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The global organ shortage has spawned illegal and unregulated organ markets. The World Health Organization estimates that five to ten per cent of all kidneys transplanted annually – perhaps 63,000 in total – are obtained in the organ bazaars of Africa, Asia, Eastern Europe and South America. Thus, we face a dual tragedy: on one side, thousands of patients who die each year waiting for a kidney; on the other, a human rights fiasco in which corrupt brokers deceive indigent donors about the nature of surgery, cheat them out of payment and ignore their post-surgical needs.
Altruistic appeals to organ donation have not yielded enough organs for transplantation. Not all developed countries have made the most use of posthumous donation, and of course they should. Unfortunately, much of the world transplant establishment – including the World Health Organization, the Transplantation Society and the World Medical Association – focuses exclusively on obliterating organ trafficking. While at face value this may seem reasonable, in reality it is a lethally one-sided prescription, because trying to stamp out underground markets either drives corruption further underground or causes it to flourish elsewhere. Government-sponsored compensation of healthy individuals who are willing to give one of their kidneys to save the life of a dying stranger is the best short-term solution.
So we start on common ground: illegal and unregulated organ markets are reprehensible consequences of individuals driven to seek transplantation therapy. The tragedy has played out across the world. The drive for survival is a very strong human instinct and one that overcomes feelings and common bonds between people. It overthrows decency and humanity and it requires consequentially strong and united laws and regulations. ‘I must leave the country tonight because they are shooting my donor tomorrow,’ was said by a patient to one of my colleagues recently. Such opportunistic human cannibalism has no place in healthcare.
Organ donation after death is the only practicable solution for heart, lung, pancreas, intestine, composite tissue and most liver recipients. There can be no solution that ignores the reality of people with these needs. By focusing on kidneys alone, where the solutions must embrace both the deceased and the living donor, you seem to have discarded the broader needs for transplantation. I thus seek more from you than a throw-away line on ‘the need to make the most use of posthumous donation’.
Let me say a few words about myself. In August 2004 I became one of those whose ‘drive for survival’ became very strong. That’s when I learned I had idiopathic renal failure. After a year of searching for a donor among people I knew well – and coming up empty – a casual (but now very dear) friend stepped in to spare me years of life-draining dialysis and premature death.
I am well aware of my good fortune. Many people without a donor are failing on dialysis, and some have no access to dialysis at all. And they will follow that survival instinct to foreign lands, despite the sickening knowledge that their new organ might come from an executed prisoner in China or an illiterate labourer in India. I, for one, had considered it. Your reference to ‘opportunistic human cannibalism’ took me aback. The tragedy we face is symmetric: hapless donors and wretched patients are locked in a morbid embrace. I outlined one model for disentangling them – a government-regulated programme of in-kind benefits to well-informed donors, offered by a third party and distributed to the next ill person, not the wealthiest. What innovations have you offered?
I realize that most types of organs must come from deceased donors. But let’s be realistic about the extent to which deceased donation can help. You tell of Chinese prisoners who are shot for their organs. This horrific practice is precisely the kind of extreme situation that takes place when there is no legal alternative. If anything, it is an argument in favour of safe and legal means of rewarding donors. Developed countries must enlarge the pool of transplantable organs, by rewarding living and posthumous donors, if they are to keep some of their citizens from becoming reluctant participants in organ trafficking. Voluntary and compensated live donation for kidneys and deceased donation (compensated or not) can and should exist side by side.
Deceased donor programmes are the central issue for organ donation. In your country [the US] deaths on the roads alone are capable of meeting the needs of your population; in China there are 79,000 deaths each year on the roads. Harnessing the existing unavoidable mortality is sufficient to meet the needs if the scientific and social requirements to retrieve those organs are resolved. The system of both blood and organ donation that provides the best protection for both the donor and the recipient is altruistic gifting. The moment that money is introduced to buy a kidney from a vendor, the nature of the exchange and the motivation changes, and with that change come dangerous consequences for both parties. The donor changes, since those driven by money are the poor and the vulnerable in the community. The altruistic, related living-donor evaporates since the recipient can simply buy a kidney and recipients would rather put someone else at risk than their own family. The deceased donors evaporate, since there is no government drive for deceased donation; and the liver, heart and lung recipients simply die. I have just described [the situation in Iran] – the only country in which there is regulated organ sale. This is not a hypothesis, but a proven fact.
I agree that countries can and should make better use of deceased donation. But even in Spain, which has the world’s highest deceased donation rate, individuals continue to die waiting. Even non-renal organs, which are in lesser demand than kidneys, are not produced in adequate numbers, according to the Spanish National Transplant Organization. As for the US, you are mistaken. Of the roughly two million Americans who die annually, only 10,500-13,000 possess organs healthy enough for transplanting. Meanwhile, 85,000 Americans are waiting for kidneys.
I challenge your assertion that deceased donation evaporates when patients can obtain their organs from compensated donors. In Iran the government began compensating living kidney donors in 1988 and since then the waiting list for kidneys has dwindled. Yet Iran also established a deceased programme to increase the supply of livers, hearts, and lungs in 2000. Before passing a law allowing deceased donation, less than one per cent of kidney transplants came from deceased donors, but by 2007 this had risen to 16 per cent.1
Altruism, while a glorious virtue, is simply not enough. You have succumbed to the straw man argument that giving an organ for free is noble but doing so in exchange for material gain is a sordid affront to human dignity.
This is a false choice. Transactions on a black market are dangerous because they are illicit, not because they are transactions. There is a fertile middle ground on which to establish safe, legal programmes that protect donors who would be happy to accept enrichment for saving the life of another. Humanitarian and financial motives intertwine all the time. Are we any less grateful to the firefighters who rescue us because they are salaried?
- B Einollah, ‘Is the Annual Number of Deceased Donor Kidney Transplantations in Iran Lower Than the Middle Eastern Countries?’ Transplantation Proceedings, September 2009 (vol 41, issue 7, pages 2718-2719).
You should take a long hard look at those 85,000 people who are registered in the US organ transplant system – a large number are never deemed fit enough actually to be transplanted by the listing transplant programme. Some 2,700 kidneys were discarded in the US last year – so the first place to make changes is in the efficiency of US systems.
Many ethical and trusting individuals like you, who advocate for buying organs, resolve the undoubted reality of abuse of the poor by the rich by using the reassuring words ‘safe and legal’. It is easy to minimize the conceptual consequences using words but so much harder in reality.
Let us take the example of the Philippines – here the trade in organs flourished until 2008. The vendors were poor people living in the slums and making a living off the waste tips of Manila and Quezon City. The kidney broker lives in the only brick home in the slum from which he extorts the kidneys, for a sum of money similar to his fee. The then president of the Philippines decreed the purchase of organs illegal. This led to a drop in the number of transplant tourists.
In Australia, by getting organized nationally, we are witnessing a 30 per cent rise in deceased organ donation this year and a rise in living kidney donation. The Transplantation Society, working with the Spanish National Transplant Organization and World Health Organization has derived a programme to achieve the changes you ask for. I cannot give you the recipe in a simple email, but if you visit these shores I can show you or you could look on www.donatelife.gov.au
Our job now is to assist the emerging economies of the world to do the same and not to rely on solutions that further entrench the disadvantages of poverty.
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Nancy Scheper-Hughes on this month's Argument
We asked Nancy Scheper-Hughes, Chancellor’s Professor of medical anthropology at the University of California, Berkeley, and director of Organs Watch, for her thoughts on this month's Argument. Read them in her article on The Organ Donors’ Bill of Rights
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