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Transplant Tourism

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Experts Advise Addressing Crisis In Organ Donations

Traveling to a foreign country to receive an organ transplant, dubbed transplant or organ tourism, is “ethically problematic,” charges bioethicist Katrina Bramstedt, a transplant specialist with the California Pacific Medical Center in San Francisco. “It takes advantage of citizens of other countries.”

Bramstedt is not alone in her views. There’s a cresting consensus worldwide that transplant tourism should be stopped—or at least dramatically curtailed. In spite of that, Bramstedt reports, several U.S. insurance companies and at least one state, West Virginia, are actively encouraging the controversial practice.

This insurance alert, which appeared in the July issue of the American Journal of Transplantation, named companies such as IndUShealth, based in Raleigh, N.C., which refers transplant patients to India, as well as United Group Programs in Florida, which offers an internationally accredited hospital in Thailand for kidney, heart, lung and liver transplants using both living and deceased donors.

Three months ago, Blue Cross of South Carolina also began to cover transplants that take place in Thailand, and Bramstedt said there are probably other companies and other states considering similar programs. In West Virginia, patients can get a rebate consisting of 20 percent by going overseas—an incentive Bramstedt termed “coercive” because it puts pressure on low-income people.

In striking contrast, over the last six months alone, at least five national and international bodies have come out against transplant tourism or have strengthened their long-standing objections to it. The World Health Organization (WHO) is among them, along with the United Network for Organ Sharing (UNOS), the nonprofit hired by the U.S. federal government to handle most transplant matters in the United States.

And last month, the Lancet medical journal called commercial transplant tourism “morally repugnant.” However, editors of the prestigious journal also warned that there are powerful opposing views with cogent arguments in the debate.

But this debate extends well beyond the academic realm and into the international arena. For instance, there is widespread interest, starting at WHO, in the paid-donor model that Iran has set up for organ transplants. Also, China promulgated regulations this spring to address its transplant practices after critics accused the country of abusing condemned prisoners in the service of commercial transplants and supplying organs through large numbers of executions. On July 3, China banned transplants for foreigners without government permission, largely closing down its organ tourist trade.

Organ of Danger? Global shortages of organ donors and long waitlists of people with failing health who need transplants have created the business of transplant tourism. This trend has been fueled by the increasingly common (and increasingly safe) use of living donors over the last two decades and the high cost or unavailability of good health care in many parts of the world.

The numbers reflect the shortages: A WHO survey of 98 countries representing more than 80 percent of the world’s people counted 66,000 kidney transplants in 2005—only about a tenth of the total number needed, resulting in thousands of deaths for those on waiting lists. That year also saw more than 21,000 liver and 6,000 heart transplants performed, three-quarters of them in industrialized or emerging economies. According to WHO, transplant tourism accounted for 10 percent of the kidney procedures.

In fact, the longest waitlists are for kidney transplants, which are needed by people with kidney disease who are dying or dependent on dialysis to clean their bloodstream of toxic waste products. Patients are also waiting for new hearts, lungs, intestines, pancreases and livers. Donations often come from the deceased, but many kidney transplants and some lung, liver or pancreas transfers involve live person-to-person donation—which entails major surgery for both a healthy donor and sick recipient.

But live donation has generated criticism for performing unnecessary surgery on a healthy person. For instance, on its Web site, the Transplantation Society says, “The widespread acceptance of live organ transplantation is clearly counter to what historically has been a medical dictum to do no harm.”

This is also where the catch comes in: The Transplantation Society says “donor care” should be a priority, and “the person who gives consent to be a live organ donor should be competent, willing to donate, free of coercion, medically and psychosocially suitable, fully informed of the risks and benefits as a donor, and fully informed of risks, benefits and alternative treatment available to the recipient.”

But move transplants to a developing economy, mix in brisk back-door business in buying and selling organs, add poor people who are healthy and rich ones who are dying and you have a major ethical dilemma.

‘Surgery On Your Wallet’ There are other concerns with transplant tourism, including hygiene in less developed regions, poor donor medical care, and the difficulties of medical follow-up for recipients when they return home.

