COVID-19 and transplant research from China: An ethical dilemma

The Journal of Heart and Lung Transplantation (JHLT) has maintained a policy of not publishing papers that do not comply with the 2007 ethics statement of the International Society for Heart and Lung Transplantation (ISHLT), which states: “Obtaining organs for transplantation from the bodies of executed prisoners contravenes the principle of voluntary donation.”¹ Authors are required to indicate that their research complies with the ISHLT policy. The clause pertaining to executed prisoners is particularly significant for Chinese authors, as China is the only country where widespread, state-sanctioned procurement of organs from prisoners has occurred and may still be occurring.^{2 , 3}

The JHLT recently published a paper related to the coronavirus disease 2019 (COVID-19) pandemic that does not conform to the guidance,⁴ describing the outcomes of 2 heart transplant recipients in China who were infected with COVID-19. One patient received their allograft in 2003, a time when the vast majority of organs came from executed prisoners.³ The second patient received their transplant in 2017. It is claimed that since January 2015, all organs in China have been procured from volunteers. Recent investigations, however, have found that data about volunteer donor programs may be unreliable,³ and there is no conclusive evidence that forced organ removal from prisoners has ceased.²

Owing to the lack of compliance with the ISHLT ethical guidance, should this paper have been published? The argument in favor of the publication of research of questionable ethics rests on the potential benefit of the research in terms of scientific value and the potential to save lives or decrease suffering in other patients. According to this argument, the greater the value of the research, the greater the imperative to publish, notwithstanding ethical breaches. This argument supports publication of this paper as it provides the first, and therefore unique, information about COVID-19–infected heart transplant recipients. Against this, we must consider the potential damage done by publishing unethical research, as publication may serve to minimize ethical breaches involved. Taking organs from non-consenting prisoners who may have been killed and their organs recovered is a terrible wrong that goes to the core of transplant ethics, violating the dead donor rule and the imperative for voluntary consent for organ donation. Publishing the paper may implicitly sanction the underlying practice. In addition, such publication makes those who use the results of that research morally complicit by becoming entangled in the underlying ethical breaches.⁵ We assume that the JHLT valued the information in this paper to the extent that they felt it outweighed the harms of publication. Recognizing the tension, the Editor agreed to include a note about the ethical breach, as follows:

Editor's Note: The article published from China may include patients transplanted at a time when concerns existed with unethical procurement of organ donors, and therefore may represent a violation of the publication policy. However, the editors have chosen to override this aspect due to the critical importance of the information provided in such a paper for the benefit and help of our patients while recognizing the dignity of those from whom the unethical organs were most probably obtained.

The note appears on the journal webpage dedicated to COVID-19 and cardiothoracic transplant⁶ and also in the published version of these papers.

In our view, the standard for publishing research that involves organs taken from executed prisoners should be exceptionally high. We can expect to see multiple papers from China reporting on various transplant-related aspects of COVID-19,⁷ requiring Editors to be alert to potential ethical breaches. However, this scrutiny is not evident. For example, Transplantation published a Global Transplantation COVID Report that fails to note that data from China almost certainly includes that derived from unethical transplantations.⁸ Opening up prestigious publication platforms such as this journal to papers that are in breach of the ISHLT ethical statement sends a strong message that the journal's ethical standards are open to exceptions (albeit during distinctly unique times). We must beware of turning an ethical blind eye to obtain apparently unique knowledge and seek ways of sharing knowledge that does not confer the prestige of publication on authors involved in ethical breaches.