3.9573650.html. 8 Carney, op. cit., pp. 69-70. Note: Names have been changed in Carney’s book to protect the privacy of interviewees. 9 See Robert C. Moellering Jr., “NDM-1: A Cause for Worldwide Concern,” The New England Journal of Medicine, Dec. 16, 2010, www. nejm.org/doi/full/10.1056/NEJMp1011715. 10 Anne-Maree Farrell, et al., Organ Shortage: Ethics, Law and Pragmatism (2011), pp. 195, 229. 11 Council of Europe/United Nations, op. cit. 12 Shimazono, op. cit. 13 “Resurgence of Pakistan’s Organ Bazaar. Can You Still Deny? Continued Violation of Transplant Law in Pakistan,” Sindh Institute of Urology and Transplantation, April 29, 2011, www.siut.org/news-events/news/resurgenceof-pakistan. 14 Ibid. 15 Asif Chaudhry, “Probe into illegal kidney transplants Surgeons made $1m from 40 clients,” Dawn, July 7, 2011, www.dawn.com/2011/07/ 07/probe-into-illegal-kidney-transplants-surgeonsmade-1m-from-40-clients.html. 16 Ahad J. Ghods and Shekoufeh Savaj, “Iranian Model of Paid and Regulated Living-Unrelated Kidney Donation,” Clinical Journal of the American Society of Nephrology, November 2006, pp. 1136-1145, http://cjasn.asn journals.org/content/1/6/1136.full. Also see Mantel, op. cit. 17 Ted Alcorn, “China’s Organ Transplant System in Transition,” Lancet, June 4, 2011, pp. 1905-1906, www.thelancet.com/journals/lancet/ article/PIIS0140-6736(11)60794-0/fulltext?ver sion=printerFriendly. 18 Carney, op. cit., p. 142. 19 See “Asian Countries amongst Favorites for Medical Tourism,” press release, RNCOS, April 21, 2011, www.rncos.com/Press_Releases/ 7

Asian-Countries-amongst-Favorites-for-MedicalTourism.htm. 20 Gary S. Becker and Julio Jorge Elías, “Introducing Incentives in the Market for Live and Cadaveric Organ Donations,” presented at the conference, “Organ Transplantation: Economic, Ethical and Policy Issues,” University of Chicago, May 16, 2003. An earlier version was presented in 2002, http://home.uchicago.edu/ gbecker/MarketforLiveandCadavericOrganDo nations_Becker_Elias.pdf. 21 Arthur J. Matas and Mark Schnitzler, “Payment for Living Donor (Vendor) Kidneys,” American Journal of Transplantation, Feb. 25, 2004, www.medscape.com/viewarticle/468104_1. 22 Council of Europe/United Nations, op. cit. Also see Ghods and Savaj, op. cit. 23 Carney, op. cit., pp. 81-82. 24 Nancy Scheper-Hughes, “A World Cut in Two,” British Medical Journal, June 21, 2008, www.bmj.com/content/336/7657/1342.full/reply #bmj_el_197479. 25 Council of Europe/United Nations, op. cit. Also see Institute of Medicine, “Organ Donation: Opportunities for Action,” May 2006, www.iom.edu/Reports/2006/Organ-DonationOpportunities-for-Action.aspx. 26 Ghods and Savaj, op. cit. 27 Council of Europe/United Nations, op. cit. 28 Carney, op. cit., p. 65. 29 Farhat Moazam, et al., “Conversations with Kidney Vendors in Pakistan: An Ethnographic Study,” Hastings Center Report, May-June 2009, pp. 29-44, www.thehastingscenter.org/Publica tions/HCR/Detail.aspx?id=3472. 30 Chaudhry, op. cit. 31 David Matas, “Anti-rejection Drug Trials and Sales in China,” speech at the Doctors Against Forced Organ Harvesting Forum, May 1, 2011, Philadelphia, Penn., www.dafoh.org/Matas_ speech.php. 32 Diflo quotes from a discussion session at a New York Academy of Sciences Anthropology Session, “Trafficking the Traffickers,” Oct. 6, 2008, www.thirteen.org/forum/topics/

About the Author Sarah Glazer, a London-based freelancer, is a regular contributor to CQ Global Researcher. Her articles on health, education and social-policy issues also have appeared in The New York Times and The Washington Post. Her recent CQ Global Researcher reports include “Radical Islam in Europe” and “Social Welfare in Europe.” She graduated from the University of Chicago with a B.A. in American history.

