The body part that accounts for most sales of organs throughout the world is the kidney. As entire populations have become older, the number of patients with kidney disease that can lead to death has dramatically increased. Dialysis machines extend the lives of many of them. But some patients for medical reasons are unable to continue on dialysis or, as is often the case in developing countries, they do not have access to such expensive machines. To survive they must undergo a kidney transplant—if they can get a kidney.
The shortage is acute almost everywhere. For example, despite vigorous educational campaigns, Americans are very reluctant to agree to donate their organs after they die. (They may distrust hospitals or believe that people should be buried with their organs intact.) People of other cultures, particularly some Asians, Muslims, and Orthodox Jews, are even more hostile to such donations. Hence the waiting list to obtain a kidney from a cadaver is long. The average wait in the US and in Britain is two to three years; in Singapore, six to eight years. Residents of the Gulf States and most of Asia may have to wait for many more years, if a waiting list is kept at all.
The only other way to obtain an organ is from a living donor—usually from a sibling, a spouse, a relative, or a friend. In the United States and Europe, living donation is now the source of 20 to 40 percent of kidneys. But what if relatives are unwilling or unable to donate? Many people will then try to purchase a kidney, with the result that there has for years been a flourishing and unregulated international traffic in organs.
The trade is so extensive that just as we are being forced to assess the consequences of global financial markets for less developed countries, so we must consider the effects of global markets in medical technologies and organs. In the early 1990s, most people who bought kidneys were either residents of the Gulf States who traveled to India to buy them or they were Asians who bought them in India and China. Now the routes crisscross the world. India remains a popular destination, despite laws prohibiting organ sale there; buyers come not only from India’s middle class and from the Middle East but also from England, Canada, and the United States. China continues to deny that its surgeons remove organs from executed prisoners, but in fact it runs an extensive transplant business, with overseas Chinese from many countries, including Singapore, Malaysia, and the United States, traveling there to purchase kidneys. The Philippines also has large numbers of kidneys available for purchase, and its hospitals actively try to sell them to the Japanese. In the same way, Turkey, Moldova, and Estonia sell to Israelis, and Bulgaria and Romania sell to them and to other Eastern Europeans as well.
Although it is technically possible to pack kidneys in ice and send them by air between countries, the trafficking is almost always in people, not organs. Part of the reason is that the country providing the kidney wants to collect the substantial hospital and surgical fees that come with transplantation. Part of the reason, too, is that health and hospital authorities in places like Japan or Israel would almost certainly refuse to transplant organs purchased and shipped from developing countries. They would have to defend publicly the ethics of such transactions—keeping them secret would be impossible—and risk the legal liabilities that would follow from using organs of unknown origin that might well be harboring deadly viruses.
The market in organs now includes many people who travel from their own country to another to sell their kidneys. With help from organ brokers or through personal contacts, they come to the United States from the Philippines or India, often enter on a specially issued humanitarian visa, tell the transplant teams that they are the cousin or niece of the recipient, and then “donate” their kidney. Surgeons have also taken to the road. One Israeli surgeon, for example, regularly accompanies his patients to Turkey and Estonia, going to where the organs are.
No one we know of has calculated the size of the organ trade, but it probably has grown by now to several thousands of transplants each year. Why has the market expanded so dramatically? For one reason, supply is even shorter of demand than it used to be. Not only have the populations of many countries aged, but transplant technology has spread almost everywhere and, as with other operations, when more surgeons are prepared to do a transplant, more patients will ask for it. Surgeons have also found that patients who receive an organ from a living donor have far better prospects than those who receive an organ from a cadaver. And transplant teams, wanting to satisfy their patients and remain competitive with rival groups, do not inquire into the source of the organs that they use. They say they are surgeons, not detectives, and, besides, their only obligation is to the patient on the operating table.
Two other considerations promote the traffic. Although commerce in organs is prohibited by many national and international transplant societies as well as by the World Medical Association (WMA), their rules are hardly ever enforced. In a new policy on organ transplants (an effort in which the authors assisted), the WMA unequivocally bans the sale of organs. Basing policy on the principle of “free and informed decision-making,” it resolved:
Payment for organs and tissues for donation and transplantation should be prohibited. A financial incentive compromises the voluntariness of the choice…. Organs suspected to have been obtained through commercial transaction should not be accepted for transplantation.
