Organ commerce - A global issue

The rapid advances in medical sciences and technology has made it possible for a greater opportunity for organ commerce not only in India but all over the world. The MOHAN Foundation website on an average gets at least 4 to 5 e-mails from the eastern European and other countries about the desire to sell kidneys. There are many organizations that advertise on the internet and claim to be the easy facilitators of such donation process.

Rapid scientific advancement in recent times has been far ahead and outpaced our social and ethical thinking. As a result we are today grappling with many ethical issues that are staring at us. It has been difficult to get a world consortium conference that can agree to what seems like the common good. The strong link of monetary resources for cutting edge medical research and need for their adequate returns afterwards has let the market forces bite into the ethics of such programmes.

The International Committee of the Red Cross Bellagio Task Force Report, says the US has nearly 38,000 people on transplant waiting lists and this number seems to be growing everyday. This has resulted in certain sections of the society lobbying for a paid donation programme. It also has resulted in many patients traveling abroad for a transplant surgery. Medical tourism is a reality in this field. Some of the countries that have given in to the market forces include India, Iran, China, Pakistan, Brazil, Turkey, Moldova, Ukraine, Russia, Bulgaria and Romania. The concerns of various international bodies has always been quite strong but without any tangible results. In this age of market forces no one is spared. The World Health Organization in its statement on the sale of organs; clearly states it  violate the Universal Declaration of Human Rights as well as its own constitution: "The human body and its parts cannot be the subject of commercial transactions.  Accordingly, giving or receiving payment-... for organs should be prohibited." The WHO advices physicians not to transplant organs "if they have reason to believe that the organs concerned have been the subject of commercial transactions.""  Similarly, the  Council of Europe in 1987 declared: "A human organ must not be offered for profit by any organ exchange organisation, organ banking centre or by any other organisation or individual whatsoever" . The International Council of the Transplantation Society unanimously affirms: "No transplant surgeon/team shall be involved directly or indirectly in the buying or selling of organs/tissues or in any transplant activity aimed at commercial gain."

Mr. Soros the self made  billionaire and a great believer of market forces is deeply concerned with the erosion of social values and the dominance of anti-social market forces in this field. In her article on The End of the Body:The Global Traffic in Organs for Transplant Surgery, Nancy Scheper-Hughes says that by their very nature markets are indiscriminate, promiscuous and inclined to reduce everything, including human beings, their labor and even their reproductive capacity to the status of commodities, to things that can be bought, sold, traded and sometimes even stolen. So, while, according to Mr. Soros, a Market Economy is generally a good thing, we cannot live by markets alone. "Open" and democratic societies require strong social institutions to serve such are all goals as social justice, political freedom, bodily integrity and other human rights. The real dilemma, as Mr. Soros sees it, is one of uneven development. The evolution of the global market has outstripped the development of a mediating global society.

In a follow-up to the Bellagio Task Force  from Department of Anthropology, University of California, Berkeley with support from the Open Society Institute (from the Soros Foundation) conducted ethnographic research in sites in Brazil, India, and South Africa during 1997-1998. Their findings were as follows:

1. Strong and persistent race, class, and gender inequalities and injustices in the acquisition, harvesting and distribution of organs;

2. Violation of national laws prohibiting the sale of organs;

3. The collapse of cultural and religious sanctions against body dismemberment and commercial use in the face of the enormous market pressures in the transplant industry;

4. The appearance of new forms of traditional debt peonage in which the commodified kidney occupies a critical space;

5. Persistent and flagrant human rights violations of cadavers in public morgues, with organs and tissues removed without any consent for international sale;

6. The spread and persistence of narratives of terror concerning the theft and disappearance of bodies and body parts globally.

Nancy Scheper-Hughes in her report on The Global Traffic In Human Organs:A Report Presented to the  House Subcommittee on International Operations and Human Rights, United States Congress on June 27, 2001 states: The growth of "medical tourism" for transplant surgery and other advanced procedures has exacerbated older divisions between North and South, and between haves and have-nots. In general, the flow of organs, tissues, and body parts follows the modern routes of capital: from South to North, from third to first world, from poor to rich, from black and brown to white, and from female to male bodies. In the very worst instance, this market has resulted in theft and coercion, as in the case of China, to a self-serving belief in rights of the rich to the "spare parts" of the poor, as in the case of the many transplant junkets arranged to carry affluent patients from Saudi Arabia, Israel and North America to Turkey, India, Romania, and the Philippines where kidney sellers are recruited from prisons, unemployment offices, and urban shantytowns.

 

 

Solution for India

In India, the issues related to both living and deceased donor programme needs to be urgently addressed and certain flaws in the Transplantation of Human Organ Act such as  the Sub Clause (3) of clause 9 needs to re-addressed. Various innovative suggestion have emnated from the task force of MOHAN Foundation and recommendations sent to the Government of India (4). These include the following

1. Strenghtening and making the Authorisation committees working  more transparent: One suggestion is putting an NGO (choose from the ones working towards the cause of organ donation in that particular city) in the committee to work as a body that can help interview families and donors and if required arrange for psychological couinselling. A pre- authorization counseling of kidney donors by NGOs can help a great deal in making a decision.

