Dilemma of commercial organ transplant in the Middle East

Abstract

In recent years, the Middle East has witnessed a significant rise in commercial transplantation activities. This practice is driven by a multitude of factors including economic disparities, inadequate healthcare infrastructure, and cultural attitudes towards organ donation. In this article, we try to explore the complex landscape of commercial transplantation within the Middle East, shedding light on the ethical, legal, and socio-economic dimensions of this contentious issue.

Background

Organ transplantation remains one of the most important advances in medicine. However, myriad medical and ethical challenges persist. Ensuring the safety of both organ donors and recipients is of utmost importance. The persistent shortage of organs despite increasing demands is fueling illicit organ trade worldwide, especially in the Middle East region [1]. Regional conflicts exacerbate the issue, affecting organ supply and demand in the area. According to the World Health Organization (WHO), commercial transplantation involves the exchange of organs or tissues for profit, posing legal and ethical difficulties such as exploitation and inequitable access [2].

Human body ownership

The more ethically challenging question is; do we as humans have full autonomy over our bodies, including the right to sell our organs? Some human rights advocates assert the individual right to bodily autonomy encompasses organ sales. However, critics do highlight the possibility of exploitation of the less fortunate individuals who may feel pressured due to financial desperation to sell their organs, which argues against the idea of autonomy being influenced by economic inequality and systemic pressures. This contentious debate centers on the intrinsic value of human life and dignity and emphasizes that certain aspects of human life are not profitable.

Islam and commercial transplant

Religious perspectives in the Middle East, including Islamic countries, add complexity to the issue. In Islam, humans are considered stewards of their bodies, with a strong emphasis on preserving life and avoiding harm. Selling organs may be deemed harmful, particularly if it exploits or endangers the seller’s health. However, Islam encourages organ donation without financial gain as an act of charity. Regulations in Islamic countries often aim to prevent the commercialization of organ transactions to protect vulnerable individuals from exploitation [3]. Limited literature exists on the perspectives of Middle Eastern individuals on this issue. A survey conducted in 2010 examined the attitudes of the Omani population toward transplantation. It was promising to find that 65% of Omanis were aware that commercial transplantations contravene Islamic and international norms, highlighting a growing awareness and adherence to ethical standards in organ transplantation within the region [4].

International organ trade

The 2008 Istanbul Summit marked a pivotal moment, urging nations to condemn commercial transplantation and promote ethical organ donation, raising awareness about organ trafficking. This sparked a global commitment against trafficking, with significant scientific interest since then [5].

To date, international organ trade persist and even thriving. Global Financial Integrity (GFI) reported in 2020, that international organ trade generates approximately 1.5 billion dollars annually from selling roughly 12,000 illegal human organs and tissue. According to GFI estimates, prices offered to individuals for their organs show significant variation. Payments for kidneys, for example, range from hundreds of dollars for individuals from less developed countries to as much as $20,000 to $30,000 in more developed nations [6]. Organs are obtained through coercion, exploitation, or criminal means including kidnaping and killing of the victims. This market thrives due to indigenous organ shortage with some Middle Eastern countries having waiting lists up to 10 years. Equal access to healthcare is a major principle that applies in medical communities. Nevertheless, the act of organ trade favors the affluent, disadvantaging the financially challenged. Proponents of commercial organ transplants do argue that donor compensation increases the rate of donation which aids in saving lives and overcoming shortages. However, commercial transactions may compromise medical protocols, leading to an inadequate screening of donors and recipients, exposing both parties to infection transmission, and surgical and immunological complications that increase the rate of harm leading to an increased rate of life lost instead of saving them.

Current situation in the Middle East

Organ trafficking in the Middle East has its own unique dynamics, influenced by conflicts like those in Syria and Iraq, while other countries in the region witnessed economic and industrial revolution. Literature on organ donation in the region is scarce [7]. However, in an earlier study from 2007, it was documented that in Oman (in 2003), there were 83 cases of living nonrelated renal transplants conducted abroad (in Iran and Pakistan). Similarly, in Saudi Arabia (in 2006), 646 renal transplants were performed outside the country, while 351 renal transplants were carried out domestically [8]. Current data from across the region is crucially required to assess the situation accurately.

In times of crisis and rising poverty, people may resort to selling their organs for profit, particularly vulnerable refugees [9, 10]. Commercial transplant targets those in dire circumstances, while citizens of more stable nations as in the Gulf region, may engage in transplant tourism due to organ shortages and long waitlists [11]. Between the largely impacted areas by war and the more stable countries in the region, governments should combat organ trading and raise awareness about the dire consequences of commercial transplantation (transplant tourism) on both donors and recipients.