So too, because prisoners are not in a position “to give consent freely and can be subject to coercion,” the WMA insists that the organs of prisoners “must not be used for transplantation.” But the WMA only provides “guidance to medical associations, physicians, and other health care providers”1 ; it neither has nor seeks authority to discipline organizations or practitioners.
A WMA official told us that when China requested admission to the association, the WMA officials made it a condition that China agree to hold an international conference on the ethics of organ transplantation, particularly the use of executed prisoners. China agreed, and was admitted to the WMA, whereupon it postponed, indefinitely, the promised conference. The WMA has done nothing by way of reaction.
National medical societies will sometimes discipline physicians who traffic in organs. In 2002, the British General Medical Council banned from practice Dr. Bhaget Makkar, a general practitioner who, in a taped interview with an undercover reporter, declared that in return for payment, he could arrange for a living donor in the UK or in India. But there is no effective international regulation.
At the same time, some economists, like David Kaserman, and philosopher-bioethicists, like Janet Radcliffe Richards, have been advocating a market in kidneys to increase the supply. Proponents of a market do not agree among themselves and make several different arguments. Some want to do no more than pay a few hundred dollars to partly cover funeral expenses for families permitting the removal of an organ from a cadaver. Others, like Kaserman, want an open market in organs with supply and demand setting the price. Still others, including an ethics committee of the American Medical Association, favor a futures market by which, for example, a donor who agrees to have his organs used after death will receive a tax credit or have it go to his estate. Many people would agree that payments for funeral expenses or post-mortem reimbursements are not objectionable. But others resist the idea of any sort of compensation for organ donation, including tax credits, and approve only the use of “ethical incentives,” such as awarding medals of honor to the families of donors.
Some who favor the sale of organs are mainly concerned with conditions in well-off countries, in which the levels of income and the social welfare systems make it unlikely that many people would be willing to sacrifice a kidney for payment. Others propose plans for developing countries where poverty is endemic, public health care systems hardly exist, and many people are willing to sacrifice a kidney for a payment of between one thousand and two thousand dollars. Sometimes the arguments in favor of markets that are put forward in well-to-do countries are invoked by physicians and hospital administrators in the third world to justify their commercial practices.
Together with Hernan Reyes, a fellow at Columbia’s medical school on leave from the International Committee of the Red Cross, we visited three Asian countries—Thailand, Singapore, and the Philippines—that have been enlarging their transplant programs. Each story is different. In Thailand there has recently been a scandal over organ sales; in spite of the objection of medical and legal authorities, many doctors have illegally arranged for their patients to pay fellow Thais for their relatives’ kidneys. Singapore has avoided a traffic in organs, but its program to provide them discriminates against Muslims. In the Philippines we found that doctors and officials are openly doing whatever they can to encourage the sale of organs. Taken together, the experience of these three countries demonstrates how in practice the commerce in organs exploits poor and vulnerable people.
As in all other Asian countries, families in Thailand are unwilling to donate an organ from a deceased relative. The country has a very high rate of traffic deaths—the result of widespread alcoholism, drug use, and a large number of motorcycles and motorbikes called “put-puts,” driven by riders who do not wear helmets. But few organs become available for transplantation because Thais, whether for religious reasons or because of popular superstition, will not allow surgeons to remove them before cremation. The waiting list for a transplant is long, and because many of the people are relatively well off, hospitals and surgeons are in a position to make substantial profits.
The Thai health care system is made up of a network of public hospitals and private, profit-seeking hospitals. Since the public hospitals are generally overcrowded, uncomfortable, and unreliable, people who can afford it use for-profit hospitals. They are modern, clean, well equipped, and staffed with skilled physicians. In fact, the staff physicians, along with some administrators, are the major stockholders in the hospital corporation and are eager to make profits. Thus the hospitals have successfully promoted themselves as centers for medical tourism. Europeans use them for cosmetic surgery or dental work at prices that are 50 to 75 percent lower than at home. (At the same time, many Thais, as well as Europeans and Americans, come to Bangkok in search of easily available, low-cost sex, frequently supplied by prostitutes; AIDS has spread widely.) For the same reasons, some, but by no means all, of the hospitals have entered the kidney trade.
