Over the past fifteen years, transplanting human organs has become a standard and remarkably successful medical procedure, giving new life to thousands of people with failing hearts, kidneys, livers, and lungs. But very few countries have sufficient organs to meet patients’ needs. In the United States, for example, some 50,000 people are on the waiting list for a transplant; fifteen percent of patients who need a new heart will die before one becomes available. The shortages are even more acute throughout the Middle East and Asia.
This lack of available organs arouses desperation and rewards greed. Would-be recipients are willing to travel far to get an organ and many surgeons, brokers, and government officials will do nearly anything to profit from the shortage. In India well-to-do people and their doctors buy kidneys from debt-ridden Indian villagers; in China officials profitably market organs of executed Chinese prisoners. The international commerce in organs is unregulated, indeed anarchic. We know a good deal about trafficking in women and children for sex. We are just beginning to learn about the trafficking in organs for transplantation.
The routes that would-be organ recipients follow are well known to both doctors and patients. Italians (who have the lowest rate of organ donation in Europe) travel to Belgium to obtain their transplants; so do Israelis, who lately have also been going to rural Turkey and bringing their surgeon along with them. Residents of the Gulf States, Egyptians, Malaysians, and Bangladeshis mainly go to India for organs. In the Pacific, Koreans, Japanese, and Taiwanese, along with the residents of Hong Kong and Singapore, fly to China. Less frequently, South Americans go to Cuba and citizens of the former Soviet Union go to Russia. Americans for the most part stay home, but well-to-do foreigners come to the United States for transplants, and some centers allot up to 10 percent of their organs to them.
All of these people are responding to the shortages of organs that followed on the discovery of cyclosporine in the early 1980s. Until then, transplantation had been a risky and experimental procedure, typically a last-ditch effort to stave off death; the problem was not the complexity of the surgery but the body’s immune system, which attacked and rejected the new organ as though it were a foreign object. Cyclosporine moderated the response while not suppressing the immune system’s reactions to truly infectious agents. As a result, in countries with sophisticated medical programs, kidney and heart transplantation became widely used and highly successful procedures. Over 70 percent of heart transplant recipients were living four years later. Ninety-two percent of patients who received a kidney from a living donor were using that kidney one year later; 81 percent of the cases were doing so four years later, and in 40 to 50 percent of the cases, ten years later.1
Transplantation spread quickly from developed to less developed countries. By 1990, kidneys were being transplanted in nine Middle Eastern, six South American, two North African, and two sub-Saharan African countries. Kidney transplants are by far the most common, since kidney donors can live normal lives with one kidney, while kidneys are subject to disease from a variety of causes, including persistent high blood pressure, adult diabetes, nephritis (inflammation of vessels that filter blood), and infections, which are more usually found in poor countries. (It is true that the donor runs the risk that his remaining kid-ney will become diseased, but in developed countries, at least, this risk is small.) The transplant techniques, moreover, are relatively simple. Replacing one heart with another, for example, is made easier by the fact that the blood-carrying vessels that must be detached from the one organ and reattached to the other are large and relatively easy to handle. (A transplant surgeon told me that if you can tie your shoes, you can transplant a heart.)
Fellowships in American surgical programs have enabled surgeons from throughout the world to master the techniques and bring them home. Countries such as India and Brazil built transplant centers when they might have been better advised to invest their medical resources in public health and primary care. For them the centers are a means for enhancing national prestige, for persuading their surgeons not to leave the country, and for meeting the needs of their own middle-class citizens.
In China, more than fifty medical centers report they perform kidney transplants, and in India hundreds of clinics are doing so. Reliable information on the success of these operations is hard to obtain, and there are reports that hepatitis and even AIDS have followed transplant operations. But according to physicians I have talked to whose patients have traveled to India or China for a transplant, and from published reports within these countries, some 70 to 75 percent of the transplants seem to have been successful.2
With patient demand for transplantation so strong and the medical capacity to satisfy it so widespread, shortages of organs were bound to occur. Most of the doctors and others involved in early transplants expected that organs would be readily donated as a gift of life from the dead, an exchange that cost the donor nothing and brought the recipient obvious benefits. However, it turns out that powerful cultural and religious taboos discourage donation, not only in countries with strong religious establishments but in more secular ones as well. The issue has recently attracted the attention of anthropologists, theologians, and literary scholars, and some of their findings are brought together in the fascinating collection of essays, Organ Transplantation: Meanings and Realities.3
In the Middle East, it is rare to obtain organs from cadavers. Islamic teachings emphasize the need to maintain the integrity of the body after death, and although some prominent religious leaders make an exception for transplants, others refuse. An intense debate occurred last spring in Egypt when the government-appointed leader of the most important Sunni Muslim theological faculty endorsed transplantation as an act of altruism, saying that permitting it was to accept a small harm in order to avoid a greater harmâ€”the same rationale that allows a Muslim to eat pork if he risks starvation. But other clerics immediately objected, and there is no agreement in favor of donation.
In Israel, Orthodox Jewish precepts define death exclusively as the failure of the heart to function, not the cessation of brain activity, a standard that makes it almost impossible to retrieve organs. The primary purpose of statutes defining death as the absence of brain activity is to ensure that organs to be transplanted are continuously supplied with oxygen and nutrients; in effect, the patient is declared dead, and a respirator keeps the heart pumping and the circulatory system working until the organs have been removed, whereupon the respirator is disconnected. Some rabbis give precedence to saving a life and would therefore accept the standard of brain death for transplantation. But overall rates of donation in Israel are very low. The major exceptions are kibbutz members, who tend to be community-minded, as well as other secular Jews.