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science/trafficking-the-traffickers-undercoverethnography-in-the-organs-trafficking-under world/147/. 33 Carney, op. cit., p. 9. 34 Critics have pointed out that a few years after Titmuss’ book came out, new tests were introduced for hepatitis C, hepatitis B and later HIV, and transfusion-related diseases plummeted. See Sally Satel, When Altruism Isn’t Enough (2008), p. 103. 35 Ibid., p. 131. 36 Ibid. 37 Ibid., p. 114. 38 Ibid., p. 135. Also see http://history.nih.gov/ research/downloads/PL98-507.pdf. 39 Carney, op. cit., pp. 13-14. 40 Farrell, op. cit., p. 29. 41 Ibid., p. 118. 42 For recent state laws see, www.kidney. org/transplantation/livingdonors/pdf/LDTax Ded_Leave.pdf. 43 Satel, op. cit., p. 140. 44 Farrell, op. cit., p. 211. 45 Ibid., p. 229. 46 See Monica Navarro-Michel, “Institutional Organisation and Transplanting the ‘Spanish Model,’ ” in ibid., pp. 151-170. Presumed consent legislation can be found in countries with some of the highest rates of deceased-organ donation (Spain, Portugal, Belgium, France) and some of the lowest (Bulgaria, Greece, Lithuania). 47 Farrell, op cit., pp. 238-239. The Directive establishes minimum guidelines but does not affect EU countries’ existing national laws on the donation or medical use of organs. 48 Ibid., p. 236. 49 Ibid., p. 238. 50 Ibid., pp. 240-243. 51 Ibid., p. 234. 52 See David Price, “Promoting Organ Donation: Challenges for the Future,” in ibid., p. 256. 53 Ibid., pp. 256-7. 54 Ibid., pp. 257-258. 55 Ibid. 56 Ghods and Savaj, op. cit. 57 Ibid., p. 55. Also see Madhav Goyal, et al., “Economic and Health Consequences of Selling a Kidney in India,” Journal of the American Medical Association, 2002, pp. 1589-1592. 58 Debra Budiani-Saberi and Amr Mostafa, “Care for Commercial Living Donors: the experience of an NGO’s outreach in Egypt,” Transplant International, 2010, pp. 1-7, http://on linelibrary.wiley.com/doi/10.1111/j.1432-2277. 2010.01189.x/pdf. For background, see Karen Foerstal, “Crisis in Darfur,” CQ Global Researcher,