 2. Providing uniform guidelines to authorization committee on how to interview, Donors and recipients - what to ask, how to look for motives of donation, if there is no HLA match in case of related donor how to proceed further

3. Recording the proceedings of the authorization committee meetings.

4. Checking the address of Donors by sending a registered letter with Acknowledgment dues postcards

5. Not releasing the list of people sitting on the committee till the previous day.

6. Authorizing select labs to undertake HLA matching

7. Post operative counseling of Donors and recipient and periodic check of this by authorization committee or a similar sub-committee.

8. Exploring possibilites of paired donations where a close relation or partner is fit and able to donate an organ but is not biologically compatible with the potential recipient. This couple can be matched to another couple in a similar situation, so that both the pairs in need of a transplant receive a matched organ. This can be extended further to also pooled donation where more than two pairs of donors and recipients are involved in the swap.

To give a momentum to the cadaver donor programme a few simple additions or amendments in the legislative act are required. 

1. A REQUIRED REQUEST LAW? that would make it compulsory for hospital staff to ask for organs in the event of brain death.

2. A mandated choice of organ donation on Indian driving licenses. Currently the application form and driving license in some of the States does have the blood group. This kind of driving license is quite common in western countries like USA.

  

3. Undertaking POSTMORTEM EXAMINATION DURING THE SAME TIME AS ORGAN RETRIEVAL SURGERY IN A MEDICO-LEGAL CASES?.  At present after organ donation for retrieval surgery the brain death patient is subjected again to postmortem and this causes unnecessary trauma to the emotions of the relatives.

4. DELINKING HOSPITALS WHERE ORGANS CAN BE RETRIEVED FROM HOSPITALS where they can actually be transplanted. Moving bodies from one hospital that is not approved to another that is  approved, limits the scope of number of brain death patients that is made available, difficult in brain death situation and most important traumatic to relatives of the patient.

 

5. Making it COMPULSORY TO APPOINT TRANSPLANT COORDINATORS  IN THE ICU?   of  hospitals undertaking cadaver organ transplant to identify and maintain brain dead patients. This transplant coordinator can be a senior nurse or a doctor.  A similar method is followed in Spain and this country has the highest organ donation rate (31 per million population).

Conclusion

If the last millineum can be called the century where man mastered technology in this millinium we are likely to be faced with many moral and ethical dilemmas on various issues like stem cells transplants, cloning and tissue enginerring. What bothers as most is the ethics that are part of its usage and application of these scientific advances. The fifty years of experience with the field of kidney donation should be sufficient for international bodies to get the ethics of donation right.  The various ethical challenges of the kidney donation programme are  likely to be the platform for comparision hence there is an urgent need to get the ethics of the organ donation and transplants right. This field and its ethical principles is an acid test that will help us in evolving and resolving many of the future ethical issues and dilemmas that we are likely to encounter. 

References

1. http://www.easydriveforum.com/about_easydriveforum.php

2. http://www.tn.gov.in/sta/tables.htm

3. Shroff S.:  Working towards ethical organ transplants. Indian Journal of Medical Ethics Vol IV No 2 April-June 2007

4. Goyal M, Mehta RL, et al: Economic and Health Consequences of selling a Kidney in India JAMA 2002, 288:1589-93

5, Cohen L.R. "Where It Hurts: Indian Material for an Ethics of Organ Transplantation," Daedelus 128(4):135-165.

6. Delmonico FL, Ethical Incentives  Not Payment  For Organ Donation NEJM 2002, 346:2002-5

7. Cantarovich.  Persons and Their Bodies: Rights, Responsibilities, and the Sale of Organs. Philosophy and Medicine. Volume 60. P  1-32.  2002.

7. http://sunsite.berkeley.edu/biotech/organswatch/pages/about2.html

8 WHO, Legislative Responses, p 452

9. WHO, Legislative Responses, p 464

 

The End of the Body:

The Global Traffic in Organs for Transplant Surgery

Nancy Scheper-Hughes

7. Ethics of Organ Donation & Transplantation Editorial. Indian Transplant Newsletter

:5:17/18, 2004. P8

6. INOS and the essence of organ sharing. Editorial. Indian Transplant Newsletter 3:10,2001

7. Shroff S,  Navin S, Abraham G et al, Transplant Proc:35, 15-17, 2003

Correspondence Address:

Dr.Sunil Shroff
Managing Trustee, MOHAN Foundation,
Chennai & Hyderabad,
Prof & Head of the Department of Urology & Renal Transplantation,
Sri Ramachandra Medical College & Research Institute,
Porur, Chennai 600 116, India
Telephone: 91 44 24761546
Fax: 91 44 26263477
Email :[email protected]