Matthew R. Weir and Edgar V. Lerma (eds.)Kidney Transplantation2014Practical Guide to Management10.1007/978-1-4939-0342-9_7

7. Ethical Issues and Transplant Tourism

Dominique E. Martin¹ and Francis L. Delmonico²

(1)

Centre for Health and Society, School of Population and Global Health, The University of Melbourne, Parkville, VIC, Australia

(2)

Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA

Dominique E. Martin

Email: Dominique.martin@unimelb.edu.au

Abstract

Thousands of patients travel to a foreign destination for organ transplantation each year. Many become customers in the global organ market: “transplant tourists” who risk their own lives and endanger those of impoverished organ vendors. This chapter reviews the hazards of transplant tourism and dispels some of the myths used to justify cross-border trade. Evidence shows that such trade is not mutually beneficial, exacerbates existing shortages of organs in destination countries, and exploits social vulnerabilities rather than global moral pluralism. Following this, the ways in which organs may be responsibly exchanged across borders are discussed, and the importance of transparency in policy and practice is highlighted. The impact of legislation prohibiting organ trafficking and trade is examined and additional strategies to discourage harmful travel for transplantation are outlined. These include efforts by professional societies to guide ethical practice and the implementation of multifaceted policies by national authorities to promote self-sufficiency in donation and transplantation.

Traveling to a Foreign Destination for Organ Transplantation

For some patients awaiting organ transplantation, traveling to a foreign country may either be perceived or become an expedient solution to a life-threatening problem. Although organ transplantation services may be available in a domestic healthcare jurisdiction, the shortage of organs compels patients to consider transplantation in a foreign destination. Some may have a relative living abroad who is willing to donate a kidney and yet cannot travel to the home country of the potential recipient. Others may have been judged medically unfit to receive, for example, a liver transplant in their own healthcare system because of systemic malignancy. Patients who travel to a foreign destination to undergo transplantation and fit the following description are referred to as “transplant tourists”: they purchase a transplantation package that includes an organ obtained through a commercial system of (living or deceased) procurement and/or distribution, with access to those organs made possible by a monetary transaction. The vendor or “donor” of the organ is paid usually through a broker.

The precise number of such transplant tourists is unknown annually. The commercial systems of such transplantation are clandestine without any demographic data transparently reported. Some years ago, the WHO speculated that the proportion of customers in the global market for human organs comprised up to 10 % of organ transplants worldwide [1]. The well-established evidence concerning the perceived benefits and realistic hazards of transplant tourism for recipients and organ vendors is discussed in this chapter, including a review of the efforts to prevent harmful travel abroad. In conclusion, an outline of the ethical strategies required to address the problem of cross-border trade in organs is provided.

Myths About the Organ Market

The mythical market for organs is conceived as a mutually beneficial exchange—an economic win–win scenario between relatively wealthy patients in need of an organ transplant (residing in a country suffering from a shortage of organs) and relatively poor but healthy individuals in other countries in need of money. This conception is founded on the following assumptions that are refuted by a now well-established experience.

Markets Do Not Make Use of Surplus Organs

Although shortages of organs are the main factor driving patients to seek transplantation abroad, the relative ease of obtaining a transplant overseas is not due to a corresponding surplus of organs in destination countries. Data from the Global Observatory on Donation and Transplantation [2] show that destination countries for transplant tourists, like the Philippines, India, China, and Egypt, rank among the lowest in the world with respect to rates of donation and transplantation activities per million population. Transplant tourists usually travel from countries with a high economic development index to locations that do not have a surplus of organs but rather a surplus of the poor.