Sept. 1, 2008, pp. 243-270. 59 Moazam, et al., op. cit., pp. 33-34. 60 Budiani-Saberi and Mostafa, op. cit., pp. 3, 4. 61 Satel, op. cit., pp. 50-51. Also see www.de clarationofistanbul.com and Budiani-Saberi and Mostafa, op. cit. 62 Budiani-Saberi and Mostafa, op. cit. 63 For background, see Roland Flamini, “Turmoil in the Arab World,” CQ Global Researcher, May 3, 2011, pp. 209-236. 64 “Resurgence of Pakistan’s Organ Bazaar. Can You Still Deny? Continued Violation of Transplant Law in Pakistan,” op. cit. Also see Chaudhry, op. cit. 65 “Ending Abuse of Organ Transplantation in China,” China Uncensored, Aug. 20, 2010, www. chinauncensored.com/index.php?option=com_ content&view=article&id=249:ending-abuse-oforgan-transplantation-in-china&catid=36:organharvesting-in-china&Itemid=79. 66 “Kidney Racket Case,” indianexpress.com, June 8, 2011, www.indianexpress.com/news/ kidney-racket-case-cbi-wants-modification-inhc-order/800842. 67 Gentleman, op. cit. 68 “Court Grants Bail to Accused Police Inspector,” Hindustan Times, Sept. 23, 2008, www. hindustantimes.com/special-news-report/NewsFeed/Court-grants-bail-to-accused-police-inspec tor/Article1-339821.aspx. 69 “Two-Track Investigation of Political Corruption and International Money Laundering Rings Nets 44 Individuals,” Press Release, U.S. Attorney, District of New Jersey, July 23, 2009, www.fbi.gov/newark/press-releases/2009/nk07 2309.htm. Also see USA v. Levy Izhak Rosenbaum, Criminal Complaint Mag No. 09-3620, U.S. District Court, District of New Jersey. 70 “Turkish doctor suspected of human organ trafficking arrested,” CNN, Jan. 12, 2011, http:// premium.edition.cnn.com/2011/WORLD/europe/ 01/12/kosovo.organs/index.html?iref=topnews. Also see “Trafficking Investigations Put Surgeon in Spotlight,” The New York Times, Feb. 11, 2011, www.nytimes.com/2011/02/11/world/europe/ 11organ.html?pagewanted=1&_r=2&emc=eta1. 71 “Organ Donors Could Be Rewarded Under Plans to Boost Registration,” The Times, April 20, 2010, www.timesonline.co.uk/tol/life_and_style/ health/article7102299.ece. Also see www.nuffield bioethics.org/human-bodies. 72 Satel, op. cit., p. 153. 73 J. R. Rodrigue, et al., “Stimulus for Organ Donation: A Survey of the American Society of Transplant Surgeons Membership,” American Journal of Transplantation, 2009, pp. 2172-2176,


FOR MORE INFORMATION Centre for Biomedical Ethics, National University of Singapore, Clinical Research Centre, Block MD11, #02-0110 Medical Drive, Singapore 117597; (65) 6516 7201; http://cbme.nus.edu.sg. Academic center that tracks organ trafficking and legislation to curb it. Coalition for Organ-Failure Solutions, 5 Sakr Kouraish, Apt. 1, Zone 7, Nasr City, Cairo, Egypt; U.S. phone: (330) 701-8399; www.cofs.org. Nonprofit international health and human rights organization dedicated to combating organ trafficking. Declaration of Istanbul on Organ Trafficking and Transplant Tourism; www.declarationofistanbul.org. A website providing up-to-date news about organ trafficking hosted by signers of the 2008 Declaration of Istanbul, a proclamation issued by transplant specialists condemning organ selling. Doctors Against Forced Organ Harvesting, P.O. Box 58123, Washington, DC, 20037; (202) 510-3894; www.dafoh.org. International group of doctors campaigning to end China’s use of prisoners for organ harvesting. Falun Dafa Information Center, P.O. Box 577, New York, NY 10956-9998; (845) 418-4870; www.faluninfo.net. Organization provides information about the persecution of Falun Gong practitioners in China, including deaths from organ harvesting. Global Observatory on Donation and Harvesting, www.transplant-observatory. org/pages/home.aspx. Hosted by the World Health Organization and the Spanish National Transplant Organization (www.ont.es); tracks news and data on organ trafficking and transplantation activities worldwide. The Hastings Center, 21 Malcolm Gordon Road, Garrison, NY 10524-4125; (845) 424-4040; www.thehastingscenter.org. Bioethics center that has published reports and articles about the ethics of organ donation. Laogai Research Foundation, 1734 20th St., N.W., Washington, DC 20009; (202) 408-8300; Founded by Harry Wu, a survivor of the Chinese slave-labor camps known as laogai; provides information about the camps and other Chinese human rights abuses including organ harvesting from executed prisoners. Sindh Institute of Urology and Transplantation, Civil Hospital, Karachi 74200, Pakistan; (92-21) 9215752 & 9215718; www.siut.org. Provides transplants and medical care for low-income patients; monitors Pakistan’s resurgent organ trade. The Transplantation Society, International Headquarters, 1255 University St., Suite 605, Montreal, QC, Canada H3B 3V9; (515) 874-1717; www.tts.org. International group of transplant physicians and specialists. World Health Organization, Clinical Procedures, CPR/EHT/HSS, Essential Health Technologies, Avenue Appia 20, 1211 Geneva 27, Switzerland; 41 22 791 21 11; www.who.int/transplantation/en/. Web site of the WHO unit responsible for promoting ethical donation and transplantation. http://deepblue.lib.umich.edu/bitstream/2027. 42/74730/1/j.1600-6143.2009.02741.x.pdf. 74 “China Considers Financial Incentives to Promote Organ Donation,” Reuters, April 25, 2011, www.reuters.com/article/2011/04/25/uschina-organs-idUSTRE73O1HX20110425.

