Transplant tourism: a literature review on development, ethical and law issues

The progress of TT is virtually parallel to the progress of organ transplantation. With the advancement in transplant techniques and the development of new effective anti-rejection medications approved by Food and Drug Administration (FDA) in 1983, the number of organ transplants has dramatically increased [15]. However, due to the economic, moral, and religious issues, the need for better immunological matching, the lack of organ donors, and other legal restrictions, organ transplantation has been restricted. These factors triggered commercial transplantation and organ trafficking in unregulated countries.

Before 2000, there were a total of 1,977 overseas transplant cases reported (Figure 3A). India was the most popular destination of TT with 1,308 cases, followed by China with 528 cases, Egypt with 14 cases, Pakistan with 5 cases, and others. The only legal document against TT at that time was the resolution of WHA44.25, which was proposed by the WHO in 1991 to call for protection of the minors and other vulnerable persons from the coercion and improper exploitation to donate organs.

Figure 3. Destination of TT before 2000 (A), during 2000-2010 (B), and after 2010 (C)

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From the year 2000 to 2010, the total number of transplant tourists was nearly five times higher than the previous period with 9,795 cases worldwide. The numbers of transplant tourists visiting China was 7,591 cases; it increased exponentially at 14 times higher in comparison to the previous period (Figure 3B). China became the most popular destination country for TT during this timeframe; India, Pakistan, and Egypt were still among the top popular sites with 667,327 and 123 cases, respectively. Philippines joined with 133 cases reported. In this decade, more legislation was announced and resolutions established by WHO, Council of European, WMA, in addition to the Istanbul declaration against TT.

From the year 2010 to 2016, the number of published papers about TT complications decreased significantly, which may denote the success in the international fight against TT. The total number of reported TT cases was 592 with China still being the most popular destination (Figure 3C). During this interval, a surge of legislation against TT, especially organ harvesting leading to death in China, emerged from the United States, the Council of Europe, and Medical Association.

Subsequently, many countries implemented laws or health policies against TT from 2006 thereafter. People participating in TT were fined or even imprisoned. Enforced consequences demonstrated more awareness in the prevention of the activity globally.

Since its establishment, a first scientific report about the harmful consequences of TT for both donors and organ recipients was published in 1990 [16]. The recipients received organ transplants through organ-brokers, and then consequently suffered from severe postoperative complications, including serious infections, leading to a high rate of mortality (18.5% at one year) [16].

Despite the expensive prices for the organs offered for sale on the internet, as described by Shimazono in 2007 such as: 75,000 USD for a kidney; 120,000 USD for a liver; 110,000 USD for a pancreas; and 150,000 USD for a lung transplant [2], the studies in India and Pakistan showed that the vendors were merely only paid a small portion. In fact, the vendors were are defined as commercial living donors whose motivation is monetary gain the destitute with a high rate of illiteracy [17]. They sold their organs to pay off debts and for other essential needs of life such as food and clothing [18]. However, there was no improvement in their economic status; their average income even declined a third after selling their organs. Moreover, their health deteriorated for the remainder of their lives [18, 19]. The similar condition has been reported in Iran, Egypt, and the Philippines. Furthermore, accompanied by physical and economical downgrade, the vendors or commercial living donors also suffered from psychological burden such as being ashamed and isolated from the society [20]. The four trafficking networks in India, South Africa, Kosovo, and the USA were discovered by authorities proved that what we know about the TT based on scientific data may be just a tip of the iceberg [8].

As China is one of the main countries practicing OT/TT since the year 2000, we are discussing separately the story of organ source in China. According to data from the Ministry of Health of China, before 2000, the annual number of kidney transplants were only about 4,000 in total, and limited report about liver transplant cases was found [21]. However, during the period from 2000 to 2007, the figure for kidney transplants exceeded 6,000 cases per year, and it even peaked to 12,000 cases annually in 2005. Concurrently, there was an exponential growth in the number of liver transplants, which increased from under 100 cases in 2000, to 2,300 cases in 2004, and finally reached its peak at 3,500 cases per year in 2005 [22]. Jiefu Huang, the former Vice Minister of Health of the People’s Republic of China stated that about 90% of organ sources were from deceased donors and most of them came from executed prisoners, and another small portion came from traffic accident victims [23]. However, there has been no transparent data of executed prisoners published by the Chinese government. According to tabulations constructed by Amnesty International report from the publicly-available data, the number of annual executed prisoners were considerably less than the number of annual organ transplant in China, specifically the estimated sentenced death in 2005 was only about 3900 people while the total number of kidney transplant reached to 12,000 cases as described above [24]. A report revealed that the Chinese government performed forced removal of organs leading to death not only from executed prisoners but also from prisoner of conscience who were mainly Falun Gong (a Chinese spiritual practice) practitioners [25-27]. The actual number of cases is difficult to get due to lack of accessible data and could be greatly underestimated. It is difficult to know the actual fact due to lacking of transparent data from China and the action of prohibiting independent investigator of Chinese government.

