‘Medical tourism’ initiatives should exclude commercial organ transplantation

The medical tourism industry is in a period of rapid global expansion.^1,2 Hospitals and clinics in Argentina, Brazil, Costa Rica, the Dominican Republic and Mexico advertise inexpensive cosmetic surgery packages. Clinics in Hungary, Poland, the Czech Republic and elsewhere in Eastern Europe market low cost dental care. Medical facilities in India, Indonesia, Malaysia, the Philippines, Singapore and Thailand target the international patient market. Helping draw patients to these countries are medical tourism companies. These businesses advertise procedures to clients seeking affordable medical care or trying to avoid delays in receiving treatment within their local communities.

In some countries, individual hospitals or private hospital chains are the main drivers behind efforts to attract international patients. In other regions, well-coordinated government programs and public-private initiatives are designed to increase market share of medical travellers. Participants in the global healthcare marketplace include travel agencies, public hospitals, private medical facilities, stand-alone clinics, government ministries, medical tourism companies, airlines, hotel chains and patients.

Whatever the general advantages and disadvantages of a global marketplace in health services, many risks accompany the inclusion of organ transplant packages among the medical procedures sold to international patients.³ These dangers are magnified in countries where kidneys are purchased in underground economies or black markets.⁴ In these settings, promoting organ transplant packages to international patients risks escalating the number of kidneys purchased from poor citizens. Growing demand for transplants prompts organ brokers to increase the number of kidneys bought from impoverished individuals and sold to international patients.

The World Health Organization identifies Colombia, India, Pakistan and the Philippines as four of the leading global hot spots for buying and selling human organs. The sale of organs is illegal in Colombia, India and Pakistan. Organ trafficking is illegal in the Philippines. Despite legislation intended to prevent the sale of organs in these countries, patients from around the world continue to purchase kidneys in these nations.⁵ Medical tourism campaigns exacerbate this problem by marketing ‘all-inclusive’ organ transplant packages to international patients. These operations include kidneys purchased from poor individuals rather than obtained from living donors or deceased persons.

In India, the Ministry of Tourism’s Incredible India website advertises kidney transplants and notes the comparatively ‘cheap’ price of renal transplants at Indian medical facilities.⁶ In Pakistan, individual clinics advertise the sale of kidney transplants.^7,8 In the Philippines, government agencies, hospitals and medical tourism companies all market organ transplants to international patients. Given the few kidneys available from living donors and deceased donors, coupled with the country’s well-known trade in organs, most of the kidneys sold within all-inclusive transplant packages are purchased from poor Filipinos. Neighbourhood organ brokers facilitate this trade in kidneys.

The Philippine Medical Tourism Program was established in 2004.⁹ The public-private initiative includes government medical centres, private hospitals, various clinics, and the Philippine government Departments of Trade and Industry, Tourism and Health. Philippine government agencies promote the sale of transplant packages to international patients. For example, the website of the Philippine Information Agency touts the low price of kidney transplants at Philippine hospitals. It states, ‘while kidney transplants can reach up to $150,000 abroad, it will only cost $25,000 here’.¹⁰ Government representatives and Philippine physicians are trying to increase the number of patients from Saudi Arabia obtaining kidney transplants in the Philippines.¹¹ Transplant physicians and government officials are members of the Philippine ‘medical tourism road show’.¹² This group travels to other countries and tries to attract foreign patients to hospitals in the Philippines.

Various medical facilities advertise kidney transplant packages in the Philippines. International patients can purchase kidney transplant packages at Asian Hospital, National Kidney and Transplant Institute, Capitol Medical Center, St. Luke’s Medical Center, Philippines Medical Center and other hospitals in the Philippines. Asian Hospital sells ‘5-star’ kidney transplant packages for US$80,000 and ‘3-star’ packages for US$65,000.¹³ Medical tourism companies and other businesses also sell kidney transplants in the Philippines. Wellness Philippines, Med Afford, Double Bright International Medical Services, Germany China Medical Company, Liver4you and Rx Pinoy all sell kidney transplant packages. The Rx Pinoy website invites online purchasers to add a kidney transplant package to their ‘shopping cart’.¹⁴ Outside the Philippines, companies such as Overseas Medical Services also sell kidney transplants in the country.¹⁵ In total, at least twelve hospitals and businesses market renal transplants in the Philippines. This behaviour occurs in a country with few living or deceased donors, little financial and medical support for Philippine patients suffering from end stage renal disease, and serious cultural and organizational barriers to finding organ donors.

Inclusion of kidney transplant facilities and kidney transplant ‘packages’ within the Philippines’ public–private medical tourism initiative is morally indefensible for several reasons. The most problematic ethical issue is that many of the transplanted kidneys are purchased from poor individuals. However, ethical issues related to the inclusion of kidney transplants in medical tourism offerings extend beyond the commodification of human organs.