Selling organs, we found, can be highly profitable. Some private hospitals are unwilling to admit accident victims on the grounds that they are too poor to pay for an extended stay with complicated procedures. But their more aggressive competitors make a different calculation. If they admit traffic victims who then die, and if their families are willing to donate their organs, the hospital would then have two kidneys available for transplant into two patients able to afford the $10,000 cost of an operation that would cost about $100,000 in the US. This was precisely the calculation that was made by Siroj Kanjanapanchapol, chief transplant surgeon and head of Bangkok’s Vachiraprakarn General Hospital (VGH).
Siroj had VGH admit a young pregnant woman who was in a coma following an auto accident and had been taken at first to a rural hospital. Siroj persuaded the family to agree that she be transferred to VGH, promising that they would not be charged for the cost of care. He also had them sign a consent form authorizing the removal of her kidneys if she died. Following her death, Siroj gave them a $2,500 payment for “funeral expenses.” He removed her kidneys, transplanted them into two patients, and charged each of them not only for the surgery but for the full amount of the “gifts” to the family. Thus, for an expenditure of $2,500, Siroj and VGH made $25,000.
Siroj and three of his hospital colleagues came under investigation, probably because they had quarreled with another VGH administrator, who described what happened to the Thai Legal Association, the Bangkok Post, and the Thai Medical Council, which set up an inquiry. One of the witnesses from the hospital said the patient had not been officially brain dead when her organs were removed. Siroj and his colleagues were accused of unethical medical conduct and were indicted for murder, the first such case in Thailand.2
Siroj, when we talked to him, vigorously defended himself. There was nothing wrong, he said, with rewarding the family’s willingness to donate the organs by waiving their medical charges at the hospital. And there was nothing wrong with allowing the patients who received the organs to reward the donors for their noble act. As for charges that the patient was still alive, Siroj claimed that it was too cumbersome to obtain the required three signatures certifying brain death—surely two, which is, in fact, the standard in most countries, was enough—and he had obtained the signatures of two colleagues.
The Thai Medical Council carefully investigated the case. It discovered that VGH has consistently violated the laws banning commerce in organs. The hospital regularly transplanted kidneys from living donors who are neither blood relatives nor spouses of the recipients. VGH also paid out substantial sums to families for agreeing to a donation, and then charged the two recipients of the organs the full cost of the payment. It even bribed people in other hospitals to transfer patients near death to VGH and paid ambulance drivers to bring badly injured patients to its emergency room. The Medical Council, moreover, concluded that Siroj along with other transplant surgeons frequently ignored the criteria for establishing brain death. The transplant surgeon, who, because of possible conflict of interest, was not supposed to certify brain death, often did so. For all these reasons, the Medical Council resolved to punish Dr. Siroj “in the most serious way and without mercy” and rescinded his medical license. His trial on the murder charge has been postponed several times and is still not underway.
Several conclusions can be drawn about this story. First, because Thailand has active medical and legal authorities, the illicit transplant activities came to light and at least some of them have been stopped. Most of the poorer countries, however, lack the professional and civic organizations that might oppose commerce in organs. Thailand is also different in having a respected monarchy. The Queen has publicly endorsed the efforts of the Thai Red Cross to oversee the distribution of organs for transplantation, and this may have some effect on commercialism.
Still, the weaknesses in Thailand’s regulatory efforts are flagrant. Its medical and legal organizations only respond to complaints; they do not initiate investigations. They let misdeeds occur and rely upon disgruntled staff members to bring them to their attention. Until Thailand sets up a central registry for organs and private hospitals come under effective supervision, surgeons and administrators are relatively free to cut their own deals with families or would-be donors; Siroj was caught, but feuds among doctors cannot be counted on to prevent profiteering in organs.