75

Michelle Roberts, “Surgeons Carry out First Synthetic Windpipe Transplant,” BBC News, July 7, 2011, www.bbc.co.uk/news/health-140 47670. 76 Ibid. 77 Farrell, op. cit., p. 22.

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Bibliography Selected Sources Books Carney, Scott, The Red Market: On the Trail of the World’s Organ Brokers, Bone Thieves, Blood Farmers and Child Traffickers, William Morrow, 2011. An investigative journalist spent five years tracing the routes of illegal organs and other body parts from the original sellers through brokers to recipients. Farrell, Anne-Maree, David Price and Muireann Quigley, Organ Shortage: Ethics, Law and Pragmatism, Cambridge University Press, 2011. Academics from Britain and elsewhere discuss financial incentives for organ donation and the donation experience in the United Kingdom, European Union and United States. Matas, David and David Kilgour, Bloody Harvest, Seraphim Editions, 2010. Two Canadian lawyer/human rights activists were nominated for a Nobel Prize for this investigation concluding that thousands of Falun Gong practitioners in China have been killed for their organs. Satel, Sally, When Altruism Isn’t Enough: The Case for Compensating Kidney Donors, AEI Press, 2008. Experts argue for legalizing payments to organ donors to increase supply. The book is based on a conference sponsored by the conservative American Enterprise Institute.

Articles

Interlandi, Jeneen, “Not Just Urban Legend,” Newsweek, Jan. 10, 2009, www.newsweek.com/2009/01/09/not-justurban-legend.html. A reporter describes the organ trafficking investigations of anthropologist Nancy Scheper-Hughes. Moazam, Farhat, et al., “Conversations with Kidney Vendors in Pakistan: An Ethnographic Study,” Hastings Center Report, May-June 2009, www.thehastingscenter.org/Publications/ HCR/Detail.aspx?id=3472. The chair of the Centre of Biomedical Ethics and Culture in Karachi and her team interviewed 32 Pakistani laborers who sold a kidney to pay off debts to their landlords. Shimazono, Yosuke, “The State of the International Organ Trade: A Provisional Picture Based on Integration of Available Information,” Bulletin of the World Health Organization, December 2007, pp. 901-980, www.who.int/ bulletin/volumes/85/12/06-039370/en/#. Based on an analysis of more than 300 articles and reports, the article concludes that, conservatively, about 5 percent of all organ transplants worldwide in 2005 involved black market transactions. The World Health Organization used the article as the basis of its estimate that 5-10 percent of transplants each year involve illegal sales. Smith, Michael, “Kidneys at Hub of Deadly ‘Transplant Tourism,’ ” The News Tribune, May 15, 2011, www.thenews tribune.com/2011/05/15/1665819/kidneys-at-hub-of-deadlytransplant.html. A Bloomberg News reporter describes the illicit market for organ transplants in Nicaragua and around the world stimulated by the growing “transplant tourism” business.

Alcorn, Ted, “China’s Organ Transplant System in Transition,” Lancet, June 4, 2011, pp. 1905-1906. Alcorn describes China’s still-paltry efforts to adopt a voluntary organ-donation system and crack down on transplant tourism.

Reports and Studies

Gu, Bo, “Chinese man wakes up — minus his kidney,” March 31, 2011,MSNBC, http://behindthewall.msnbc.msn. com/_news/2011/03/31/6382271-chinese-man-wakes-upminus-his-kidney. Twenty-six-year-old Hu Jie, who changed his mind about selling a kidney, describes how his kidney was forcibly removed by a broker’s henchmen, a widely publicized story signaling a renewed black market in China.