In much of Asia, cultural antipathy to the idea of brain death and, even more important, conceptions of the respect due elders, have practically eliminated organ transplantation. For all its interest in new technology and its traditions of gift-giving, Japan has only a minuscule program, devoted almost exclusively to transplanting kidneys from living related donors. As the anthropologist Margaret Lock writes: “The idea of having a deceased relative whose body is not complete prior to burial or cremation is associated with misfortune, because in this situation suffering in the other world never terminates.”4 For tradition-minded Japanese, moreover, death does not take place at a specific moment. The process of dying involves not only the heart and brain but the soul, and it is not complete until services have been held on the seventh and forty-ninth days after bodily death. It takes even longer to convert a deceased relative into an ancestor, all of which makes violating the integrity of the body for the sake of transplantation unacceptable.
Americans say they favor transplantation but turn out to be very reluctant to donate organs. Despite countless public education campaigns, organ donation checkoffs on drivers’ licenses, and laws requiring health professionals to ask families to donate the organs of a deceased relative, the rates of donation have not risen during the past five years and are wholly inadequate to the need. As of May 1997, according to the United Network for Organ Sharing, 36,000 people were awaiting a kidney transplant, 8,000 a liver transplant, and 3,800 a heart transplant.5 One recent study found that when families were asked by hospitals for permission to take an organ from a deceased relative, 53 percent flatly refused.
The literary critic Leslie Fiedler suggests that the unwillingness of Americans to donate organs reflects an underlying antipathy to science and a fear of artificially creating life, a fear exploited, he suggests, in the many Hollywood remakes of the Frankenstein story. Moreover, donation would force Americans to concede the finality of death, which Fiedler is convinced they are reluctant to do.6 I suspect, however, that the underlying causes are less psychological than social. Americans are unaccustomed to sharing resources of any kind when it comes to medicine. Since Americans refuse to care for one another in lifeâ€”as witness the debacle of national health insuranceâ€”why would they do so in death? Receiving help is one thing, donating it is another.
If organs are in such short supply, how do some countries manage to fill the needs of foreigners? The answers vary. Belgium has a surplus of organs because it relies upon a “presumed consent” statute that probably would be rejected in every American state. Under its provisions, you must formally register your unwillingness to serve as a donor; otherwise, upon your death, physicians are free to transplant your organs. To object you must go to the town hall, make your preference known, and have your name registered on a national computer roster; when a death occurs, the hospital checks the computer base, and unless your name appears on it, surgeons may use your organs, notwithstanding your family’s objections. Iwas told by health professionals in Belgium that many citizens privately fear that if they should ever need an organ, and another patient simultaneously needs one as well, the surgeons will check the computer and give the organ to the one who did not refuse to be a donor. There is no evidence that surgeons actually do this; still many people feel it is better to be safe than sorry, and so they do not register any objections.
One group of Belgian citizens, Antwerp’s Orthodox Jews, have nonetheless announced they will not serve as donors, only as recipients, since they reject the concept of brain death. An intense, unresolved rabbinic debate has been taking place over the ethics of accepting but not giving organs. Should the Jewish community forswear accepting organs? Should Jews ask to be placed at the bottom of the waiting list? Or should the Jewish community change its position so as to reduce the prospect of fierce hostility or even persecution?
The data is from the United Network for Organ Sharing (UNOS) Scientific Registry, as of July 5, 1997.↩
Xia Sui-sheng, "Organ Transplantation in China: Retrospect and Prospect," Chinese Medical Journal, 105 (1992), pp. 430-432.↩
Edited by Stuart J. Youngner, Renée C. Fox, and Laurence J. O'Connell (University of Wisconsin Press, 1996).↩
"Deadly Disputes: Ideologies and Brain Death in Japan," in Youngner et al., Organ Transplantation, pp. 142-167.↩
According to a recent report on CNN's Headline News, there are only 4,000 livers a year being donated. In response to the shortage, the UCLA Medical Center has developed a procedure for dividing livers taken from the cadavers of donors, so that two recipients can share it.↩
"Why Organ Transplant Programs Do Not Succeed," in Youngner et al., Organ Transplantation, pp. 56-65.↩
The data is from the United Network for Organ Sharing (UNOS) Scientific Registry, as of July 5, 1997.↩
Xia Sui-sheng, “Organ Transplantation in China: Retrospect and Prospect,” Chinese Medical Journal, 105 (1992), pp. 430-432.↩
Edited by Stuart J. Youngner, Renée C. Fox, and Laurence J. O’Connell (University of Wisconsin Press, 1996).↩
“Deadly Disputes: Ideologies and Brain Death in Japan,” in Youngner et al., Organ Transplantation, pp. 142-167.↩
According to a recent report on CNN’s Headline News, there are only 4,000 livers a year being donated. In response to the shortage, the UCLA Medical Center has developed a procedure for dividing livers taken from the cadavers of donors, so that two recipients can share it.↩
“Why Organ Transplant Programs Do Not Succeed,” in Youngner et al., Organ Transplantation, pp. 56-65.↩