Medical Examiner

Yuan a Kidney?

China’s proposals to pay organ donors flout the status quo. That’s a good thing.

China proposes to pay organ donors. Is that a good thing?

China’s record on organ trafficking is by now a well-known international horror story. The vast majority of organs transplanted each year in Chinese hospitals are taken from executed criminals—and allegedly from political detainees, such as members of the the Falun Gong; charges that are currently under investigation by the U.N. Human Rights Council and Amnesty International. Now, paradoxically, China is proposing forward-thinking transplant policies; commendable laws that, if properly carried out, challenge the status quo and major international health organizations.   

China’s black market is why paying patients—citizens as well as foreigners—can get a new kidney or liver in a matter of days or weeks. Such lightning speed is unheard of in countries without black markets in organs; in countries that rely solely on altruistic giving, the wait for a deceased-donor organ is years long. In major cities in the United States, for example, it is not unusual for patients on dialysis to wait eight or 10 years before a kidney becomes available—a wait that only about half can survive.   

Last winter, a 26-year-old migrant worker from Hunan made headlines in the Chinese press because he wanted to sell a kidney to pay off gambling debts. A black-market broker promised him 40,000 yuan (about $6,000), but at the last minute the migrant worker got cold feet. According to the man’s story, the broker then took him to a small hospital and bound him to an operating table, where a nurse sedated him and surgeons removed his left kidney. Authorities are now investigating, but China’s thriving kidney trade makes accounts like these sound quite plausible.

In 2007, China began licensing transplant centers in an effort to raise standards of practice and regulate performance. Only 163 of the more than 600 centers qualified and are now authorized to perform transplants, the vice minister of health Huang Jiefu, told the Lancet in an article published earlier this month. Huang, who is regarded as uncommonly open about his aversion to using prisoners as the major source of transplantable organs, still acknowledges that the market is far from moribund. Indeed, the same Lancet article notes that transplant specialists in the United States and Europe say they still occasionally see patients who report having purchased their transplants in China.

Meanwhile, the need for organs is remains vast. The Chinese population itself drives a demand because the country has virtually no culture of altruistic deceased organ donation. Last year, roughly 1.5 million Chinese needed kidneys, livers, lungs, and hearts, but only 10,000 received them—the vast majority through illicit means.

Even in countries with much better records of deceased organ donation, the shortfalls are dramatic. In desperation, patients go underground. The World Health Organization estimates that 5 to 10 percent of the roughly 60,000 kidney transplants operations performed worldwide each year are obtained in the shady organ bazaars of Northern 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.

Last month, the China’s health ministry announced a proposal that could expand the pool of organs available for transplant surgeries. Huang told the Chinese press that his office was considering several possible incentives. These include tax rebates, deduction of transplant-related hospital fees, medical insurance, tuition waivers for donors’ family members, or deduction of burial fees for people who donated in death.

Unfortunately, much of the international transplant establishment—including the World Health Organization, the Transplantation Society, and the World Medical Association—focuses exclusively on obliterating illicit organ sales. While this may seem like a reasonable approach to abhorrent practices, in reality it is a lethal prescription.

Efforts to stamp out corruption either drive it further underground or cause unauthorized markets to pop up elsewhere. And the organ trade, like a vampire, is hard to kill. When the Turkish authorities clamped down on illicit sales about six years ago, patients from the Middle East who had traveled there for kidneys rerouted to the Philippines. Then in 2008, the president of the Philippines banned foreigners from receiving transplants. Fewer transplants were conducted with the tragic and predictable trade-off that patients either died or went elsewhere, perhaps to Lima, Peru; Cairo; or Pristina, Kosovo.   

Paying for organs is not “opportunistic human cannibalism,” as Jeremy Chapman, the past president of the international, Montreal-based Transplantation Society, puts it. The patient is no predator; he is as desperate to save his life as an impoverished donor is to salvage his own.

Nor are organ sales “a filthy business in the same subcategory as the sex trade and child pornography,” as nephrologist Gabriel Danovitch of the University of California at Los Angeles has claimed. Prostitution and child pornography—legal or not—debase everyone involved. Organs, by contrast, are the rare trafficked good that saves lives. And if the vendors were able to engage in licit, safe, transparent, and regulated transactions they too could improve their welfare.

But alas, this sensible vision runs afoul of ideology. “Altruism is the bioethical foundation [for obtaining organs],” affirmed a 2009 report by Council of Europe and the United Nations, “Organs should not give rise to financial gain.”[i]

Why not?It is all too easy to romanticize altruism. The “gift of life” is indeed precious. I received it from a friend in 2006. But I am not so naive about my good fortune as to ignore reality that altruism is not producing enough organs. 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 solution.

In-kind benefits such as those China is considering, paired with lengthy medical screening, would be unattractive to desperate people (who might otherwise rush to donate for a large sum of instant cash). This should allay concerns that poorer citizens would be effectively forcedto donate.

But coming from a government that has legitimized organ harvesting from detained individuals, China’s proposals may be rejected out of hand by the international medical community. Understandably so. After all, China’s transplant practices are profoundly opaque with few details on clinical protocols or outcomes published in the medical literature except in the breach.

If China is serious about creating an incentive program, transparency and accountability will be vital to its integrity and safety. Transactions on a black market are dangerous because they are illicit, not because they are transactions.

A number of countries recognize this and have carefully modified their laws to permit donor enrichment. Singapore, for example, helps cover health insurance costs for living kidney donors.. In Manila, a major transplant center offered business grants and home-improvement packages to donors. That government-approved program lasted four years until 2008, when it was dismantled by the Philippine government under pressure from the World Health Organization.

In Israel, citizens who register to become posthumous donors get slight priority on the waiting list for organs, if they ever need one. Israeli families may also now accept up to $13,400 to “memorialize” the deceased donor with, for example, a scholarship in his name. More controversially, Iran pays cash to kidney donors. China’s initiative, should it be undertaken with requisite oversight, would be unprecedented in scope and in range of benefits offered to donors.

These countries’ efforts are being studied by the Nuffield Council on Bioethics, a British ethics think tank that’s pondering how the United Kingdom can increase organ donation. It’s considering a broad range of potential actions, from the innocuous (an official “thank you” to the donor) to the audacious (creating a free market in body parts). The council will release its report in the fall. 

No one seriously thinks the council will opt for unfettered sales, but the bottom line of any serious consideration is inescapably this: The only way to save lives and starve underground markets abroad is to provide more transplants at home. And the only way to do that is to break radically—and ethically—with a status quo that forbids an informed donor to be rewarded for saving the life of a stranger.