New national policy for deceased organ donation in China

A group of pioneering surgeons in Shanghai, led by Professor Yan-Zhen Lin from Ruijin Hospital, made their initial liver transplantation attempt in 1978, marking the beginning of liver transplant history in the People’s Republic of China (PRC) (1). Liver transplantation in China has now reached levels of success comparable to that in Europe and North America. The most recent report from the China Liver Transplant Registry, the official national liver transplant registry of Mainland China authorized by the National Health and Family Planning Commission of the PRC, indicates as of December 2011, a total of 20,877 liver transplantation surgeries had been performed from 1980 through 2011 in 81 certified transplant centers. Of these donated livers, 93% were procured from deceased donors. The 1-, 3-, and 5-year survival rates were 78%, 65%, and 61% respectively (2). The PRC is now clearly a giant in this field.

This remarkable progress and the results have been tainted historically by two questionable practices: the use of executed prisoners as a source of donor organs and the presence of transplant tourism. The global community has always remained confident, however, that China has the capacity to move away from these negative practices.

Indeed, things have recently changed for the better. Perhaps due to the exposure created by hosting the Olympic Games in 2008, Chinese authorities and the transplant community of the PRC have reacted positively to change their transplantation practices. One event suggesting this positive trend noticed by the international community, was the publication in 2007 by Dr. Jiefu Huang, the Vice Minister of Health of the PRC and Professor of Surgery of Peking Union Medical College in Beijing (1). In the article, Dr. Huang reviewed the historical background and ethical and legislative perspectives of liver transplantation in the PRC. Dr. Huang openly acknowledged that the nation is in a process of transition, and that some socio-cultural beliefs and customs must be modernized to keep pace with such social developments. He courageously admitted that there is “no doubt that Chinese medical ethics have not kept pace with rapidly changing technologies” in the field of organ transplantation. Those who read the text may have considered that the daunting burden faced by this large country at the time was too much to overcome.

Reading between the lines however, it is clear that the PRC has realized the problem, and is willing to cooperate with the world community and honor the ethical commitment of the international society as presented in the Istanbul Declaration (3). This seemed to be a very positive turning point. In fact, a draft of legislation involving medical standards of brain death was completed based on intensive consultations with national and international medical and ethical experts, and the legislation was approved and came into effect May 1, 2007, setting the course for this positive trend.

A recent report by Huang and colleagues provides an update of the trend, an evolution of the positive movement (4). The report presents the outlines of the development of a new national policy for organ donation and transplantation in the PRC. This new policy was welcomed by the Transplant Society, and interpreted as a welcome alternative to the unethical practice of recovering organs from prisoners sentenced to death that had been predominant in their country (5).

The report by Huang and colleagues describes in detail the components of this comprehensive plan that have been implemented. After establishing regulations by the State Council of China (the highest executive authority), the PRC conducted a series of pilot trials to obtain organs from donors after circulatory death, and initial experience of the pilot trials was previously reported (6). What must be emphasized is that any system that is to become sustainable in a nation or a region requires understanding and acceptance by the people. Organ donation is no exception and the authors describe the care implemented in the process. Death has cultural and societal aspects unique to each society that must also be respected by the country’s organ donation system. The newly introduced program is based on the lessons learned from previous trials and respects the current Chinese cultural hesitation to determine death by strict scientific neurologic criteria. For this reason, the PRC has developed and implemented categories of donations after circulatory death particular in their country. The organizational structure described for donation and transplantation in the PRC is very concrete. Subordinating to the State Council, the China Organ Transplant Committee and the China Organ Donation Committee were established to function as the national policy-making bodies and submit drafted policies. The two entities govern the following four systems pertinent to organ donation and transplantation: Promotion of Deceased-Organ Donation, Organ Procurement, Organ Allocation, and National Registry of Transplant Recipients. To secure credibility, it emphatically emphasizes that ‘any accredited transplant hospital that fails to develop a deceased organ donation program will have their transplant license revoked’. Finally, it also states that, those participating in organ trafficking will face criminal charges, a very strong positive message that the international community has waited to hear from the PRC.

The integrated momentum in the PRC presented by the authors can be instructive to neighboring Asian countries. For many years, despite the large contributions of many physicians and surgeons to the development of transplantation mainly in the Western society, the development of transplantation practices on this side of the globe in their true essence has been questioned. Living donor transplantation has progressed, demonstrating not only technical maturity but also exposing the vulnerability of society’s acceptance of an altruistic deed of becoming an organ donor under the guidance of modern science. As in any advanced clinical science, transplantation requires integrated effort, including genuine concentration by highly educated and motivated human resources, as well as ethical and strategic, effective policy-making. With the main forces of Asia PRC gaining momentum towards a trusted and accountable path of development of organ transplantation, their neighbors have much work to do on their own turf.