Singapore’s government, unlike its neighbors, carefully regulates organ distribution and has successfully avoided financial corruption. But its system suffers from something else, a fundamental bias that effectively excludes Muslims from getting transplants.
Singapore’s citizens, like other Asians, object to organs being removed from deceased relatives; as a result, the waiting list for kidneys is long. Singapore has an extensive network of dialysis centers; most people—61 percent—pay for treatment themselves, but the rest get government assistance. Still, many patients need transplants and so they travel to China to get the organs of executed prisoners; indeed, a handful of them, ten to fifteen a year, get organs from executed prisoners who are in Singapore. As surgeons explained to us, capital punishment is carried out in Singapore by hanging; the moment the trapdoor swings open and the neck is snapped, orderlies take the body to an adjoining operating room to have the organs removed. However, neither travel nor executions have much of an effect on the waiting list.
In 1987, Singapore enacted a Human Organ Transplantation Act (HOTA), a law unique in Asia. Anyone who suffers a fatal accident is presumed to be a kidney donor, unless he or she had formally “opted out” of the system by signing a card that declares, “I hereby object to the removal of my kidneys upon my death for transplantation,” and then sending it to the Organ Donor Registry. To avoid provoking public protests, the act included two qualifications. It restricted the presumed consent to road accidents; terminally ill patients and their families would not have to worry that hospital physicians were neglecting them in order to obtain their kidneys. HOTA, moreover, only applied to kidneys, not to the heart, which is considered by Singapore families the most precious organ. Donations of cadavers still vary year to year but they now average forty, not, as before, fewer than ten.
The law, however, excluded all Muslims, including the ethnic Malays who make up some 15 percent of Singapore’s population. Although Muslim religious leaders, like Orthodox Jewish rabbis, disagree among themselves on whether organ donation is permissible, Muslims generally are reluctant to donate organs. Still, it was not cultural pluralism but political discrimination that accounted for Singapore’s exclusion of Muslims from receiving transplants.
In typical bureaucratic Singaporean style, the policy on transplants is written, codified, and available for all to see. We were given a copy at our first interview. An elaborate point system governs the national transplant waiting list. Patients have to accumulate some forty to fifty points to reach the top of the list and receive an organ. Medical criteria count, and so does severity of illness. Each year on the waiting list brings the would-be recipient 2.5 points. Social criteria are even more important. Full-time professional employment brings five points, full-time ordinary employment, four points. Age matters as well: people under thirty-one receive five points, and no one over sixty is eligible for transplant.
Muslims go on the list with a debit of sixty points. Since they have a record of opting out of the donor pool, the government argues they should be penalized. But no one else in Singapore who opts out is treated this way. It is true the debit is canceled if the would-be recipient agrees to donate his organs after death, and if, in addition, two Muslim friends also sign such a donation agreement. In effect, this concession is no concession at all but amounts to a demand for heretical behavior or conversion: abandon Muslim principles or forgo a transplant.
Anti-Muslim bias pervades Singaporean policy generally. Relatively few Muslims hold public office or high military positions. The government apparently believes that Muslims are more loyal to Islam than to Singapore and fear what might happen if a conflict erupted with Malaysia. But in another sense, the bias in medical treatment runs even deeper. No other country we know of has penalized persons who don’t consent to contribute their organs when they die. When we asked transplant surgeons about the exclusion of Muslims, we were told bluntly that Singapore has its own standards. No organization, to the best of our knowledge, no transplant society or international medical group, has protested this blatant discrimination.
Lying outside Manila’s small district of office buildings and hotels are its vast and wretched slums. The pollution is thick there, the stench of garbage strong. The Philippines was for fifty years an American colony and the US, which supported the repressive and incompetent Marcos regime, has a heavy responsibility for such misery.
Many Filipinos understandably seek to emigrate. Young women study nursing so that they can find jobs in US hospitals. As soon as medical students graduate, many of them take the examinations administered at the American embassy that will allow them to practice in the US. The numbers are so large that an American embassy official thought that Philippine medical schools required their students to pass the American test. Not surprisingly, a great many slum dwellers in Manila are ready to sell their kidneys.