This unethical practice was stated by Council of Europe [9]. Concerns about ethical standards implemented in research publications using materials from executed prisoners, a recent review investigating on Chinese organ transplantation concluded that around 92.5% (412/445 included studies) failed to clarify whether or not, the organs were sourced from executed prisoners and 99% (439/445 included studies) failed to report that organ sources gave consent for transplantation [28]. Scholars in genocide study presented that forced organ harvesting from Falun Gong practitioner in China is one part of Chinese Government’s effort to eradicate of this group [29].

International efforts to fight against TT has been continuously evolving. The effectiveness of legislation imposed by some countries of origin including Europe, Malaysia, Israel, Turkey, United States, Australia, Spain, Taiwan was reported in details in Table 3. Before 2000, there were extremely limited organizations or nations that paid attention to TT; Turkey played a pioneer in ordering legislation with the law on organ transplantation in 1979 [30]. This law was used as a model by many other countries in the following time. In 1991, WHO proposed resolution calling for protecting the vulnerable from TT. After the 2000, TT expanded very rapidly resulting in some severe unethical issues; criminal organ trafficking network and forced organ-harvesting leading to death in China. Many international organizations and nations have raised their voices against TT. The most significant evolution in the fight against TT was the declaration of Istanbul in 2008, which officially condemned organ commercialism and TT. Moving forward, with the efforts of human rights activists and medical specialist association, law against TT has been implemented in numerous countries of origin (Table 3), and law regulating organ transplantation has also been implemented in countries of destination.

Law implementation and related policies against TT has been effective in many countries of origin to reduce the number of transplant tourists travelling abroad to countries where laws prohibiting organ sales are poorly enforced or overrode by loopholes. Council of Europe was the leading league of countries that actively fought against TT. From the Convention on Human Rights and Biomedicine in 1997, an additional protocol concerning Transplantation of Organ and Tissues of Human Origin, to the passing law prohibited organ trafficking in 2016 and 2017. The number of patients going abroad for transplant within this region has dropped down significantly [9]. The same trend occurred in Israel and Malaysia. After implementing law in 2008, the number of patients going abroad for kidney transplant decreased from 155 in 2006 to 35 in 2011 [31]. Amongst the top three countries of tourist’s origin, Taiwan implemented a law against TT in 2015, yet there is no report on its effectiveness till now [32]. Malaysia implemented a policy that refuses to dispense immunosuppressive therapy for free to TT patient without the approval of the Ministry of Health from January 2012, resulting in at least one third reduction of the number of patients engaging in TT annually [33].

On the other hand, some top countries of destination where transplantation takes place, according to a subsequent report from the Council of Europe, transplant legislation was adopted. In October 2014, Hangzhou Resolution was promulgated which terminate the usage of organ from executed prisoners [34]. However, recent reports have provided that thousands of patients from South Korea, Gulf Region and Western Chinese community still going to China for organ transplant [35]. Regular visit transplant center of members of the Declaration of Istanbul Custodian travel to China suspected that TT is still active and on-going [9]. The same story has been reported in India, although this country building law in 2008, but TT is still ongoing with poor regulation [9]. After implementing the laws, Philippines had a success in controlling the foreigner transplant tourist but was unable to deal with local one [36]. There was no report on other countries of destination in medical literature.

There are several limitations in our narrative review. Since there was no universal obligation to report cases of TT, the reported numbers might underestimate the magnitude of the problem. Moreover, even after China announced that starting 2015, hospital-based donors would be the sole source of organs in response to international criticism, the reported numbers following this announcement appeared to be falsified according to a recent study [37]. In addition, being a narrative review with unstructured search terms, some studies might have been missed from our search.