Foreign patients who purchase access to deceased donor organs directly impact domestic patients in need of transplantation. In the absence of formal waiting lists and equitable organ allocation systems, wealthy foreign patients may “outprice” poorer locals. Locals may also be reluctant to donate organs that are likely to be purchased by foreigners rather than allocated to members of their own community, resulting in lower supplies. Commercial activities may discourage deceased donation by impairing trust in the integrity of organ procurement ([3], p. 961). Markets in organs obtained from living “donors” also impair public access to transplantation for domestic patients, as individuals who sell organs such as a kidney or part of a liver to a foreign patient are then unable to donate to a relative or member of their own community. Immediate financial pressures in poor societies are likely to encourage selling rather than related donation. Furthermore, markets for foreign transplant patients may divert limited healthcare resources away from the priority healthcare needs of local communities and may impair access through higher prices for health care.

Although providing payment for organs in some poor communities has increased supplies of kidneys from living vendors, for example, in Iran, the assumption that markets are therefore necessary to increase supplies is mistaken. For example, in Spain, and more recently Croatia, systematic changes in policy and procurement practices have resulted in dramatic increases in the supply of organs from deceased donors such that these two countries have the highest donation rates in the world [4]. Rates of living donation of kidneys in countries such as Turkey and the Netherlands are greater than those of paid kidney vendors in Iran [2]. Nor is there evidence that payment is a requirement for motivating donation in particular cultures, as the successful program of living-related unpaid kidney donation at the Sindh Institute of Urology and Transplantation in Pakistan demonstrates [5]. Pakistan’s history as a major destination for “transplant tourists” is indicative of the socioeconomic vulnerability of its population rather than a cultural reluctance to donate organs in the absence of payment.

Transplant Tourism Is Not Indicative of Moral Pluralism

Where international travel for health care involves ethically contentious activities, cultural diversity and respect for moral pluralism have been invoked as justifications for allowing or even facilitating trade [6]. The existence of illicit organ markets in some countries is not, however, evidence of moral pluralism. Thus, transplant tourism is not a matter of seeking out a foreign society that shares an individual’s personal moral preferences regarding organ markets. Organ trading is legally prohibited in the countries to which foreign patients travel, and selling organs is associated with religious condemnation and social stigma in the communities in which organs are sold. The ability to buy an organ abroad is indicative of economically mediated power to circumvent ethically underpinned prohibitions in one’s own country and to undermine such prohibitions abroad. These prohibitions are aimed at protecting vulnerable individuals and communities who may be harmed by organ markets, rather than restricting individual liberty.

Cross-Border Trade in Organs Is Not a Mutually Beneficial Exchange

The majority of living kidney vendors are ultimately harmed by their participation in organ markets. The decision to sell an organ may be nominally voluntary; however, it frequently occurs in the setting of impaired or constrained autonomy. Inadequate consenting procedures and coercive economic factors such as the treatment of organs as debt collateral ([7], p. 676) exacerbate vulnerabilities such as illiteracy and social disenfranchisement in vendor communities. Living organ vendors are inadequately screened and lack appropriate follow-up care. They are often cheated of promised payments and suffer long-term impairments to health, economic and social status, employment opportunities, and psychological well-being. These consequences are revealed in studies of kidney vendors from Pakistan [8, 9], India [10], Colombia [11], the Philippines [12], Iran [13], and Turkey and Eastern Europe [14]. In the case of commercial transplant travel to China, the execution of prisoners to provide organs for foreign patients offers only financial benefits to the other parties involved. The use of organs from executed prisoners has provoked such widespread condemnation [15] that transplant travel there has decreased markedly in recent years and the Chinese government has expressed plans to eradicate the practice altogether [16].

Furthermore, the purchase of an organ abroad is not necessarily beneficial to recipients. Although problematic continuity of care in the setting of illicit cross-border healthcare provision and poor selection of transplant recipients [17] may play a part in poorer outcomes for transplant “tourists,” the higher rates of infection and graft failure associated with purchased organs seem largely due to the qualities of organs deemed suitable for sale. Naqvi et al. [9] found high rates of hepatitis infection and ill health among kidney vendors in Pakistan and concluded that as many as 25 % of vendors would have been excluded using appropriate standards of donor screening. In the market, financial incentives encourage both vendors and brokers of organs to withhold relevant health information, to avoid screening, and to accept organs for sale that expose recipients to life-threatening infections and complications.