Indeed, medical risks for foreign patients can be high, stressed bioethicist Bramstedt. Travel is a health burden for the seriously ill, and studies show that transplant patients risk infection with HIV, hepatitis and other diseases in countries where hygiene and patient care standards are lower.

Recent studies of the medical risks show that transplant tourists survive surgery at about the same rate as other transplant patients. However, the research also indicates that these travelers have more infections—and lower long-term success rates.

For example, a review of 10 Minnesota patients who had “surreptitious” kidney transplants in China, Iran and Pakistan—nine from living donors—found that nine of the 10 survived. However, the study, published in December 2006, also found these patients had high rates of infection that were “life threatening” for four of them.

Another extremely serious problem, according to Bramstedt, is that some countries encourage transplants for patients who’ve been turned down because they’re too sick or won’t benefit for other reasons. “A patient like this who gets a transplant overseas might then live for another month with a very poor quality of life. I’ve seen it. It’s surgery on your wallet,” she said.

Transplant tourist troubles have been chronicled by concerned observers since the late 1970s, not long after the first successful live-donor kidney transplant in 1954—twin brothers were involved—and the first heart transplant in 1967. In the 1980s, tracking abuses became part of the professional work of anthropologist Nancy Scheper-Hughes, a professor of medical anthropology at the University of California, Berkeley, who is now an advisor to WHO on transplant matters and director of Organs Watch. Scheper-Hughes has documented organ trafficking in Argentina, Brazil, China, Cuba, India, Israel, Moldova, Romania, the Philippines, South Africa, Taiwan, Turkey and the United States. Her reports in the late 1990s documented various problems with donor consent, such as in Brazil, where a police investigation revealed that a morgue had allegedly removed “several thousand” pituitary glands without consent from poor people’s cadavers and sold them to private medical firms in the United States for hormone production.

More recently, the January 2007 Bulletin of the World Health Organization cited the case of a Pakistani mother of seven who sold one of her kidneys for class="import-text">2007August. Transplant Tourism.txt,500 in Pakistan to a clinic serving overseas clients who pay up to ,000 for an organ transplant. The case of this woman, who received no post-operative care, “is echoed by thousands more in Pakistan and other countries,” the WHO bulletin said. In fact, in a March WHO transplant meeting in Geneva, it was revealed that nearly half of the residents of some villages in Pakistan have only one kidney because of organ sales.

On March 6, the U.S. State Department’s Country Reports on Human Rights Practices for 2006 raised concerns about China’s reported removal of organs from executed prisoners without their consent, noting a public medical statement that “most” organs used in transplants in China were from prisoners.

Scheper-Hughes and others praised the Chinese government’s new transplant regulations, which give Chinese citizens priority when organs become available, prohibit foreigners on tourist visas from receiving transplants, and require foreign patient transplants to be cleared by Chinese health authorities.

Global Transplant Tipping Point? Although WHO first condemned organ sales in 1991, the recent rush of interest and action suggest we may have reached a global tipping point on the issue.

According to Dr. Luc Noel, the WHO transplant chief who spoke at the March Geneva meeting, “If all countries agree on a common approach and stop commercial exploitation, then access will be more equitable and we will have fewer health tragedies.”

In addition to WHO and UNOS addressing transplant tourism, the Transplantation Society (TTS) and the American Society of Transplan-tation have also recently spoken out on the issue. There seems to be global agreement that the main solution to transplant tourism and waiting lists is to increase the number of “charitable” informed consent donations of organs, with an emphasis on organs from the deceased. On June 5, the European Commission proposed to ramp up donor numbers through the creation of a European organ donor card that could be carried in a wallet.

The recent Lancet editorial that called transplant tourism and commercialization “morally repugnant” also noted that there were good arguments and utilitarian pressures for the practice, warning that unless donations increase, “the case for legalizing and regulating the commercial sale of human organs [will] have the upper hand.”

Those In Favor There are serious arguments in favor of openly permitting commercialization of organ transplants, including the bald truth that it may be impossible to eradicate and crackdowns would only send it further underground.

