Organ transplantation law in Pakistan to curb kidney trade: chance for global reflection

Sir,

Statistics on the number of kidney transplantations by individual facilities (particularly origins of the donors and recipients) are not disseminated in Pakistan, one of the major ‘Kidney Outlets’, where a minimum of 4000 unethical kidney allo-transplantations take place annually, accounting for 20% of illegal allografts worldwide [1]. The absence of a transplant registry is highlighted by marked variance in approximations for 2006 (Table 1). Concealment of data on Karachi is noticeable [2].

Table 1.

Approximations of renal transplantations in Pakistan for 2006

Source	GoPa	WHO	Transplant Society of Pakistan	Newspapers [3]	Foreign journalb	The Transplant Society
Quoted figure	1600–2200	600–700	3000–4500	3000	4000b	2000

^aGovernment of Pakistan.

^bIndia Journal of Medical Ethics [1].

Fifty to seventy-five percent of the recipients are foreigners [3]. The annual turnover for this trade is around US $20 million. Effectively, we share the disease burden of overseas communities [4]. This translates into a dialysis:transplant ratio of 10:1 for the local population.

Efforts to establish ethical transplant practices in Pakistan date from 1988. Following the intervention by the Supreme Court of Pakistan in July 2006, a law to regulate organ transplantation (and curbing the burgeoning kidney trade in particular) was drafted by the law ministry, in January 2007. This draft had to be revised in August 2007, in order to accommodate reservations on the part of the judiciary on the clauses dealing with compensation for donors. Transplantation of Human Organs and Tissues Ordinance 2007 stands promulgated as of 3 September 2007. A related bill awaits ratification by lawmakers.

This bill is based on promotion of living-related donations, according to the ministry of health. A closely mat- ched non-related person may only provide an organ out of compassion when a genetically-related donor is unavailable. Cadaveric donation is not among the designated priorities. The edict imposes strict penalties for brokers and those indulging in unsupervised removal, storage and grafting of organs. A federal monitoring authority and evaluation committees in designated institutions have been convened. A donor from their country of origin will have to accompany non-residents if they want to avail of our services [5].

Transplant registry, a nationwide pool of potential donors, a donor card system, as well as allocation of resources for disadvantaged end-stage renal disease (ESRD) patients, donor care and follow-up are planned. Transplant institutions will only be allowed to function if they (and personnel thereof) meet prescribed licensure criteria. Limited experience (28 cadaveric grafts to date), non-existence of a brain-death law and doubts about public approval of cadaveric mode of organ harvesting preclude the optimistic notion of the Transplant Society of Pakistan that a deceased organ donation programme will help save 50 000 lives every year.

Pakistani law has global implications because of rampant transplant tourism [6]. It is consistent with contemporary trends [7]. Organ donation by relatives should be portrayed as an act of dignity. I suggest that a sustained strategy of directed donations be adopted, with more effective early identification of a genetically-related donor for each ESRD patient. A strong family setup, and motivation by specialist counsellors, may both play a critical role.

Conflict of interest statement. None declared.