Kidney disease, it turns out, occupies a special place in the history of the Philippines because Ferdinand Marcos suffered from it. He had his own collection of dialysis machines; when dialysis failed, he had two kidney transplants. (The surgeons, we were told, were flown in from the United States.) Marcos built the most impressive medical facility in Manila, the National Kidney and Transplant Institute (NKTI). It remains the leading public transplant center in the country, performing more transplants than any other hospital, public or private.
Where do the kidneys they transplant come from? In fact, they are sold openly and legally. Physicians and state officials readily defend sales of kidneys, citing the views of “ethicists” on the faculty of a local Catholic college to the effect that selling one’s organs shall be seen as a matter of free choice. Many residents of a squatter community called Tondo, which is located on the top of a garbage dump, have sold their kidneys. In 1999, an enterprising Manila television reporter filmed an hour-long program on the local kidney trade, including scenes in which row after row of men from Tondo lifted their shirts to show the camera the long and jagged scars from operations to remove kidneys.
As the men explained, and the physicians that we interviewed confirmed, medical teams go out to the slum, perform blood and tissue tests on the men, store the results, and then, when a would-be recipient arrives for a transplant, they get in touch, sometimes through a broker of organs, with the man whose blood and tissue provide the best match for a transplant. When asked about their health, the men complained of a variety of pains and disabilities. When asked about their economic condition, many of them said they were worse off. Before they sold their kidneys, they had typically worked at loading ships on the docks. After the sale, they were no longer physically able to do the heavy lifting required, or they had been summarily fired because their bosses thought they were no longer able to do it.
The television program and subsequent press stories forced government and hospital officials to defend their policies. Almost every one of them insisted that nothing was wrong with people selling kidneys; the only problem was with the middlemen, the brokers, who were exploiting the sellers. The traffic in organs, they said, merely had to be regulated, not ended. But the principles and methods proposed for regulation were so flimsy as to demonstrate unequivocally that the only concern was to maintain a profitable business. The formula the officials proposed to govern the transactions would regulate nothing. According to the chief surgeon of the NKTI and a colleague from a local Catholic college, the sums to be paid to the sellers should not be so large as to be “irresistible,” or so small as to be “exploitative.” But why would anyone sell a kidney unless the money seemed irresistible; and the practice itself is exploitative.
None of our questions seemed to trouble the politicians, surgeons, hospital administrators, or academics we talked to. When we asked Juan Flavier, a former minister of health now in the Philippine Senate, whether he was concerned that Philippine practices violated WMA principles, he said that to the best of his knowledge, the WMA did not vote in the Philippines. When we asked a Catholic college faculty member how he could argue in favor of organ sale when the Pope had issued an injunction against it, he expressed surprise that the Pope had taken such a position. When we asked surgeons how they felt about violating the policies of international transplant societies, they told us that dialysis was in such short supply in the Philippines and kidney donation so rare that only the sale of kidneys could save their patients from death. And when we asked whether such patients were a small elite, limited to those able to afford the purchase of a kidney, the surgery, and lifetime costs of anti-rejection drugs, we were told that yes, this was mostly true, but after all, the Philippines was a very poor country.
The information that has accumulated on the growing trade in organs undermines several popular defenses of it. For example, advocates for a market in organs contend that organ sales enable the poor to escape from poverty. A group of American physicians, bioethicists, and social scientists insisted, for example, that kidney sales should be allowed, since “we cannot improve matters by removing the best option that poverty has left.”3 But recent findings contradict this proposition. An anthropologist from Berkeley, Lawrence Cohen, has interviewed thirty families from Madras with a relative who sold a kidney; another team, based at Pennsylvania State University, surveyed some three hundred people in Madras who had sold a kidney six years earlier. Both came to the identical conclusion: the people who sell kidneys are generally in debt before they sell a kidney and back in debt after they sell. “Decisions to sell a kidney,” the team concluded, “appear to have less to do with raising cash toward some current or future goal than with paying off a high interest debt to local moneylenders. Sellers are frequently back in debt within a few years.”4
Cohen goes even further, suggesting that once a geographic region becomes known to organ brokers as a likely source of kidneys, the brokers intensify their search for sellers there; creditors then become more aggressive in calling in debts, and relatives of patients become still more reluctant to donate a kidney when they can buy one.5 In other words, the result is a wider market in organs. As Amartya Sen has persuasively argued, economic development is too easily thwarted by notions of a “false liberty,” the kind implicit in a so-called right to sell a kidney. Such practices deflect attention from the changes that are necessary to modernize an economy. Escaping from poverty requires fundamental changes in a country’s economy, not incentives for the poor to sell their body parts.