In response to ethical challenges, Middle Eastern nations like Saudi Arabia have implemented strict policies against commercial organ transplants. Saudi Arabia recognized early on the risks of transplant tourism and the exploitation of vulnerable individuals, as well as health hazards like infection transmission and surgical complications. Saudi Arabia has enacted laws prohibiting profit from organ donation and imposing severe penalties on those involved in illicit organ trade [12]. The Saudi Center for Organ Transplantation (SCOT) oversees a framework prioritizing the well-being of donors and recipients. Similarly, the UAE’s Federal Decree Law No (5) of 2016 bans the sale of human organs and tissues for transplantation [13].

Iran’s legal organ trading

While most Middle Eastern countries reject organ trading, Iran stands as an exception with a regulated system allowing kidney donation for financial gain. The Iranian model of kidney transplantation (IMKT) was established in 1988. The government of Iran has established a unique, well-regulated, system that permits kidney donation in exchange for a financial gain by the donor. In Iran, the Kidney Foundation (KF) arranges matches between donors and recipients. Both donors and recipients register with the foundation and undergo needed medical assessments. Once a matched pair agrees on a price, payment is processed through the KF, which notifies transplantation centers overseen by the Ministry of Health. The government covers transplant costs and provides donors with 1 year of medical coverage and potential military exemption. Unlike the commercial transplant practice, the medical team does not receive payment and the recipient bears most of the cost as government compensation [16].

While this system allows for monetary compensation for kidney transplantation but does not tolerate transplant commercialism. The system aims to overcome the shortage of organ donors in the country while reducing rates of illegal organ trade in the black market [14–16]. Donors in the IMKT are supported by law and protected by medical insurance. Donors get paid by the recipient and the government pays a reward to donors, a fixed 10 million Rials, equal to about 1200 USD, called the gift of altruism [16]. However this practice in Iran is heterogeneous and varies from one city to another with some cities like Shiraz has a growing black market [16]. Critics, including some medical professionals, raise ethical concerns regarding the impact on donors’ health and well-being [15]. Some reports suggested negative impacts on donor physical and mental wellbeing [15]. Despite its potential, Iran’s model requires stringent laws ensuring ethicality and equality to safeguard donor and recipient welfare.

Role of the healthcare worker

Healthcare workers face ethical dilemmas when patients consider commercial transplant. Torn between saving patients’ lives and ethical concerns regarding commercial transplant, our role is to ensure patient well-being and raise awareness about the risks of commercial transplantation for both donors and recipients. In Oman, a 2015 survey found that the main reason for considering commercial transplantation was the lack of live-related donors. Shockingly, the second most common answer was a concern about the risks of organ donation on the health of family members being organ donors [17]. Patients often overlook the risks donors face, regardless of kinship. The healthcare worker’s role extends beyond individual care to broader advocacy for systemic change in the practice. The medical community shapes policies to ensure a safe and ethical organ donation process free from financial interests and human harm.

Proposed solutions

Addressing commercial organ transplants in the Middle East requires a collaborative, multidisciplinary approach. While conflicts persist, prioritizing solutions for refugee issues is crucial. Both medical and non-medical communities must address the refugee crisis and prevent organ trafficking. Initiatives promoting voluntary donations through awareness campaigns are vital. By fostering altruism and emphasizing donation importance, communities can sustainably reduce reliance on commercial transactions.

Conclusion

As we grapple with this ethical conundrum, a collaborative dialog between medical professionals, ethicists, religious scholars, and policymakers is essential. Finding a balance that addresses the urgent need for organs while upholding ethical standards, minimizing health risks, and preserving the integrity of healthcare professionals is crucial for the region’s healthcare system. The Middle East stands at the forefront of a global discussion on the future of organ transplantation a future that must be shaped by careful consideration, emphasizing empathy and universal well-being over financial status.

Authors’ contributions

RM. A. formulated study conception, intellectual input, wrote the manuscript, final approval of published version. AA. A. Participated in intellectual input, revision of the manuscript, final approval of the published version. Y.T. Revised the manuscript, final approval of the published version. T.A.  Revised the manuscript, final approval of the published version. RS. A. Participated in intellectual input, revision of the manuscript, final approval of the published version.

Funding

This research received no external funding.

Availability of data and materials

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.