Professor Eytan Mor, director of the Transplantation Department at Beilinson Hospital in Israel, wrote in the journal Harefuah that “transplant tourism functions according to market laws and is profit driven, as opposed to the legal organ exchange programs in Europe and the U.S.A., which are nonprofit and patient oriented.” (Israel permits transplant tourism and insurers cover it.)

However, Mor described the donor shortage situation as a “crisis” and proposed alternatives and third-way thinking. Although the altruistic ethic of transplantation should remain the dominant basis for organ donation, he recently told The Washington Diplomat by e-mail that he thinks nations should set up international organ exchange programs under formal agreements to address the shortage. They should also consider adding regulated compensated donation systems for kidney transplants.

Interestingly, one country already doing that is Iran, where there are no patient waiting lists. Iran was singled out as providing a “gold standard” for the regulated compensation model in the Lancet editorial. In 1988, Iran adopted a compensated and regulated living-unrelated donor renal transplant program. By 1999, its renal transplant waiting list was gone. Iran’s program was described in a 2005 article by Dr. Ahad J. Ghods, who is affiliated with the Nephrology and Transplantation Unit at the Iran University of Medical Sciences and Hashemi Nejad Kidney Hospital.

In an e-mail to The Washington Diplomat, Ghods said his article “reflects present policies” and its description of Iran’s renal transplant program remains accurate. In Iran, he said, “Foreigners are not allowed to undergo renal transplantation from living-unrelated Iranian donors. They are also not allowed to volunteer as kidney donors for Iranian patients.”

But several ethical issues still remain, he added. Because government donor compensation is relatively low, it is supplemented by a donor gift determined at a patient-donor meeting, a situation Ghods finds problematic, although poor donors’ gifts are provided by charitable organizations. A solution, he suggested, might be to increase the basic contribution.

The Lancet editors, though praising the Iranian model, argued it was flawed because a paid organ trade is always likely to “flow in one direction” economically and increase the gap between rich and poor.

Ghods’s own 2006 data both support and refute that argument. In a socioeconomic study of 500 transplants at his center in Tehran, 50.4 percent of the recipients were poor, 36.2 percent were middle class, and 13.4 percent were rich, showing apparent equality between rich and poor in providing transplants to those who need them. However, a large proportion of the paid organ donors were poor—84 percent—backing up critics’ fears about economics and the difficulties of genuine informed consent.

The Gift of Life “Each day has a deeper meaning. I love seeing the early morning sunshine and the rain. I realize that life is very fragile and how special I am because someone was so generous to give me a second chance,” said Malcolm, the recipient of two lungs in a transplant performed at Virginia’s Inova Fairfax Hospital in 2000 when he was 64 years old.

Now a spokesperson for the Washington Regional Transplant Consortium (WRTC), Malcolm said he thanks “the generosity of my lungs’ donor and the lung transplant team at Inova Fairfax [who] saved my life.”

If you would like to consider becoming a donor and helping someone like Malcolm, the consortium recommends the following steps: First, become informed. The agency answers common questions on its Web site at www.wrtc.org.

Next, WRTC says, if you wish to go forward, “document your decision.” In Virginia you can do that online at www.save7lives.org. You can also designate yourself a donor on your driver’s license or fill out a form that you can download from the WRTC Web site.

Next, talk to your family about your decision and provide them with copies of your documents. In the event of your death, they will have to provide medical information and assist the process. However, donation will not affect or hinder in any way funeral plans, WRTC emphasizes, and most religious traditions accept or encourage organ donations.

And WRTC notes that if someone from another country should pass away here and wish to give “the gift of life,” they can donate to local Washingtonians even if they are an international resident or diplomat.

In fact, WRTC serves approximately 4 million area residents. But there’s an even more striking statistic that the group points out on its Web site: Eighteen people die every day because there are not enough organ donors, but one organ donor can save the lives of seven people—a powerful reminder that sometimes charity does begin at home.

About the Author

Carolyn Cosmos is a contributing writer for The Washington Diplomat.

Last Edited on November 29, 1999