Advertising organ transplants to international patients risks increasing rather than curtailing the number of poor Philippine citizens selling kidneys to organ brokers. In urban slums and other poor areas, organ brokers buy kidneys from poor Filipinos. Most individuals receive US$2000 or less for selling a kidney. Research on organ selling in underground economies indicates that when individuals sell a kidney they usually receive substandard medical care following nephrectomy, experience no long term economic benefits, suffer a decline in self-assessed health status and do not receive the sums they were promised in exchange for selling a kidney.^16,17 Proponents of commercial organ transplantation argue that poor individuals should be allowed to profit from selling a kidney. However, several studies indicate that the money poor individuals expect to obtain from selling a kidney goes to debt collectors.¹⁸

Public–private initiatives that include marketing kidney transplant packages increase the likelihood that the underground sale of organs will flourish. In countries with underground economies in organ trafficking, government support for the sale of organ transplants risks fostering a public perception that government legislators support rather than oppose purchase of kidneys from poor, vulnerable and easily exploited citizens.

Selling all-inclusive organ transplant packages to international patients raises serious questions concerning health equity, social justice and fair access to required medical care. In the Philippines, few individuals suffering from end-stage renal disease are able to afford out-of-pocket expenses for kidney transplantation or long-term dialysis treatments. Selling kidneys and kidney transplant operations to international patients risks reducing the number of organs available to Philippine citizens. Some reports indicate that foreign patients ‘outbid’ local citizens for organ transplants. Including organ transplants within medical tourism packages risks undermining health equity and reducing the already low number of Philippine citizens able to obtain access to organ transplants.

Given the global scarcity of organs available for transplantation, Philippine hospitals can charge high prices by advertising transplants that include kidneys purchased from living providers. Though advertised prices are modest compared to the cost of transplantation in many other countries, organ transplants rank among the most expensive medical procedures Philippine medical facilities advertise to international patients. With the profits to be made from selling kidney transplants to international patients, there is a serious risk that facilities lacking necessary resources to deliver competent transplant services will nonetheless sell organ transplant packages to international customers. In the Philippines, at least 21 facilities perform kidney transplants. Of those 21 institutions, 13 facilities perform ten kidney transplants or fewer per year.¹⁹ Kidney transplantation should occur in medical facilities with specialized, highly trained healthcare providers, appropriate organizational resources, requisite institutional infrastructure, and ethical organ procurement practices. Selling organ transplants to international patients is profitable for Philippine healthcare facilities. However, the profits to be gained from offering these procedures means there is a significant danger that cash-strapped public hospitals and private medical centres will sell operations they are ill-equipped to perform.

Philippine government officials are aware of the country’s market in kidney sales. Parallel to the black market, a government-run program now offers ‘compensation’ in exchange for kidneys. In this program, citizens receive ‘gratitudinal gifts’ in exchange for providing a kidney.²⁰ The Philippines has no legislation, court decisions or policy statements indicating what demarcates cash-based gratitudinal gifts from outright payment for kidneys. Failure to specify what gratitudinal gifts are acceptable or unacceptable means the Philippine government risks institutionalizing, bureaucratizing and legitimizing commercial sale of organs. Even more problematic, hospital administrative committees are supposed to screen individuals before ‘compensation’ is provided in exchange for kidneys. However, including organ transplants within the list of medical services sold to international patients generates irresolvable professional and institutional conflicts of interest. Hospitals can generate US$80,000 or more per operation by selling kidney transplant packages to international patients. The profits produced from selling kidney transplant packages risk compromising the judgment of administrative bodies tasked with screening individuals seeking to provide a kidney in exchange for compensation. Knowing that their institutions generate significant earnings by selling kidney transplants to international patients, social workers, psychologists and physicians involved in screening individuals seeking to exchange a kidney for compensation risk feeling pressure to rubber-stamp such requests. This conflict of interest is embedded within bureaucratic structures in which members of screening committees are employed by the very institutions that profit by selling kidney transplant packages.

Buying, selling and brokering organs is illegal in the vast majority of countries. Through legislative reform and police investigations both India and Pakistan have attempted to address their black markets in human organs. However, government officials and healthcare providers in some countries seek the profits to be generated from selling all-inclusive organ transplant packages to international patients. In India, while some government officials are trying to eliminate the country’s underground economy in the sale of human organs, the Ministry of Tourism promotes the sale of organ transplants and the country’s organ transplant facilities actively solicit international patients. While the Philippines is a less well-known example of a country that risks increasing the number of poor individuals exchanging kidneys for cash, by including organ transplant packages in the menu of options marketed to international patients, it is establishing itself as a leading global destination site for commercial sale of human organs.

Given the many dangers associated with selling purchased organs to medical tourists, organ transplant facilities and transplant procedures should be excluded from medical tourism initiatives. Including organ transplants among the procedures marketed to international patients risks undermining health equity and reducing the number of citizens who have access to organ transplantation. More importantly, government support for marketing organ transplants to international patients, when such efforts occur in settings where kidneys are routinely purchased from poor individuals, suggests that government officials condone purchase of organs from their poorest and most vulnerable citizens. Countries seeking to eliminate underground economies in sale of organs must exclude organ transplant packages from medical tourism initiatives.

Footnotes

DECLARATIONS —

Competing interests None declared

Funding None

Ethical approval Not applicable

Guarantor LT

Contributorship LT is the sole contributor