In 2012, Dr. Mitwalli from Riyadh personally reported the case of a 15-year-old Saudi Arabian girl who traveled to China and received a kidney transplant obtained from an unrelated living “donor.” She returned with urinary sepsis and biopsy of the transplanted kidney revealed cytomegalovirus infection and interstitial fibrosis. She subsequently died. Numerous studies from countries including Canada, Saudi Arabia, the United States, Taiwan, Malaysia, Turkey, and the United Kingdom confirm that transplant “tourists” suffer higher rates of infection, graft failure, and other complications [18].

The negative impact of “transplant tourism” extends beyond the immediate participants. Reliance on outsourcing discourages investment in the technical infrastructure, societal education, and cultural evolution required to build effective and sustainable systems of deceased and living organ donation. Increasing transplant tourism from Israel at the beginning of the last decade resulted in falling rates of living-related kidney donation and stagnant rates of deceased donation domestically [19]. After removing insurance coverage for foreign transplants and financial disincentives to living donation and rewarding registered donors with priority in organ waiting lists through new legislation in 2008, Israel has witnessed significant growth in living and deceased donation within the country, with 68 % more transplants performed in 2011 than the previous year [20].

Not All Travel for Transplantation Is Unethical

In condemning harmful “transplant tourism,” it is important to note that some patients may travel abroad for transplantation and organs may be exchanged across international borders in ethically responsible circumstances. Examples include situations where living-related donor and recipient pairs are separated by nationality or country of residence, but where there is evidence of close emotional ties and the absence of financial motivations or coercive elements; international paired kidney donation chains [21]; and regional organ sharing programs such as EuroTransplant ([22], pp. 361–362), which are designed to minimize discard of organs and to help address urgent needs through equitable and cooperative mechanisms. In some cases, patients may seek transplantation abroad, bringing with them their own living-related donors, due to a lack of transplantation services in their own country (e.g., [23]). Efforts to ensure transparency in these circumstances are critical to avoid corruption. In the cross-border setting, it can be especially difficult for transplantation programs to identify coercive or commercial relationships between prospective foreign donors and recipients. Effective screening of such pairs is best performed by responsible medical authorities in their country of origin, who should also take responsibility for maintaining follow-up care of recipients and donors.

Finally, some countries offer limited compassionate access to transplantation programs for foreign patients. With the possible exception of patients who unexpectedly suffer life-threatening organ failure while traveling or living abroad (e.g., [24], p. 3), patients who are granted access to a foreign transplant program are likely to be selected at least in part as a result of their capacity to pay for transplantation services. That is, the organs offered to foreign patients are not allocated according to equitable criteria, and more medically urgent cases or better candidates for transplantation from foreign countries will miss out as a result of poverty.

Although the number of organs allocated to foreign patients in the United States, for example, is sometimes balanced by the number donated by foreigners within the country, programs that offer even limited access to organs for foreign patients risk impairing access for local patients who form part of the potential donor community. In 2008, for example, analysis of UNOS data revealed that 44 nonresident alien donors provided 134 organs for transplantation in the United States, whereas 198 nonresident aliens received deceased donor organs. Transparency in such programs is critical to sustain public trust that organs will primarily be shared among members of the potential donor community and to ensure that allocation to foreign patients occurs equitably and is not influenced by the potential profits inherent in selling health care to foreign patients. Systems should be carefully implemented and monitored to prevent efforts to circumvent the equitable allocation of organs and the integrity of the donation and transplantation program through the purchase of medical visas and/or the effective purchase of citizenship rights by foreign patients. With this aim in mind, UNOS has recently revised their policy to better promote transparency and equity in the treatment of nonresidents [25].

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