Modern Age Transplantation Issues
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Modern Age Transplantation Issues
Gabriel M. Danovitch
ORGAN TRAFFICKING AND TRANSPLANT TOURISM
The phenomenon of human organ trafficking was first recognized in the 1990s. Originally a hidden and limited activity in the backstreets of a handful of developing countries, it became a widespread and sometimes brazen activity that involved potential recipients traveling to clinics around the world to receive a kidney from poor and poorly paid “donors.”1
The World Health Organization (WHO) estimated that organ trafficking accounted for as much as 10% of all organs transplanted worldwide. It designated “hot-spots” of organ trafficking activity in India, Pakistan, Egypt, Colombia, and the Philippines, where the source of organs was from the living, and China, where the source of organs was executed prisoners.
The main “exporters” of transplant recipients, unfortunately named “transplant tourists,” were wealthy countries of the Persian Gulf and included Japan, Israel, and other developed economies.
In 2004, the World Health Assembly (WHA), the decision-making body of the WHO, issued a revision of its 1991 “Guiding Principles for Human Organ Transplantation” that made clear that the buying and selling of organs for transplantation was to be condemned, and it asked its member nations to take steps to bring the phenomenon to an end.2
In May 2008, the two leading international professional organizations for transplantation and nephrology, The Transplantation Society (TTS) and the International Society of Nephrology (ISN), convened an international summit meeting on organ trafficking and transplant tourism in Istanbul. The outcome of the meeting was the Declaration of Istanbul (DoI) on Organ Trafficking and Transplant Tourism that was then endorsed by over 130 national and international professional organizations including the Council of Europe and the Vatican and has since entered the legislation of several governments and health ministries.
Major international medical journals and organizations have been lobbied successfully to apply an “academic veto” on submissions that include data obtained from transplants involving organ trafficking or the use of organs from executed prisoners.
In order to promote and sustain the DoI, the Declaration of Istanbul Custodian Group (DICG) was established, composed of representatives from the two parent organizations, TTS and ISN, and other interested individuals. A Web site (www.declarationofistanbul.org
was developed that contains translations of the DoI in multiple languages, a downloadable patient-oriented educational pamphlet entitled “Thinking of Buying a Kidney: STOP,” in multiple languages, a bibliography of relevant articles, and a news section of relevant material from the international press.
Although the DoI deals mainly with living organ donation, the DICG has expressed its firm objection to payments to the families of deceased donors, and it strongly supports the principle of “financial neutrality” for organ donors. The DICG also remains alert to counter recurrent calls by a vocal minority to permit payments (other than those required to maintain financial neutrality), in one form of the other, to organ donors or their families.
In the years that have followed the DoI, there has been much progress and some setbacks related to its core mission. Colombia, a country that once permitted nearly 20% of its deceased donor organs to be transplanted into foreigners, has essentially put an end to the practice. Progress, albeit fragile, has been made in Pakistan and India. Israel, once an “exporter” of transplant recipients, has implemented radical changes in policy that has nearly eliminated the practice.
China, after much international pressure and widespread repugnance over its policy of “donation by execution,” has made the practice illegal and appears to be replacing it by ethically acceptable deceased donation practices. As of this writing, Egypt remains a major location for organ trafficking and reports of trafficking activities have come from Sri Lanka and Nepal.
The positive changes that have taken place in Colombia and Israel, for example, are a manifestation of the impact of a combination of professional pressure, governmental support, and legislation. A call has been made for governmental accountability to achieve “self-sufficiency” in organ donation and transplantation so that each country or geographical region addresses the need of its own population from within its own population.
In July of 2018, on the 10th anniversary of the DoI, an updated version of the Declaration was published. It consists of a preamble, definitions of critical concepts, a series of principles (Table 19-1
), and a separate commentary. All of these are available at www.declarationofistanbul.org
TABLE 19-1 2018 Updated Version of the Declaration of Istanbul
The 2018 Declaration of Istanbul on Organ Trafficking and Transplant Tourism
Governments should develop and implement ethically and clinically sound programs for the prevention and treatment of organ failure, consistent with meeting the overall health care needs of their populations.
The optimal care of organ donors and transplant recipients should be a primary goal of transplant policies and programs.
Trafficking in human organs and trafficking in persons for the purpose of organ removal should be prohibited and criminalized.
Organ donation should be a financially neutral act.
Each country or jurisdiction should develop and implement legislation and regulations to govern the recovery of organs from deceased and living donors and the practice of transplantation, consistent with international standards.
Designated authorities in each jurisdiction should oversee and be accountable for organ donation, allocation and transplantation practices to ensure standardization, traceability, transparency, quality, safety, fairness, and public trust.
All residents of a country should have equitable access to donation and transplant services and to organs procured from deceased donors.
Organs for transplantation should be equitably allocated within countries or jurisdictions, in conformity with objective, nondiscriminatory, externally justified, and transparent rules, guided by clinical criteria and ethical norms.
Health professionals and health care institutions should assist in preventing and addressing organ trafficking, trafficking in persons for the purpose of organ removal, and transplant tourism.
Governments and health professionals should implement strategies to discourage and prevent the residents of their country from engaging in transplant tourism.
Countries should strive to achieve self-sufficiency in organ donation and transplantation.
MARIJUANA IN TRANSPLANTATION
Marijuana (also known as cannabis) refers to smoked or ingested products from the cannabis sativa plant. When assessing marijuana use by a transplant patient, health care providers should determine whether the use represents
Therapeutic use for a medical indication, under the supervision of a treating physician.
Recreational use without harms.
Recreational use with harms—from risky use to cannabis use disorder (CUD).
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