“Resurgence of Pakistan’s Organ Bazaar. Can You Still Deny? Continued Violation of Transplant Law in Pakistan,” Sindh Institute of Urology and Transplantation, April 29, 2011, www.siut.org/media-siut/data-files/resurgence-ofpakistan-organ-trade.pdf. A Karachi medical center reports a resurgence of Pakistan’s illegal organ trade since a law criminalizing organ selling took effect in 2007.

Gutmann, Ethan, “China’s Gruesome Organ Harvest,” The Weekly Standard, Nov. 24, 2008, www.weeklystandard. com/Content/Public/Articles/000/000/015/824qbcjr.asp. An investigative journalist and fellow at the Foundation for Defense of Democracies, an advocacy group in Washington, describes large-scale organ harvesting from Falun Gong prisoners while still alive, confirmed by his interviews with escapees from Chinese labor camps.

“Trafficking in Organs, Tissues and Cells and Trafficking in Human Beings for the Purpose of the Removal of Organs,” Council of Europe/United Nations, 2009, www.coe.int/t/dghl/ monitoring/trafficking/docs/news/OrganTrafficking_study. pdf. A WHO estimate that 5-10 percent of annual worldwide kidney transplants involve trafficking is conservative, according to this comprehensive report.

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The Next Step: Additional Articles from Current Periodicals Black Market Bryant, Lisa, “EU May Investigate Kosovo PM for Organ Trafficking,” Voice of America, Dec. 15, 2010, www.voa news.com/english/news/europe/EU-May-Investigate-KosovoPM-for-Organ-Trafficking-111952224.html. The European Union plans to investigate allegations that Kosovo’s prime minister has sold human organs on the black market. Ogilvie, Jessica Pauline, “A Kidney Market At What Cost?” Los Angeles Times, March 28, 2011, p. E1, articles.latimes. com. The unregulated, underground market for human organs in developing countries has had catastrophic effects for both donors and recipients. Simon, Alina, “New Law to Plug Black Market for Organs,” New Straits Times (Malaysia), Oct. 5, 2010, www.nst.com. my/nst/articles/14tissue/Article/. The Malaysian Health Ministry is drafting a new law intended to ensure that organ and tissue transplantation is conducted without turning to the black market.

China “China to Launch Crackdown in Illegal Organ Transplants,” Xinhua (China), April 18, 2011, news.xinhuanet.com/ english2010/china/2011-04/19/c_13834757.htm. The Chinese Ministry of Health is launching a nationwide campaign to target illegal organ transplants performed by unqualified medical institutions. Kamm, John, “Is Mercy Coming to China?” The Washington Post, Aug. 16, 2010, p. A13, www.washingtonpost.com/ wp-dyn/content/article/2010/08/15/AR2010081502150.html. The executive director of the Dui Hua Foundation, a San Francisco-based human rights group, says capital punishment has reached astonishing levels in China largely to harvest organs from executed prisoners.

Smith, Lewis, “Sale of Human Organs Should Be Legalised, Say Surgeons,” The Independent (England), Jan. 5, 2011, www.independent.co.uk/life-style/health-and-families/healthnews/sale-of-human-organs-should-be-legalised-say-surgeons2176110.html. Many leading British surgeons are calling for the legalization of organ sales in order to meet growing demand. Widhiarto, Hasyim, “When Disease Creates Demand,” Jakarta (Indonesia) Post, Oct. 25, 2010, www.thejakarta post.com/news/2010/10/25/when-disease-creates-demand. html. An estimated 80,000 people in Indonesia are waiting for kidney transplants, leading many to wonder whether illegal organ trafficking is occurring in the country.