Since Japanese, Israelis, and Malaysians can purchase organs abroad, these countries can avoid addressing the cultural attitudes and practices that discourage donation at home. The global growth in kidney sales also poses a special challenge to American doctors. Some of their Chinese and Indian patients go abroad, have a transplant, and then return to them for continuing care. Should the physicians approve of such a solution? Some practitioners duck the question, saying that if surgeons can refuse to ask about the source of the kidney, so can they. But others are urging colleagues to make it clear in advance to such patients that they disapprove of their plans and will refuse them nonemergency treatment if they carry them out. Were this to become standard practice, at least some transplant tourism from the first to the third world would be curtailed.
If physicians and surgeons were to take the WMA and transplant societies’ declarations seriously, moreover, and refuse to hold conventions in China, or refuse to accept Indian surgical residents or train Singaporean or Filipino surgeons, the market in organs would shrink. Medicine has become such a global enterprise that the doctors in those countries would not tolerate such sanctions and would change their priorities. (Perhaps, if the market for organs diminishes, more families, relatives, and friends will be willing to become donors or to allow organs to be supplied from cadavers.)
In fact, international pressure on the medical profession and on the richer countries to prevent commerce in organs is mounting. This past June, in response to evidence of a flourishing trade in kidneys in Eastern Europe, the parliamentary assembly of the Council of Europe issued a declaration on “trafficking in organs.” The assembly, which has no powers of enforcement, insisted that “this type of crime should not remain the sole responsibility of countries in Eastern Europe,” that the press and television should not be the only ones to investigate it, and, still more notably, that physicians and others who participate in such activities should face criminal penalties. It urged all member states to tighten their laws on the donation of organs and to establish “the legal responsibility of the medical profession for tracking irregularities and sharing information.” Criminal codes should be amended “to insure that those responsible for organ trafficking are adequately punished, including sanctions for…brokers, intermediaries, hospital/ nursing staff and medical laboratory technicians,” along with “medical staff who encourage and provide information on ‘transplant tourism.'” The assembly encouraged member states “to deny national medical insurance reimbursements for illegal transplants abroad,” and to “deny national insurance payments for follow-up care of illicit transplants.”
Will such initiatives be successful? It is still hard to be optimistic. Patients are desperate, hospitals and surgeons are greedy, brokers are energetic, and the poor are more and more available for exploitation. We can hope that the medical profession, on its own or in response to external pressures, will begin to take its social and ethical responsibilities seriously and promote a universal commitment—one that could be enforced—to preserving the integrity of the bodies of all citizens. So far there is little sign that the medical profession is willing to accept any such obligation.
October 23, 2003
World Medical Association Statement on Human Organ and Tissue Donation and Transplantation, adopted by the 52nd WMA General Assembly in Edinburgh, Scotland, during October 2000. ↩
It is not the first such prosecution elsewhere. Until a few years ago, the Japanese refused to recognize brain death; the first surgeons to perform a heart transplant in Japan were charged with murder, as was a heart transplant recipient who had the procedure done abroad. None of them were convicted. ↩
J. Radcliffe-Richards et al., “The Case for Allowing Kidney Sales,” The Lancet, June 27, 1998, pp. 1950–1952. ↩
Madhav Goyal et al., “Economic and Health Consequences of Selling a Kidney in India,” JAMA, October 2, 2002, pp. 1589–1593. ↩
Lawrence Cohen, “Where It Hurts: Indian Material for an Ethics of Organ Transplantation,” Daedalus, Vol. 128, No. 4 (Fall 1999) pp. 135–165. ↩