Everything has a value, except human life

Dear Editors,

Basic economics dictates that when demand is greater than supply, the resource’s value increases. That dictum has moral challenges in healthcare and does not justify unethical behavior to satisfy demand. Recently, the New York Times published a stark reminder by exposing practices at a transplant hospital in Herat, Afghanistan, a program with World Bank funding [1,2]. Despite legal prohibitions on organ trafficking in Afghanistan, the Loqman Hakim Hospital is reported to have performed >1 000 kidney transplants in the past 5 years. The article profiled a number of paid donors desperate to pay off debts or finance medical care for the dying loved ones. These donors described crippling disabilities after surgery and no follow-up care. A member of the local provincial council is quoted as saying, “In Afghanistan everything has a value, except human life.” When questioned about the relationship between donors and recipients, the hospital’s vice president said, “It’s not our business.” Most in the transplant community disagree.

Media exposés showing the dark side of transplantation, such as the recent one reported the New York Times, are an opportunity for transplant organizations to leverage public consciousness to pressure national and transnational governments to enforce anti-trafficking laws. However, in this recent example, there has been little response and even less outrage from the transplant community. Because the practice is opaque, precise estimates are difficult to come by, but an estimated 5–10% of kidney and liver transplants worldwide are said to have been performed with illegally obtained organs [3,4]. The experiences described in the New York Times article are consistent with the empirical studies. In a study of 239 paid kidney donors in Pakistan, 69% were bonded laborers to their landlords and 93% sold their kidneys primary for debt repayment. Even more tragic, 88% of respondents reported no improvement in their economic status, and nearly all reported deterioration in their overall health [5]. These findings have been confirmed in other countries as well [6,7]. Characterizations of this illicit trade conjure images of shadowy mafia-like figures orchestrating these crimes and exploiting those suffering from crushing poverty; however, they occur through actual involvement of a small number of transplant professionals and the willful ignorance of some in spite of the condemnation of the majority of transplant professionals [8,9]. Is the transplant community effectively acknowledging that they are powerless to stop the expansion of these practices?

The transplant community’s ethical imperative and challenge is to prevent the exploitation of society’s poorest, most vulnerable members for the benefit of those with greater means. Fortunately, the World Health Organization’s Guiding Principles on Human Cell, Tissue and Organ Transplantation [10] provide a framework to achieve this by:

• Maximally developing deceased donor organ donation infrastructure.

• Demanding accountability by agencies with responsibility and oversight over human trafficking, such as the United Nations Office on Drugs and Crime.

• Mandating that every center collect auditable data on donors, including relationship to recipient, and authorizing accreditation bodies (e.g., Joint Commission International) to evaluate these data.

This last point, in particular, is critical; the ability to identify trafficking cases and quantify the scope of the problem is an important step in minimizing the gap between what the transplant community publicly advocates for and what happens in practice. Most transplant societies endorse the Declaration of Istanbul on Organ Trafficking and Transplant Tourism and the subsequent Doha Communiqué, which specifically calls for healthcare professionals to assist in preventing and addressing organ trafficking. Robust transplant community advocacy led to significant changes globally and particularly in countries regarded as organ trafficking hotspots [11]. Despite our community’s considerable efforts to prevent organ trafficking, these stories periodically surface in the lay media.

Our community has a professional and moral obligation to continue to advocate for systematic and global changes and encourage transparency and accountability of governments in enforcing organ trafficking prohibitions. Indeed, through an evolutionary process of developing shared norms, the transplant community was able to advocate more strongly and score numerous legislative victories aimed at curbing organ trafficking [12].

The transplant community can build on these previous efforts, with more robust pathways for reporting organ trafficking to more precisely quantify the scope of the problem and enact solutions to prevent it by lobbying for governments to pass new anti-organ trafficking legislation and strengthening existing laws.