Laws and Regulations “Relaxed Rules May Lead to More Organ Donations,” Yomiuri Shimbun (Japan), Aug. 11, 2010, www.yomiuri. co.jp/dy/national/T100810004970.htm. The relaxation of requirements for organ donations would raise the number of annual donors in Japan for the foreseeable future, according to the Japan Society for Transplantation. Rahn, Kim, “NK Defector in Legal Dispute Over Organ Transplantation,” Korea Times (South Korea), May 23, 2011, www.koreatimes.co.kr/www/news/nation/2011/05/113_87 535.html. A South Korean law designed to prevent organ trafficking is preventing a North Korean defector from receiving a transplant, even though he has found a donor.

CITING CQ GLOBAL RESEARCHER Sample formats for citing these reports in a bibliography include the ones listed below. Preferred styles and formats vary, so please check with your instructor or professor.

Varma, K.J.M., “China to Amend Organ Transplant Rules to Encourage Donations,” Press Trust of India, Jan. 10, 2011. China is set to amend its organ transplant regulations to build a national donation system that relies less on obtaining organs from executed prisoners.

MLA STYLE

Demand

Flamini, R. (2007, April 1). Nuclear proliferation. CQ Global Researcher, 1, 1-24.

Callahan, Maureen, “Invasion of the Body Snatchers,” The New York Post, June 12, 2011, p. 28, m.nypost.com. The growing demand for organs such as kidneys has led to profitable trading rings in the United States, Brazil, Egypt, Israel, Japan and South Africa.

CHICAGO STYLE


Flamini, Roland. “Nuclear Proliferation.” CQ Global Researcher 1 Apr. 2007: 1-24.

APA STYLE

Flamini, Roland. “Nuclear Proliferation.” CQ Global Researcher, April 1, 2007, 1-24.

July 19, 2011

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Voices From Abroad: KANCHHA BUDHATHOKI

JOSE OLIVEROS

ISMAIL MERICAN

Garment factory worker Nepal

Catholic Bishop, Philippines

Health Director-General Malaysia

Misled “He [a fellow worker] said he would find me a good job in India. When we reached New Delhi, we went to a hospital and they tested my blood. Another day they gave me alcohol then they gave me an injection. I became unconscious and when I woke up I was in hospital and they had already taken one of my kidneys.” Nepali Times, June 2011

JOHN KAMM Executive Director, Dui Hua Foundation, China

Preserving dignity “Human organ sale or trade, by its very nature, is morally unacceptable. It is contrary to the dignity of the human person, his or her authentic autonomy and the essential equality of all persons. The dignity of the human person as the image of God includes not only his or her soul but his or her corporeal being. Hence, our body ought not to be treated as a commodity or object of commerce, which would amount to the dispossession or plundering of the human body.” Philippines News agency July 2010

Not just a deterrent “While many have thought UANG IEFU the death penalty is invoked Vice Health Minister to deter crime, there is anChina other reason capital punishment reached such astonishing levels in China. For years Transplants and ethics “With the amendment, organs were harvested from China will be a step closexecuted prisoners.” er to building up a national News Journal (Delaware) organ donation system, August 2010 which is being run as a pilot project in 11 provinces ALITHA AGHURAM and regions now and thus the sustainable and Director, Multi Organ ensure healthy development of Harvesting Aid Network organ transplants and save more lives. An ethically India proper source of organs for China’s transplants that is Only in times of need sustainable and healthy “Ninety-nine percent of us would benefit more pawill accept an organ transplant tients.” if we need one to live, but not even one of every 10 of Press Trust of India, January us are signed up to donate.” 2011

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New Straits Times (Malaysia) November 2010

LIU RENWEN Law Researcher, Chinese Academy of Social Sciences China Harmful to society “Some poor people sell their own organs for a small amount

Chinadaily.com.cn, February 2011

DENG LIQIANG Legal Affairs Director, Chinese Medical Doctor Association, China Illuminated circumstances “The scarcity of available human organs is a global phenomenon. It is just more obvious in China because of the number of illegal organ trades due to poverty.” Anchorage (Alaska) Daily News, February 2011

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India Today, August 2010

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Related donors only “If living donation is to be carried out, it should come from genetically, legally or emotionally related donors. . . . Unrelated donation is not a preferred solution to increase the donor pool.”

of money. Although it might be voluntary, they are not aware of the health risks. What’s more, the illegal organ trade is harmful to society as a whole.”